Patients Awaiting Liver Transplantation Research Articles

Nutritional Assessment and Tools Used in Chronic Liver Disease Patients Awaiting Liver Transplant

Nutritional Assessment and Tools Used in Chronic Liver Disease Patients Awaiting Liver Transplant

Persisting dental foci increase the risk for bacterial infections before and after liver transplant.

Patients awaiting liver transplant are usually assessed for presence of dental foci to prevent bacterial infection post-transplant, but evidence to support dental examination and treatment is limited. We investigated if treatment of dental foci decreased bacterial infections before and after transplant. Patients transplanted at the university hospital of Bonn were retrospectively assessed for occurrence of bacterial infections before and after transplant according to presence and treatment of dental foci. 35/110 patients showed good oral health, 39/110 patients received dental care and 36/110 patients did not receive dental care despite poor oral health. Patients with alcohol-associated liver disease presented with the highest rate of dental foci. Bleeding complications due to oral care occurred in five patients with poor coagulation. After transplant, the number of infections per patient was higher in patients with poor oral health (2.9) compared to patients after dental care (1.9) or with good oral health (1.8) (p=.02), with streptococcal infections being more frequent in patients with poor oral health. Before transplant, bacterial infections, in particular bacteraemia and spontaneous bacterial peritonitis, were also more common in patients with untreated dental foci. Streptococci and Staphylococci were more often detected in patients with dental foci. Dental treatment was associated with a reduction in bacterial infections. Presence of dental foci is associated with an increased risk for bacterial infections not only after but also before liver transplant. Dental treatment might be a safe and effective procedure to mitigate this risk.

Power of mortality prediction in patients awaiting liver transplantation according to the Global Leadership Initiative on Malnutrition criteria and Subjective Global Assessment and Royal Free Hospital Global Assessment scores

ObjectivesThis study aimed to analyze the performance of the Global Leadership Initiative on Malnutrition (GLIM) criteria and Subjective Global Assessment (SGA) and Royal Free Hospital Global Assessment (RFH-GA) scores in predicting 12-mo mortality in patients awaiting liver transplantation. MethodsThis is a longitudinal observational study, carried out between March 2019 and November 2021. Clinical data were collected and nutritional assessment was performed through anthropometry and application of validated instruments, such as the SGA, GLIM criteria, and RFH-GA. A Cox regression model was carried out, in which the dependent variable was mortality in 1 y, and the independent variables were the classifications of nutritional status by the different methods. ResultsThe sample consisted of 126 patients, most of them male (56.35%). Malnutrition was diagnosed in 85.71% of the patients according to the RFH-GA, 62.70% according to the SGA, and 56.31% according to the GLIM criteria. Malnutrition assessed by GLIM was related to a 3.79-fold increase in the chance of mortality over time in patients awaiting liver transplantation. Moreover, the GLIM criteria had good discriminatory power in identifying mortality in patients awaiting liver transplantation, compared with the initial and final SGA and RFH-GA scores and the Model for End-stage Liver Disease–Sodium (MELD-Na) index. ConclusionsThe GLIM criteria were a good predictor of increased risk of mortality in malnourished patients with chronic liver disease awaiting liver transplantation, compared with the SGA and RFH-GA scores and the MELD-Na index.

Acute-on-Chronic Liver Failure: Diagnosis to Liver Transplantation

Abstract:Introduction: Patients with acute-on-chronic liver failure(ACLF) have different characteristics from those presented by non-ACLF patients with liver diseases. The degree of ACLF impacts the outcome with or without transplantation, with divergences in the literature, especially regarding post-transplant prognosis. Objectives: To review the different aspects of patients with ACLF, including the concepts of the syndrome adopted by various institutions, the treatment of complications, and to describe the knowledge about the outcomes with or without transplantation of patients with the syndrome reported in the literature. Methods: Twenty-two articles were included in the PubMed, MEDLINE and the Scientific Electronic Library Online (SciELO) databases with the descriptors “ACLF definitions” and “Liver transplantation ACLF.” The concepts and data from the selected texts were compared and used as a basis for writing this article. Results: There are some differences in the definition of the syndrome, varying especially between Western and Eastern countries. ACLF patients awaiting liver transplantation have characteristics distinct from those presented by non-ACLF patients. The degree of ACLF also impacts the outcome with or without transplantation, with divergences in the literature especially regarding the post-transplant prognosis of ACLF-3 patients, with an increasing trend in the indication of transplantation even for these patients. Conclusions: Outcomes vary among ACLF patients according to the degree of the disease. Liver transplantation has been more frequently indicated in ACLF-3, with waiting time impacting outcomes. Further studies are needed to define which subgroups of patients benefit most from liver transplantation.

The role of prehabilitation on short-term outcomes after liver transplantation: A review of the literature and expert panel recommendations.

Prehabilitation programs as part of ERAS protocols are being increasingly used in multiple surgeries, improving postoperative outcomes. Data regarding prehabilitation programs in patients awaiting liver transplantation and their outcomes is scarce. To identify whether prehabilitation programs based on exercise training conducted prior to liver transplantation improve short-term postoperative outcomes, and to provide expert panel recommendations. Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies included those evaluating postoperative outcomes, as well as those evaluating functional outcomes. CRD42021236305. Of the 170 studies screened, only one assessed the primary objective. Most studies focus on the preoperative impact of exercise training on aerobic capacity, muscle mass and/or strength, showing positive effects and no significant adverse events, but are underpowered and with heterogenous designs and interventions. The non-randomized observational study which assessed relevant postoperative outcomes, showed a non-significant trend towards reduced 90-day readmission rate and shorter length of stay in the prehabilitation group. Prehabilitation prior to liver transplantation is unlikely to be harmful, and likely to have short term benefits on functional status. We cautiously recommend prehabilitation on the basis of absence of harm and possibility of benefit (Quality of Evidence; Very Low | Grade of Recommendation; Low).

Nutritional Assessment and Clinical Determinants in Patients Awaiting Liver Transplant

Background: Malnutrition is a usual problem in liver cirrhosis patients, progressing with advancement of disease. Protein-calorie malnutrition is related with illness and death, and the value of nutritional status assessment tools for malnutrition is debated. We conducted this study to monitor undernutrition assessment among cirrhotics using subjective global assessment (SGA) and standard anthropometric parameters and to observe the association of different clinical characteristics with SGA score and Child-Pugh classification. Methods: Patients enrolled were end-stage liver disease (ESLD) patients and obtained informed consent. The nutritional screening was performed using the SGA and standard anthropometry along with mid-upper arm circumference (MUAC), mid-arm muscle circumference (MAMC), triceps skin fold thickness (TST), and hand grip strength (HGS). Results: 141 ESLD patients awaiting liver transplant (LT) were enrolled in the study and among them, 113 (80.1%) were males and 28 (19.9%) females. Patient’s average age at presentation was 49.5 years. Alcoholism was the major etiological factor (51.1%) and its median duration was 10 years. The liver disease severity as per Child-Pugh classification was as follows: the majority, 66 (46.8%), were in Child-Pugh category B, and 27 (19.1%) were in Child-Pugh category C. The comparison of nutritional parameters with the Child-Pugh classification showed a statistical significance (P<0.05) with BMI (body mass index) and MAMC between the Child-Pugh categories. The comparison of SGA nutrition scores shows that it does not significantly differ on average between gender, Child-Pugh classification, aetiologies, co-morbidity, oedema, and ascites status. The nutritional score was further categorized as normal, moderately malnourished, and severely malnourished based on the SGA score, and it shows that the nutritional level is significantly correlated with Child-Pugh classification and co-morbidity. The level of liver function parameters was not correlated with the level of different nutritional parameters. Conclusion: SGA and HGS can be used as an easy and economical tool for evaluating the level of nutrition among cirrhotics and can be consistently used in liver clinics for malnutrition screening, and one can plan for nutrition education and counselling. Nutritional level monitoring is challenging in patients with ESLD due to fluid retention, and SGA will be a better nutritional screening tool for nutritional assessment./p>

Sarcopenia in chronic advanced liver diseases: A sex-oriented analysis of the literature.

Sarcopenia, defined as progressive and generalized loss of muscle mass and strength, is common in chronic liver disease. It significantly impacts the quality of life and increases the risk of liver-related complications and mortality in cirrhotic patients. Moreover, recent studies showed a negative impact of sarcopenia on patients awaiting liver transplantation (LT), on post-LT outcomes, and on response to hepatocellular carcinoma therapies. Data about the influence of sex on the incidence, prevalence, diagnosis and treatment of sarcopenia in chronic liver diseases are poor and conflicting. The aims of this review of the literature are to define sex differences in sarcopenic cirrhotic patients and to highlight the necessity of a sex stratified analysis in future studies. This analysis of the literature showed that most of the studies are retrospective, with a higher prevalence of sarcopenia in males, probably due to anatomical differences between the sexes. Moreover, diagnostic criteria for sarcopenia are different between studies, as there is not a defined cut-off and, as a consequence, no comparable results. In conclusion, sex seems to have an impact on sarcopenia, and future studies must accurately investigate its role in identifying and treating high-risk patients, reducing the negative impact of sarcopenia on the survival and quality of life of cirrhotic patients.

Outruling cholangiocarcinoma in patients with primary sclerosing cholangitis wait-listed for liver transplantation: A report on the Irish national experience

BackgroundThe presence of diffuse biliary stricturing in Primary Sclerosing Cholangitis (PSC) makes the diagnosis of early Cholangiocarcinoma (CCA) in this context difficult. A finding of incidental CCA on liver explant is associated with poor oncological outcomes, despite this; there remains no international consensus on how best to outrule CCA in this group ahead of transplantation. The objectives of this study were to report the Irish incidence of incidental CCA in individuals with PSC undergoing liver transplantation, and to critically evaluate the accuracy of diagnostic modalities in outruling CCA in our wait-listed PSC cohort. MethodsWe conducted a retrospective analysis of our prospectively maintained database, which included all PSC patients wait-listed for liver transplant in Ireland. Results4.41% of patients (n = 3) were found to have an incidental finding of CCA on liver explant. Despite only being performed in 35.06% of wait-listed PSC patients (n = 27), Endoscopic Retrograde Cholangiopancreatogram (ERCP) with brush cytology was found to be the most effective tool in correctly outruling CCA in this context; associated with a specificity of 96.15%. ConclusionOur findings support a future role for routine surveillance of PSC patients awaiting liver transplantation; however further research is required in order to identify which investigative modalities are of optimal diagnostic utility in this specific context.

AB110. SOH22ABS195. Sarcopenia is an important predictor of frailty in patients awaiting liver transplant

AB110. SOH22ABS195. Sarcopenia is an important predictor of frailty in patients awaiting liver transplant

Outcomes of Split Liver Transplantation vs Living Donor Liver Transplantation in Pediatric Patients: A 5-Year Follow-Up Study in Korea.

BackgroundThe number of pediatric patients awaiting liver transplantation has decreased. Due to its increased use in Korea, split liver transplantation (SLT) may be a substitute for living donor liver transplantation (LDLT); however, the outcomes of pediatric SLT and LDLT in Korea remain unreported.Material/MethodsWe reviewed data of Korean patients aged <18 years who received SLT from 2005 to 2014, based on the Korea national database and compared to recipients who underwent LDLTs at Seoul National University Hospital during the same period.ResultsA total of 63 and 56 patients were included in SLT and LDLT, respectively. The most common indication for LT was biliary atresia (60.3% in SLT vs 67.9% in LDLT). The Pediatric End-Stage Liver Disease score did not differ between the groups (P>0.05). The 1-, 3-, and 5-year overall survival rates were 92.1%, 90.2%, and 86.6% in the SLT and 96.4%, 94.6%, and 94.6% in the LDLT groups, respectively (P=0.21); the corresponding graft survival rates were 88.9%, 87.1%, and 83.6% in the SLT and 92.9%, 91.0%, and 91.0% in the LDLT groups, respectively (P=0.31). Fulminant hepatic failure was a risk factor for graft failure [OR, 8.77 (1.08–70.92); P=0.042], but not overall survival [OR, 11.78 (0.56–247.29); P=0.11].ConclusionsThe graft and overall survival rates of SLT and LDLT were not different in pediatric patients in Korea, and fulminant hepatic failure was the only risk factor affecting graft survival outcomes.

Sarcopenia HIBA score predicts sarcopenia and mortality in patients on the liver transplant waiting list.

Sarcopenia is a prevalent condition that predicts prognosis in patients awaiting liver transplantation (LT). The gold standard for the diagnosis of sarcopenia is the assessment of the muscular area at L3 with computed tomography (CT) scan (skeletal muscle index [SMI]), but the routine use of CT scan is limited in clinical practice. Thus, we designed a single‐center observational study aimed to evaluate the clinical factors associated with the presence of sarcopenia by SMI, and to build a score capable of predicting or excluding the presence of sarcopenia in patients on the LT waiting list (WL). Binary logistic regression analysis was performed to establish the factors independently associated with sarcopenia, and the Sarcopenia Hospital Italiano de Buenos Aires (HIBA) score was built from the resulting model after internal validation analysis by bootstrapping and correction for optimism. The predictive capability of mortality on the WL was evaluated with competing risk regression analysis. A total of 215 patients with cirrhosis on the LT WL were included. The independent factors associated with the presence of sarcopenia were male sex (odds ratio [OR]: 6.09, p < 0.001), body mass index (OR: 0.74, p < 0.001), Child Pugh (OR: 1.44, p < 0.001), and the ratio creatinine/Cystatin C (OR: 0.03, p = 0.007). The Sarcopenia HIBA score constructed with these variables showed an area under the curve of 0.862. During follow‐up, 77 (36%) patients underwent LT, 46 (21%) died, and 92 (43%) remained alive. After adjusting for Model for End‐Stage Liver Disease–Sodium, Sarcopenia HIBA score was an independent predictor of WL mortality (subhazard ratio: 1.19; 95% confidence interval 1.01–1.40; p = 0.042). Sarcopenia HIBA score is an easy‐to‐use, objective, and reliable diagnostic and predictive tool that can be useful to improve the prognostic evaluation and allow identifying a group of patients with a higher risk of death while awaiting LT.

Longevity of seropositivity after anti SARS-CoV-2 vaccination in patients awaiting liver transplant

Introduction: Anti-SARS-CoV-2 vaccines demonstrated a high rate of success in preventing severe COVID-19 and decreasing infection rate. Few data are available in pre-liver transplant (LT) patients. IgG anti-Spike reflect humoral response to vaccination.

Nontransplant options for portomesenteric thrombosis.

Portomesenteric thrombosis (PMT) is a serious condition encountered mainly in cirrhotic patients awaiting liver transplantation. More recently, this potentially fatal complication has been described after bariatric surgery and inflammatory bowel disease. Several consensus guidelines have been published over the past few years and this mini review was conducted to discuss updated nontransplant treatment options based on currently available evidence. Anticoagulation is the mainstay of treatment for PMT involving <50% of the main portal vein. Transjugular intrahepatic portosystemic shunt are usually preserved for patients with more extensive disease or those with clinically significant portal hypertension that are treatment refractory. The extent of PMT, response to therapy, and complications related with PMT are the determinants of therapy.

Outcome of Patients Awaiting Deceased Donor Liver Transplantation During COVID-19 Pandemic

Introduction: COVID-19 pandemic caused by SARS-CoV-2 has caused direct as well as collateral damage to the healthcare systems across the world. Reduction in cadaver organ availability may impact patients awaiting deceased donor transplantation. Aim: To determine the clinical outcome of patients awaiting Deceased donor liver transplantation (DDLT) during COVID-19 pandemic. Methods: A retrospective, comparative study of patients awaiting DDLT at our centre from January to December 2020 (pandemic year) against those waitlisted in 2019 (pre-pandemic year) were carried out. Demographics, disease etiology, MELD Na score, clinical event such as DDLT (primary outcome), rescue LDLT or mortality were analyzed between both groups. Chi square test and Student t test was utilized for analysis. A P value of <0.05 considered statistically significant. Results: 175 and 160 patients were awaiting DDLT during the pre-pandemic and pandemic year, respectively. Demographic data of the study population showed age (mean 52±11.2 [95% C.I:50.3- 53.7] vs 52±11.1 [95%C.I:50.4-53.9] years; P=0.911), male:female (6.3:1 vs 6.6:1; P=1.0), etiology of liver disease showed predominantly NASH (92 (52.6%) vs 78 (48.8%);P=0.513)) and ALD (38 (21.7%) vs 41 (25.6%); P=0.440)) in pre-pandemic and pandemic year respectively. Mean MELD Na at the time of listing was 19.6±6.0 [95%C.I:18.7-20.5] vs 19.2±6.3 [95%C.I:18.3-20.2]; P=0.632 and at the time of clinical event was 25±9 [95%C.I:22-27] vs 28±10 [95%C.I:25-31]; P=0.035 between 2019 and 2020 study patients, respectively. Clinical events are as follows: DDLT (21 (12%) vs 10 (6.3%); P=0.089), rescue LDLT (26 (14.9%) vs 12 (7.5%); P=0.039), death on the waiting list (32 (18.3%) vs 44 (27.5%); P=0.05) and awaiting transplant (96 (54.9%) vs 94 (58.8%); P=0.508) and mean duration of patients awaiting liver transplantation was 200 vs 428 days (P=0.00) between the pre-pandemic and pandemic year, respectively. Conclusion: COVID-19 pandemic has caused a considerable reduction in DDLT, leading to a significant longer duration in waitlist and mortality.

Frailty is associated with increased risk of cirrhosis disease progression and death.

The Liver Frailty Index (LFI) is a well-studied tool that evaluates frailty in patients with cirrhosis. Consisting of grip strength, chair stands, and balance testing, the LFI has been associated with increased mortality in patients awaiting liver transplant. We aimed to extend our understanding of frailty in cirrhosis by exploring the relationship between the LFI and the risk of (1) cirrhosis progression, (2) mortality, and (3) unplanned hospitalizations, in both compensated and decompensated disease. Adult patients with cirrhosis from four centers in North America and one in India were included. Frailty was measured at baseline using the LFI and categorized as robust (LFI < 3.2), prefrail (LFI 3.2-4.5), and frail (LFI > 4.5). Progression of cirrhosis was defined by an increase in clinical stage, ranging from 1 to 5, from baseline using the D'Amico classification. Factors associated with progression, mortality, and hospitalizations were evaluated using multivariate regression models, with transplant as a competing risk. In total, 822 patients with cirrhosis were included. Average Model for End-Stage Liver Disease (MELD) score was 15.5±6.0. In patients with compensated cirrhosis, being frail versus robust was associated with increased risk of progression to the next cirrhosis stage or to death (HR, 2.45; 95% CI, 1.14-5.29) and with an increased risk of unplanned hospitalizations (2.32; 95% CI, 1.13-4.79), after adjusting for age, sex, and MELD score. Similar HRs were observed in patients with decompensated cirrhosis. Frailty was an independent predictor of cirrhosis progression or death and unplanned hospitalization across patients with compensated and decompensated cirrhosis. Future studies are needed to evaluate the possibility of slowing cirrhosis disease progression by reversing or preventing frailty.

The GLIM criteria failed to diagnose malnutrition in patients awaiting liver transplant

Rationale: The Global Leadership Initiative on Malnutrition (GLIM) is a new framework that aims to operationalize the diagnosis of malnutrition. The GLIM consists of the combination of at least one phenotypic (PC) and one etiologic criteria (EC). To verify its reliability, the authors recommend contrasting it with a standard tool.

Predictors of outcomes following liver transplant in hepatopulmonary syndrome: An OPTN database analysis

Hepatopulmonary syndrome (HPS) is a type of pulmonary vascular disease occurring exclusively in those with underlying liver disease, associated with significant mortality in patients awaiting liver transplantation (LT). LT is curative in HPS, and these patients are granted Model for End Stage Liver Disease (MELD) exception points to expedite LT. The purpose of this study is to use multivariable competing risk Accelerated Failure Time models and propensity matching to examine the relationship between pre-LT hypoxemia and post-LT outcomes in HPS. We performed a retrospective cohort study of UNOS/OPTN database of all adult patients undergoing LT between January 1, 2006 and January 12, 2020. Pre-LT PaO2 was significantly associated with post-LT mortality in HPS, with each 1 mmHg increase in PaO2 significantly decreasing the risk of post-LT mortality (coefficient 0.039, HR = 0.95, p = 0.001). HPS patients with a pre-LT PaO2 < 54 mmHg demonstrated increased mortality following LT as compared to matched non-HPS cirrhotic patients. We conclude that HPS patients with a PaO2, 54 mmHg are at increased risk of post-LT mortality and may identify high-risk patients who would benefit from additional resources during LT, and that the effects of HPS MELD exception points to optimize post-LT outcomes should be continuously re-evaluated.

Effect of Aprotinin on Liver Injury after Transplantation of Extended Criteria Donor Grafts in Humans: A Retrospective Propensity Score Matched Cohort Analysis.

The number of patients awaiting liver transplantation still widely exceeds the number of donated organs available. Patients receiving extended criteria donor (ECD) organs are especially prone to an aggravated ischemia reperfusion syndrome during liver transplantation leading to massive hemodynamic stress and possible impairment in organ function. Previous studies have demonstrated aprotinin to ameliorate reperfusion injury and early graft survival. In this single center retrospective analysis of 84 propensity score matched patients out of 274 liver transplantation patients between 2010 and 2014 (OLT), we describe the association of aprotinin with postreperfusion syndrome (PRS), early allograft dysfunction (EAD: INR 1,6, AST/ALT > 2000 within 7–10 days) and recipient survival. The incidence of PRS (52.4% vs. 47.6%) and 30-day mortality did not differ (4.8 vs. 0%; p = 0.152) but patients treated with aprotinin suffered more often from EAD (64.3% vs. 40.5%, p = 0.029) compared to controls. Acceptable or poor (OR = 3.3, p = 0.035; OR = 9.5, p = 0.003) organ quality were independent predictors of EAD. Our data do not support the notion that aprotinin prevents nor attenuates PRS, EAD or mortality.

Urgent Liver Transplantation from Deceased Donor With a Calcified Hydatid Cyst: A Case Report

Liver transplantation is the final treatment option for end-stage liver disease and acute liver failure, although availability of donor organs is a major limitation. The large gap between the growing list of patients awaiting liver transplantation and the scarcity of donor organs has fueled efforts to maximize the existing donor pool and identify new avenues. We treated a 13-year-old boy who had acute liver failure, due to Wilson's disease, with transplantation of a liver from a deceased liver donor with a calcified hydatid cyst. After 3 years of follow-up, liver function tests remained normal, hydatid cyst serology was negative, and no hydatid cyst or other problems were observed.

Bridge-to-Transplant External-Beam Radiation Therapy in Patients With Hepatocellular Carcinoma: A Utilization Analysis of the United Network for Organ Sharing (UNOS) Database

<h3>Purpose/Objective(s)</h3> External-beam radiation therapy (EBRT), and more explicitly stereotactic body radiation therapy (SBRT), is a safe and effective bridging therapy to liver transplantation for patients with hepatocellular carcinoma (HCC). However, the national prevalence and clinicopathologic parameters of patients receiving EBRT as a bridging modality in the United States are unknown. The United Network for Organ Sharing (UNOS) is a non-profit organization that manages the national liver transplant waiting list in the United States. Our aim was to determine the national prevalence of EBRT in patients with HCC waitlisted for liver transplantation in the United States. <h3>Materials/Methods</h3> We retrospectively analyzed the UNOS dataset from 10/2013 – 6/2020 and identified adults waitlisted for HCC who had applied for Model of End-Stage Liver Disease (MELD) exceptions to receive waiting list prioritization. The primary outcome was the period prevalence of EBRT (coded as EBRT by UNOS, inclusive of all dose and fractionation schedules). Clinicopathologic parameters, defined as the earliest available recorded value starting from waiting list registration, were compared in patients receiving or not receiving EBRT using Kruskal-Wallis or chi-square tests, as applicable. <h3>Results</h3> We identified 18,447 HCC patients who submitted MELD exception applications during the study period. Ultimately, 11,171 patients received a liver transplant (60.6%) at a median of 7 months (IQR: 4-11) from exception application. 15,759 (85.4%) patients received any liver-directed therapy (LDT). A total of 658 patients received EBRT either alone or in combination with other LDTs (3.6% of the overall cohort). EBRT utilization among all patients increased over time, with an average annual percent increase of 14%. Use of EBRT significantly differed by region, with region 10 (MI, OH, IN) having the largest proportion of patients receiving EBRT (8.7%) compared to region 3 (FL, GA, MS, AL, LA, AR) having the lowest (1.7%, <i>P</i> < 0.001). No statistical difference was detected in EBRT vs. no EBRT groups in regards to tumor size, total bilirubin, presence of portal vein thrombosis, or alpha-fetoprotein level (<i>P</i> > 0.05). <h3>Conclusion</h3> In this first study evaluating national data for the use of EBRT as a bridging therapy for HCC patients awaiting liver transplantation, EBRT was used rarely compared to other LDTs. Although it is becoming more prevalent over the last decade, EBRT continues to be under-utilized relative to other LDTs. As an established safe and effective bridging therapy for HCC, low national utilization of EBRT (and in turn, SBRT) highlights a real-world gap in the treatment armamentarium for HCC and an opportunity to improve the care of patients with advanced liver disease needing liver transplantation.