List For Liver Transplantation Research Articles

Liver transplantation for bile duct injury after open and laparoscopic cholecystectomy

BackgroundBile duct injury (BDI) after cholecystectomy is a serious complication. In a small subset of patients with BDI, failure of surgical or non-surgical management might lead to acute or chronic liver failure. The aim of this study was to review the indications and outcome of liver transplantation (LT) for BDI after open and laparoscopic cholecystectomy.MethodsPatients with BDI after cholecystectomy who were on the waiting list for LT between January 1987 and December 2010 were identified from LT centres in Spain. A standardized questionnaire was sent to each unit for extraction of data on diagnosis, previous treatments, indication and outcome of LT for BDI.ResultsSome 27 patients with BDI after cholecystectomy in whom surgical and non-surgical management for BDI failed were scheduled for LT over the 24-year interval. Emergency LT for acute liver failure was indicated in seven patients, all after laparoscopic cholecystectomy. Two patients died while on the waiting list and only one patient survived more than 30 days after LT. Elective LT for secondary biliary cirrhosis after a failed hepaticojejunostomy was performed in 13 patients after open and seven after laparoscopic cholecystectomy. One patient from the elective transplantation group died within 30 days of LT. The estimated 5-year overall survival rate was 68 per cent.ConclusionEmergency LT for acute liver failure was more common in patients with BDI after laparoscopic cholecystectomy, and associated with a poor outcome.

Index of Suspicion

Index of Suspicion

A seleção de pacientes utilizando-se o critério meld melhora a sobrevida a curto prazo dos pacientes submetidos ao transplante de fígado?

The Model for End-Stage Liver Disease (MELD) score introduced in 2002 has come to improve selection of patients dying in the liver transplantation waiting list. To evaluate the short-term survival in liver transplantation around the world when MELD score was applied as selection criteria. METHODS - A review has been done at the online database PubMed/ Medline/Scielo. The expressions applied for the search were "liver transplantation and/or MELD and/or survival analysis" from 2002 to 2009. Among the 124 analyzed articles, 94 were excluded due to irrelevance of the subject and lack of information. Were considered L1, L2A and MELD>20 the sickest patient; L2B, L3 and MELD< 20 the healthiest. Was compiled the data of transplanted patients, their one-year survival rate related to MELD score and compare it with pre-MELD era. MELD score has been applied, mainly in America and Europe patients, range from 8.4 to 30. One-year survival ranged from 66.5 to 92%. Analysis of patient survival rate significance between the pre-MELD and post-MELD era showed: Group I (L1 and L2A) x Group III (MELD>20), significant (p<0,0001); Group II (L2B and L3) x Group IV(MELD<20), not significant. Also, comparative one-year survival by country in the MELD era was search. The MELD score have significantly improved short-term survival for the sickest patient on the waiting list for liver transplantation; additionally, it does not have any significant impact in survival for the healthiest patient.

Primary Surgical Resection Versus Liver Transplantation for Transplant-Eligible Hepatocellular Carcinoma Patients

Hepatocellular carcinoma (HCC) is a leading cause of mortality worldwide. Existing studies comparing outcomes after liver transplantation (LT) versus surgical resection among transplant-eligible patients are conflicting. The purpose of this study was to compare long-term survival between consecutive transplant-eligible HCC patients treated with resection versus LT. The present retrospective matched case cohort study compares long-term survival outcomes between consecutive transplant-eligible HCC patients treated with resection versus LT using intention-to-treat (ITT) and as-treated models. Resection patients were matched to LT patients by age, sex, and etiology of HCC in a 1:2 ratio. The study included 171 patients (57 resection and 114 LT). Resection patients had greater post-treatment tumor recurrence (43.9 vs. 12.9 %, p < 0.001) compared to LT patients. In the as-treated model of the pre-model for end stage liver disease (MELD) era, LT patients had significantly better 5-year survival compared to resection patients (100 vs. 69.5 %, p = 0.04), but no difference was seen in the ITT model. In the multivariate Cox proportional hazards model, inclusive of age, sex, ethnicity, tumor stage, and MELD era (pre-MELD vs. post-MELD), treatment with resection was an independent predictor of poorer survival (HR 2.72; 95 % CI, 1.08-6.86). Transplant-eligible HCC patients who received LT had significantly better survival than those treated with resection, suggesting that patients who can successfully remain on LT listing and actually undergo LT have better outcomes.

Very low calorie ketogenic weight reduction diet in patients with cirrhosis: a case series

Weight reduction may be necessary in patients with end-stage liver disease (ESLD) before liver transplantation. Although very low calorie diets (VLCDs) are a highly effective weight loss strategy, they risk inducing protein-calorie malnutrition, sarcopenia and hepatic encephalopathy in ESLD patients. We report for the first time on the use of VCLDs in ESLD. Two severely obese individuals with ESLD underwent a modified VLCD to become eligible for liver transplantation. Patients consumed four protein supplements and one lean meal daily, equivalent to 800 kilocalories (kcal) and were closely monitored during the diet period. Subject 1, a 46-year-old male with alcoholic cirrhosis, lost 44.1 kg after 28 weeks on a modified VLCD. Liver function and MELD (model for end-stage liver disease) scores improved and he currently does not require listing for transplantation. Subject 2, a 64-year-old female with non-alcoholic steatohepatitis, lost 39.7 kg after a 30-week modified VLCD. She is awaiting liver transplantation listing with a stable MELD score. VLCDs were well tolerated by both patients without adverse effects. In conclusion, under close medical supervision VLCDs in patients with ESLD can be safe and effective in reducing weight, facilitating liver transplantation listing, and possibly improving liver damage.

Hyper- and hypometabolism are not related to nutritional status of patients on the waiting list for liver transplantation

Metabolic disorders and malnutrition are well known conditions reported in patients with liver disease (LD), but the relationship between them are underexplored. So, the aim of this study was to assess the resting energy expenditure (REE) of these patients, identifying the prevalence of hyper- and hypometabolism. In addition, to evaluate whether malnutrition and clinical variables were associated with REE and metabolic disorders. The REE was measured by indirect calorimetry and predicted by the Harris and Benedict formula (REEHB). Nutritional status was assessed by different methods. The etiology, severity and complications of LD were also evaluated. A total of 81 patients were assessed. The measured REE was 1587.5 ± 426.6 kcal. The REE was overestimated by the REEHB (REE:REEHB <0.8) in 7.4% and underestimated (REE:REEHB >1.2) in 24.7% of the patients. The REE was lower in malnourished patients (p < 0.05). However, hyper- and hypometabolism were not associated with nutritional status (p > 0.05). The REE and hypermetabolism were not associated with LD, but hypometabolic patients had a higher prevalence of Child C, and had higher values for MELD, INR and total bilirubin (p < 0.05). After multiple regression analyses, the REE was significantly associated (p < 0.05) with intracellular body water, arm muscle area and serum glucose. Serum glucose was only significantly associated (p < 0.05) with hypermetabolism, and INR with hypometabolism. Changes in resting metabolism are present but not universal. The hypermetabolism was associated with extrahepatic factors, and hypometabolism with the severity of LD. Under these conditions in the clinical setting, calculated energy requirements using the HB formula should be adjusted.

Negative energy balance secondary to inadequate dietary intake of patients on the waiting list for liver transplantation

ObjectivesThe aim of this study was to evaluate the energy balance (EB) of patients on the waiting list for liver transplantation, using total energy expenditure (TEE) assessment and total caloric intake (TCI). MethodsWe analyzed nutrient adequacy and factors associated with it. EB was obtained by subtracting the TCI (obtained by 3-d food record) from TEE, which was measured as resting energy expenditure and physical activity factor calculation. Socioeconomic and clinical data also were evaluated. Univariate and multiple linear regressions were used (P < 0.05). Seventy-three patients were included. ResultsThe TEE was 2318.5 kcal, and the TCI was 1485.1 kcal, with 81.6% of patients presenting with negative EB. There was no significant association between TCI and socioeconomic variables, medications, and encephalopathy (P > 0.05). Women, less-educated patients, those with ascites, and those who were malnourished presented with lower TCI (P < 0.05). Severity of disease, by Child-Pugh and Model for End-Stage Liver Disease scores were associated with EB (P < 0.05). Child-Pugh remained significant after multivariate analyses. Energy inadequacy was observed in 91.8% of patients, and protein inadequacy in 72.6% of patients. Polyunsaturated fatty acid (64.4%) and monounsaturated fatty acid (91.8%) and fiber (94.5%) inadequacies also were high. The percentage of adequate intake was less than 10% for vitamins B5 and D, calcium, folic acid, and potassium, and higher percentages of adequate intake (>80%) were found for iron and vitamins B1 and B12. Moreover, 54.8% and 16.4% of the patients had excessive sodium and cholesterol intakes, respectively. ConclusionNegative EB was highly prevalent among patients on the waiting list for liver transplantation, and was associated with the severity of liver disease. Negative EB was primarily affected by low food intake. The food intake data were characterized by low overall energy and protein intake and inadequate composition of the patient’s diet plan, which tended to be characterized by specific nutrient deficiencies and excesses.

Construcción de un cuestionario para evaluar los conocimientos de los pacientes en lista de espera de trasplante hepático: estudio piloto

To evaluate the suitability of a questionnaire designed to assess the knowledge of patients on the waiting list for liver transplantation, through a pilot study. A descriptive study of the construction of a knowledge questionnaire for patients on the waiting list for liver transplantation. This study was developed in the liver pre-transplant clinic of the Hospital Clinic of Barcelona from October 2011 to April 2012. An initial questionnaire was designed. This draft was improved following the recommendations of experts in liver transplantation, and after the completion of a preliminary test. The questionnaire obtained was applied to 25 patients in the pilot study. The quality of the questions was measured using the discrimination index and the index of attraction. The construct was assessed by principal component analysis and factor analysis. The questionnaire consisted of 36 items (questions). Of these, 31 are independent. The discrimination index identified only 4 questions with a good (desired information ai=.30) and very good (list exclusion ai=.40, list and time on list ai=.58) level of discrimination. The remaining questions had a poor or insufficient level of discrimination (ai<29). The principal component analysis and factor analysis indicated that the questions related to the disease (10) and the waiting list (4) were essential in the questionnaire, and the questions related to demographic data (7) and the therapeutic regimen (8) should be eliminated. The questionnaire obtained needs to be modified to assess the knowledge of patients on waiting list for liver transplantation.

Patients With Cirrhosis and Denied Liver Transplants Rarely Receive Adequate Palliative Care or Appropriate Management

Patients with cirrhosis who are receiving palliative care and are not eligible for liver transplantation (LT) are often hospitalized multiple times, with lack of expectations or understanding of death and dying. We evaluated how frequently these patients received appropriate and palliative care. We performed a retrospective study of 102 consecutive adult patients (67% men; mean age, 55 years) who were removed from the list for or declined LT from January 2005 through December 2010 at the University of Alberta, Canada. Patients' medical records were reviewed to determine their access to palliative care and relief of symptoms, the appropriateness of the goals for their care, and their requirements for acute care services. The patients' median Model for End-stage Liver Disease score was 20, and median time from denial of LT to death was 52 days (range, 10-332 days). The most common reasons that patients were removed from the transplant wait list were noncompliance or substance abuse (26%) and severe illness or organ dysfunction (25%). After patients were removed from the list, 17% received renal replacement therapy, and 48% were subsequently admitted to the intensive care unit. Patients spent a median of 14 days (range, 6-33 days) in the hospital after they were removed from the transplant wait list. On the basis of the Edmonton Symptom Assessment System, 65% of patients had evidence of pain, 58% had evidence of nausea, 10% had depression, 36% had anxiety, 48% had dyspnea, and 49% had symptoms of anorexia. Twenty-eight percent of all the patients had documentation of do not resuscitate status on their charts, and only 11% were referred for palliative care. Patients with cirrhosis who have been removed from the wait list for LT are infrequently referred for palliative care (∼ 10% of cases), although a high percentage have pain or nausea. Goals of care and do not resuscitate status are rarely discussed. Improved planning of goals of care and access to palliative services are required for these patients.

Prognostic Marker for Liver Disease due to Alpha1-Antitrypsin Deficiency

Only some Alpha1-antitrypsin deficiency (A1ATD) PiZZ patients develop liver cirrhosis and portal hypertension. Aim of the study was to investigate the course of liver disease associated with PiZZ A1ATD and to determine prognostic factors. We retrospectively reviewed the clinical and laboratory data of all PiZZ children up to 18 years of age admitted to our centre since 1978. 53 patients (age at first visit 2 days to 12 years) met our criteria. The children were divided into 2 groups: group 1 'bad prognosis', meaning the patients which were on the waiting list for liver transplantation (LTx), had a liver transplantation or had died, and group 2 'good prognosis', containing the patients they were living with their own liver. We analysed family history including smoking, gestational age, maternal age at delivery, date of birth, sex, neonatal history, breast-feeding, symptoms at presentation, clinical and laboratory data and date of LTx and/or death. Various anamnesis parameters such as manifestation of neonatal cholestasis showed no prognostic significance. In contrast the laboratory parameters thrombocytes (p=0.008), bilirubin (p<0.001), prothrombin time (p<0.001), choline-sterase (p<0.001), gamma-GT (p=0.001) and GOT (p=0.002) showed a correlation with a liver transplantation and/or death. Prognosis is difficult to determine at an early stage of this disease, but various laboratory parameters can help to predict an outcome. Therefore a regular follow-up is necessary for the children.

Organ donation following brain stem death after ventricular assist device implantation

The availability of donor organs is the biggest limitation for lung transplantation, and a significant proportion of patients die on the waiting list. We describe a case of a 44-year-old lady who developed subarachnoid hemorrhage and cerebral edema on second postoperative day after left ventricular assist device implantation. She was declared brain stem dead 2 days later, and her organs were transplanted to suitable recipients on the waiting list for lung, liver and kidney transplantation.

Clinical predictors of primary cardiopathies in liver transplantation candidates

Purpose: Up to 50% of deaths in the perioperative period of liver transplantation are attributed to cardiovascular events. The existence of cardiovascular disease increases the perioperative risk and mortality in the first month post-transplant. There is no specific score validated for preoperative liver transplantation evaluation, nor clinical predictors that identify those patients who need thorough assessment and care. The aim of this study is to identify predictors of the presence of heart disease among patients evaluated for liver transplantation. Methods: 453 outpatients consecutively evaluated in the waiting list for liver transplantation underwent a cardiological assessment protocol that included: history and physical examination, estimation of functional capacity, electrocardiography, chest radiography and echocardiography. Myocardial perfusion scintigraphy, dobutamine stress echocardiography or coronary angiography were performed in patients with moderated or high likelihood of coronary disease. The severity of cirrhosis was estimated by MELD score (Model for End-Stage Liver Disease), which is calculated from laboratory tests (prothrombin time, bilirubin and creatinine). Statistical analysis: Continuous variables were presented as mean and standard deviation or median. Categorical variables were presented as proportions and/or percentages. Continuous variables were compared with the Mann-Whitney test and categorical variables with the chi-square test. The p value <0.05 was considered statistically significant. To find predictors of heart disease, we used simple linear regression and multiple regression. We used the statistical package SPSS 18.0. Results: 60 (13.2%) patients were diagnosed with heart disease. In the population with cardiovascular disease, 6.6% had coronary artery disease, 5.0% valvular heart disease, 4.0% heart failure with systolic dysfunction and 1.0% sustained arrhythmias. High blood pressure (HBP), chronic kidney disease (CKD) and poor functional capacity (FC) were more common in patients with heart disease (P <0.05). In simple linear regression, the following parameters were predictors of cardiopathy: HBP: odds ratio (OR)=3.05 (confidence interval (CI)=1.4 to 4.4) p = 0.002; CKD: OR=3.05 (CI=1.27 - 7.32) p = 0.01; MELD score ≥ 24: OR = 3.2 (CI 1.08 to 10.0) p = 0.03. In multiple logistic regression, only HBP (OR = 4.0) and MELD score≥ 24 (OR = 3.9) remained as predictors of heart disease. Conclusion: High blood pressure and severe liver disease with MELD score ≥ 24 are predictors of the presence of heart disease in patients evaluated for liver transplantation.

Significance of incorporation of model for end-stage liver disease score with TNM staging in patients with hepatocellular carcinoma undergoing hepatic resection.

Currently, the tumor-node-metastasis (TNM) system is used in hepatectomy patients for tumor staging of HCC patients. However this can only evaluate the histopathological factor. MELD score is an objective measure for liver function widely used as a severity index for priority on the waiting list for liver transplantation. Here we suggest a modified TNM staging system based on the MELD score and test its relation with post-operative outcome of HCC. We retrospectively collected 922 HCC patients undergoing hepatic resection, with TNM stage I (n=239), stage II (n=375) and stage III (n=308); giving points 0 to 2 for each stage (from I to III). Pre-operative MELD score was calculated and assigned 0 points for MELD <6; 1 for 6-8; 2 for >8. The two scores were added together to form a modified MELD-base TNM stage score and tested the correlation of this new scoring system with outcome after liver resection. The modified MELD-base TNM stage score resulted in score 0 (n=114), score 1 (n=247), score 2 (n=335), score 3 (n=164), and score 4 (n=62). The disease-free survival in each group showed significant difference (p<0.05), the lower the score, the better the outcome. The MELD-based TNM staging system reliably separates patients with HCC into homogeneous groups with respect to post-resectional prognosis. Further prospective validation studies are required to confirm the feasibility of this strategy.

Consequences of the Implementation of the Model for End-stage Liver Disease System for Liver Allocation in Brazil

BackgroundIn July 2006, the system for liver allocation in Brazil started to rely on the Model for End-stage Liver Disease (MELD) scale, replacing the previous chronological criteria. Under the new system, the score for listing pediatric patients is obtained by multiplication of the calculated PELD score by 3. The current criteria also features extra points for diseases such as hepatocellular carcinoma (HCC). This study sought to analyze the consequences of implementation of the MELD system on waiting list mortality, posttransplant survival rates and characteristics of the transplanted patients. MethodsWe retrospectively studied data from the State Health Secretariat of São Paulo, regarding all patients registered on the waiting list for liver transplantation in the State of São Paulo, in two periods: July 2005 to July 2006 (pre-MELD era) and July 2006 to July 2010 (MELD era). Patient survival rates calculated using the Kaplan-Meier method were compared by the log-rank test. P values <.05 were considered statistically relevant. ResultsAfter implementation of the MELD, waiting list registrations decreased by 39.8%; the percentage of transplants in HCC recipients increased from 2.4% to 23.7%; pediatric transplants increased from 6.5% to 9.3%; deaths on the list fell from 599 in the pre-MELD era to 359 in the last year analyzed; recipients with higher MELD displayed significantly lower posttransplant survival rates; HCC patients, better survival after transplantation (P = .002); No difference was observed comparing survival rates between pre-MELD and MELD eras (P = 474) or between adults and children (P = .867). ConclusionUnder the MELD system for liver allocation in Brazil, there was a reduction in waiting list mortality and an increased number of transplantations in pediatric and HCC recipients. Survival rates of patients with higher MELD score were inferior. However, this result was offset by the greater survival in HCC recipients, with no difference in patient survival rates between the pre-MELD and MELD eras.

Prevalence of high-risk human papilloma virus among women with hepatitis C virus before liver transplantation.

We sought to assess the prevalence and risk factors for high-risk human papillomavirus (HPV) infection among female liver transplant (LT) candidates. Traditional health screening before LT listing has included Pap smear and is typically carried out by the patient's local provider. The prevalence of high-risk HPV in this population has not been studied. With Institutional Review Board approval, 62 LT candidates received a liquid-based Pap smear with high-risk HPV testing as part of their pre-transplant evaluation by a single provider. Clinical variables included age, ethnicity, insurance status, prior Pap smear, and HPV results, HPV risk factors including age of first intercourse, number of lifetime partners, last sexual activity, smoking, birth control pill use, history of sexually transmitted infections, human immunodeficiency virus status, immunosuppressive medication, medical diagnoses, prescribed medications, and history of hepatitis A, B, C, or D. The 62 women had a median age of 56 years, and 39% had high-risk behavior known to be associated with HPV. Ten of 62 patients (16.1%) had high-risk HPV at baseline screening, 5 of whom had atypical cytology. All of the patients who were positive for high-risk HPV had an etiology of hepatitis C virus (HCV) as the underlying cause of liver disease, with the majority (90%) having no history of high-risk behavior for HPV. In contrast, all patients with high-risk behavior who were HCV negative were HPV negative. Fisher's exact test demonstrated a statistically significant relationship between HPV and HCV; odds ratio = 24.4, 95% confidence interval, 1.4, 438.7, P-value = 0.0013. None of the other potential risk factors were associated with HPV in this cohort. In this study, we provide evidence of a strong association between HCV and HPV in LT candidates, which has not been previously reported. HPV positivity was observed in non-sexually active women, suggesting a reactivation of dormant HPV. An association between hepatitis C and high-risk HPV could involve impairment of T-cell function by hepatitis C. These data support close surveillance in women's health screening for LT candidates. Further studies to characterize immune responses in these patients will be in order.

Impact of MELD score implementation on liver allocation: experience at a Brazilian center

Introduction. Model for end-stage liver disease (MELD) is an accurate predictor of mortality in patients with cirrhosis, and has been used on liver allocation in Brazil since 2006. However, its impact on organ allocation, waiting list and post-transplant mortality is still poorly characterized. This study aimed to assess the impact of implementation of the MELD system on liver allocation and mortality after liver transplantation (LT) in Southern Brazil.Material and methods. Adult patients with chronic liver disease on the waiting list for primary deceased-donor LT were divided into two cohorts (pre- and post-MELD implementation) according to the date of waiting list placement. Disease severity, as assessed by MELD score at placement, was similar in both cohorts. Patients were followed for at least 18 months to assess the outcomes of interest (death/LT).Results. Higher MELD scores correlated with waiting list mortality, which increased 20% with each additional point (HR 1.2; 95%CI 1.14–2.26; p < 0.001). Waiting list mortality was 30.9% before and 21.7% after MELD implementation (nonsignificant). Transplant rate increased after MELD implementation (52 vs. 40%, p = 0.002). After excluding patients with hepatocellular carcinoma, mean MELD scores at LT were significantly higher in the MELD era (p < 0.01). There was no significant correlation between MELD scores at LT and post-LT survival. During 18-month follow-up, post-LT mortality rate was 25.4% before and 20% after MELD implementation (nonsignificant).Conclusion. MELD implementation was associated with a reduction in waiting list mortality. Although sicker patients received LT in the MELD era, post-transplant survival was similar in both periods.

Predictors of mortality in patients on the waiting list for liver transplantation.

The demand for liver transplantation (LTx) increases every year, which is in contrast to the stagnation in the number of donors. This phenomenon has given rise to longer waiting times, which results in higher pre-transplantation mortality. Thus, our aim for this study was to identify risk factors, including nutritional variables, for mortality for patients who are on the waiting list for LTx. Patients on the waiting list were assessed to identify risk factors for mortality. Data related to demographic, socioeconomic, and etiologic factors, liver disease severity, complications, medications, and biochemical tests related to disease, nutritional status, diet intake, and physical activity were collected. There were 159 patients followed, and 47.8% (76) were transplanted. The mortality rate while on the waiting list was 25.7% patient-years, and 40 patients died (28.0%). Variables associated with mortality during this period (p < 0.05) were the following: severe malnutrition (OR 2.5/CI: 1.2-5.3), low serum sodium values (OR: 1.1/CI: 1.01-1.2), and cryptogenic cirrhosis (OR: 2.2/CI: 1.1-4.6). Special attention should be given to patients with low serum sodium, those who are diagnosed with cryptogenic cirrhosis and the severely malnourished. An early diagnosis of malnutrition and an appropriate nutritional intervention is mandatory in such patients.

613 Hepatitis C Virus (HCV) Diagnosis and Clinical Outcomes of Patients With HCV-Related Hepatocellular Carcinoma (HCC): A Comparative Study of Asians Versus Non-Asians

BACKGROUND AND AIMS: In addition to hepatitis B virus, HCV is also an important cause of HCC in Asians; however, it is often overlooked. This study aims to examine baseline characteristics, timing of HCV diagnosis and long-term survival of HCV-related HCC in Asians compared to non-Asian patients. METHODS: We conducted a retrospective cohort study of 798 consecutive Asian (n=220) and non-Asian (n=572) patients with HCV-related HCC who were identified via computer query using ICD-9 diagnosis at a U.S. university medical center between 7/1996 and 6/2012. Individual records were reviewed. RESULTS: Asians were much older (66 [38-88] vs. 56 [31-87] years, P ,0.0001) and more likely to be female (33% vs. 19%, P,0.0001). A significantly larger proportion of Asians were also diagnosed with HCC within only 2 years of HCV diagnosis compared to non-Asians (35% vs. 20%, p=0.001). Non-Asians were more likely to have decompensated liver disease and had higher median Child-Turcotte-Pugh score (6 [5-11] vs. 7 [5-13], P ,0.0001). Asian patients were more likely to undergo liver-directed palliative therapy (46% vs. 28%) and much less likely to be listed for liver transplantation(20% vs. 48%) (P ,0.001), despite similar rates of meeting Milan criteria for liver transplantation (52 vs.58%, P=0.16). Overall, there was a trend for higher median survival rates in Asians compared to non-Asians (30 vs. 21 months, P=0.091). Among those who were listed for liver transplantation, there was no statistically significant difference in survival between Asians and non-Asians in the first 2 years (72% vs. 68%) but there was divergence with Asians having higher survival afterwards (61% vs. 51%) (Figure 1). However, among those undergoing liver-directed palliative therapy, Asians had significantly higher long-term survival compared to non-Asians (5-year survival: 28% vs. 10%, P,0.0001) (Figure 2). On multivariate Cox proportional hazards model also inclusive of age, sex, BCLC staging, Child-Pugh score, meeting Milan criteria, liver transplantation listing, non-Asian ethnicity was an independent predictor for lower overall survival (HR=0.70 [0.52-0.86]). CONCLUSIONS: Despite being older and having a lower rate of liver transplantation listing, Asian HCV/HCC patients had higher median survival compared to non-Asian patients, particularly among those undergoing palliative therapy. Non-Asians were more likely to have decompensated liver disease and non-Asian ethnicity was an independent predictor for poorer long-term survival. Compared to non-Asians, Asians with HCV-related HCCwere also muchmore likely to have delayed HCV diagnosis. Improved strategies in HCV screening in Asians are needed as it may lead to earlier diagnosis and treatment of HCV infection and possible prevention of HCC development in this ethnic population with a disproportionate HCC disease burden.

616 C-FOS Mediated Regulation of the Apical Sodium Dependent Bile Acid Transporter (ASBT) Plays a Critical Role in the Ileal Response to FGF-19

BACKGROUND AND AIMS: In addition to hepatitis B virus, HCV is also an important cause of HCC in Asians; however, it is often overlooked. This study aims to examine baseline characteristics, timing of HCV diagnosis and long-term survival of HCV-related HCC in Asians compared to non-Asian patients. METHODS: We conducted a retrospective cohort study of 798 consecutive Asian (n=220) and non-Asian (n=572) patients with HCV-related HCC who were identified via computer query using ICD-9 diagnosis at a U.S. university medical center between 7/1996 and 6/2012. Individual records were reviewed. RESULTS: Asians were much older (66 [38-88] vs. 56 [31-87] years, P ,0.0001) and more likely to be female (33% vs. 19%, P,0.0001). A significantly larger proportion of Asians were also diagnosed with HCC within only 2 years of HCV diagnosis compared to non-Asians (35% vs. 20%, p=0.001). Non-Asians were more likely to have decompensated liver disease and had higher median Child-Turcotte-Pugh score (6 [5-11] vs. 7 [5-13], P ,0.0001). Asian patients were more likely to undergo liver-directed palliative therapy (46% vs. 28%) and much less likely to be listed for liver transplantation(20% vs. 48%) (P ,0.001), despite similar rates of meeting Milan criteria for liver transplantation (52 vs.58%, P=0.16). Overall, there was a trend for higher median survival rates in Asians compared to non-Asians (30 vs. 21 months, P=0.091). Among those who were listed for liver transplantation, there was no statistically significant difference in survival between Asians and non-Asians in the first 2 years (72% vs. 68%) but there was divergence with Asians having higher survival afterwards (61% vs. 51%) (Figure 1). However, among those undergoing liver-directed palliative therapy, Asians had significantly higher long-term survival compared to non-Asians (5-year survival: 28% vs. 10%, P,0.0001) (Figure 2). On multivariate Cox proportional hazards model also inclusive of age, sex, BCLC staging, Child-Pugh score, meeting Milan criteria, liver transplantation listing, non-Asian ethnicity was an independent predictor for lower overall survival (HR=0.70 [0.52-0.86]). CONCLUSIONS: Despite being older and having a lower rate of liver transplantation listing, Asian HCV/HCC patients had higher median survival compared to non-Asian patients, particularly among those undergoing palliative therapy. Non-Asians were more likely to have decompensated liver disease and non-Asian ethnicity was an independent predictor for poorer long-term survival. Compared to non-Asians, Asians with HCV-related HCCwere also muchmore likely to have delayed HCV diagnosis. Improved strategies in HCV screening in Asians are needed as it may lead to earlier diagnosis and treatment of HCV infection and possible prevention of HCC development in this ethnic population with a disproportionate HCC disease burden.

614 The Oncogenic Role of Praja1 on Disrupting TGF-β Signaling in Hepatocellular Cancer

BACKGROUND AND AIMS: In addition to hepatitis B virus, HCV is also an important cause of HCC in Asians; however, it is often overlooked. This study aims to examine baseline characteristics, timing of HCV diagnosis and long-term survival of HCV-related HCC in Asians compared to non-Asian patients. METHODS: We conducted a retrospective cohort study of 798 consecutive Asian (n=220) and non-Asian (n=572) patients with HCV-related HCC who were identified via computer query using ICD-9 diagnosis at a U.S. university medical center between 7/1996 and 6/2012. Individual records were reviewed. RESULTS: Asians were much older (66 [38-88] vs. 56 [31-87] years, P ,0.0001) and more likely to be female (33% vs. 19%, P,0.0001). A significantly larger proportion of Asians were also diagnosed with HCC within only 2 years of HCV diagnosis compared to non-Asians (35% vs. 20%, p=0.001). Non-Asians were more likely to have decompensated liver disease and had higher median Child-Turcotte-Pugh score (6 [5-11] vs. 7 [5-13], P ,0.0001). Asian patients were more likely to undergo liver-directed palliative therapy (46% vs. 28%) and much less likely to be listed for liver transplantation(20% vs. 48%) (P ,0.001), despite similar rates of meeting Milan criteria for liver transplantation (52 vs.58%, P=0.16). Overall, there was a trend for higher median survival rates in Asians compared to non-Asians (30 vs. 21 months, P=0.091). Among those who were listed for liver transplantation, there was no statistically significant difference in survival between Asians and non-Asians in the first 2 years (72% vs. 68%) but there was divergence with Asians having higher survival afterwards (61% vs. 51%) (Figure 1). However, among those undergoing liver-directed palliative therapy, Asians had significantly higher long-term survival compared to non-Asians (5-year survival: 28% vs. 10%, P,0.0001) (Figure 2). On multivariate Cox proportional hazards model also inclusive of age, sex, BCLC staging, Child-Pugh score, meeting Milan criteria, liver transplantation listing, non-Asian ethnicity was an independent predictor for lower overall survival (HR=0.70 [0.52-0.86]). CONCLUSIONS: Despite being older and having a lower rate of liver transplantation listing, Asian HCV/HCC patients had higher median survival compared to non-Asian patients, particularly among those undergoing palliative therapy. Non-Asians were more likely to have decompensated liver disease and non-Asian ethnicity was an independent predictor for poorer long-term survival. Compared to non-Asians, Asians with HCV-related HCCwere also muchmore likely to have delayed HCV diagnosis. Improved strategies in HCV screening in Asians are needed as it may lead to earlier diagnosis and treatment of HCV infection and possible prevention of HCC development in this ethnic population with a disproportionate HCC disease burden.