Higher MELD Research Articles

Clinical, neuropsychological and neurophysiological indices and predictors of hepatic encephalopathy (HE)

Background & aims The occurrence of overt hepatic encephalopathy (HE) marks a significant progression in the natural history of liver disease. The aims of the present study were: 1) to describe a large cohort of patients with cirrhosis in terms of neuropsychological/neurophysiological HE indices, and 2) to test if the severity of liver disease and/or any such indices [Psychometric Hepatic Encephalopathy Score (PHES), Scan test, electroencephalography (EEG)] predicted mortality/HE risk in a subgroup of such cohort. Method 461 patients with cirrhosis (59±10 years; 345 males) were included; information on previous overt HE episodes was available in 407. Follow up information on mortality/HE-related hospitalization in 134/127, respectively. Information on previous overt HE episodes and both mortality and HE-related hospitalization over the follow up in 124. Results Patients with a history of overt HE (60%) had poorer liver function, worse neuropsychiatric indices, higher ammonia levels and higher prevalence of portal-systemic shunt. The risk of HE-related hospitalization over the follow up was higher in patients with higher MELD score and worse Scan performance. Mortality was higher in those with higher MELD. Amongst patients without a history of overt HE, those with worse PHES had higher HE risk. Amongst patients with a history, those with higher MELD, better PHES and worse Scan performance had higher HE risk. Conclusions In patients without previous overt HE episodes, neuropsychological and neurophysiological tests predict HE, while in those with previous overt HE episodes, HE development largely depends on the severity of liver dysfunction.

The impact of marijuana use on liver transplant recipients: A 900 patient single center experience.

Increased societal prevalence of marijuana continues to challenge liver transplant (LT) programs. This study aimed to examine the potential effects of marijuana use on outcomes. This retrospective study included recipients who underwent LT between 1/2012 and 6/2018. According to pre-LT marijuana use, patients were classified into recent (≤6months of LT), former (chronic use but not ≤6months), or non-users. Additionally, the impact of post-LT marijuana use on survival was assessed. Of 926 eligible patients, 184 were pre-LT marijuana users (42 recent; 142 former) (median follow-up: 30.3months). Pre-users were more likely to be male, White, and have histories of tobacco, alcohol, and illicit drug use. Additionally, recent users were of higher acuity, with higher MELD and requiring ICU admission. Patient survival at 1-year was 89% in non-users, 94% (HR: 0.494, 95% CI: 0.239-1.022 vs. non-users) in former users, and 83% (HR: 1.516, 95% CI: 0.701-3.282) in recent users. Post-operative complications in pre-LT users and the survival analysis for post-LT marijuana users vs. non-users did not show significance. Our results demonstrated that marijuana use did not have an adverse impact on post-LT outcomes; however, further studies utilizing larger cohorts are warranted.

A Danish population-based case series of patients with liver cirrhosis and coronavirus disease 2019

Objectives Coronavirus disease 2019 (COVID-19) is an ongoing major health emergency, but its occurrence and clinical impact on patients withliver cirrhosis is unknown. Therefore, we conducted a population-based study of 2.6 million Danish citizens investigating the occurrence and impact of COVID-19 in patients with liver cirrhosis. Materials and methods A prospective population-based cohort study was conducted in the Capital Region of Denmark and Region Zealand in the study period between 1 March 2020 up until 31 May 2020, with the only eligibility criteria being a reverse-transcriptase polymerase chain reaction for presence of viral genomic material confirming COVID-19. The patients were subsequently stratified according to presence of pre-existing liver cirrhosis. Results Among 575,935 individuals tested, 1713 patients had a diagnosis of cirrhosis. COVID-19 occurredsignificantly lessamongpatients with cirrhosis (n = 15; 0.9%, p < .01) compared with the population without cirrhosis (n = 10,593; 1.8%). However, a large proportion (n = 6;40.0%) required a COVID-19 related hospitalization which was correlated with higher values of alanine aminotransferase (p < .01) and lactate dehydrogenase (p = .04). In addition, one-in-three (n = 2; 13.3%) required intensive therapy. Four patients died (26.7%) and mortality was associated with higher MELD scores, co-existing type 2 diabetes, and bacterial superinfections. Conclusion In conclusion, patientswith cirrhosis may have a lower risk of COVID-19; but a higher risk of complications hereto and mortality.

Management of variceal bleeding in the liver transplant waiting list

Objective: to study the outcomes of main surgical methods for stopping and preventing variceal hemorrhage in waitlisted cirrhotic patients. Material and methods. In our prospective case-control study, the «case» cohort included 132 patients with cirrhosis complicated by recurrent varicose bleeding, while the «control» group consisted of 92 patients with one episode of bleeding esophageal varices. Treatment included conservative therapy, endoscopic ligation, transjugular intrahepatic portosystemic shunt, and the original azygoportal disconnection technique. Results. High MELD scores, severe hepatic encephalopathy, portal vein thrombosis, high degree of varices, and recurrent bleeding significantly affect the mortality of cirrhotic patients. Irrational use of nonselective beta-blocker monotherapy has a negative impact on treatment outcomes. Combined use of drug therapy and surgical methods of stopping and preventing varicose bleeding, reduces the number of relapses, prolongs patients’ life to two years or more, which allows to move on to the next stage of cirrhosis treatment – liver transplantation. Conclusion. The likelihood of recurrent variceal hemorrhage increases in patients who undergo passive surgical tactics. Azygoportal disconnection should be considered as the operation of choice if the patient has more than one episode of variceal bleeding. Timely and adequate treatment measures, clinical and diagnostic monitoring reduce waitlist mortality.

Clinical, neuropsychological and neurophysiological indices and predictors of hepatic encephalopathy (HE).

The occurrence of overt hepatic encephalopathy (HE) marks a significant progression in the natural history of liver disease. The aims of the present study were to: 1) describe a large cohort of patients with cirrhosis in terms of neuropsychological or neurophysiological HE indices, and 2) test if the severity of liver disease and/or any such indices [Psychometric Hepatic Encephalopathy Score (PHES), Scan test, electroencephalography (EEG)] predicted mortality/HE risk in a subgroup of such cohort. Four hundred and sixty-one patients with cirrhosis (59±10years; 345 males) were included; information on previous overt HE episodes was available in 407. Follow-up information on mortality/HE-related hospitalization in 134/127 respectively. Information on previous overt HE episodes and both mortality and HE-related hospitalization over the follow-up in 124. Patients with a history of overt HE (60%) had poorer liver function, worse neuropsychiatric indices, higher ammonia levels and higher prevalence of portal-systemic shunt. The risk of HE-related hospitalization over the follow-up was higher in patients with higher MELD score and worse Scan performance. Mortality was higher in those with higher MELD. Among patients without a history of overt HE, those with worse PHES had higher HE risk. Among patients with a history, those with higher MELD, better PHES and worse Scan performance had higher HE risk. In patients without previous overt HE episodes, neuropsychological and neurophysiological tests predict HE, while in those with previous overt HE episodes, HE development largely depends on the severity of liver dysfunction.

Comparison of results on the use of extended criteria liver doners for transplants in Espírito Santo.

liver Transplantation is currently the treatment of choice for several terminal liver diseases. Despite the increase in performed transplants, the waiting lists continue to increase. In order to expand the supply of organs, transplantation teams have started to use previously rejected livers for transplants because of an increased risk of unfavorable outcomes. to evaluate the use of livers of expanded criterion donators. retrospective study of medical records. The livers were classified as normal or expanded criteria. The groups were divided in low and high MELD. A multivariate analysis was performed through logistic regression. there was no statistical difference regarding early, late and global mortality between the groups. Decreased survival was observed in patients with high MELD (higher or equal to 20) when they received grafts from expanded criterion donators. The association between the occurrence of cardiorespiratory arrest and presence of elevated total bilirubin in donators was associated with higher mortality rates in expanded criterion livers. the overall results are similar, but expanded criteria liver donators was associated with higher mortality in patients with high MELD.

Comparison of Entropy vs. Bispectral Index Anesthetic Depth Monitoring during Isoflurane Anesthesia in Living Donor Liver Transplantation: Observational Study

Liver transplantation (LT) recipients are known to require less anesthetic agents. Providing minimally required anesthetics while avoiding awareness is especially important in LT recipients because it would help manage perioperative hemodynamic instability with less vasopressor and fast track recovery. This study aims to compare state entropy (SE) against bispectral index (BIS) during isoflurane anesthesia in LT. We adjusted anesthesia to BIS values 40 - 60, and compared it with concomitant SE values. BIS, SE values, and anesthetic requirements according to liver failure severity, etiology and LT stages were analyzed. For BIS-SE differences, SE value that is different from the concomitant BIS by more than 15 was defined as a significant disagreement. Mann Whitney, Kruskal Wallis test and a Poisson exact test were used for analysis. The BIS-SE pair sets of 2895 from 38 patients were analyzed. BIS, SE values and anesthetic requirements were significantly lower in MELD ≥ 20 (p < 0.001 in all) and in alcoholic etiology (p < 0.001 in all). For BIS-SE differences, 320 disagreement data pairs were seen at a rate of 1.33 times/hr (95% CI = [1.19, 1.48], p < 0.001). A significant disagreement was delineated in MELD score ≥ 20 (3.04 times/hr, CI = [2.64, 3.49], p < 0.001), alcoholic etiology (3.19 times/hr, [2.67, 3.78], p < 0.001) and postreperfusion stage (1.63 times/hr, [1.43, 1.85], p < 0.001). In these significant BIS-SE differences, 95.9% (307/320 disagreement data pairs) showed higher BIS than SE. In conclusion, in high MELD and alcoholic etiology, anesthetic requirements were significantly less, and BIS and SE showed great discrepancy with lower SE values. Therefore, when SE monitoring is used during LT, anesthesiologists may need to consider that in high MELD and alcoholic etiology, SE tends to show lower values than the concomitant BIS values that are within optimal anesthetic depth ranges.

Laparoscopic Cholecystectomy in Cirrhotic Patients: A Retrospective Study.

Introduction: Cirrhosis is a leading cause of morbidity and mortality around the world. Although cirrhotic patients are considered to have a higher risk for surgical procedures than non-cirrhotic ones, there are certain pathologies such as gallstones cholecystitis that cannot be treated otherwise. The focus of this study is to evaluate the main characteristics of the patients with lithiasic cholecystitis and liver cirrhosis and to assess if there is a correlation between them and postoperative morbidity evaluated with Dindo-Clavien classification. Material and Methods: This is a retrospective study. The database from General Surgery Department of Fundeni Clinical Institute was queried between 2014-2018 using as key words "cirrhosis" and "cholecystitis". The initial interrogation reveled 57 cases out of which 3 were excluded since other resections were associated. Results: This study identified that Dindo-Clavien classification positively correlates with the open approach (0.405, p=0.002), emergency surgery (0.599, p=0.000), acute cholecystitis (0.476, p=0.000), high MELD score (0.291, p=0.008) and Child score (0.346, p=0.007) and furthermore with high levels of total bilirubin (0.220, p=0.047), high INR (0.286, p=0.010), the presence of ascites (0.303, p=0.022) and portal hypertension (0.266, p=0.044). It also correlates negatively with the levels of hemoglobin (-0.295, p=0.044). Conclusion: Adequate estimation of perioperative mortality and morbidity is generally limited by the retrospective nature of most studies and the patient's selection criteria. Emergency surgery, acute cholecystitis and the open approach carry the highest risk for unfavorable results of cholecystectomy in cirrhotic patients.

1605. Differences in Clinical Characteristics of Third Generation Cephalosporin Resistance and Treatment Outcomes in Escherichia coli and Klebsiella pneumoniae Bacteremia in Patients with Liver Cirrhosis

BackgroundThis study aimed to identify characteristics of third-generation cephalosporin (3GC) resistance in Escherichia coli bateremia (ECB) and Klebsiella pneumoniae bacteremia (KPB) in patients with liver cirrhosis (LC), and to investigate the effects of appropriateness of empirical antibiotic treatment on outcomes.MethodsWe retrospectively collected demographic, clinical and microbiological information on all ECB and KPB episodes in LC patients ≥ 18 years of age hospitalized to a tertiary-care teaching hospital in South Korea from 2007 to 2018. Clinical characteristics associated with 3GC resistance and treatment failure were analyzed using a multivariate logistic regression model. Treatment failure was defined as persistent bacteremia for ≥ 7 days, or relapsed bacteremia ≤ 30 days, or all-cause mortality ≤ 30 days.Results3GC resistance rates of E. coli were 30.3% overall and increased significantly during the study period (P=0.001), while the rates of K. pneumoniae were not changed (24.3% overall) (P=0.994). Of total 356 ECB and KPB episodes, 112 were caused by 3GC resistant strains. The factor associated with 3GC resistance was isolation of 3GC resistant strain ≤ 1 year in both ECB (OR, 7.754; 95% CI, 2.094~28.716) and KPB (OR, 2.774; 1.318~5.838). In ECB, beta-lactam or fluoroquinolone treatment ≤ 30 days was another factor associated with 3GC resistance (OR, 2.774; 95% CI, 1.318~5.838), but not in KPB. The factor associated with treatment failure was high MELD score in both ECB (OR, 1.193 at 1 increase; 95% CI, 1.118~1.272) and KPB (OR, 1.163; 95% CI 1.083~1.250). Additionally, in ECB, non-alcoholic LC (OR 3.262; 95% CI 1.058~10.063), high Charlson Comorbidity Index (OR, 1.285; 95% CI 1.066~1.548), and inappropriate empirical antibiotic treatment (OR, 3.194; 95% CI 1.207~8.447) were associated with treatment failure.ConclusionDuring the study period, 3GC resistance increased in ECB, but not in KPB. In ECB, the severity of the underlying disease and the appropriateness of empirical antibiotics were associated with treatment failure, but there was no correlation in KPB. In ECB of LC patients, the appropriateness of empirical antibiotics was a factor associated with treatment outcome, and is the only correctable factor in the clinical setting.Disclosures All Authors: No reported disclosures

Non-selective beta-blockers increase overall and liver mortality in alcoholic cirrhosis with MELD≥12 over 5 years of follow-up.

Non-cardioselective beta-blocker (NSBB) effects on mortality in cirrhosis are controversial. We evaluated the impact of NSBBs on mortality according to liver severity and mortality cause. Two hundred and fifty-eight patients with alcoholic cirrhosis were included in a retroprospective cohort: 129 NSBB-treated and 129 controls. The NSBB group had the following significant baseline differences: higher MELD, more frequent previous gastrointestinal bleeding, large oesophageal varices (OV) and lower heart rate. Propranolol dose was 160mg/d in 81% of NSBB patients. (i) Liver function: during 5.3 ± 2.6 years of follow-up, MELD progression was higher in NSBB patients: 1 (-1-4) than in controls: 0 (-1-1) (P = .017). (ii) Overall survival: no significant differences were observed between NSBBs and controls (Kaplan-Meier curves: P=.291). In multivariate Cox analysis, baseline MELD interacted with NSBB (P=.011). Thus, the NSBB hazard ratio (HR) was 0.99 (0.50-1.98) in MELD<12 vs 3.17 (1.19-8.42) in MELD≥12. (iii) Liver survival: NSBB decreased liver survival (Kaplan-Meier: P=.031). In multivariate Cox analysis, baseline MELD interacted with NSBB (P<.001). The NSBB HR was 0.81 (0.30-2.19) in MELD<12 vs 6.23 (1.94-20.0) in MELD≥12. In competing risk multivariate analysis for liver mortality, the MELD-NSBB interaction was significant (P<.001): the NSBB HR was 1.02 (0.36-2.91) in MELD<12 vs 9.24 (3.18-26.9) in MELD≥12. 4) Non-liver survival: contrastingly, non-liver survival was increased by NSBBs, especially in MELD≥12 (competing Kaplan-Meier: P=.044). These results were confirmed in propensity risk score (PRS)-matched patients. In alcoholic cirrhosis with rather high propranolol doses, overall and liver survival are significantly aggravated when MELD is ≥12.

MELD Score Reflects the Mood, Sleep, and Daily Living Ability in Liver Transplantation Candidates: A Descriptive Study.

BackgroundThis study aimed to assess the psychosocial status (mood, sleep quality, and activities of daily living) of candidates on an orthotopic liver transplantation (OLT) waiting list and to identify the association between psychosocial factors and MELD score in end-stage liver disease (ESLD).Material/MethodsFifty-three OLT waiting list candidates completed 4 scales (Hamilton Rating Scale for Depression [HAMD-17], Hamilton Anxiety Rating Scale [HAM-A], Pittsburgh Sleep Quality Index [PSQI], Activities of Daily Living Scale [ADL]) to assess their affective status, sleep quality, and daily living ability. Candidates were divided into 2 groups, the high MELD score group (MELD score ≥15) and the low MELD score group (MELD score <15), and statistical analyses, including the Spearman test for correlation and the Mann-Whiney U-test, were conducted.ResultsThe high MELD group had significantly higher scores than the low MELD score group for HAM-A (P=0.024), PSQI (P=0.021), and ADL (P=0.000). In addition, the MELD score was positively correlated with HAMD-17 (r=0.362, P<0.01), HAM-A (r=0.430, P<0.01), PSQI (r=0.289, P<0.05), and ADL (r=0.585, P<0.01).ConclusionsMELD score could be a comprehensive indicator in OLT for more promptly detecting biopsychosocial problems derived from ESLD. It also provides a reference for both medical and psychosocial intervention before and after OLT.

Covert hepatic encephalopathy and spontaneous portosystemic shunts increase the risk of developing overt hepatic encephalopathy.

The aim of the study was to evaluate the presence of covert hepatic encephalopathy (cHE) and its characteristics according to the presence of spontaneous portosystemic shunts (SPSS) and their influence on the development of overt hepatic encephalopathy. Secondary analysis of a multicentre study, which evaluated the association between SPSS and complications of cirrhosis. The present study population includes those patients who also underwent cHE diagnostic evaluation. Presence of SPSS was evaluated by cross-sectional imaging and quantified by total SPSS-area. Logistic and Cox-regression competing risk analyses were performed. About 65 patients were included of age 58 (IQR 50-66), MELD 15 (IQR 10-20), with alcoholic liver disease 63%. Thirty-two patients (49%) had cHE, had higher MELD [16 (IQR 12-24) vs 13 (IQR 9-17), P=.027], a greater proportion of SPSS [n=18 (56%) vs n=8 (24%); P=.008] and a higher total cross-sectional SPSS-area [28.3 (0-94.2) vs 0 (0-14.1); P=.005]. On multivariate analysis MELD [OR 1.11 (95% CI 1.01-1.21)] and presence of SPSS [OR 3.95 (95% CI 1.22-12.80)] were independently associated to cHE at baseline. During follow-up cHE was an independent predictor of oHE [cHE: HR 6.93 (95% CI 2.64-18.20). The effect of cHE on the development of oHE was greater in patients with SPSS [only cHE: HR 5.66 (95% CI 1.82-17.62), cHE and SPSS: HR 8.63 (95% CI 3.15-23.65)]. cHE is independently associated to the presence of SPSS (and total cross-sectional SPSS-area) and MELD. Furthermore, the presence of SPSS seems to increase the risk of cHE of developing of overt hepatic encephalopathy.

WGO Guidance for the Care of Patients With COVID-19 and Liver Disease.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the least deadly but most infectious coronavirus strain transmitted from wild animals. It may affect many organ systems. Aim of the current guideline is to delineate the effects of SARS-CoV-2 on the liver. Asymptomatic aminotransferase elevations are common in coronavirus disease 2019 (COVID-19) disease. Its pathogenesis may be multifactorial. It may involve primary liver injury and indirect effects such as “bystander hepatitis,” myositis, toxic liver injury, hypoxia, and preexisting liver disease. Higher aminotransferase elevations, lower albumin, and platelets have been reported in severe compared with mild COVID-19. Despite the dominance of respiratory disease, acute on chronic liver disease/acute hepatic decompensation have been reported in patients with COVID-19 and preexisting liver disease, in particular cirrhosis. Metabolic dysfunction-associated fatty liver disease (MAFLD) has a higher risk of respiratory disease progression than those without MAFLD. Alcohol-associated liver disease may be severely affected by COVID-19—such patients frequently have comorbidities including metabolic syndrome and smoking-induced chronic lung disease. World Gastroenterology Organization (WGO) recommends that interventional procedures such as endoscopy and endoscopic retrograde cholangiopancreatography should be performed in emergency cases or when they are considered strictly necessary such as high risk varices or cholangitis. Hepatocellular cancer surveillance may be postponed by 2 to 3 months. A short delay in treatment initiation and non-surgical approaches should be considered. Liver transplantation should be restricted to patients with high MELD scores, acute liver failure and hepatocellular cancer within Milan criteria. Donors and recipients should be tested for SARS-CoV-2 and if found positive donors should be excluded and liver transplantation postponed until recovery from infection.

Definition, reasons, and risk factors for mortality of patients listedfor liver transplantation - a single-center study.

In Germany, following the principle "sickest first", patients awaiting liver transplantation (LTPL) are often transplanted with high MELD score and run the risk that they can no longer be transplanted, getting "too sick for transplant". In a retrospective single-center study, we analyzed the mortality of adult patients on the waiting list for LTPL during the years 2014 to 2017. To stratify risk factors, we compared characteristics of deceased and transplanted patients. The main reasons for mortality were sepsis (42.9 %), malignancy (24.3 %) and bleeding (10.0 %). Risk factors for mortality (OR, univariate logistic regression, p < 0.05) were acute on chronic liver failure (ACLF), loss of E-MELD, sepsis, pneumonia, proof of pathogens, candidemia, stay at ICU, multiple organ failure and mechanical ventilation. Multivariate analysis revealed pneumonia (p < 0.001) and high MELD (p = 0.031) as risk factors. Transplantation was more likely in patients with E-MELD. We suggest a Waiting List Mortality Index for Transplantation (WMIT), by dividing deceased patients to transplanted patients to assess mortality. Average WMIT in our cohort was 0.65. Mortality on the waiting list is mainly determined by pneumonia and infections in high-MELD patients. Therefore, patients with ACLF after infections should be prioritized for LTPL. A WMIT might suitably represent waiting list mortality.

Spectrum of hepatic encephalopathy admitted in a tertiary care center

Objectives: Few of the common symptoms for which cirrhotic patient seeks medical care are gastrointestinal bleed, abdominal distension (ascites), altered sensorium (hepatic encephalopathy [HE]), etc. This study was done to look at the spectrum of HE among cirrhotic patients admitted in a tertiary care center. Material and Methods: This hospital-based study was carried on 36 HE patients (with liver cirrhosis and age &gt;18 years) admitted in the department of gastroenterology of a tertiary care center, between April 2019 and November 2019. Results: Constipation and infections were the two most frequent precipitating factors identified. Majority patients (77.8%) belonged to CTP Class C. In-hospital mortality was observed in seven patients. The OR was significant for infections and in-hospital mortality (OR – 28.80 and P &lt; 0.05). A moderate positive correlation (Pearson’s correlation, r = 0.335) was seen between MELD score and in-hospital mortality among HE patients. Conclusion: A larger mass of HE patients belongs to CTP Class C. Constipation and infections are the two most common precipitating factors for HE. All HE patients who have concomitant infection and/or high MELD score should be managed on priority basis.

S0622 Upper Endoscopic Outcomes in High MELD Patients Undergoing Inpatient Transplant Evaluation

INTRODUCTION: Patients with cirrhosis have increased risks of bleeding related to portal hypertension (including esophageal varices, and portal hypertensive gastropathy), as well coagulopathy from hepatic dysfunction, thrombocytopenia, and impaired INR. There is limited data evaluating the upper endoscopy outcomes of interventions in patient with increased MELD scores, or those undergoing transplant evaluation. Our aims were to determine upper endoscopy outcomes of intra-procedure bleeding, post-procedure bleeding, and IR intervention in patients undergoing inpatient liver transplant evaluations at a single high-volume liver transplant center. METHODS: Retrospective review of patients who underwent inpatient liver transplant evaluation at a single high-volume center were evaluated between January 2017 and July 2019, with 235 patients identified. 62 of those required an inpatient upper endoscopy as a part of their transplant evaluation. Univariate analysis with Pearson Chi-squared or ANOVA was performed. Multivariate logistic model selection was performed using AIC. The final logistic model utilized MELD, INR, platelets, and banding to predict the probability of intra or post-procedure bleeding after endoscopies during urgent liver transplant evaluation. The model was tested using the Hosmer-Lemeshow goodness of fit test. A P-value of 0.05 was considered statistically significant. RESULTS: Of sixty-two patients who underwent upper endoscopy, 9 were noted to have intra-procedure or post-procedure bleeding. Of those 9 patients that bled, 6 were related to varices, and 1 patient required an interventional radiology procedure for hemostasis. While not statistically significant, 7 of the patients with procedure-related bleeding had underlying alcoholic cirrhosis (P = 0.089). Univariate MELD differences between the two groups were not significant (P = 0.40) with group means of 23.39 for the outcome group and 20.33 for the non-outcome group. On multivariate analysis (Table 1), a platelet count > 100 demonstrated a statistically significant 0.10 times decreased odds of bleeding (P = 0.035). MELD, INR, and banding were not significant on multivariate analysis. CONCLUSION: Based on our single center results, we have demonstrated that performing upper endoscopies in patients with a high MELD can be done safely. Those with a platelet count below 100 may have a slightly increased risk of bleeding based on multivariate analysis. A larger sample size is needed to evaluate these findings along with external validation.Table 1

Liver transplantation in Italy in the era of COVID 19: reorganizing critical care of recipients

Transplant programs have been severely disrupted by the COVID-19 pandemic. Italy was one of the first countries with the highest number of deaths in the world due to SARS-CoV-2. Here we propose a management model for the reorganization of liver transplant (LT) activities and policies in a local intensive care unit (ICU) assigned to liver transplantation affected by restrictions on mobility and availability of donors and recipients as well as health personnel and beds. We describe the solutions implemented to continue transplantation activities throughout a given pandemic: management of donors and recipients’ LT program, ICU rearrangement, healthcare personnel training and monitoring to minimize mortality rates of patients on the waiting list. Transplantation activities from February 22, 2020, the data of first known COVID-19 case in Italy’s Emilia Romagna region to June 30, 2020, were compared with the corresponding period in 2019. During the 2020 study period, 38 LTs were performed, whereas 41 were performed in 2019. Patients transplanted during the COVID-19 pandemic had higher MELD and MELD-Na scores, cold ischaemia times, and hospitalization rates (p < 0.05); accordingly, they spent fewer days on the waitlist and had a lower prevalence of hepatocellular carcinoma (p < 0.05). No differences were found in the provenance area, additional MELD scores, age of donors and recipients, BMI, re-transplant rates, and post-transplant mortality. No transplanted patients contracted COVID-19, although five healthcare workers did. Ultimately, our policy allowed us to continue the ICU’s operations by prioritizing patients hospitalized with higher MELD without any case of transplant infection due to COVID-19.

IMPACT OF THE BASELINE ANTI-A/B IGG TITER ON THE CLINICAL OUTCOME IN ABO-INCOMPATIBLE LIVER TRANSPLANTATION

Backgrounds: The use of ABO incompatible (ABOi) living donors is an attractive solution for expanding the liver donor pool. We investigated the impact of the baseline anti-A/B IgG titer on the transplant outcomes in ABOi liver transplantation (LT). Methods: We analyzed 394 adult patients who underwent living donor LT (303 ABO compatible LT and 91 ABOi LT) between 2012 and 2018. ABOi LT patients were categorized by baseline IgG titer: low IgG titer (≤ 1:64, n=51) versus high IgG titer (≥ 1:128, n=40). All ABOi LT patients received desensitization therapy including rituximab and plasmapheresis. Results: Patients with high IgG titer experienced antibody rebound (≥ 1:64) more frequently than those with low IgG titer during the first month after LT (35.0% vs. 15.7%, P=0.033). Patient survival rates for ABO compatible, low IgG titer, and high IgG titer were 85.0%, 91.5%, and 74.4%, respectively, at 3 years post-transplantation (P=0.006). High IgG titer (HR, 2.76; 95% CI, 1.39-5.48; P=0.004) and MELD score of >20 (HR, 2.32; 95% CI, 1.22-4.41; P=0.010) were independent risk factors for mortality. Infection was the leading causes of death in all groups, but the proportion was significantly higher in high IgG titer group than in other groups (81.8% vs. 30.8% vs. 33.3%). Conclusion: Patients with high IgG titer (≥ 1:128) are associated with a higher risk of death after ABOi LT than those with low IgG titer (≤ 1:64). Thus, ABOi LT patients with high IgG titer should be managed with great care.

Impact of hepatitis C treatment on long-term outcomes for patients with hepatocellular carcinoma: a United States Safety Net Collaborative Study

BackgroundWidespread HCV treatment for hepatocellular carcinoma (HCC) patients remains limited. Our aim was to evaluate the association of HCV treatment with survival and assess barriers to treatment. MethodsPatients in the U.S. Safety Net Collaborative with HCV and HCC were included. Primary outcome was overall survival (OS). Secondary outcomes were recurrence-free survival (RFS) and barriers to receiving HCV treatment. ResultsOf 941 patients, 57% received care at tertiary referral centers (n=533), 74% did not receive HCV treatment (n=696), 6% underwent resection (n=54), 17% liver transplant (n=163), 50% liver-directed therapy (n=473), and 7% chemotherapy (n=60).HCV treatment was associated with improved OS compared to no HCV treatment (70 vs 21 months, p<0.01), persisting across clinical stages, HCC treatment modalities, and treatment facilities (all p<0.01). Surgical patients who received HCV treatment had improved RFS compared to those who did not (91 vs 80 months, p=0.03). On MVA, HCV treated patients had improved OS and RFS.On MVA, factors associated with failure to receive HCV treatment included Black race, higher MELD, and advanced clinical stage (all p<0.05). ConclusionHCV treatment for HCC patients portends improved survival, regardless of clinical stage, HCC treatment, or facility type. Efforts must address barriers to HCV treatment.

Inflammation-Based Prognostic Scores in Patients with Hepatitis B Virus-Related Hepatocellular Carcinoma After Liver Transplantation.

BackgroundInflammation-based prognostic scores including systemic immune-inflammation index (SII), platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) have prognostic value in various cancers. We investigated the prognostic value of SII, PLR and NLR in patients who underwent liver transplantation (LT) for HBV-related hepatocellular carcinoma (HCC).MethodsWe retrospectively analyzed the records of 189 patients who underwent LT for HBV-related HCC. The receiver operating characteristic (ROC) curve was used to determine the optimal SII, PLR and NLR cut-off value. Overall survival (OS) and recurrence-free survival (RFS) following LT were calculated. The Kaplan–Meier method and the Cox proportional hazards model were used to evaluate the prognostic value of SII, PLR and NLR.ResultsThe 1-, 3-, and 5-year OS rates were significantly lower in the high SII group (74.1%, 34.2%, and 32.3%, respectively) than in the low SII group (78.5%, 66.9%, and 59.9%, respectively; p = 0.000). The 1-, 3-, and 5-year RFS rates were, respectively, 75.9%, 59.7%, and 49.4% in the high SII group and 93.3%, 80.2%, and 73.7% in the low SII group (p = 0.000). Finally, OS curves were plotted by the Kaplan–Meier method and compared using the Log rank test. High PLR and NLR scores were also associated with poor OS (p = 0.000 and p = 0.003) and poor RFS (p = 0.000 and p = 0.000). The multivariate analysis demonstrated that AFP ≥400 ng/mL, high MELD score, largest tumor size ≥5cm, SII ≥449.61, NLR ≥5.29, and PLR ≥98.52 were independent prognostic factors for OS.ConclusionHigh SII, PLR and NLR are significantly poor prognostic factors for overall survival and recurrence-free survival in patients with HBV-related hepatocellular carcinoma after liver transplantation.