Specialist Liver Research Articles

Patient Reaction to Telemedicine for Clinical Management of Hepatitis C Virus Integrated into an Opioid Treatment Program.

Background and Introduction: Virtual integration of hepatitis C virus (HCV) infection management within the opioid treatment program (OTP) through telemedicine may overcome limited treatment uptake encountered when patients are referred offsite. To evaluate the diffusion of telemedicine within the OTP, we conducted a pilot study to assess acceptance of and satisfaction with telemedicine among 45 HCV-infected opioid use disorder (OUD) patients on methadone.Materials and Methods: We administered a modified 11-item telemedicine satisfaction questionnaire after the initial HCV telemedicine evaluation, when initiating HCV treatment, and 3 months post-HCV treatment completion. Among a patient subset, a semistructured interview further assessed issues of participant referral to the telemedicine program as well as convenience and confidentiality with the telemedicine encounters.Results: Patients demonstrated their acceptance of telemedicine-based encounters by referral of additional participants. They highlighted the convenience of on-site treatment with a liver specialist through recognition of the benefit of "one-stop shopping." They also expressed confidence in the privacy and confidentiality of telemedicine encounters.Discussion: In this pilot study, telemedicine appears to be well accepted as a modality for HCV management among OUD patients on methadone. Virtual integration of medical and behavioral therapy through telemedicine warrants further investigation for its use in this population.Conclusions: In this pilot study, we found that a largely racial minority population of substance users grew to accept telemedicine over time with diminished privacy and confidentiality concerns. Telemedicine was well accepted within the OTP community as reflected by participant referral to the program.

A nurse-led FibroScan® outreach clinic encourages socially deprived heavy drinkers to engage with liver services.

To determine whether a portable FibroScan® device can be an acceptable screening tool for chronic liver disease in a community alcohol support service, through recording uptake, determining apparent prevalence of undiagnosed fibrosis/cirrhosis in participants and report engagement following referral to specialist liver services of those individuals referred because of a FibroScan® reading ≥7.1kilopascals (kPa). Alcohol-related liver disease, including cirrhosis, is a major cause of death in the UK. Liver disease is silent and usually presents late. Socially deprived patients with alcohol-related liver disease are a "hard to engage" population and at higher risk of death than less deprived. A FibroScan® device is a non-invasive tool for measuring liver stiffness. A result of ≥7.1kPa can indicate possible chronic liver disease. Prospective observational study. Individuals who self-identified as harmful drinkers were recruited. Consented individuals attended for a liver FibroScan® . Those with a reading ≥7.1kPa were referred to a nurse-led liver clinic for further investigations, results of which determined referral to a liver specialist in secondary care. Participants referred were monitored for compliance over a 6-month period. Seventy-nine consented individuals participated, an uptake of 67% of those informed of the study. Of the 79 scans performed, three were unreliable leaving 76 participants. After scanning, 20/76 (26%) had a FibroScan® ≥7.1kPa requiring referral on to the nurse-led clinic. All 20 (100%) engaged in further assessment. Of those, 12 required onward referral to specialist services. Subsequent compliance with specialist services in this sample (n=12) was ≥90%. A nurse-led FibroScan® outreach clinic encourages socially deprived drinkers to engage with liver services. A 67% uptake suggests a nurse-led FibroScan® service in a community alcohol service is acceptable. High engagement gives potential for early intervention and improved health outcomes.

Supportive and palliative care in people with cirrhosis: International systematic review of the perspective of patients, family members and health professionals

People with cirrhosis have unmet needs, which could benefit from a palliative care approach. Developing effective services needs to be based on evidence from those with personal experience. This review aims to explore; patient and family perspectives of perceived needs including communication; health professionals' perspectives on delivery of care and improving palliative care between specialities. A literature search was conducted in Medline, Embase and CINAHL using key words reporting on the perspectives of patients with liver cirrhosis (18 years and over), family members or health professionals on the provision of care in liver cirrhosis. Study quality was assessed using the Mixed Methods Appraisal Tool. Qualitative and quantitative findings were grouped together according to the main relevant themes identified. Nineteen research studies predominantly from high-income Western countries were identified, with a total sample consisting of 1,413 patients, 31 family carers and 733 health professionals. Patients and family members had limited understanding of cirrhosis or its impact. They wanted better information about their disease, its treatment and help with psychological and practical needs. Health professionals had difficulty communicating about these issues to patients and their families. General practitioners left care predominantly to the liver clinicians, who lacked confidence to have discussions about prognosis or future care preferences. The role of palliative care was recognised as important in caring for this group through earlier integration with liver and community services. Health professionals need support to improve their communication with patients, to address patients' broader needs beyond medical treatment and to develop new models to improve palliative care coordination between different medical specialities. Future research should focus on developing communication aides, testing existing tools to identify suitable patients for supportive care and exploring robust ways of evaluating supportive care interventions, with more studies needed from middle- and low-income countries. Registration number: PROSPERO CRD42017064770. Patients and their families had a poor understanding of advanced liver disease and its impact on them. They need more information about the treatments they receive and how to get practical and psychological support. Liver specialists and GPs found it difficult to talk to patients and their families about the seriousness of advanced liver disease and the lack of healthcare options available to them if their condition gets worse. All doctors and nurses involved in the care of patients with advanced liver disease recognise that palliative and supportive care have an important role in improving patient care.

FRI-049 - Is a telehealth-to-home group lifestyle intervention a feasible and safe option for specialist liver clinics?

FRI-049 - Is a telehealth-to-home group lifestyle intervention a feasible and safe option for specialist liver clinics?

Managing professional knowledge boundaries during ECHO telementoring consultations in two Veterans Affairs specialty care liver clinics: A theme-oriented discourse analysis

Introduction Consultations are the traditional method of communication between generalist and specialist providers managing patients with specialty care needs. Traditional written consultations have limitations, including inadequate clinical information and inappropriate, or unclear consultation questions. Teleconsultations minimize these limitations through real-time communication between generalist and specialist providers to actively manage professional knowledge boundaries about specialty care problems. Methods We video-recorded 37 teleconsultation sessions, resulting in 115 consultations between generalist and specialty care providers participating in Veterans Affairs (VA) Extension for Community Healthcare Outcomes (ECHO) liver clinics. Data were collected at two US sites across nine months to observe consultation communication among 33 primary care generalists and three liver specialists. Video recordings were transcribed verbatim and analysed using theme-oriented discourse analysis to characterize consultation question content and format. Results Generalists' consultation question content addressed a range of topics, including treatment, diagnosis, interpreting results, patient communication, screening and surveillance, and care coordination. Some generalists relied on descriptive narratives rather than a specific question to convey complex patient cases. Consultation question format showed nearly even division between targeting general medical knowledge and specialty care knowledge domains, including specialty care, medical, organizational, and experiential knowledge. Discussion Timely access to specialists through teleconsultation has the potential to transform specialty care delivery. This article examines provider-to-provider interactions to understand how the communication process contributes to knowledge management during teleconsultations. Video studies of health information technology use provide a rich opportunity for analysing real-time communication that may help improve cross-specialty collaboration and the coordinated management of patients with specialty care needs.

Radioembolisation in patients with hepatocellular carcinoma that have previously received liver-directed therapies

PurposeRadioembolisation is part of the multimodal treatment of hepatocellular carcinoma (HCC) at specialist liver centres. This study analysed the impact of prior treatment on tolerability and survival following radioembolisation.MethodsThis was a retrospective analysis of 325 consecutive patients with a confirmed diagnosis of HCC, who received radioembolisation with yttrium-90 resin microspheres at eight European centres between September 2003 and December 2009. The decision to treat was based on the clinical judgement of multidisciplinary teams. Patients were followed from the date of radioembolisation to last contact or death and the nature and severity of all adverse events (AEs) recorded from medical records.ResultsMost radioembolisation candidates were Child-Pugh class A (82.5%) with multinodular HCC (75.9%) invading both lobes (53.1%); 56.3% were advanced stage. Radioembolisation was used first-line in 57.5% of patients and second-line in 34.2%. Common prior procedures were transarterial (chemo)embolisation therapies (27.1%), surgical resection/transplantation (17.2%) and ablation (8.6%). There was no difference in AE incidence and severity between prior treatment subgroups. Median (95% confidence interval [CI]) survival following radioembolisation was similar between procedure-naive and prior treatment groups for Barcelona Clinic Liver Cancer (BCLC) stage A: 22.1 months (15.1–45.9) versus 30.9 months (19.6–46.8); p = 0.243); stage B: 18.4 months (11.2–19.4) versus 22.8 months (10.9–34.2); p = 0.815; and stage C: 8.8 months (7.1–10.8) versus 10.8 months (7.7–12.6); p = 0.976.ConclusionsRadioembolisation is a valuable treatment option for patients who relapse following surgical, ablative or vascular procedures and remain suitable candidates for this treatment.

A Computational Analysis of Blood Flow through Portal Vein under Normal and Extrahepatic Obstructions

Portal hypertension is an alarming disease globally whereas Extrahepatic portal vein obstruction (EHPVO) is an important cause of portal hypertension among children in most of the Asian countries. The frequent occurrence of this disease is due to the formation of thrombosis in the portal vein. To acquire insights into the behaviour of hemodynamics, EHPVO case is studied by the technique of computational fluid dynamics (CFD) by considering partial block formation with different sizes inside the main portal vein. On the basis of block sizes, three cases namely normal portal vein (without block in the portal vein) case, 40% block in the portal vein case and 85% block in the portal vein case are simulated by assuming a 2D steady, laminar and fully developed flow with no-slip wall condition using AnsysTM Fluent. Our study reveals that the flow distribution between the left and right branches of the portal vein is significantly influenced by the formation of the block in the main portal vein. It is concluded that Extrahepatic portal vein obstruction leads to the possibility of Hypertrophy and Atrophy complex to the liver and could heighten the risk of liver diseases. Our numerical examination will play a great role to the Liver Specialist for understanding the flow behavior with obstructed flow path as well as the diagnosis of associated liver disease and their treatments.Journal of Bangladesh Academy of Sciences, Vol. 41, No. 2, 183-199, 2017

\u201cB in IT\u201d - a community-based model for the management of hepatitis B patients in primary care clinics using a novel web-based clinical tool

BackgroundThe current model of care for the treatment of chronic hepatitis B (CHB) in Australia is through specialist Hepatology or Infectious Diseases clinics, and limited accredited primary care practices. Capacity is limited, and less than 5% of Australians living with CHB currently access therapy. Increasing treatment uptake is an urgent area of clinical need. Nucleos(t)ide analogue therapy is safe and effective treatment for CHB that is suitable for community prescribing. We have evaluated the success of a community-based model for the management of CHB in primary care clinics using a novel web-based clinical tool.MethodsUsing guidelines set out by the Gastroenterological Society of Australia, we developed an interactive online clinical management tool for the shared care of patients with CHB in primary care clinics, with remote oversight from tertiary hospital-based hepatologists and a project officer. We call this model of care the “B in IT” program. Suitable patients were referred from the specialist liver clinic back to primary care for ongoing management. Compliance with recommended appointments, pathology tests and ultrasounds of patients enrolled in “B in IT” was assessed and compared to that of the same patients prior to community discharge, as well as a matched control group of CHB outpatients continuing to attend a specialist clinic.ResultsThirty patients with CHB were enrolled in the “B in IT” program. Compliance with attending scheduled appointments within 1 month of the suggested date was 87% across all 115 visits scheduled. Compliance with completing recommended pathology within 1 month of the suggested date was 94% and compliance with completing recommended liver ultrasounds for cancer screening within 1 month of the suggested date was 89%. The compliance rates for visit attendance and ultrasound completion were significantly higher than the control patient group (p < 0.0001) and the “B in IT” patients prior to community discharge (p = 0.002 and p = 0.039, respectively).ConclusionsThe “B in IT” program’s novel web-based clinical tool supports primary care physicians to treat and monitor patients with CHB. This program promotes community-based care and increases system capacity for the clinical care of people living with CHB.

Guidelines for clinical diagnosis and treatment of herb-induced liver injury

In recent years, the issues related to herb-induced liver injury (HILI) have received much concern. Its clinical diagnosis is much difficult than that of Western medicine-induced liver injury due to its complicated drug combination and multiple constituents. Moreover, it is also correlated with physiques, inheritance and basic diseases. China Association of Chinese Medicine has released the first standards for HILI diagnosis and treatment technology in 2016, namely Guidelines for clinical diagnosis of herb-induced liver injury (hereinafter referred to as the Guidelines). The diagnostic processes with different diagnostic results were explained in this paper to help clinicians, particularly liver specialists, in diagnosing liver diseases by applying the operation of the Guidelines.

Fifteen-minute consultation: liver disease in children

Liver disease in children can present in many ways from the frequently encountered prolonged neonatal jaundice to the comparatively rare acute liver failure. In this article, we will discuss ‘red...

Recent advances in managing hepatitis D.

Hepatitis D virus (HDV) infection leads to the most severe form of chronic viral hepatitis and requires the attention of a liver specialist. In this review, I will recapitulate recent advances in the management of HDV, present background information on HDV infection as well as current chronic hepatitis D treatment, briefly examine the HDV life cycle and discuss new management strategies.

First-line selective internal radiotherapy plus chemotherapy versus chemotherapy alone in patients with liver metastases from colorectal cancer (FOXFIRE, SIRFLOX, and FOXFIRE-Global): a combined analysis of three multicentre, randomised, phase 3 trials

SummaryBackgroundData suggest selective internal radiotherapy (SIRT) in third-line or subsequent therapy for metastatic colorectal cancer has clinical benefit in patients with colorectal liver metastases with liver-dominant disease after chemotherapy. The FOXFIRE, SIRFLOX, and FOXFIRE-Global randomised studies evaluated the efficacy of combining first-line chemotherapy with SIRT using yttrium-90 resin microspheres in patients with metastatic colorectal cancer with liver metastases. The studies were designed for combined analysis of overall survival.MethodsFOXFIRE, SIRFLOX, and FOXFIRE-Global were randomised, phase 3 trials done in hospitals and specialist liver centres in 14 countries worldwide (Australia, Belgium, France, Germany, Israel, Italy, New Zealand, Portugal, South Korea, Singapore, Spain, Taiwan, the UK, and the USA). Chemotherapy-naive patients with metastatic colorectal cancer (WHO performance status 0 or 1) with liver metastases not suitable for curative resection or ablation were randomly assigned (1:1) to either oxaliplatin-based chemotherapy (FOLFOX: leucovorin, fluorouracil, and oxaliplatin) or FOLFOX plus single treatment SIRT concurrent with cycle 1 or 2 of chemotherapy. In FOXFIRE, FOLFOX chemotherapy was OxMdG (oxaliplatin modified de Gramont chemotherapy; 85 mg/m2 oxaliplatin infusion over 2 h, L-leucovorin 175 mg or D,L-leucovorin 350 mg infusion over 2 h, and 400 mg/m2 bolus fluorouracil followed by a 2400 mg/m2 continuous fluorouracil infusion over 46 h). In SIRFLOX and FOXFIRE-Global, FOLFOX chemotherapy was modified FOLFOX6 (85 mg/m2 oxaliplatin infusion over 2 h, 200 mg leucovorin, and 400 mg/m2 bolus fluorouracil followed by a 2400 mg/m2 continuous fluorouracil infusion over 46 h). Randomisation was done by central minimisation with four factors: presence of extrahepatic metastases, tumour involvement of the liver, planned use of a biological agent, and investigational centre. Participants and investigators were not masked to treatment. The primary endpoint was overall survival, analysed in the intention-to-treat population, using a two-stage meta-analysis of pooled individual patient data. All three trials have completed 2 years of follow-up. FOXFIRE is registered with the ISRCTN registry, number ISRCTN83867919. SIRFLOX and FOXFIRE-Global are registered with ClinicalTrials.gov, numbers NCT00724503 (SIRFLOX) and NCT01721954 (FOXFIRE-Global).FindingsBetween Oct 11, 2006, and Dec 23, 2014, 549 patients were randomly assigned to FOLFOX alone and 554 patients were assigned FOLFOX plus SIRT. Median follow-up was 43·3 months (IQR 31·6–58·4). There were 411 (75%) deaths in 549 patients in the FOLFOX alone group and 433 (78%) deaths in 554 patients in the FOLFOX plus SIRT group. There was no difference in overall survival (hazard ratio [HR] 1·04, 95% CI 0·90–1·19; p=0·61). The median survival time in the FOLFOX plus SIRT group was 22·6 months (95% CI 21·0–24·5) compared with 23·3 months (21·8–24·7) in the FOLFOX alone group. In the safety population containing patients who received at least one dose of study treatment, as treated, the most common grade 3–4 adverse event was neutropenia (137 [24%] of 571 patients receiving FOLFOX alone vs 186 (37%) of 507 patients receiving FOLFOX plus SIRT). Serious adverse events of any grade occurred in 244 (43%) of 571 patients receiving FOLFOX alone and 274 (54%) of 507 patients receiving FOLFOX plus SIRT. 10 patients in the FOLFOX plus SIRT group and 11 patients in the FOLFOX alone group died due to an adverse event; eight treatment-related deaths occurred in the FOLFOX plus SIRT group and three treatment-related deaths occurred in the FOLFOX alone group.InterpretationAddition of SIRT to first-line FOLFOX chemotherapy for patients with liver-only and liver-dominant metastatic colorectal cancer did not improve overall survival compared with that for FOLFOX alone. Therefore, early use of SIRT in combination with chemotherapy in unselected patients with metastatic colorectal cancer cannot be recommended. To further define the role of SIRT in metastatic colorectal cancer, careful patient selection and studies investigating the role of SIRT as consolidation therapy after chemotherapy are needed.FundingBobby Moore Fund of Cancer Research UK, Sirtex Medical.

Hepatitis‐Viral

Hepatitis‐Viral

Advanced chronic liver disease in the last year of life: a mixed methods study to understand how care in a specialist liver unit could be improved

ObjectiveTo identify the limitations in palliative care provision in the last year of life for people with liver cirrhosis and potential barriers to and enablers of palliative care.DesignMixed methods, including...

Hepatic steatosis in participants in a program of low-dose CT screening for lung cancer

ObjectiveDetermine the frequency of moderate-to-severe hepatic steatosis (HS) in asymptomatic participants in a low-dose CT (LDCT) screening program for lung cancer, to identify risk factors, and develop recommendations. MethodsBaseline LDCT scans of the chest of 170 participants in an IRB-approved study between August 2011 and April 2016 were reviewed. Demographic variables, comorbidities, and liver function tests were documented. Hepatic and splenic attenuation values hounsfield unit (HU) were measured. Regression analyses were performed. ResultsAverage liver attenuation was 57.6HU (standard deviation (SD) 9.3) and average liver/spleen (L/S) ratio was 1.3 (SD 0.3). Liver attenuation was <40HU for 9 (5.3%), liver/spleen (L/S) ratio <0.8 for 6 (3.5%), and either <40HU or L/S ratio <0.8 for 9 (5.3%). Male sex (p=0.004), diabetes (p=0.0005), emphysema (p=0.03), and high BMI (p=0.0006) were significant predictors of HS. Aspartate aminotransferase (p=0.0018) and alanine aminotransferase (p=0.012) were negatively correlated with liver attenuation. Reduced serum levels of alpha-1-antitrypsin may be a common factor of emphysema and HS. ConclusionLDCT can detect HS in asymptomatic participants with frequencies similar to previous reports. If liver attenuation is below 40HU and/or L/S ratio below 0.8, further evaluation of HS to the primary care physician or liver specialist is recommended.

Pain Management Following Intestinal Transplantation

Background: Medical and surgical complications (acute and chronic rejection, obstruction and diversion colitis) following intestinal transplantation are well documented in the literature. There is limited research regarding optimal pain management in this group of patients. Prior to 2012 children and families were managed by a limited multidisciplinary team (Fig 1). Post 2012 children receive a significantly evolved multidisciplinary service (Fig 2). All pain nurses are non-medical prescribers and provide 7 day cover, the only paediatric pain service in the UK to do this. This development ensures timely adjustments and improvement in analgesia.FigureFigureAim: A descriptive audit demonstrating the evolution of the multi-disciplinary management of pain for children and families following complications of intestinal transplantation. Method: A retrospective review of medical notes was performed comparing the service provided to patients pre 2012 and post 2012. Specific documentation was examined to determine input from different services and the impact of the progressive development from an adhoc independent pain nurse to a designated specialist team. Feedback was gathered from families who experienced care during the above time periods. Results: Pre 2012 analgesia options were limited in comparison to current practice with morphine, paracetamol and occasionally a neuropathic adjunct being available. Currently a greater range of analgesia is used including fentanyl, ketamine and clonidine. The latter is used in acute and chronic pain management in this group of patients with pharmacy support. In addition specialist input from psychologists and psychiatrists helps manage acute on chronic pain. Psychosocial meetings are held weekly to discuss the holistic care of the child, including pain management. Discussion: The liver specialist nursing team have developed strong links with the pain service, increasing their knowledge and understanding of pain management. The pain nurses meet patients and families in the pre-transplant assessment to discuss pain management in the post-transplant period. The development and expansion of the pain service with support from pharmacy and psychology has improved pain management for patients undergoing intestinal transplantation. This is reflected in views of health care professionals involved in the patient’s journey but more importantly from patient and family feedback. However families acknowledged complementary therapy would be a useful addition and this is now being offered to them. Multidisciplinary team Birmingham Children's Hospital.

A multidimensional education program at substance dependence treatment centers improves patient knowledge and hepatitis C care.

BackgroundHCV treatment among people who inject drugs (PWID) is low. Education programs may be suitable strategies to improve patients’ knowledge about their condition and to overcome barriers to access treatment.MethodsThe Health Educational Program (HEP) consisted of patient workshops and educational videos and leaflets, and healthcare professionals’ workshops. HEP was implemented at seven substance dependence treatment centers (STDC) in Portugal. The study comprised two cross-sectional evaluations conducted before and after HEP. At both evaluations, adult patients with confirmed HCV diagnosis and registered in the STDC were consecutively included. For patients that completed both evaluations, the overall knowledge score were calculated and compared with McNemar test. Linear regression modelling was used to evaluate factors associated with baseline knowledge. Rates of referral and attendance to referral specialist, treatment proposal, initiation and retention at both evaluations were also compared with McNemar test.ResultsOverall, 504 patients with chronic hepatitis C were included: 78 % male, mean age 42.3 ± 6.6 years, 14 % school education ≤ 4 years, disease duration 11.0 ± 6.0 years and 26 % HIV co-infected. A higher baseline knowledge was independently associated with educational level ≥ 10 years (regression coefficient [B] =15.13, p < 0.001), current use of intravenous drugs (B = 7.99, p = 0.038), previous referral for treatment (B = 4.26, p = 0.008) and previous HCV treatment (B = 5.40, p = 0.003). Following HEP, mean knowledge score increased from 69 % to 79 % (p < 0.001). The rate of patient referral to a liver specialist increased from 56.2 % to 67.5 % (p < 0.001).ConclusionsAn HEP conducted at STDCs improved significantly patient knowledge about hepatitis C, even among patients with a high baseline knowledge. The HEP has also increased the rate of referral to the liver specialist and showed a great potential to support healthcare professionals in managing HCV. Education programs may promote treatment access among PWID, a population that represents the majority of HCV infected patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1883-6) contains supplementary material, which is available to authorized users.

Effect of Continuous Renal Replacement Therapy on Outcome in Pediatric Acute Liver Failure.

To establish the effect of continuous renal replacement therapy on outcome in pediatric acute liver failure. Retrospective cohort study. Sixteen-bed PICU in a university-affiliated tertiary care hospital and specialist liver centre. All children (0-18 yr) admitted to PICU with pediatric acute liver failure between January 2003 and December 2013. Children with pediatric acute liver failure were managed according to a set protocol. The guidelines for continuous renal replacement therapy in pediatric acute liver failure were changed in 2011 following preliminary results to indicate the earlier use of continuous renal replacement therapy for both renal dysfunction and detoxification. Of 165 children admitted with pediatric acute liver failure, 136 met the inclusion criteria and 45 of these received continuous renal replacement therapy prior to transplantation or recovery. Of the children managed with continuous renal replacement therapy, 26 (58%) survived: 19 were successfully bridged to liver transplantation and 7 spontaneously recovered. Cox proportional hazards regression model clearly showed reducing hyperammonemia by 48 hours after initiating continuous renal replacement therapy significantly improved survival (HR, 1.04; 95% CI, 1.013-1.073; p = 0.004). On average, for every 10% decrease in ammonia from baseline at 48 hours, the likelihood of survival increased by 50%. Time to initiate continuous renal replacement therapy from PICU admission was lower in survivors compared to nonsurvivors (HR, 0.96; 95% CI, 0.916-1.007; p = 0.095). Change in practice to initiate early and high-dose continuous renal replacement therapy led to increased survival with maximum effect being visible in the first 14 days (HR, 3; 95% CI, 1.0-10.3; p = 0.063). Among children with pediatric acute liver failure who did not receive a liver transplant, use of continuous renal replacement therapy significantly improved survival (HR, 4; 95% CI, 1.5-11.6; p = 0.006). Continuous renal replacement therapy can be used successfully in critically ill children with pediatric acute liver failure to provide stability and bridge to transplantation. Inability to reduce ammonia by 48 hours confers poor prognosis. Continuous renal replacement therapy should be considered at an early stage to help prevent further deterioration and buy time for potential spontaneous recovery or bridge to liver transplantation.

A Descriptive Analysis of a Multidisciplinary Health Agency Providing Treatment to Uninsured Hepatitis C Patients

Introduction: A majority of hepatitis C (HCV) patients will not receive treatment because many are uninsured and cannot afford treatment. Mercy Health Center, a small non-profit health agency, is unique in that it provides treatment at no cost to uninsured patients in its HCV clinic utilizing a multidisciplinary care model. The multidisciplinary team is comprised of a gastroenterologist, pharmacist, social worker, psychologist, nutritionist, and nurse practitioner. The objectives of this study were to describe clinical characteristics of uninsured HCV patients served by the treatment team, report treatment completion and sustained virologic response (SVR) rates, and estimate the amount of HCV medications provided at no cost to uninsured patients. Methods: A retrospective chart review was performed and identified 69 uninsured HCV patients who received medical care at Mercy Health Center between January 2008 and March 2015. Demographic, medical, psychiatric, substance use, HCV clinical characteristics, laboratory, and medication data were extracted. Chi-square, t-test, and logistic regression were used in the analysis. Results: The mean age at evaluation was 48 years with a mean birth year of 1964. Three-fourths of the patients were unemployment, a third had multiple HCV exposures, nearly half acquired HCV due to illicit drug use, and more than half had active psychiatric disorders. Most patients had medical comorbidities (87%), and the most common medical conditions were hypertension, gastroesophageal reflux disease (GERD), and diabetes. Of those who received HCV treatment, 84% successfully completed treatment and 85% achieved SVR. The agency facilitated and provided >$1.3 million of HCV antiviral therapeutics at no cost to uninsured patients. Conclusion: With appropriate support, uninsured HCV patients, who are often regarded as “difficult-to-treat” patients, can achieve HCV treatment completion and SVR rates similar to that of insured HCV patients. Liver specialists are encouraged to advocate for treatment and care for uninsured and poor HCV patients in health agencies and health systems. It is important for health systems to serve poor and uninsured HCV patients, otherwise population-wide reductions in HCV morbidity and mortality will not be realized.

PTU-093a An Audit of Primary Prophylaxis Against Variceal Bleeding Amongst Patients with Cirrhosis

Introduction Variceal bleeding occurs in 30–50% of patients with portal hypertension with early mortality (within 6 weeks) after a first variceal bleed approaching 20%. 1 In 2015, the updated BSG guidelines recommend that all patients with cirrhosis should be screened for varices at diagnosis. 1 Primary prophylaxis with non-selective beta-blockers (NSBB) or variceal band ligation (VBL) should be offered to those with grade 2–3 oesophageal varices, or any varices with red signs. Appropriate endoscopic surveillance intervals are recommended for the others. Here, we aim to audit the implementation of these recommendations in our patient cohort. Methods Between January and March 2015, consecutive patients with cirrhosis who attended specialist liver clinics at our institution were included. Clinical, demographic and endoscopic data was collected retrospectively. Results 111 patients (50 alcohol-related liver disease [ARLD], 25 non-alcoholic steatohepatitis [NASH], 25 viral hepatitis and 11 others) were studied. The mean age was 61±12 and 68 (61%) were male. The Child’s-Pugh score was A: 93 (84%), B: 15 (14%) and C: 3 (2%). Upon diagnosis of cirrhosis, 64 (58%) patients underwent endoscopic variceal screening; varices were detected in 37 (34%). Variceal screening at diagnosis was higher amongst NASH (80%) and viral hepatitis (64%) than ARLD (43%). Amongst those with varices (n = 37), primary prophylaxis was warranted in 28 and given in 27 (96%). After initiation, NSBB were rarely titrated according to clinical response. Amongst those requiring interval variceal screening or surveillance (n = 70), 40 (57%) underwent correctly-timed endoscopy. This was higher amongst NASH (71%) and viral hepatitis (69%) than ARLD (24%). Variceal haemorrhage occurred in 7 (6%) patients, 3 (43%) of whom had never undergone any endoscopic screening. Conclusion Our results demonstrate room for greater adherence to the guidelines with regards to initial screening and subsequent surveillance endoscopy. Once varices are identified, primary prophylaxis is initiated in the majority of patients, though with little evidence of subsequent titration to clinical response. Varices screening and appropriate primary prophylaxis is a proposed quality indicator in cirrhosis care. In order to improve quality of care, we highlight the need to perform screening endoscopy at diagnosis, and to titrate primary prophylaxis after initiation. Reference 1 Tripathi D, et al . UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 0 :1–25. Disclosure of Interest None Declared