Awaiting Liver Transplantation Research Articles

Association between protein‐energy malnutrition and healthcare use among adult patients after liver transplantation: A retrospective cohort study

Association between protein‐energy malnutrition and healthcare use among adult patients after liver transplantation: A retrospective cohort study

Ascities after Liver Cirrhosis Diagnosis and Treatment

Ascities after Liver Cirrhosis Diagnosis and Treatment

The impact of MELD exception points for hydrothorax on posttransplant mortality: a propensity score-matched analysis.

Hepatic hydrothorax is a challenging complication of end-stage liver disease, and.patients with this complication can receive model for end-stage liver disease (MELD) exception points if they meet specific criteria as defined by United Network for Organ Sharing (UNOS). This research aimed to analyze the effect of receiving MELD exception points for hepatic hydrothorax on posttransplant mortality, using a national transplant database. Patients >18 years in the UNOS database awaiting liver transplant between 2012 and 2023 were identified based on their petition for MELD exception points. Using a 1: 1 propensity score-matched analysis, 302 patients who received MELD exception points for hepatic hydrothorax were compared with 302 patients who did not receive MELD exception points.Demographic, clinical and laboratory values were compared. The primary outcome was posttransplant mortality. Multivariate logistic regression controlled for potential confounders. No significant difference was observed in mean age (58.20 vs 57.62 years), mean initial MELD score (16.93 vs 16.54), or mean Child-Pugh score (9.77 vs 9.74) in patients with hepatic hydrothorax receiving MELD exception points versus their matched cohort who did not recieve exception points. The proportion of males was slightly higher among patients who received MELD exception points (57.6% males vs 53.6% males). A majority of patients in both groups had Child-Pugh grade C (>56%). Patients receiving MELD exception points for hepatic hydrothorax had a statistically significant 44% decrease in the odds of posttransplant death compared to those who did not (OR 0.56; 95% CI 0.37-0.88; P = 0.01). Among the combined cohort, each year increase in age resulted in a 3.9% increase in mortality (OR 1.04; 95% CI 1.01-1.07; P = 0.005), and every one-unit increase in serum creatinine resulted in a 40% increase in mortality (OR 1.40; 95% CI 1.03-1.92; P = 0.03). Receiving MELD exception points for hepatic hydrothorax is associated with a significant reduction in the odds of posttransplant mortality. These findings underscore the importance of MELD exception points for hepatic hydrothorax among patients with decompensated cirrhosis, potentially improving patient prioritization for liver transplantation and influencing clinical decision-making.

Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant.

Malnutrition, sarcopenia (low muscle mass), and physical frailty have gained increasing recognition in candidates for liver transplant (LT) as these conditions can impact postoperative functional capacity. Multidimensional prehabilitation programs have been proposed as a safe intervention in adults awaiting LT but the nutritional pillar of prehabilitation has been understudied. This review summarizes the nutritional recommendations for prehabilitation for individuals with cirrhosis awaiting LT. Three major aspects of nutritional prehabilitation are discussed: (1) Assess: Evaluate nutritional status and assess for malnutrition, sarcopenia, and frailty to guide the nutritional prehabilitation intervention intensity, increasing across universal, targeted, and specialist levels; (2) Intervene: Prescribe a nutritional prehabilitation intervention to meet established nutrition guidelines in cirrhosis with a targeted focus on improving nutritional status and muscle health; (3) Reassess: Follow-up based on the required intensity of nutritional care with as needed intervention adjustment. Topics covered in the review include nutritional care levels for prehabilitation, energy prescriptions across body mass index strata, detailed considerations around protein intake (amount, distribution, and quality), carbohydrate and fat intake, other nutritional considerations, and the potential role of dietary supplements and nutraceuticals. Future research is warranted to more accurately evaluate energy needs, evaluate emerging dietary supplementation strategies, and establish the role of nutraceuticals alongside food-based interventions. While the general principles of nutritional prehabilitation are ready for immediate application, future large-scale randomized controlled trials in this space will help to quantify the benefit that can be gained by transitioning the LT approach from passive "transplant waitlist time" to active "transplant preparation time."

Reversing malnutrition and low muscle strength with targeted enteral feeding in patients awaiting liver transplant: A randomized controlled trial.

Most patients with decompensated cirrhosis fail to meet their nutrition targets. The impact of nasogastric feeding (NGF) on malnutrition in cirrhosis remains unknown. This study aims to assess the impact of pre-transplant NGF on pre- and post-liver transplant outcomes. This single-centre, prospective randomized controlled trial of 55 patients with severe malnutrition and low handgrip strength (HGS) compared standard high-energy high-protein diet to diet plus supplemental nocturnal NGF whilst awaiting transplant. The primary outcome was change in HGS. Median age was 58.5 years (IQR 51.1-64), median MELD 24 (20-28.5), and 32 (58%) were male. Median duration of NGF was 63.0 days (34.5-127), following which time the median between group difference in HGS was 3.6kg (95% CI: 1.7-5.2, p<0.001); an increase of 20% from baseline. Mid upper-arm circumference, triceps skinfold and immune function all increased significantly with NGF. Muscle and nutritional parameters continued to improve with increasing duration of feeding. NGF significantly increased daily energy intake between groups by 1285kcal (95% CI: 860-1677) and protein intake by 51g (95% CI: 32-71) (both p<0.001). All NGF patients met >100% of their measured nutritional requirements. Post-transplant clinical outcomes were similar between groups. Targeted enteral feeding before LT improves HGS, anthropometry and immune function in severely malnourished cirrhotic patients. These findings provide a strong rationale for early consideration of NGF to reverse malnutrition and improve muscle strength. Appropriately powered studies should explore whether NGF can also impact clinically relevant outcomes including pre- and post-transplant mortality.

Outcomes of critically ill patients with liver failure who require mechanical ventilation: A retrospective, single-center study.

Critically ill patients with liver failure have high mortality. Besides the management of organ-specific complications, liver transplantation constitutes a definitive treatment. However, clinicians may hesitate to introduce mechanical ventilation for patients on liver transplantation waitlists because of poor prognosis. This study investigated the outcomes of intensive care and ventilation support therapy effects in patients with liver failure. This single-center study retrospectively enrolled 32 consecutive patients with liver failure who were admitted to the intensive care unit from January 2014 to December 2020. The medical records were reviewed and analyzed retrospectively for Acute Physiologic and Chronic Health Evaluation (APACHE)-II. The model for end-stage liver disease scores, 90-day mortality, and survival was assessed using the Kaplan-Meier method. The average patient age was 45.5 ± 20.1 years, and 53% of patients were women. On intensive care unit admission, APACHE-II and model for end-stage liver disease scores were 20 and 28, respectively. Among 13 patients considered for liver transplantation, 4 received transplants. Thirteen patients (40.6%) were intubated and mechanically ventilated in the intensive care unit. The 90-day mortality rate of patients with and without mechanical ventilation in the intensive care unit (13, 61.5% vs. 19, 47.4%, p = 0.4905) was similar. APACHE-II score >21 was an independent predictor of mechanical ventilation requirement in patients with liver failure during intensive care unit stay. Although critically ill patients with liver failure are at risk of multiorgan failure with poor outcomes, mechanical ventilation did not negatively affect the 90-day mortality or performance rates of liver transplantation. Clinicians should consider mechanical ventilation-based life support in critically ill patients with liver failure who are awaiting liver transplantation.

Advancements in Vaccine Strategies for Chronic Liver Disease Patients: Navigating Post-COVID Challenges and Opportunities.

This review addresses the vital role of vaccinations in managing patients with chronic liver disease (CLD), especially in the context of the post-COVID-19 landscape. The pandemic has highlighted the unique vulnerabilities of CLD patients, including those awaiting liver transplantation and post-transplant individuals, who face heightened risks of infection due to compromised immune responses. Recent advancements in vaccine technology, such as mRNA platforms, novel adjuvants, and advanced delivery systems, have significantly accelerated vaccine development, enhancing both speed and efficacy. Moreover, the emergence of personalized vaccines, tailored to everyone's unique immunological profile, presents new opportunities, particularly for those with chronic conditions. This review synthesizes the current state of evidence regarding vaccine recommendations for CLD patients, focusing on their response to vaccinations and proposing effective strategies to protect this vulnerable group from vaccine-preventable diseases. It also explores the challenges in implementing these strategies and considers the impact of emerging vaccine delivery systems on improving outcomes for CLD patients. The paper aims to provide nuanced guidance on vaccination in the rapidly evolving healthcare landscape, addressing both technological innovations and comprehensive patient care strategies.

Sarcopenia in cirrhotic patients: Does frailty matter while waiting for a liver transplant?

Sarcopenia reflects patient frailty and should be routinely assessed due to its high prevalence in cirrhotic patients awaiting liver transplants. Pre-transplant nutritional optimization should be tailored for patients with a definitive diagnosis of sarcopenia, therefore improving functional status at transplant and reducing post-transplant mortality. Hepatologists and transplant surgeons should have raised awareness regarding sarcopenia and the reflected frailty that hinder posttransplant outcomes. The policymakers should also take into account when modifying the organ allocation model that sarcopenia or frailty might become a decisive factor in allocating organs for cirrhotic patients, in order to ensure post-transplant survival and quality of life.

Place of tyrosine kinase inhibitors in the first line of treatment of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) in Russia and worldwide is steadily increasing over time. The majority of HCC patients are diagnosed at a late stage of the disease, which is not suitable for potentially curative treatment methods. Before the emergence of new treatment regimens, the median overall survival for this condition was just over one year. Studying combinations of immunotherapy and targeted therapy has improved clinical outcomes compared to monotherapy with tyrosine kinase inhibitors, but the new treatment regimens cannot be prescribed to all patients with advanced HCC. The combination of atezolizumab with bevacizumab may be prescribed to eligible patients with advanced hepatocellular carcinoma who do not have varicose veins and have no history of hypertensive crises. In real clinical practice, it is extremely difficult to select patients who meet the inclusion criteria for clinical trials. Monotherapy with tyrosine kinase inhibitors is also effective regardless of the etiology of HCC development and can be prescribed to patients with signs of liver insufficiency (Child-Pugh B) as opposed to combined therapy. Double immunotherapy has shown its efficacy in second-line treatment, and in the future, these combinations may also demonstrate their effectiveness in first-line treatment of hepatocellular carcinoma. There is insufficient evidence on the effectiveness of immunotherapy in patients awaiting liver transplantation. For this category of patients, the drugs of choice are lenvatinib and sorafenib. The article highlights the specific considerations in choosing the treatment regimen based on the etiology of the disease, treatment goals, concomitant patient conditions, and the presence/severity of liver insufficiency.

Clinical course of ascitic syndrome and acute kidney injury in the setting of nonselective beta‑blockers or endoscopic variceal ligation for primary prevention of bleeding in cirrhotic patients awaiting liver transplantation

Objective: to compare the effects of nonselective beta-blockers (NSBB) and endoscopic variceal ligation (EVL) on patient survival, ascites dynamics, and development of acute kidney injury (AKI) during primary prevention of bleeding from the esophageal varices and cardia in patients with decompensated cirrhosis on the liver transplant waiting list (LTWL). Materials and methods. A retrospective comparative study of the clinical data of patients with severe ascites and esophageal varices without a bleeding history at the time of their inclusion in the LTWL was performed. Group 1 patients (n = 84) were prescribed NSBB, alpha and beta-adrenoblockers in order to prevent bleeding and reduce progression of decompensated cirrhosis. Group 2 patients underwent EVL. Results. Demographic, laboratory and instrumental parameters of patients in the compared groups had no significant differences. In both groups, there were no significant differences between the indicators of severity of liver lesions (MELD-Na, Child–Turcotte–Pugh), frequency of severe ascites, frequency of varicose nodes grades 2–3. At follow-up, bleeding developed in 22 patients (13.25%) – 13 patients in the NSBB group and 9 patients in the EVL group (15.47% and 10.97%, respectively, p &gt; 0.05). Patient survival was significantly higher in the EVL group than in the NSBB group. Incidence of refractory ascites, number of patients with grade 3 ascites, and AKI stages 2–3 in the NSBB group, were significantly higher (p &lt; 0.05) than in the EVL group. MELD-Na was the independent predictor of mortality in the EVL group, while low mean arterial pressure (mAP) and presence of AKI were those for patients receiving NSBB. Conclusion. NSBB and EVL are effective methods of primary prevention of bleeding. Mortality rate, number of patients with refractory ascites and severe ascites, and number of patients with AKI stages 2–3 were higher in the NSBB group than in the EVL cohort. In EVL patients, the independent predictor of death was MELD-Na, while in NSBB patients, the independent predictors of mortality were low mAP and presence of AKI.

Frequency of Chest Complications after Liver Transplantation

Background: Liver transplantation is a critical intervention for patients with advanced liver disease. However, postoperative complications, particularly pulmonary complications, significantly impact patient outcomes. Understanding these complications is essential for improving post-transplant care. Objective: To investigate the prevalence and nature of pulmonary complications in liver transplant recipients and to identify potential risk factors associated with these complications. Methods: This study was conducted at the Hepatobiliary and Liver Transplant Centre, Shaikh Zayed Hospital, Lahore, Pakistan, over a six-month period. A case series design with non-probability purposive sampling was employed. The sample size, determined using the WHO Sample Size Tool, was set at 100 participants, given logistical constraints. Data collection involved detailed postoperative assessments to identify pulmonary complications. The study included participants of all sexes and ages awaiting liver transplantation, excluding those undergoing a second transplant. Data analysis was performed using SPSS version 25. Results: Out of 100 liver transplant recipients, 98.5% (n=128) presented with stable vital signs at the time of data collection, while 1.5% (n=2) were unstable. Discharge planning indicated 68.5% (n=89) under observation and 23.1% (n=30) with routine planning. In terms of education, 59.2% (n=77) had 10 years of education, and 16.9% (n=22) were illiterate. Donor health status was excellent in 98.5% (n=128) of cases. Pulmonary complications included respiratory infections (23.8%, n=31), pleural effusion (36.2%, n=47), atelectasis (15.4%, n=20), bronchospasm (7.7%, n=10), and pneumonia (9.2%, n=12). Conclusion: The study highlights a significant incidence of pulmonary complications post-liver transplantation, with pleural effusion, respiratory infections, and atelectasis being the most common. These findings underscore the need for enhanced monitoring and proactive management of pulmonary complications in liver transplant recipients.

Addition of Kidney Dysfunction Type to MELD-Na for the Prediction of Survival in Cirrhotic Patients Awaiting Liver Transplantation in Comparison with MELD 3.0 with Albumin.

It is well known that renal dysfunction has a devastating effect on the prognosis of liver cirrhosis. In this study, the aim was to assess whether the incorporation of the kidney dysfunction type into the MELD-Na score enhances its predictive capacity for outcomes in patients awaiting liver transplantation (LT), compared to utilizing the MELD 3.0 score with albumin. In total, 2080 patients awaiting the LT were enrolled at two tertiary care institutions in Korea. Discrimination abilities were analyzed by using Harrell's c-index and iAUC values between MELD-Na-kidney dysfunction type (MELD-Na-KT) and MELD 3.0 with albumin. Clinical endpoints encompassed 3-month survival, 3-month transplant-free survival (TFS), overall survival (OS), and total TFS. Out of the total of 2080 individuals, 669 (32.16%) were male. Regarding the types of renal function impairment, 1614 (77.6%) were in the normal group, 112 (5.38%) in the AKD group, 320 (15.35%) in the CKD group, and 34 (1.63%) were in the AKD on CKD group. MELD 3.0 with albumin showed better discrimination (c-index = 0.714) compared to MELD-Na-KT (c-index = 0.708) in predicting 3-month survival. Similar results were observed for OS, 3-month TFS, and total TFS as well. When divided by sex, MELD 3.0 with albumin showed the comparable prediction of 3-month survival to MELD-Na-KT (c-index 0.675 vs. 0.671, p-value 0.221) in males. However, in the female group, MELD 3.0 with albumin demonstrated better results compared to MELD-Na-KT (c-index 0.733 vs. 0.723, p-value 0.001). The integration of kidney dysfunction types into the MELD-Na did not yield superior prognostic results compared to the MELD 3.0 score with albumin. Rather, in the female group, the MELD 3.0 score with albumin was better able to predict survival. These findings suggest that laboratory values pertaining to liver dysfunction or creatinine levels may be more significant than the type of kidney dysfunction when predicting the short-term prognosis of LT candidates.

Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities.

Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.

Tailoring allocation policies and improving access to paediatric liver transplantation over a 16-year period

Mortality on the paediatric liver transplantation (pLT) waiting list (WL) is still an issue. We analysed the Italian pLT WL to evaluate the intention-to-treat (ITT) success rate and to identify factors influencing success. All children (<18 years) listed for pLT in Italy between 2002-2018 were included (Era 1 [2002-2007]: centre-based allocation; Era 2 [2008-2014]: national allocation; Era 3 [2015-2018]: national allocation+mandatory-split policy). A total of 1,424 patients (median age: 2.0 [IQR 1.0-9.0] years; median weight: 12.0kg [IQR 7-27]) were listed for pLT. Median WL time was 2 days (IQR 1-5) for Status 1 and 44 days (IQR 15-120) for non-Status 1 patients; 1,302 children (91.4%) were transplanted (67.3% with split grafts), while 50 children (3.5%) dropped off the WL (2.5% death, 1.0% clinical deterioration). Predictive factors for receiving LT included Status 1 (hazard ratio [HR] 1.66, p= 0.001), Status 1B (HR 1.96, p= 0.016), Status 2A (HR 2.15, p= 0.024) and each 1-point increase in PELD/MELD score. Children with recipient's weight >25kg, blood group O or awaiting pLT combined with other organs had less chance of being transplanted. ITT patient survival rates were 90.5% at 1 year and 87.5% at 5 years, remaining stable across eras. Risk factors for ITT survival were re-transplantation (HR 5.83, p <0.001), Status 1 (HR 2.28, p= 0.006), Status 1B (HR 2.90, p= 0.014), Status 2A (HR 9.12, p <0.001), recipient weight <6kg (HR 4.53, p <0.001) and low-volume activity (HR 4.38, p= 0.001). In Italy, continuous adaption of paediatric organ allocation policies via the introduction of national allocation, paediatric prioritisation rules and a mandatory-split policy have helped maximise the use of donors for paediatric candidates and to minimise WL mortality without compromising outcomes. Globally, paediatric liver transplant candidates still suffer from high mortality. Over recent decades, the continuous adaption of organ allocation policies in Italy has led to excellent outcomes for children awaiting liver transplantation. The mortality rate of paediatric liver transplant candidates has been minimised to almost zero, mainly using grafts from deceased donors. Paediatric prioritisation rules, national organ exchange organisation and a mandatory-split liver policy have resulted in a unique allocation model for paediatric liver transplant candidates and represent a landmark for the paediatric transplant community.

Midodrine reduces new-onset acute kidney injury and hyponatremia in children with cirrhosis and ascites awaiting liver transplantation: Results from an open-label RCT.

Midodrine, an oral α-1-adrenergic receptor agonist, counters arterial hypovolemia and reduces complications in adult patients with cirrhosis. This randomized controlled trial (RCT) aimed to assess the efficacy and safety of midodrine in preventing complications and improving survival in children with cirrhosis and ascites who are awaiting liver transplantation (LT). This open-label RCT conducted from January 2022 to May 2023 included children under 18 years with cirrhosis and ascites. Patients were randomized to receive either midodrine plus standard medical therapies (SMTs) or SMT alone. The primary outcome measure was the incidence of cirrhosis-related complications within 6 months. Thirty-five subjects were enrolled and randomized. Patients in the midodrine arm had a lower incidence of new-onset acute kidney injury (AKI) compared with the SMT arm (11.1% vs. 41.2%). Patients in the midodrine arm showed a decline in serum creatinine and improvement in glomerular filtration rate, whereas no changes were observed in the SMT arm. There was a lower incidence of new-onset hyponatremia in the midodrine arm (20% vs. 56%). Midodrine led to reduction in plasma rennin activity (PRA) and improvement in systemic hemodynamics. There was no difference in the rate of resolution of ascites, recurrence of ascites, requirement of therapeutic paracentesis, cumulative albumin infusion requirement, episodes of spontaneous bacterial peritonitis, and hepatic encephalopathy between the two arms. Midodrine, when added to SMT, was effective in reducing the incidence of new-onset AKI and hyponatremia in pediatric cirrhotics awaiting LT. It also improved systemic hemodynamics and showed a trend towards reducing PRA.

Severe hepatic encephalopathy with mechanical ventilation may inform waitlist priority in acute liver failure: A UNOS database analysis.

Patients with acute liver failure (ALF) awaiting liver transplantation (LT) may develop multiorgan failure, but organ failure does not impact waitlist prioritization. The aim of this study was to examine the impact of organ failure on waitlist mortality risk and post LT outcomes in patients with ALF. We studied adults waitlisted for ALF in the United Network for Organ Sharing (UNOS) database (2002-2019). Organ failures were defined using a previously described Chronic Liver Failure modified sequential organ failure score assessment adapted to UNOS data. Regression analyses of the primary endpoints, 30-day waitlist mortality (Competing risk), and post-LT mortality (Cox-proportional hazards), were performed. Latent class analysis (LCA) was used to determine the organ failures most closely associated with 30-day waitlist mortality. About 3212 adults with ALF were waitlisted, for hepatotoxicity (41%), viral (12%) and unspecified (36%) etiologies. The median number of organ failures was three (interquartile range 1-3). Having ≥3 organ failures (vs. ≤2) was associated with a sub hazard ratio (HR) of 2.7 (95%CI 2.2-3.4)) and a HR of 1.5 (95%CI 1.1-2.5)) for waitlist and post-LT mortality, respectively. LCA identified neurologic and respiratory failure as most impactful on 30-day waitlist mortality. The odds ratios for both organ failures (vs. neither) were higher for mortality 4.5 (95% CI 3.4-5.9) and lower for delisting for spontaneous survival .5 (95%CI .4-.7) and LT .6 (95%CI .5-.7). Cumulative organ failure, especially neurologic and respiratory failure, significantly impacts waitlist and post-LT mortality in patients with ALF and may inform risk-prioritized allocation of organs.

INFUSE: Rationale and design of a multi-center, open label, collaborative study to treat HRS-AKI with continuous terlipressin infusion

BackgroundHepatorenal syndrome-acute kidney injury (HRS-AKI) carries significant morbidity and mortality among those with end-stage liver disease. Bolus terlipressin for treatment of HRS-AKI received FDA approval in September 2022. US implementation of terlipressin, however, is hindered by the paucity of local data on the optimal patient population and administration mode, as well as the effect on transplant priority. The INFUSE study is designed to evaluate the use of continuous terlipressin infusion among transplant candidates with advanced liver disease and HRS-AKI. MethodsFifty prospective patients with HRS-AKI will receive a single bolus of terlipressin 0.5 mg followed by continuous infusions of terlipressin from 2 to 8 mg/day for up to 14 days. The cohort will be enriched with those listed, in evaluation, or eligible for liver transplantation, while those with ACLF grade 3, MELD ≥35, and serum creatinine >5.0 mg/dL will be excluded. Fifty patients who received midodrine plus octreotide or norepinephrine for HRS-AKI will serve as a retrospective comparator cohort. ConclusionThe INFUSE study aims to assess the safety and efficacy of continuous terlipressin infusion among largely transplant-eligible patients with HRS-AKI, and to provide US-based data on transplant outcomes. This novel study design simultaneously mitigates terlipressin adverse events while providing renal benefits to patients, thus addressing the unmet medical need of those with HRS-AKI who have limited treatment options and are awaiting liver transplantation in the US.

Nonselective beta-blockers may lead to stage 2 acute kidney injury and waitlist mortality in child class C cirrhosis.

Nonselective beta-blockers (NSBB) protect patients with compensated cirrhosis; however, it is unclear if NSBB is associated with acute kidney injury (AKI) in patients with decompensated cirrhosis. We aimed to determine if the use of NSBB was associated with an increased risk of stage II AKI or greater and waitlist mortality (WLM) among patients with decompensated cirrhosis awaiting liver transplant stratified by cirrhosis severity. Included were 1816 outpatients listed for liver transplantation at UCSF from June 2012 to April 2022. Our primary outcome was stage 2 AKI (>200% increase in serum creatinine). Our secondary outcome was WLM (all-cause mortality). Our primary exposure was the use of any NSBB derived using natural language processing of clinical notes. Multivariable Cox proportional hazards models with time-dependent variables were used to determine the HR of NSBB use on stage 2 AKI and WLM, stratified by Child-Pugh Score. The average age of the cohort was 58 years old, with 35% identifying as female. In multivariable time-dependent models, NSBB use was associated with 1.53 × (95 CI 1.19-1.97) the hazard of stage 2 AKI in the cohort overall and 1.80 × (95 CI 1.26-2.57) among those with Child C cirrhosis, respectively. Similarly, NSBB use was associated with 1.30 × (95 CI 1.07-1.59) and 1.45 × (95 CI 1.03-2.03) the hazard of WLM, overall and in Child C, respectively. NSBB use was not significantly associated with AKI nor WLM among those with Child A. NSBB use is associated with Stage 2 AKI and WLM in patients awaiting liver transplantation and Child C cirrhosis. These data suggest cautious use of NSBBs in patients in this population.

MELD 3.0 in Advanced Chronic Liver Disease.

The MELD (model for end-stage liver disease) 3.0 score was developed to replace the MELD-Na score that is currently used to prioritize liver allocation for cirrhotic patients awaiting liver transplantation in the United States. The MELD 3.0 calculator includes new inputs from patient sex and serum albumin levels and has new weights for serum sodium, bilirubin, international normalized ratio, and creatinine levels. It is expected that use of MELD 3.0 scores will reduce overall waitlist mortality modestly and improve access for female liver transplant candidates. The utility of MELD 3.0 and PELDcre (pediatric end-stage liver disease, creatinine) scores for risk stratification in cirrhotic patients undergoing major abdominal surgery, placement of a transjugular intrahepatic portosystemic shunt, and other interventions requires further study. This article reviews the background of the MELD score and the rationale to create MELD 3.0 as well as potential implications of using this newer risk stratification tool in clinical practice.

Preexisting portal vein thrombosis and adult LDLT: A retrospective cohort analysis

BackgroundPortal Vein Thrombosis (PVT) is a common concern in cirrhotic patients awaiting liver transplantation (LT), with high morbidity and mortality rates. While preexisting PVT was traditionally considered a contraindication for the LT procedure, recent advances in surgical techniques have provided new possibilities for operating on these patients. This retrospective cohort study compared the surgical outcomes of adult living donor liver transplantation (LDLT) patients with and without preexisting PVT. MethodsThe study analyzed data from 416 liver transplant recipients and included 270 patients without PVT and 69 patients with PVT who underwent LDLT between March 2019 and March 2023. Preoperative imaging methods and intraoperative assessments were used to diagnose PVT and classify the extent of the thrombus using the Yerdel classification. Various surgical techniques were employed to remove the thrombus and establish a portal flow to the graft. Postoperatively, patients were monitored for complications and followed up regularly. ResultsThere were no significant differences between the non-PVT and PVT groups regarding recipient age, gender, body mass index, primary disease leading to transplantation, Child-Pugh class, or Model for End-Stage Liver Disease (MELD) score. The operative variables, including graft type, duration of surgery, and cold and warm ischemia times, were also similar between the groups. The surgical procedures varied based on the Yerdel classification grade of PVT, with most patients undergoing partial or complete thrombectomy. The mean hospital stays, intensive care unit (ICU) stay duration, and reexploration rates were comparable between the non-PVT and PVT groups. However, the incidence of portal vein thrombosis was significantly higher in the PVT group (p < 0.001). Other complications, such as portal vein stenosis and hepatic artery thrombosis, occurred in a small number of patients. ConclusionThis retrospective cohort analysis demonstrates the feasibility of performing LDLT in patients with preexisting PVT using various surgical techniques. While the overall surgical outcomes and postoperative complications were comparable between patients with and without PVT, the incidence of portal vein thrombosis was higher in the PVT group. Further studies are needed to explore optimal management strategies for PVT in LDLT patients and improve outcomes in this population.