Liver Transplant Team Research Articles

A-154 Non-standard body fluid validation of d-dimer analysis of organox liver perfusate to support clinical evaluations of donor livers prior to transplantation

Abstract Background Non-standard body fluid analysis is considered a challenge to laboratories since very few have been approved by the FDA for routine testing. As medical procedures evolve, the laboratory must balance the requirement to uphold regulatory standards while also supporting procedures that improve patient care. The LUMC Liver Transplant Team recently implemented the use of the FDA-approved OrganOx Metra normothermic machine perfusion instrument for maintaining donor livers under physiologic conditions prior to transplantation. The team mitigates risk for biliary complications associated with fibrin microthrombi by perfusing a combination of alteplase rTPA with fresh frozen plasma and monitoring the prevalence of fibrin through the release of D-dimers over the course of ex situ normothermic preservation. Liver perfusate is not an FDA-approved specimen type for the analysis of D-dimer and requires laboratory verification as a compatible specimen for analysis. Methods The D-dimer HS 500 assay was performed on an ACL TOP 750 analyzer. Carry-over studies evaluated activated partial thromboplastin time (aPTT) of a normal control (citrated plasma) specimen initially, and repeatedly in-between sets of D-dimer measurements of heparinized perfusate specimen. Recovery studies were performed by mixing liver perfusate with citrated plasma spiked with D-dimer in known ratios, allowing for the calculation of an expected value of D-dimer. Results Carry-over studies measuring aPTTs of normal plasma specimens provided %CVs of 1 and 3%. Recovery of D-dimer in seven sets of independent add-mixture series (three mixed specimen per set) was on average 105% with a range from 95 to 113% recovery. Conclusions Concern for cross-contamination of perfusate specimen containing heparin anticoagulant on analyzers used to evaluate routine coagulation testing was mitigated by the results of the carry-over study, which provided %CV within the manufacturer limit for intraday precision. Recovery studies evaluating matrix effect for the analysis of D-dimer on liver perfusate generated under the LUMC liver transplant protocol indicated that the matrix of the perfusate did not impact D-dimer analysis, as compared to the FDA-approved specimen type.

From Patients to Providers: Assessing Impact of Normothermic Machine Perfusion on Liver Transplant Practices in the US.

Normothermic machine perfusion (NMP) of livers allows for the expansion of the donor pool and minimization of posttransplant complications. Results to date have focused on both donor and recipient outcomes, but there remains potential for NMP to also impact transplant providers. Using United Network for Organ Sharing Standard Transplant Analysis file data, adult deceased donors who underwent transplantation between January 1, 2016, and December 31, 2022, were identified. Transplanted livers were divided by preservation methods (static cold storage [SCS] and NMP) and case time (day-reperfusion 8 am to 6 pm ). Patient factors, transplant characteristics, and short-term outcomes were analyzed between Mahalanobis-metric-matched groups. NMP livers represented 742 (1.4%) of 52,132 transplants. NMP donors were more marginal with higher Donor Risk Index scores (1.78 ± 0.50 NMP vs 1.49 ± 0.38 SCS, p < 0.001) and donation after cardiac death frequency (36.9% vs 8.4%, p < 0.001). NMP recipients more often had model for end-stage liver disease (MELD) exception status (29.9% vs 23.4%, p < 0.001), lower laboratory MELD scores (20.7 ± 9.7 vs 24.3 ± 10.9, p < 0.001), and had been waitlisted longer (111.5 [21.0 to 307.0] vs 60.0 [9.0 to 245.0] days, p < 0.001). One-year graft survival (90.2% vs 91.6%, p = 0.505) was similar between groups, whereas length of stay was lower for NMP recipients (8.0 [6.0 to 14.0] vs 10.0 [6.0 to 16.0], p = 0.017) after adjusting for confounders. Notably, peak case volume occurred at 11 am with NMP livers (vs 9 pm with SCS). Overall, a higher proportion of transplants was performed during daytime hours with NMP (51.5% vs 43.0%, p < 0.001). NMP results in increased use of marginal allografts, which facilitated transplantation in lower laboratory MELD recipients who have been waitlisted longer and often have exception points. Importantly, NMP also appeared to shift peak caseloads from nighttime to daytime, which may have significant effects on the quality of life for the entire liver transplant team.

Reexamining "psychosocial clearance": A procedural framework for psychosocial evaluation in liver transplantation.

Psychosocial and "nonmedical" phenomena are commonly encountered in liver transplantation (LT) evaluations. They are simultaneously crucial decision-making factors and some of the most difficult and controversial clinical matters clinicians confront. Epidemiology, societal trends, and the preponderance of psychological and behavioral factors underpinning common end-stage liver diseases ensure that LT teams will continue to encounter highly complex psychosocial patient presentations. Psychosocial policies, practices, and opinions vary widely among clinicians and LT centers. Liver clinicians already report insufficient psychosocial expertise, which creates a large gap between the stark need for psychosocial expansion, improvement, and innovation in LT and the lack of accompanying guidance on how to achieve it. While the clinical domains of an LT psychosocial evaluation have been well-described, few articles analyze the procedures by which teams determine candidates' "psychosocial clearance" and no conceptual frameworks exist. This article proposes a framework of core domains of psychosocial evaluation procedures, common pitfalls, and practical improvement strategies.

Review article: Emerging and current management of acute-on-chronic liver failure.

Acute-on-chronic liver failure (ACLF) is a clinically and pathophysiologically distinct condition from acutely decompensated cirrhosis and is characterised by systemic inflammation, extrahepatic organ failure, and high short-term mortality. To provide a narrative review of the diagnostic criteria, prognosis, epidemiology, and general management principles of ACLF. Four specific interventions that are explored in detail are intravenous albumin, extracorporeal liver assist devices, granulocyte-colony stimulating factor, and liver transplantation. We searched PubMed and Cochrane databases for articles published up to July 2023. Approximately 35% of hospital inpatients with decompensated cirrhosis have ACLF. There is significant heterogeneity in the criteria used to diagnose ACLF; different definitions identify different phenotypes with varying mortality. Criteria established by the European Association for the Study of the Liver were developed in prospective patient cohorts and are, to-date, the most well validated internationally. Systemic haemodynamic instability, renal dysfunction, coagulopathy, neurological dysfunction, and respiratory failure are key considerations when managing ACLF in the intensive care unit. Apart from liver transplantation, there are no accepted evidence-based treatments for ACLF, but several different approaches are under investigation. The recognition of ACLF as a distinct entity from acutely decompensated cirrhosis has allowed for better patient stratification in clinical settings, facilitating earlier engagement with the intensive care unit and liver transplantation teams. Research priorities over the next decade should focus on exploring novel treatment strategies with a particular focus on which, when, and how patients with ACLF should be treated.

"But I didn't drink!": What to do with discordant phosphatidylethanol results.

Liver transplantation (LT) teams must be adept at detecting, evaluating, and treating patients' alcohol use, given its prominence among psychological and behavioral phenomena which cause and contribute to liver diseases. Phosphatidylethanol (PEth) is a highly useful alcohol biomarker increasingly recommended for routine use in hepatology and LT. PEth is unique among alcohol biomarkers because of its wide detection window, high sensitivity and specificity, and the correlation of its numerical value with different patterns of alcohol use. Alongside myriad clinical opportunities in hepatology and LT, PEth also confers numerous challenges: little guidance exists about its clinical use; fearing loss of LT access and the reactions of their clinicians and families, candidates and recipients are incentivized to conceal their alcohol use; and liver clinicians report lack of expertise diagnosing and treating substance-related challenges. Discordance between patient self-reported alcohol use and toxicology is yet another common and particularly difficult circumstance. This article discusses the general toxicological properties of PEth; explores possible scenarios of concordance and discordance among PEth results, patient history, and self-reported drinking; and provides detailed clinical communication strategies to explore discordance with liver patients, a key aspect of its use.

Nutrition, frailty assessment, and interventions for the liver transplant candidate.

Nutrition, frailty assessment, and interventions for the liver transplant candidate.

Single center experience of therapeutic plasma exchange in a resource-constrained setting: A study of trends in scope and complications.

Therapeutic apheresis procedures are becoming an increasingly integral part of modern medical practice, be it as a part of therapy or pre-conditioning regimes for solid organ transplants. In our center, we follow the American Society for Apheresis (ASFA) guidelines for categorizing these procedures. However, lack of a centralized registry for therapeutic apheresis in India, lack of consolidated data as well as a resource-constrained setting prevent it from being utilized to its full potential. This study was a retrospective analysis of therapeutic plasma exchange (TPE) procedures performed from January 2015 to October 2022 in the Department of Transfusion Medicine at a large tertiary care hospital in North India. All consecutive TPE procedures were included. Overall and specialty-wise scoring for all patients was performed. Mean scores were calculated. A total of 1434 procedures were performed during the study duration of 7 years. These procedures were performed for 284 different patients. Majority of the procedures were referred from nephrology (895 of 1434, 62.4%), followed by neurology, gastroenterology, and liver transplant teams, hematology, critical care, rheumatology, pediatrics, and internal medicine. Complete response, partial response, and no-response were observed in 1077 (75.1%), 201 (14%), and 156 (10.9%) procedures respectively. Only 14 procedures reported adverse effects. Increasing effectiveness of TPE in a number of procedures and a variety of indications has broadened its scope, while the small number of adverse events, when supervised by trained Transfusion Medicine physicians has made TPE a more viable and safer alternative to other treatment modalities.

A248 OUTCOMES OF COVID-19 ILLNESS AND ACCESS TO APPROPRIATE TREATMENT IN LIVER TRANSPLANT RECIPIENTS IN BRITISH COLUMBIA THROUGHOUT THE PANDEMIC

Abstract Background COVID-19 continues to cause significant illness and mortality worldwide. Solid Organ Transplant Recipients (SOTR) have a higher rate of COVID-19 infection and worse outcomes than those who are immunocompetent. Dexamethasone, tocilizumab, and baricitinib have improved inpatient outcomes. Sotrovimab, remdesivir, and nirmatrelvir/ritonavir have recently been approved for used in high risk, minimally symptomatic outpatients. Previous experience has shown that use of monoclonal antibodies and oral antiviral agents have reduced morbidity and mortality of COVID-19 in SOTR. Purpose To assess the experiences and outcomes of COVID-19 and access to directed therapy in SOTR in British Columbia (BC). Method Data was compiled from patient disclosure to liver transplant clinicians on COVID-19 infection and gathered from patient charts in the SOTR Clinic at Vancouver General Hospital. Inclusion criteria were patients followed at the clinic with a positive COVID-19 test or clinical confirmation of COVID-19 syndrome. This is a retrospective, quality assurance study and did not require ethics review. Result(s) 158 SOTR reported COVID-19 infections between March 2020 and September 2022. 3 patients died within 30 days of COVID-19 infection, 2 (1.26%) of which the cause of death was directly due to COVID-19, and the other who had cholangitis with severe sepsis and multi-organ system failure. 24 patients required admission to hospital, 7 requiring critical care support. 41 patients did not receive any therapy for COVID-19: there was none available at that time (n=26), it was contraindicated due to a drug interaction (n=2) or medical condition (n=1), was refused (n=1), or the infection was reported too late to qualify (n=10). 83% (92/112) of outpatients received available anti-viral treatment: sotrovimab (n=27), remdesivir (n=63), or nirmatrelvir/ritonavir (n=2). In inpatients (n=24), 13 received corticosteroids, 6 dual treated with tocilizumab (n=4) or baracitinib (n=2). 4 inpatients received remdesivir. Three patients were treated in hospital after initiating outpatient therapy, one with progression of COVID-19 illness despite starting remdesivir. Two patients had adverse effects of medications provided: one was prescribed nirmatrelvir/ritonavir by a physician outside of the transplant program, which caused tacrolimus toxicity (serum concentration of 69.4 ng/mL) with nausea, vomiting, and diarrhea. Another patient had an episode of hypotension after receiving sotrovimab and sustained an acute kidney injury (AKI). Both patients fully recovered. There were no deaths on antiviral therapy. Of 145 patients who had laboratory investigations done within 30 days of COVID-19 infection, 16 had a transient rise in liver enzymes, 14 had an AKI and 11required an adjustment in their tacrolimus dose. Conclusion(s) Involving the liver transplant team early in the course of COVID-19 illness allows patients to safely access COVID-19 directed therapy to avoid progression of illness, and medication interactions or toxicity. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Experience with the transition process of adolescents with chronic diseases from pediatric to adult care in a general hospital.

The continuity of care from pediatrics to adult medicine is key to optimal health care. To describe the experience of the transition process of adolescent patients with chronic diseases from pediatric to adult care in a general hospital. Cross-sectional study of patients aged 16-24 years with a history of liver transplantation, kidney transplantation, endocrine, metabolic, rheumatic diseases, and myelomeningocele seen at a tertiary care teaching general hospital between 2015 and 2019 during the transition process. The process of health care and transition success were assessed. The Transition Readiness Assessment Questionnaire (TRAQ) was used. A total of 372 patients were included. The myelomeningocele clinic, the kidney transplant and the liver transplant teams were the most common specialties. Thirty-seven percent of participants were involved in the transition process. The mean duration of follow-up by pediatrics until transition initiation was 9 years. The mean age at the beginning of transition was 19 years, and the mean age at the end, 21 years. The joint clinic transition strategy was the most frequent, used in 96% of cases. The median value of the ordinal TRAQ was 4; of these, 32% had already seen adult care physicians. A successful transition was achieved by 32.7%. The continuity of care during transition is a process that took almost 2 years; more than one third of the patients had a successful transition.

RF06 | PSAT153 Osteoporosis Screening of Liver Transplant Patients in a Tertiary Urban Medical Center

Abstract Background Liver transplantation is an established treatment for patients with end-stage liver disease. In 2021 more than 8,400 liver transplants were performed in the United States. Although successful transplantation can reverse many complications of end organ failure, disturbance of bone and mineral metabolism may persist, which can contribute substantially to morbidity and mortality. It is important to assess whether liver transplant patients are getting bone density screening and treatment. Objective Our goal is to assess current practice in bone density screening in patients who have undergone liver transplant at our medical center, to identify if these patients are being screened for metabolic bone disease before and after transplant, and to improve management of such patients by initiating a provider work flow that is based on available data and evidence. Study Design: The first phase was a survey of the liver transplant team to assess the current protocol for screening. The second phase involved retrospective chart review of patients at our institution who had a liver transplant between October 2008 and April 2021. The findings will be used to create an institutional protocol for osteoporosis screening and management. Results Survey results: 62.5% of liver transplant providers knew that guidelines or a protocol are being used to screen liver transplant recipients for osteoporosis. 75% said that dual-energy x-ray absorptiometry (DXA) scans are always obtained before liver transplantation, while 25% said they are sometimes obtained. There were mixed results regarding monitoring post transplant. All respondents agreed that creating a protocol for osteoporosis screening would improve outcomes of bone health in transplant patients. Chart review results: We reviewed 243 liver transplant recipients between October 2008 and April 2021. After excluding duplicate transplants and those less than 18 years old, 234 patients were included in analysis. 59% of patients were men with a median age of 63.5. The most common etiologies of pre-transplant liver disease were Hepatocellular Carcinoma (29%), Hepatitis C (17%), alcoholic cirrhosis (16%) and NASH (5%). 72% of transplant patients had a DXA before transplant and 28% did not. Of those with a pre-transplant DXA, 28% had normal bone density, 50% had osteopenia, and 20% had osteoporosis. The remainder did not have data available. Among those with a diagnosis of osteoporosis pre-transplant, 41% received treatment while 56% did not receive any bone-specific therapy. Discussion The majority of providers in our liver transplant team are aware of the need for bone health screening and treatment in liver transplant candidates. Most patients received a DXA prior to transplant however less than half of the patients with osteoporosis were started on treatment. Our study shows the need for developing an institutional work flow to optimize bone health in patients undergoing liver transplant. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:06 p.m. - 1:11 p.m.

Feasibility of using a patient-reported outcome measure into clinical practice following pediatric liver transplantation: The Starzl Network experience.

Patient-reported outcome measures (PROMs) are not routinely used in clinical care by pediatric liver transplant (LT) teams. The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) assessed feasibility of using a disease-specific Quality of Life (QoL) questionnaire in the ambulatory setting at 10 SNEPT sites. A mixed methods feasibility project assessing administration processes, barriers, and user experiences with the Pediatric Liver Transplant Quality of Life (PeLTQL) tool. Iterative processes sought stakeholder feedback across four phases (Pilot, Extended Pilot, Development of a Mobile App PeLTQL version, and Pilot App use). A total of 149 patient-parent dyads completed the PeLTQL during LT clinic follow-up. Clinicians, parents, and patients evaluated and reported on feasibility of operationalization. Only two of 10 SNEPT sites continued PeLTQL administration after the initial two pilot phases. Reasons include limited clinical time and available personnel aggravated by the COVID-19 pandemic. In response, a mobile application version of the PeLTQL was initiated. Providing PeLTQL responses electronically was "very easy" or "easy" as reported by 96% (22/23) parents. Administration of a PROM into post-pediatric LT clinical care was feasible, but ongoing utilization stalled. Use of a mobile app towards facilitating completion of the PeLTQL outside of clinic hours may address the time and work-flow barriers identified.

S1307 Provider Perceptions of Code Status for Patients With End-Stage Liver Disease

Introduction: Liver transplantation (LT) is the only curative option for patients with end-stage liver disease (ESLD). Patients with ESLD have high rates of in-hospital mortality and low rates of survival to hospital discharge after in-hospital CPR. As ESLD is one of the few diseases where patients are close to death but also to a total cure, some studies suggest that LT listing and hospice referral should not be mutually exclusive. While many centers require that a patient be “full code” for LT listing or evaluation, this is not a United Network for Organ Sharing (UNOS) mandate. This study aims to assess LT providers’ awareness of organizational policies and their perspectives on code status requirement, with the eventual goal of providing patients with goal-concordant care while balancing the need of ethical solid organ allocation for transplant. Methods: Healthcare providers involved in the LT evaluation process at a high-volume transplant center anonymously completed a 13-question survey. Provider specialties are shown in Table. Answers were displayed using descriptive statistics. Results: Out of 83 providers who filled out the survey, 40% reported that they either often or always discussed code status with patients, often in a hospital setting. 62% were unaware of the institutional protocol that patients had to be full code for LT evaluation or listing, and 95% were unaware that UNOS did not have a full code requirement for the LT process. 93% of participants felt that patients undergoing LT evaluation should discuss code status. 15% felt that patients should remain full code throughout, 54% felt that patient should have their choice of code status during LT evaluation and listing, and 31% felt that patients should have their choice during evaluation but become full code once listed. Conclusion: These results show a need for increased educational initiatives among providers involved in the LT process, as there is a lack of knowledge among providers regarding policy on code status. Among the subset who was aware of a protocol, knowledge of the actual requirements varied. While most providers believe that a discussion regarding code status is necessary for patients who wish to undergo LT, there was a diverse range of opinions on code status requirement throughout the LT evaluation and listing process. Initiatives to further the dialogue of code status and advanced care planning in a high mortality patient population are needed. Table 1. - Description of Survey Respondents Role on LT team Number of Respondents Gastroenterology/Hepatology Attending 6 Critical Care Attending 5 Transplant Surgeon 3 Palliative Medicine Attending 3 Gastroenterology Fellow 9 Internal Medicine Resident 32 Advanced Practice Provider 14 Transplant Coordinator 6 Transplant Selection Committee 1 Social Worker 1 Other 3

345.3: TTS/ILTS Paired Transplant Center Program: Two Years of Clinical and Academic Advancements

Introduction: The Paired Transplant Center Program is a TTS/ILTS initiative to expand worldwide surgical capacity of Liver Transplantation (LT). Hepatocellular carcinoma, HBV and HCV rates in Mongolia are among the highest in the world, for this reason, it is imperative to increase surgical capacity in this region. Our LT team (Supporting Center - SC) and our counterparts in Mongolia (Emerging Center - EC) through collaborations in a university-based academic Center for Global Surgery were accepted for the Paired Transplant Centers Program award in 2020. We aim to report on the academic and clinical advancements of our alliance. Methods: This is a descriptive study to report the first 2 years of our partnership; We have organized online multidisciplinary lectures of selected LT topics with speakers from SC, EC, and international LT leaders. LT and related clinical protocols and guidelines are discussed during these meetings, allowing bilateral knowledge exchange. Research sessions include group review of abstracts and manuscripts from both teams. We also surveyed the participants of our group to obtain feedback about our past collaborations and future expectations of our projects. Results: Our group consists of a multidisciplinary team of 30 participants (SC=17, EC=13). We had 27 lectures on diverse LT topics, and we participated in over 14 LT international meetings including ILTS and TTS. We have submitted 2 manuscripts, presented 4 abstracts and received support to sponsor 1 research scholar. We reviewed and discussed bilateral protocols on immunosuppression, donor selection and follow-up, biliary complications, COVID-19 vaccination and perioperative care. Twenty-two (73% response rate) participants of our group answered the survey, 77% agrees that the TTS/ILTS Paired Transplant Center Program has contributed to their academic growth by providing new ideas for quality improvement and research projects, 68% agree that the collaboration has increased their knowledge in transplant and help them provide better care for their patients 72%, 81% think they would benefit from discussing pediatric transplantation topics and clinical cases and 26% and 66% respectively see language/translation and other clinical and academic duties as a challenge for our meetings. Conclusion: Our results show that it is feasible to have clinical and academic advancements through online efforts that ultimately impact bilateral patient care. Partnering with ECs and participating together in international studies helps expand their network for further independent collaborations. COVID-19 has limited in-person collaborations; however, telehealth platforms have been a useful and affordable tool for international collaboration among LT centers around the world.

The mediating effect of social functioning on the relationship between social support and fatigue in middle-aged and young recipients with liver transplant in China.

ObjectiveThe objective of the study was to explore the relationship between social support and fatigue as well as the mediating role of social functioning on that relationship.BackgroundPsychosocial factors such as social support and social functioning may influence patients’ fatigue symptoms. There is limited evidence on the relationship between social support, social functioning, and fatigue in liver transplant recipients.MethodsA total of 210 patients with liver transplants from two tertiary hospitals were enrolled in the current study. Questionnaires used include one for general demographic data, the Perceived Social Support Scale (PSSS), Social Disability Screening Schedule (SDSS), and Fatigue Symptom Inventory (FSI).ResultsA total of 126 (60%) recipients reported fatigue. Gender, residence, BMI, and liver function were the primary factors affecting fatigue. Social support was positively correlated with social functioning and was negatively correlated with fatigue. The effect of social support on fatigue was partially mediated by social functioning (35.74%).ConclusionThe fatigue of liver transplant recipients should be attended to. The higher the social support, the lower the fatigue of liver transplant recipients. Social support may also reduce fatigue through social functioning. The liver transplant team should help the liver transplant recipient establish a social support system, restore social functioning, and reduce fatigue symptoms.

Salvage Liver Transplant in the Treatment of a Child With Local Recurrence of Hepatoblastoma

Hepatoblastoma is the most common primary liver cancer of childhood, accounting for two-thirds of primary malignant hepatic neoplasms. Radical surgical removal combined with efficient chemotherapy is essential for cure. Despite a complete tumor resection, hepatoblastoma may recur as isolated local disease. Intrahepatic recurrence of hepatoblastoma after liver resection is among the indications for liver transplant. Here, we present a patient who underwent salvage liver transplant for the treatment of local recurrence of hepatoblastoma. A 13-year-old boy who was diagnosed with hepatocellular carcinoma arising from the left liver lobe and who had been treated with surgical resection was admitted to our outpatient oncology clinic for further evaluation because alpha-fetoprotein levels had started to increase after surgery. Histopathological reexamination of hemihepatectomy material showed a histological aspect of an epithelial hepatoblastoma. Magnetic resonance imaging revealed multifocal lesions in the right liver lobe compatible with local recurrence. Despite a favorable initial response to chemotherapy, the tumor showed progression with increased alpha-fetoprotein levels. The patient was deemed a viable candidate for an urgent liver transplant and underwent right lobe living donor liver transplant. He had excellent graft function without any complications or signs of malignancy in the last follow-up visit at 7 months posttransplant. Salvage liver transplant is a lifesaving and sometimes the only treatment option for patients with local recurrence of hepatoblastoma. Although transplant in the salvage setting has been associated with worse outcomes than primary transplant, recent data have indicated more favorable and acceptable outcomes. Further studies are warranted to better understand the role of salvage liver transplant in the treatment of hepatoblastoma. Early consultation with the liver transplant team is critical in children who are most likely to need extreme resection or liver transplant.

Palliative care in cirrhotic patients: Brief summary of recent AASLD guidance.

Palliative care in decompensated cirrhotic patients is a developing concept which should be used in cirrhotic patients during the advanced and terminal stages. Hepatologists and liver transplant teams mostly ignore the patients palliative care issues while intensively dealing with the liver diseases and its complications. This review is a brief summary of the recently published guidance discussing the palliative care, symptom based treatments and end of life with a collaborative and standartized approach which is recommended to all health care workers of cirrhotic patients.

Auxiliary Liver Graft Can Be Protected From HBV Infection in HBsAg Positive Blood Circulation.

Auxiliary grafts have a high risk of Hepatitis B virus (HBV) infection in patients with chronic HBV-related diseases. Hepatitis B virus-related auxiliary partial orthotopic liver transplantation (APOLT) cases were reviewed to show the results of current methods to block native-to-graft HBV transmission. Three patients received APOLT for HBV-related liver cirrhosis and a recurrent upper gastrointestinal hemorrhage between April 2015 and January 2017 by the liver transplant team of Beijing Friendship Hospital affiliated with Capital Medical University. All three patients were positive for HBV surface antigen (HBsAg) and had a negative HBV DNA test result before transplantation. After auxiliary transplantations, HBsAg was found to be positive in two patients and negative in one patient. To avoid graft infection of HBV, entecavir-based therapy was employed and the remnant native livers of the recipients were removed 51–878 days after liver transplantation. Then, serum conversions of HBsAg were found in all three cases. For the first time, this case series shows the possibility of blocking the transmission of HBV from a native liver to a graft in auxiliary transplantation by entecavir-based therapy. Among the cases, a left lobe graft was successfully implanted as a replacement of the right lobe of the recipient, which is also discussed.

Designing and Psychometric Properties of Appraisal Adherence to Care and Treatment Scale in Liver Transplantation Recipients

Background: Care and treatment adherence are important factors for given good liver transplantation outcomes. Objectives: Design and validate an instrument to appraise adherence to care and treatment in liver transplantation recipients. Methods: A mixed-methods sequential exploratory study was conducted in two phases from 2017 to 2019, in the Liver Transplantation Clinic Tehran, Iran. In the qualitative phase, the concept of care and treatment adherence in liver transplantation recipients extracted by a conventional content analysis was performed on semi-structural interviews that were conducted on 18 liver transplantation recipients that were recruited through purposive sampling technique. Also, two physicians, one nurse coordinator of the liver transplantation team, and two family members were interviewed. The scale was developed based on operational definitions extracted from the qualitative phase. The validity was assessed by face, content, construct validity, and confirmatory factor analysis. The reliability was also evaluated by calculating test-retest intraclass correlation coefficient and Cronbach's alpha. The exploratory factor analysis was carried out with 286 filled the questionnaire. Results: Four factors were extracted in factor analysis. These factors explained 45.622% of the variance. The final version of the scale consisted of 20 items. The Cronbach's alpha coefficient reported as 0.889 for the total scale and the intraclass correlation coefficient was reported as 0.912. The confirmatory factor analysis led to a fitting model. Chi-square indices were reported as CMIN/DF = 2.34, NFI = 0.94, CFI = 0.96, and RAMSEA = 0.067. Conclusions: With a four factors structure, validity and reliability of adherence to care and treatment scale are acceptable; therefore, it can be used for appraisal care and treatment adherence in liver transplant recipients.

Patients' Experiences of Life Challenges After Liver Transplantation: A Qualitative Study.

Patients experience a new life with different challenges after liver transplantation (LT). Identifying these challenges can facilitate the improvement of their quality of life. This study aimed to explore patients’ experiences of post-LT life challenges. This qualitative study was performed in 2019 through the content analysis approach. Participants were liver transplant recipients purposively recruited from a LT clinic. Semistructured interviews were conducted for data collection. Data were analyzed through Graneheim and Lundman’s conventional content analysis approach. Meaning units were identified and coded, and the codes were grouped into subcategories and categories according to their similarities. In total, 18 transplant recipients were interviewed. Their age mean was 51 years and their transplant age ranged from 4 months to 12 years. Their post-LT life challenges were categorized into 4 main categories, that is, self-care deficit, the need for seeking information, fears and concerns, and hope–despair duality. Nurses and members of LT team are recommended to assess transplant recipients’ life challenges and develop comprehensive plans for managing their challenges and problems and improving their quality of life.

Challenge to establish the liver transplantation in developing country (Mongolia) progress of the liver transplantation program in Mongolia

Background: The history of organ transplantation in Mongolia dates back to 10 years. The number of patients with end stage liv er disease increased in worldwide and Mongolia has high prevalence of hepatitis B virus, hepatitis C virus and hepatocellular car cinoma. The most effective treatment in end stage liver disease is liver transplantation (LT). It has a lot of difficulties including high financial cost, lifelong follow-up treatment and affordable choice of health insurance system in inception and setting up of LT project in developing country such as Mongolia. In Mongolia, LT project has been started from 2011 and continued success fully. Methods: Totally 106 patients had transplanted liver from living donor, and one patient from deceased donor. Cooperation of LT project between Mongolian National University of Medical Science, Mongolian First Central Hospital and Asan Medical Center, nowadays project is going successfully. Results: Twenty-eight of the 99 cases of LT have performed by mixed LT team, and seven other cases performed by Mongolian LT team. Thirty-four patients were received from living donor LT, and one was received from deceased donor. All of the patients who transplanted from living donor were survived and three patients died due to the laboratory deficits and, inadequate knowl edge of patients. The complications which we faced were acute rejection, infection, biliary complication and sinusoidal obstruc tive syndrome. Conclusions: Government support, affordable choice of health insurance system and demonstrating by experienced LT team were an important for evolving LT in low-income or developing country such as Mongolia.