Post-orthotopic Liver Transplantation Research Articles

Noninvasive Intracranial Pressure Morphology in Acute Liver Failure: Pre- and Post-orthotopic Liver Transplantation (P7-2.003)

Noninvasive Intracranial Pressure Morphology in Acute Liver Failure: Pre- and Post-orthotopic Liver Transplantation (P7-2.003)

Early Intra-Abdominal Bacterial Infections after Orthotopic Liver Transplantation: A Narrative Review for Clinicians.

Despite recent advances in the transplant field, infectious complications after orthotopic liver transplantation (OLT) are major causes of morbidity and mortality. Bacterial intra-abdominal infections (IAIs) are predominant during the first month post-transplantation and affect patient and graft survival. Recently, the emergence of multidrug resistant bacteria has generated great concern in OLT patients. We performed this narrative review of the literature in order to propose a "ready-to-use" flowchart for reasoned empirical antibiotic therapy in the case of suspected post-OLT IAIs. The review was ultimately organized into four sections: "Epidemiology and predisposing factors for IAI"; "Surgical-site infections and perioperative prophylaxis"; "MDRO colonization and infections"; and "Reasoned-empirical antibiotic therapy in early intra-abdominal infections post OLT and source control". Multidisciplinary teamwork is warranted to individualize strategies for the prevention and treatment of IAIs in OLT recipients, taking into account each patient's risk factors, the surgical characteristics, and the local bacterial epidemiology.

Spontaneous middle lobe torsion: An institutional case series.

Lobar torsion is a rare occurrence in which a portion of the lung is twisted on its bronchovascular pedicle. The vast majority are observed in the acute postoperative period often following right upper lobectomy. Spontaneous middle lobe torsion independent of pulmonary resection is exceptionally rarer; fewer than 15 cases have been recorded. We present an institutional case series of 2 patients postorthotopic liver transplantation who developed spontaneous middle lobe torsion due to large pleural effusions. We provide the medical course as well as intraoperative techniques for our 2 patients along with a review of the literature. Both patients in this case series underwent orthotopic liver transplant complicated postoperatively by a large pulmonary effusion. Patient one developed an abdominal hematoma requiring evacuation and repair, after which he developed progressive shortness of breath. Bronchoscopy revealed a right middle lobe obstruction; upon thoracotomy, 180-degree torsion with widespread necrosis was evident and the middle lobe was removed. He is doing well to date. Patient 2 experienced postoperative pleural effusion and mucus plugging; computed tomography revealed abrupt middle lobe arterial occlusion prompting urgent operative intervention. Again, the middle lobe was grossly ischemic and dissection revealed a 360-degree torsion around the pedicle. It was resected. He is doing well to date. As the result of its rarity, radiographic and clinical diagnosis of spontaneous pulmonary lobar torsion is challenging; a high index of suspicion for spontaneous middle lobe torsion must be maintained to avoid delays in diagnosis. Prompt surgical intervention is essential to improve patient outcomes.

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?

Abstract 14374: Clinical and Echocardiographic Characteristics of Patients Who Develop Post Liver Transplant Non-Ischemic Cardiomyopathy

Background: Non-ischemic cardiomyopathy is a well-known but poorly understood cardiac complication post orthotopic liver transplantation (OLT). Methods: We performed a nested case control study in a cohort of 590 patients who underwent OLT at Loma Linda University between 2013 - 2021. 29 (4.9%) patients developed post-OLT non-ischemic cardiomyopathy. 100 patients who did not develop cardiomyopathy were selected randomly from the cohort to serve as control group. Clinical characteristics of cases and controls were compared and echocardiograms of patients who developed cardiomyopathy reviewed. Results: Patients who developed cardiomyopathy were more likely to be female, less likely to have history of hypertension, had lower baseline hemoglobin and platelets, and higher MELD scores ( Table 1) . Mean pre-transplant ejection fraction (EF) was 69% among patients who developed cardiomyopathy. Cardiomyopathy developed on average 10 days after OLT with mean EF dropping to 26%. 24 (83%) patients had reduced EF (<40%) and 5 (17%) had mid-range EF (40-49%). Wall motion analysis revealed global hypokinesis in 11 (38%) patients, mid-ventricular takotsubo in 11 (38%) patients, apical takotsubo in 5 (17%) patients, and basal takotsubo in 2 (7%) patients (Figure 1) . 24 (83%) patients recovered EF (≥ 50%) on average of 113 days after initial diagnosis of cardiomyopathy. Conclusions: Female sex and higher MELD scores were associated with development of non-ischemic cardiomyopathy post OLT. Global hypokinesis and mid-ventricular takotsubo were the most common patterns of wall motion abnormality. EF recovery was noted in majority of patients indicating operative stress related etiology.

S2572 Bleeding Duodenal Varix Treated With Hemostatic Clips

Introduction: Duodenal varices are a rare etiology of upper gastrointestinal bleeding with a prevalence of 0.4% in patients with portal hypertension undergoing esophagogastroduodenoscopy (EGD). Ectopic varices account for 1–5% of variceal bleeding, of which 17–40% are estimated to occur within the duodenum. Definitive guidelines on the management of duodenal varices, which have an estimated mortality rate of 40%, have not been established. We report the use of hemostatic clips to achieve hemostasis in a case of a bleeding duodenal varix due to portal hypertension in an orthotopic liver transplant patient with a dysfunctional mesocaval shunt. Case Description/Methods: A 42-year-old female with advanced liver cirrhosis (MELD 17) secondary to alcohol use and primary biliary cholangitis status post orthotopic liver transplantation complicated by portal vein thrombosis and biliary stricture for which she underwent mesocaval shunting and biliary reconstruction with recurrent portal hypertension. She presented with one day of bright red blood per rectum. On admission, her vital signs were significant for hypotension (81/61 mmHg) and tachycardia (132 bpm). Her hemoglobin was 7.6 g/dL (baseline 12 g/dL). Computed tomography angiography was remarkable for prominent proximal duodenal mucosal varices, portosystemic shunting with prominent splenorenal and gastric/gastroesophageal varices, and portal vein thrombosis. EGD was significant for a large (>5 mm) actively bleeding varix in the second portion of the duodenum, for which two hemostatic clips were successfully placed with resolution of bleeding. The patient remained hemodynamically stable post-procedure and was transferred to her transplant center for further management with no further bleeding episodes. Discussion: Alcoholic-associated liver disease (ALD) is one of the most common causes of cirrhosis. As the incidence and prevalence of ALD continues to rise, it is important that management of duodenal variceal bleeding becomes more standardized. Only a few cases have reported the use of hemostatic clips in these patients. Treatment options include band ligation, coiling, cyanoacrylate injection, balloon-occluded retrograde transvenous obliteration, and transjugular intrahepatic portosystemic shunt. Standardized treatment modalities for duodenal variceal bleeds have not been well-established and further studies are required to investigate appropriate management strategies. Our case demonstrates that hemostatic clips can be effectively used to achieve hemostasis (Figure 1).Figure 1.: (A) Computed tomography angiography (CTA) revealing prominent proximal duodenal mucosal varices, likely from the superior mesenteric vein. (B) Esophagogastroduodenoscopy (EGD) demonstrating a large (>5 mm) actively bleeding varix in the second portion of the duodenum. (C) EGD demonstrating hemostatic clips placed on the duodenal varix with resolution of bleeding.

S2910 Transcatheter Aortic Valve Replacement Restoring Candidacy for Liver Transplant in Cirrhotic Patients

Introduction: Current guidelines for preoperative workup for an orthotopic liver transplant (OLT) recommend echocardiogram and cardiac testing that classically rule-out patients with superimposed severe aortic stenosis as transplant candidates. We evaluated the potential of transcatheter aortic valve replacement (TAVR) as a bridging therapy to restore the candidacy of cirrhotic patients with severe AS for liver transplant. Case Description/Methods: A retrospective chart review was performed on 472 patient records that underwent liver transplants at a single large tertiary care center between 2017 and mid-2021. We identified patients who had a history of severe aortic stenosis corrected by TAVR. We extracted demographic and long-term outcome data. Two patients underwent the TAVR procedure which alleviated AS and allowed for reinstatement of eligibility for OLT. Evaluation at 1-month, 3-months and 1-year post-liver transplant showed no complications in the function of or related to the prosthetic aortic valves. Patient survival at 1 year and 2 years post-transplant was 100%. Mean time of follow-up post-transplant was 27 months. Graft survival at 1 year and 2 years was 100% with no evidence of rejection. Both 1 year and 2-year follow-up labs showed that patients were normotensive and had lipid profiles within the normal range. One of the patients had baseline high HbA1c consistent with their history of type 2 diabetes that continued to show in their follow-up labs while the other had normal glucose and HbA1C throughout. Noteworthy post-transplant complications included a left lower quadrant hematoma in one patient which resolved spontaneously and alcoholic recidivism managed through transplant psychiatry care. One patient did have a left-sided facial droop and right-sided pronator drift two days following the liver transplantation. CTA showed 74% stenosis of the right ICA and MRI confirmed hypoxic ischemia. Facial droop and drift resolved upon revaluation a few hours after onset. (Table) Discussion: In the setting of these growing contraindicated problems of AS and liver cirrhosis, we wanted to contribute to the currently scarce compilation of case reports that illustrates the effect that the TAVR procedure has on relieving the pre-transplantation risks of aortic stenosis in high-risk patients. The patients do have the potential for other cardiovascular diseases long-term and should be monitored closely with modification of risk factors. Table 1. - This is a comparison of echocardiogram parameters of aortic valve morphology and function for both patients #1 and #2 before and after TAVR as well as after OLT Parameters Patient #1 Patient #2 Before TAVR After TAVR After OLT Before TAVR After TAVR After OLT Aortic valve peak gradient (mmhg) 16.9 12.2 16.6 67.7 51.4 50.0 Aortic valves mean gradient (mmhg) 8.4 5.8 9.8 38.3 24.5 25.5 Left ventricular ejection fraction (%) 61 46 55 >70 67 63 Aortic valve area, Vmax (cmÂ2) 2.22 1.53 3.12 0.92 0.98 1.18 The post-TAVR parameters occurred 2 days after the procedure for patient #1 and <6 months for patient #2 due to care referral to our offices. The post OLT echo parameters were measured two months after patient #1's transplant and 4 days after patient #2 transplant.

S3064 Intestinal Post-Transplant Lymphoproliferative Disorder

Introduction: Post-transplant lymphoproliferative disease (PTLD) is a group of lymphoid disorders arising in the setting of immunosuppression following a solid organ or stem cell transplantation. PTLD impacts 2.8% of adults and 15% of children post-orthotopic liver transplant (OLT) at a median of 8 years. The small intestine, rich in B cells, is a common site for PTLD and the treatment is chemotherapy. Here, we present a case of a patient post-OLT presenting with abdominal pain, and anemia found to have small bowel PTLD resulting in jejunal perforation with eventual resolution of symptoms after surgical resection and chemotherapy. Case Description/Methods: 65-year old obese F with non-alcoholic steatohepatitis decompensated by hepatopulmonary syndrome with O2 dependence and hepatocellular carcinoma underwent an uneventful OLT (CMV +/-) with no immediate postoperative complications and resolution of the hepatopulmonary syndrome. Presented 2 months after the OLT with worsening LLQ abdominal pain and acute anemia. An EGD and colonoscopy completed shortly after admission showed evidence of gastric, duodenal, and descending colon non-bleeding ulcers that were biopsied. Pathology showed EBV+ atypical B cell proliferation concerning for large B cell lymphoma and monomorphic-PTLD. An EBV viral load obtained at that time was elevated and subsequent CT Abdomen/Pelvis showed scattered small sub-centimeter mesenteric and retroperitoneal lymph nodes. Her immunosuppression was minimized without a change in symptoms. She subsequently developed large volume haematochezia leading to shock and underwent an EGD and colonoscopy followed by a push enteroscopy that revealed multiple ulcers but no active bleeding site. Immediately after the procedure, she developed an acute abdomen due to a perforated Jejunal ulcer. Had an emergent exploratory laparotomy and jejunectomy with subsequent improvement in her anemia. She was treated with R-CHOP for PTLD with the resolution of her presenting symptoms. Discussion: PTLD, however rare, remains the commonest post-transplant malignancy. Once there is suspicion (pain, weight loss, and anemia post OLT), EGD/Colonoscopy reveals suspicious malignant-looking ulcers, and mucosa or lymph node biopsy confirms PTLD. The patient ultimately underwent treatment with 4 cycles of R-CHOP with surveillance EBV PCR and imaging with resolution of complete symptoms. Immediate treatment should be started with lowering immune suppression and chemotherapy rather than waiting for self-resolution in PTLD cases.Figure 1.: Jejunal and Gastric ulcers (seen on prior scopes as well) were found on the Push enteroscopy just prior to the perforation of the bleeding jejunal ulcer and eventual surgical resection of the jejunum that resolved her anemia.

Endoscopic therapy using a self-expandable metallic stent with an anti-migration system for postorthotopic liver transplantation anastomotic biliary stricture.

BACKGROUNDEndoscopic therapy using multiple plastic stents (MPSs) is the standard therapy for postorthotopic liver transplantation (p-OLT) anastomotic biliary stricture (ABS). However, this approach demands repeated procedures. Recent studies using fully covered self-expandable metallic stents (FCSEMS) have shown encouraging results, but migration occurs in 10% to 40% of cases. The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system (Am-FCSEMS) in patients with p-OLT ABS.AIMTo evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.METHODSThis study was conducted in a private tertiary care centre in São Paulo, Brazil and was approved by our institution's Human Research Committee. From April 2018 to October 2020, regardless of previous endoscopic treatment (MPS or FCSEMS), 17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study. The exclusion criteria were pregnancy, nonanastomotic biliary or hilar stricture, hepatic artery stenosis/thrombosis, isolated biliary fistulae, a distance shorter than 2 cm from the stricture to the hepatic hilum, and patient refusal. The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that remained in place for a 12-mo period. Biliary sphincterotomy was performed in patients with native papilla, and an Am-FCSEMS (10 mm in final diameter and 60 or 80 mm in length) was placed (HanarostentTM MI Tech, Co). Balloon stricture dilation was performed only if necessary to introduce the stent.RESULTSThree patients were excluded due to loss to follow-up before stent removal. Among the 14 patients included and followed, 7 were women, and the average age was 56 years (range: 28-76). The average period of Am-FCSEMS placement was 362 ± 109 d. Technical success occurred in all 14 patients (100%). There were no cases of distal stent migration. Complete resolution of the stricture occurred in 13/14 patients (92.85%). Adverse events occurred in 3/14 patients (21.42%): 2 patients with mild acute pancreatitis (14.28%) and 1 patient (7.14%) with stent dysfunction (occlusion by biliary sludge and stones, which was treated endoscopically without the need for stent removal). No deaths occurred related to therapy. All stents were removed using foreign body forceps or snares without difficulty. After Am-FCSEMS removal, all 13 patients who had ABS resolution were followed-up for an average of 411 ± 172 d, and there was no stricture recurrence or need for further endoscopic therapy.CONCLUSIONIn this retrospective study, endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective, with a high stricture resolution rate that was probably due to the absence of stent migration.

Recurrent Catatonia Pre- and Postorthotopic Liver Transplant

Recurrent Catatonia Pre- and Postorthotopic Liver Transplant

Lack of alloimmunization to the D antigen in D‐negative orthotopic liver transplant recipients receiving D‐positive red blood cells perioperatively

D-negative patients undergoing orthotopic liver transplantation (OLT) might require a large number of red blood cell (RBC) units, which can impact the inventory of D-negative blood. The blood bank might need to supply these patients with D-positive RBCs because of inventory constraints. This study evaluates the prevalence of anti-D formation in D-negative OLT patients who received D-positive RBCs perioperatively, as this will assist in successful patient blood management. This was a retrospective study performed at a single academic medical centre. Electronic medical records for all 1052 consecutive patients who underwent OLT from January 2007 through December 2017 were reviewed. D-negative patients who were transfused perioperatively with D-positive RBCs and had antibody screening at least 30 days after transfusion were included. Of a total of 155 D-negative patients, 23 (14.8%) received D-positive RBCs perioperatively. Seventeen patients were included in the study. The median age was 54 years (range 36-67 years); 13 (76.5%) were male. The median number of D-positive RBC units transfused perioperatively was 7 (range 1-66 units). There was no evidence of D alloimmunization in any patient after a median serologic follow-up of 49.5months (range 31 days to 127.7months). The average number of antibody screening post OLT was 7.29. Our study showed that transfusion of D-positive RBCs in D-negative OLT recipients is a safe and acceptable practice in the setting of immunosuppression. This practice allows the conservation of D-negative RBC inventory.

Liver allograft findings of donation after cardiac death versus brain death in recipients with hepatitis C related cirrhosis: a matched histologic comparison

As the demand for organ transplantation increases, utilization of liver allografts of donation after cardiac death (DCD) is becoming increasingly necessary. Althoughthe clinical outcomes of DCD allografts have been well described, the histologic features are not well characterized. Liver biopsies (n=131) from age-matched DCD (n=60) and donation after brain death (DBD; n=71) recipients with hepatitis C virus were compared. Histologic features were studied in a blinded fashion, subgrouped into time 0, 0-6 months, and >6 months. In time 0 biopsies, more DCD cases had zone 3 (43.8 vs 29%) and bridging necrosis (19 vs 0%), albeit not statistically significant. At 0-6 months, more DCD cases had portal edema (p=0.01). Pericholangitis (30.4% vs 18.8%) and acute cholestasis (21.7% vs 12.5%) were more common in DCD, but not statistically significant. At >6 months, pericholangitis (19% vs 4.5%) persisted in DCD, although not statistically significant. Overall, both groups had similar bile duct injury, portal inflammation, and fibrosis. Postoperative biliary complications were more common in DCD (19% vs 0%). Three-year and 10-year graft survival and patient outcomes were similar in both cohorts. Biliary alterations were more prevalent in the 0-6 month time period DCD biopsies, reflecting increased vulnerability of this group to biliary complications in the early post-orthotopic liver transplant (OLT) period. This finding may suggest poor graft perfusion despite comparable cold ischemia times. However, these features improved and DCD recipients have similar graft and overall survival compared to DBD recipients, indicating that carefully selected DCD liver allografts are a viable option for transplantation.

Eliminated routine postorthotopic liver transplant antibiotics in uncomplicated patients leads to equivalent safety outcomes.

The purpose of this retrospective study was to evaluate safety and efficacy end points of a postoperative antibiotic prophylaxis protocol in liver transplant (LT) patients, which was revised to limit antibiotic use. In the routine antibiotics group (RA), patients routinely received prophylactic antibiotics for around 3 days postoperatively for a variety of rationales, versus the limited antibiotics group (LA), in which patients received antibiotics for the treatment of secondary peritonitis. Patients were included if they were 18 or older and underwent liver transplant between January 2016 and September 2019. In total, 216 patients remained after exclusion: 118 patients in the RA group and 98 patients in the LA group. We detected a significant difference in the primary end point of postoperative antibiotic days of therapy. The median days of therapy was 2 for the RA group and 0 for the LA group (P < 0.005). Significantly fewer patients received only intraoperative antibiotics in the RA group versus the LA group: 42 (35.6%) versus 76 (73.5%) respectively (P < .005). There was no significant difference in secondary or safety outcomes, including surgical site infections. This study provides evidence that limiting the duration of prophylactic antibiotics postoperatively and treating most patients with only intraoperative antibiotics is safe.

New onset nonischemic cardiomyopathy post liver transplantation.

A new onset acute heart failure (HF) with a sudden drop in the left ventricular ejection fraction (LVEF) post orthotopic liver transplant (LT) is a rare but a potentially fatal complication. Because in most of the cases there is no evidence of coronary thrombosis, it can be classified as nonischemic cardiomyopathy. More specifically, clinical presentation of this syndrome shares many features with stress-induced or takotsubo cardiomyopathy. The known factors that predispose these patients to acute HF during or shortly after LT include cirrhotic cardiomyopathy, rapid hemodynamic changes during LT surgery, and the large concentrations of catecholamines, either administered or released endogenously during surgery. The hemodynamic changes during surgery, such as the drop in preload during the anhepatic phase (occasionally requiring massive transfusions and vasopressors) and subsequent increase in preload with acidic and hyperkalemic plasma in the reperfusion phase, lead to rapid electrolyte and hemodynamic shifts. In several cases, intraoperative onset of HF, with or without ventricular arrythmia, could be timed to the reperfusion phase (and occasionally in the anhepatic and pre-anhepatic phases). In other cases, the HF syndrome started hours to days post-surgery. Recovery of cardiac function occurred in the majority of patients during the same admission; however, these patients generally need significantly longer hospitalizations and aggressive supportive care (occasionally requiring mechanical ionotropic and ventilatory support). If recover, the patients have a similar 1-year mortality as those LT patients that did not have this complication. Because no reliable risk stratification currently exists, intraoperative transesophageal echocardiography might be the most dependable way of detecting and addressing this syndrome promptly. Given the mechanism of takotsubo cardiomyopathy, beta-blockade and a preferential use of non-catecholaminergic vasopressors may be a reasonable way to manage this syndrome.

S1790 Severe Pancolitis: The Battle Between Medications and Ischemia

Introduction: Mycophenolate Mofetil (MMF) is an essential drug in the treatment of solid organ transplant recipients (SOTRs) to maintain immunosuppression. Gastrointestinal side effects such as vomiting and diarrhea are common manifestations of its use; however, MMF-induced pancolitis with endoscopic findings of ischemic injury is an uncommon presentation. We illustrate a case of severe pancolitis secondary to chronic MMF use. Case Description/Methods: A 66-year-old female with a history of hepatitis C and hepatocellular cancer status post orthotopic liver transplant in 2015 presented to the emergency room with a 2-day history of nausea, diarrhea, and severe abdominal pain. There was no blood or mucous in her stool. Home medications included MMF 500mg twice daily and cyclosporine 75mg twice daily. Vitals showed a temperature of 37.4°C, pulse of 104 bpm, and normotension. Examination showed diffuse abdominal tenderness without rigidity or guarding. Labs significant for a mild leukocytosis. Stool cultures and Clostridium difficile testing were negative. A CT scan of the abdomen revealed pancolitis with diffuse colonic wall thickening and adjacent stranding. Subsequent sigmoidoscopy revealed severe stenosis with abnormal, friable, grey mucosa in the rectosigmoid colon that could not be traversed (Figure 1). Given concern for ischemia, CT angiography was performed and there was patency throughout the superior mesenteric artery, inferior mesenteric artery, and their branches. Histopathology results from the sigmoidoscopy was negative for cytomegalovirus and herpes simplex virus, but it did reveal chronic colitis with fibrin thrombi likely related to chronic ischemia versus drug-induced injury. Given the lack of prior prodromal illness, negative infectious workup, and no evidence of vessel occlusion, a diagnosis of MMF-induced pancolitis was made. MMF was discontinued and her symptoms improved with supportive care. Follow-up colonoscopy as an outpatient several weeks later demonstrated healing colitis. Discussion: MMF remains a mainstay in SOTRs, but gastrointestinal (GI) side effects such as nausea, vomiting, diarrhea, and abdominal pain remain prevalent. About a half of patients have normal colonoscopy evaluations, with colitis-like characteristics being the most common histologic finding. However, our patient had severe stenosis complicated by ischemic injury, which is an uncommon pattern. Clinicians should keep this diagnosis in their differential for patients on MMF who have persistent GI symptoms.Figure 1.: A) CT scan showing pancolitis with wall thickening. B) Sigmoidoscopy showed stenosis and abnormal mucosa in rectosigmoid colon.

S3374 Plastic vs Metal Stents for Anastomotic Biliary Strictures After Orthotopic Liver Transplant (OLT)

Introduction: Biliary anastomotic stricture is the most common complication of orthotopic liver transplantation (OLT) occurring in about 20% of cases. Endoscopic stent placement across the stricture with plastic or metal stents is the first-line treatment strategy. The aim of this study is to investigate the difference between plastic and metal stents in terms of anastomotic biliary stricture resolution and adverse events. Methods: This is a retrospective study of post OLT patients who underwent ERCP over a 3-year period between 2018-2020. Out of 178 post OLT patients who underwent ERCP, 108 were excluded because of only one ERCP performed and repeat ERCP was not indicated or because ERCP was performed for indications other than anastomotic biliary strictures. Data was collected up to 3 consecutive ERCP procedures during the studied period. Results: A total of 70 patients with anastomotic biliary strictures were included in the study. ERCP was performed on a native papilla in 32 (45.7%), advanced cannulation techniques were performed in 5 (7.1%), and prophylactic pancreatic stents were placed in 6 (8.6%) cases. Plastic stents (PS) were used in 53 (75.7%) of which multiple plastic stents were used in 27 cases, whereas 17 (24.3%) cases were treated with fully covered self-expanding metal stents (FCSEMS). Average follow up duration was 2.2 (1-3) months for PS and 3.7 (2-5) months for FCSEMS (P < 0.01). Biliary strictures resolved in 21 (30.0%) patients on repeat ERCP most of which from the FCSEMS group (58.8% vs 20.8%) (P = 0.009). Plastic stents were exchanged to FCSEMS in 11 (20.8%) patients during the second ERCP follow-up. On the third ERCP during the studied period, biliary strictures resolved in 71.4% of the FCSEMS group vs 33.3% of the PS group (P = 0.03). Using multiple plastic stents instead of a single plastic stent didn’t seem to improve biliary stricture resolution rate. Two patients (2.4%) developed post-ERCP pancreatitis, both patients had a native papilla and underwent FCSEMS placement with sphincterotomy and without pancreatic duct manipulation (P = 0.06). There was no difference between the stents used in terms of post-procedural cholangitis or stent migration rates. Conclusion: FCSEMS outperformed PS with respect to the anastomotic biliary stricture resolution rate over 3 endo-therapy sessions. Post-ERCP pancreatitis, although uncommon, occurred exclusively in the FCSEMS group.

Bisphosphonate therapy after liver transplant improves bone mineral density and reduces fracture rates: an updated systematic review and meta-analysis.

To investigate the efficacy of bisphosphonates and compare oral and IV formulations on bone mineral density (BMD) and fracture incidence in post-orthotopic liver transplant (OLT) patients. Electronic databases were searched, and six RCTs and three cohort studies were included out of 711 articles. Main outcomes included post-OLT BMD changes, fracture incidence, and treatment adverse reactions. Pairwise meta-analysis was conducted for binary and continuous outcomes, while pooled fracture incidence utilized single-arm meta-analysis. Post-OLT fracture incidence was reported in nine studies (n=591). Total fracture incidence was 6.6% (CI: 3.4-12.4%) in bisphosphonate group and 19.1% (CI: 14.3-25.1%) in calcium and vitamin D group. Total fractures were significantly lower in patients on bisphosphonate, compared to calcium and vitamin D (n=591; OR=0.037; CI: 0.18-0.77; P=0.008). Overall fractures were significantly lower in the oral group (n=263; OR=0.26; CI: 0.08-0.85; P=0.02) but not in the IV group (n=328; OR=0.45; CI: 0.16-1.26; P=0.129). Both oral and IV bisphosphonates are effective in reducing fracture incidence post-OLT compared to calcium and vitamin D. Oral formulations may also have an advantage over IV in reducing bone loss and fracture incidence post-OLT.

Transplantation of liver from hepatitis C-infected donors to hepatitis C RNA-negative recipients: Histological and virologic outcome.

The virologic and histologic outcomes of a hepatitis C virus (HCV)-infected liver graft into an HCV-negative recipient are not well understood. We aimed to evaluate thesustained virologic response(SVR)rate and the liver histology at 1year post-Orthotopic liver transplantation (OLT) with an HCV-infected graft. A total of 33 patients received the HCV antibody (Ab)+/nucleic acid amplification test (NAT)+ graft. Of these patients, 23 were HCV-negative recipients and 10 were HCV-positive recipients. The 1-year biopsy data were available for 24 patients: 15 patients in HCV-negative group who received an HCV Ab+/NAT+graft and 9 patients in HCV-positive group who received an HCV Ab+/NAT+ graft. Patients with (+) HCV ribonucleic acid (RNA) were started ondirect-acting antiviral (DAA) treatment approximately 107days after OLT using either a Glecaprevir-Pibrentasvir or Sofosbuvir-Velpatasvir or Sofosbuvir-Ledipasvir. All patients (n=33) were treated withDAA and achieved SVR. The 1-year post-OLT liver biopsies were available in 24 patients: 9 patients had F1 and F2 fibrosis and 17 patients had minimal to moderate inflammation.There was no statistical difference in fibrosis and inflammation between the HCV-negative vs. HCV-positive recipients. All patients who received the NAT+ graft developed viremia and subsequently achieved SVR with treatment. At 1year protocol liver biopsy, patients had inflammation consistent with viral hepatitis despite the successful eradication of HCV.

Acute Heart Failure Post Liver Transplantation: A Systematic Literature Review

Purpose Acute severe heart failure (HF) developing shortly, within hours or days, after orthotopic liver transplantation (OLT) is a known but poorly understood phenomenon. The pattern of echocardiographic changes with profound drop in left ventricular ejection fraction (LVEF) and regional wall motion abnormalities typically matches Takotsubo cardiomyopathy. Our purpose is to conduct a literature review and analysis of all the published cases that had acute severe HF after OLT. Methods We found 20 published peer reviewed case studies that described cases of HF after OLT with individual patient data available. We excluded cases of patients that had any transplant other than liver. We compiled and analyzed all the available data from each of these cases using an Excel spreadsheet. Results Our final sample had 63 patients, 56% of which were males, who developed acute HF post OLT with a mean age of 55±10, median of 57, and ranging 26-73.The average Model for End-Stage Liver Disease score was 26 ±8. In 31 patients, ischemic evaluations were performed with either a nuclear stress, dobutamine stress, or angiography and almost all (97%) of them had no evidence of ischemia. Of the 49 patients with Biomarker data, 45 (92%) had a rise in cardiac markers (troponin or CKMB). Of the 17 patients with ECG data, 10 (59%) had abnormalities at the time of HF and 8 out of 9 (89%) had a prolonged QTc. On average, acute HF developed in 1.9 ± 2.7 days after OLT (median 1 day). The mean Left Ventricular Ejection Fraction (LVEF) prior to surgery was 62.2% ±7.3 and dropping to a mean of 23.2% ± 8.2 after surgery. Of the 39 cases with known outcomes, 9 (23%) had died and five of them for cardiac reasons. 28 (72%) had full EF recovery, 5 (13%) had incomplete EF recovery, and 6 (15%) had no EF recovery. The average Recovered LVEF was 51.4% ± 13.1. Of 54 patients with reported echocardiographic findings, 52 (96%) had findings that were consistent with Takotsubo Cardiomyopathy. Conclusion Acute HF post liver transplant is diagnosed within hours to days after OLT and results in high mortality (23%). A rapid drop in LVEF with frequent recovery (85%), elevated cardiac enzymes, negative ischemic evaluation, and ECG changes suggest Takotsubo-like syndrome. The timing of changes suggests that most cases of takotsubo post liver transplant get triggered intraoperatively. Patients should be aggressively supported as they have a good potential for recovery.

S2740 A Case Report in Managing COVID-19 in a Liver Transplant Recipient

INTRODUCTION: Coronavirus Disease 2019 (COVID-19) is a pandemic impacting the entire globe, with over 5.3 million cases worldwide and 1.6 million US cases. Given the scarcity of information on COVID-19 infections in liver transplant patients, this case explores a patient 7 months post-liver transplant on immunosuppression who presented with COVID-19. CASE DESCRIPTION/METHODS: The patient was a 67-year-old female with a past medical history of alpha-1-antitrypsin cirrhosis status post orthotopic liver transplant (OLT) in October 2019, COPD, hypertension, CKD, and insulin-dependent diabetes. She was asymptomatic but tested positive at her nursing home on routine testing. Then lab work showed elevated liver function tests (LFTs)—AST 258, ALT 423, AP 210 from a normal baseline—which prompted the decision to bring her to the hospital. We held her Cellcept and continued her normal tacrolimus and prednisone dosing, 2 mg twice a day and 2.5 mg daily, respectively. We also continued her Mepron and Valcyte prophylaxis. During her 9-day course the only complications she had were fevers day 2–3 and profuse diarrhea day 3–6. Though low suspicion, we treated her empirically for a community-acquired pneumonia and possible C diff. We considered the administration of convalescent plasma but did not since she never became hypoxic. Her transaminitis—a phenomenon seen in 14.8–53% of COVID cases—persistently down-trended thus liver biopsy was not pursued. DISCUSSION: This patient was considered high-risk for decompensation given her age, medical history, and immunosuppression, however her clinical course was mild. Per AASLD guidelines we stopped her Cellcept and continued her tacrolimus and prednisone. We were concerned since kidney transplant patients tended to have poorer outcomes than the general population. The only literature on COVID in OLT patients was a case series from Italy with 6 patients which showed that short-term OLT recipients (<2 years) had better survival rates than long-term recipients (>10 years). The short-term group tended to have significantly higher rates of full immunosuppression, but had lower rates of comorbidities such as diabetes, hypertension, and kidney disease. Although our patient was a short-term recipient on immunosuppression, she was unique in that she had significant comorbidities. Her case demonstrates that OLT patient with a new transaminitis should be considered for COVID-19, and that their immunosuppressive agents may have a protective role against the infection.Table 1.: This table shows the trend of the patient’s LFTs from 1 month prior to admission determined to be her baseline on routine lab work, her admission LFTs (which was her peak), and her LFTs on discharge.