Undergoing Liver Transplant Evaluation Research Articles

The Complex Relationship Between Pain, Mental Health, and Quality-of-Life in Patients With Cirrhosis Undergoing Liver Transplant Evaluation.

Patients with cirrhosis undergoing liver transplant evaluation have high rates of pain and mental health comorbidities; both may significantly impair health-related quality of life (HRQL). We investigated the association between pain, anxiety/depression, and HRQL in this population. In 62 patients with cirrhosis undergoing liver transplant evaluation, we performed 4 validated assessments to characterize: pain (Brief Pain Inventory-Short Form, BPI-SF), anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-8), and liver-specific HRQL (Chronic Liver Disease Questionnaire). The presence of pain was determined using the BPI-SF screening question. Linear regression was used to identify demographic or clinical factors predictive of pain severity (PS) and interference (PI) and to evaluate the association between pain, anxiety/depression, and HRQL. Seventy-one percent of patients reported pain, 26% had clinical depression, and 24% had moderate-severe anxiety. Neither liver disease severity, nor its complications were associated with pain (PS or PI), but anxiety and depression were predictors of pain on bivariate analysis. Only depression remained a significant predictor of PS (b=0.28, P<0.05) and PI (b=0.30, P<0.05) in multivariable models. HRQL was inversely associated with PS, PI, depression, and anxiety, but only anxiety (b=-0.14, P=0.003) remained associated with HRQL in the adjusted model. Pain is present in over 70% of patients with cirrhosis undergoing liver transplant evaluation. Anxiety and depression were highly correlated with pain and appeared to be key drivers in predicting poor HRQL. Evaluating and managing mental health comorbidities should be explored as a strategy to improve HRQL in patients with cirrhosis and pain.

Patient-Reported Outcome Screens for Cognitive Dysfunction and Predicts Admissions in Cirrhosis

IntroductionHepatic encephalopathy (HE) is a frequent complication of cirrhosis, leading to preventable hospitalizations and increased mortality. Despite the availability of validated neuro-psychometric tests to diagnose HE, only 10% of clinicians regularly screen for HE due to lack of time, equipment, and trained personnel. Materials and MethodsWe studied the association between patient-reported cognitive function and the National Institutes of Health Toolbox Cognition Battery (a validated measure of HE) in patients with cirrhosis. A single-center prospective study of adult patients undergoing liver transplantation evaluation was performed from 10/2020 to 12/2021. Cognition was assessed using the National Institutes of Health Toolbox Cognition Battery and a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey. ResultsTwenty-three liver transplantation candidates were enrolled; the mean age was 56.4 (±9.7) years, 39% were female and the most common etiologies of cirrhosis were primary biliary cirrhosis/primary sclerosing cholangitis/overlap syndrome (30%), hepatitis C (22%) and alcohol-associated liver disease (22%). The mean MELD-Na was 14.9 (±6.4). The mean PROMIS Cognitive Function T-score (PROMISCF) was 49.2 (±9.6). The mean T-scores for the List Sort Working Memory test, Flanker Inhibitory Control and Attention test, and Pattern Comparison Processing Speed test were 46.4 (±9.9), 37.8 (±6.2), and 50.22 (±16.4), respectively. PROMISCF correlated with the List Sort Working Memory test (r = 0.45, P = .03). The mean hospitalization rate was 1.6 days admitted per month. On adjusted multivariate analysis, PROMISCF predicted total hospitalization days (P < .001), hospital admissions (P = .01), and hospitalization rate (P < .001). ConclusionsA brief survey can screen for HE and predict hospitalizations in patients with cirrhosis.

Resolution of hypogammaglobulinemia in a patient with immunodeficiency and decompensated cirrhosis

The liver plays an important but understudied role in humoral immunity. We present a case of a 62-year-old male with common variable immunodeficiency (CVID) previously on immunoglobulin replacement therapy (IGRT) and Hennekam syndrome. At the time of diagnosis 17 years ago, he was experiencing recurrent sinopulmonary infections. He was found to have low immunoglobulin (Ig) levels: IgG was 296 mg/dL, IgAwas 6 mg/dL, and IgM was 76 mg/dL. He had nonprotective titers to S. pneumoniae despite vaccination with pneumococcal polysaccharide vaccine-23. Immune workup was also notable for T cell lymphopenia requiring prophylactic trimethoprim/sulfamethoxazole. Even with IGRT, serum IgG remained in the 400–500 mg/dL range, likely due to “third-spacing” from his lymphatic disorder. However he did not have any significant infections while on IGRT. In the past year the patient was diagnosed with cirrhosis secondary to non-alcoholic steatohepatitis, and is undergoing liver transplant evaluation. He self-discontinued IGRT at the time of diagnosis. Six months after stopping IGRT the patient remained infection-free. Immunoglobulin panel revealed a serum IgG of 819 mg/dL, the patient’s highest recorded value.Elevated serum immunoglobulin levels have been observed in patients with advanced liver disease, however the pathophysiology is poorly understood. Several theories have been proposed. First, there is diminished ability of the failing liver to trap and clear antigens and endotoxins absorbed from the gut. The presence of portal hypertension results in increased systemic circulation of antigens and endotoxins, which leads to increased stimulation of plasma cells and thus increased production of immunoglobulin. In addition, patients with advanced liver disease have shown decreased capacity to catabolize immunoglobulin. Interestingly, at follow up the patient was found to have protective titers to S. pneumoniae, likely reflecting lingering antibodies from his infusions months prior. The patient is being monitored off IGRT.To our knowledge, this is the first case of resolving hypogammaglobulinemia in an immunodeficient patient with cirrhosis. It demonstrates an unforeseen consequence of cirrhosis in a patient requiring IGRT for CVID. Increases in IgG and IgM preceded transaminitis, highlighting the importance of delving deeper when there is unexplained resolution of hypogammaglobulinemia.

Approach to the patient with decompensated cirrhosis and aortic stenosis during liver transplantation evaluation.

Aortic stenosis (AS) is the most common valvular disease and is reported to be present in 2%-7% of people over the age of 65. Risk factors for aortic stenosis and NASH overlap; thus, as the population ages, there is an increased likelihood that patients undergoing liver transplantation evaluation may have severe aortic stenosis. There is a high mortality rate associated with cardiac surgeries in patients with cirrhosis. Further, there are no guidelines that assist in the decision making process for patients with cirrhosis and AS. In this review, we highlight key studies that compare transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) in patients with cirrhosis. We propose an algorithm as to how to approach the patient with aortic stenosis and considerations unique to patients with cirrhosis (i.e., anticoagulation, EGD for variceal assessment; need to determine timing after TAVI before listing).

Essential Tips for Hospice & Palliative Care Clinicians Caring for Patients with Advanced Liver Disease Undergoing Liver Transplant Evaluation (FR252)

Essential Tips for Hospice & Palliative Care Clinicians Caring for Patients with Advanced Liver Disease Undergoing Liver Transplant Evaluation (FR252)

Increasing prevalence of obesity and diabetes among patients evaluated for liver transplantation in a Swiss tertiary referral center: a 10-year retrospective analysis.

Non-alcoholic fatty liver disease (NAFLD) is now the first cause of chronic liver disease in developed countries. We aimed to assess trends in the prevalence of obesity, type 2 diabetes mellitus (T2DM) and NAFLD in patients undergoing liver transplantation evaluation and to assess whether obese patients were less likely to be listed or had an increased drop-out rate after listing. We conducted a retrospective study of all consecutive patients who underwent liver transplantation evaluation at a Swiss tertiary referral centre between January 2009 and March 2020. A total of 242 patients were included, 83% were male. The median age was 59 years (IQR, 51-64 years). The most common causes of end-stage liver disease were viral hepatitis (28%), alcoholic liver disease (21%) and NAFLD (12%). Obesity was present in 28% of our cohort, with a significant increase over time. Prevalence of type 2 diabetes mellitus followed the same trend (p = 0.02). The proportions of non-listed and listed obese patients did not differ (21% vs. 30% respectively; p = 0.3). The prevalence of obesity and type 2 diabetes mellitus significantly increased over our study period. Obese patients had similar chances of being listed. The landscape of liver transplantation indications is shifting towards NAFLD, highlighting the urgent need to prevent NAFLD progression.

Management of Acute Coronary Syndrome in Patients with Liver Cirrhosis.

Liver cirrhosis (LC) is becoming increasingly common among patients presenting with acute coronary syndromes (ACS) and is associated with significant cardiovascular morbidity and mortality. Management of such patients is complicated by LC related complications. Literature is scarce on the safety of antithrombotic regimens and invasive strategies for ACS in patients with LC, especially those undergoing liver transplant evaluation. Recently there has been evidence that cirrhosis is an independent risk factor for adverse outcomes in ACS. As patients with LC are generally excluded from large randomized trials, definitive guidelines for the management of ACS in this particular cohort are lacking. Many antithrombotic drugs require either hepatic activation or clearance; hence, an accurate assessment of hepatic function is required prior to initiation and dose adjustment. Despite a demonstrated survival benefit of optimal medical therapy and invasive revascularization techniques in LC patients with ACS, both strategies are currently underutilized in this population. This review aims to present currently available data and provide a practical, clinically oriented approach for the management of ACS in LC. Randomized clinical trials in LC patients with ACS are the need of the hour to further refine their management for favorable outcomes.

Utility of Framingham Score for Optimizing Preoperative Evaluation Among Patients Undergoing Liver Transplant Evaluation

Cardiac testing of candidates for liver transplant (LT) requires balancing risks and benefits of cardiac procedures. The goal of this study was to evaluate the utility of the Framingham score (FS) for optimizing preoperative risk stratification for coronary artery disease (CAD). In this single-center retrospective study of 615 adults undergoing LT evaluation from 2016 to 2019, data of preoperative evaluation, post-LT 1-year mortality, and post-LT cardiac events were reviewed. Patients >30 years of age with normal echocardiogram underwent FS calculation. Elevated FS (≥35%) patients were triaged to undergo angiogram for CAD evaluation; FS <35% patients underwent stress testing as initial CAD evaluation. Of 615 patients referred for LT, 481 underwent cardiac testing. Ninety-five were excluded from the FS pathway because of age, abnormal baseline echocardiogram, or known CAD. Of the remaining 386 patients in the FS pathway, 342 had a low FS and 44 had a high FS. In patients with low FS, 90% underwent stress testing as initial test; 16% underwent invasive testing at some time. In those with elevated FS, 59% underwent invasive testing as initial test. Listing rate and posttransplant outcomes were similar between patients with low and high FS. We demonstrated the feasibility of a simple algorithmic evaluation process using FS for optimizing pre-LT risk stratification for CAD. Although exceptions to the protocol occur, the proposed protocol allows for a streamlined approach by prioritizing testing based on cardiac risk. This approach may maximize diagnostic yield while limiting invasive procedures.

Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation

IntroductionPatients with end stage liver disease (ESLD) have a hyperdynamic state due to decreased systemic vascular resistance and increased cardiac output. Preoperative evaluation with dobutamine stress echocardiography (DSE) is used to risk-stratify patients prior to liver transplant. We sought to identify the impact of inducible left ventricular outflow tract obstruction (LVOTO) on DSE on post-operative liver transplant outcomes. MethodsPatients with ESLD who underwent liver transplant at Cleveland Clinic between January 2007 and August 2016 were identified. Pre-operative DSE data, and post-operative intensive care unit (ICU) data were extracted. Patients with inducible LVOTO were compared to those without LVOTO. ResultsOf the 515 patients identified who underwent DSE prior to liver transplant, 165 (30%) were female, and 95 (18%) had LVOTO. There were no major differences in baseline characteristics between the two groups. In the LVOTO group, rest gradients were 10.8 ± 3 mm Hg while peak gradients were 90 ± 48.2 mm Hg. No significant differences in ICU length of stay or duration of mechanical ventilation between both groups were noted. There were 21 deaths at 30 days. There were 2 (2.1%) deaths in the LVOTO group, versus 19 (4.5%) deaths in the non LVOTO group (p = 0.28). Higher Model for End Stage Liver Disease (MELD) scores predicted longer duration of mechanical ventilation and ICU length of stay. ConclusionInducible LVOTO on DSE does not adversely affect the short-term outcomes post liver transplant. Presence of inducible LVOTO should not be the mere reason to deny liver transplant among patients with ESLD.

Alcohol-related cirrhosis is associated with high coronary artery calcium scores in patients undergoing evaluation for orthotopic liver transplantation.

Coronary artery disease is a major cause of morbidity and mortality in liver transplant patients. Coronary artery calcium (CAC) score has been used to evaluate the risk of CAD in non-cirrhotic patients. However, its significance in cirrhotic patients is unknown. This study aimed to identify factors associated with elevated CAC scores in patients with end-stage liver disease undergoing liver transplant evaluation. We retrospectively reviewed all patients who underwent liver transplantation evaluation and had coronary CT scan between January 2015 and December 2018. Patients with prior history of CAD were excluded. CAC score was calculated based on the method described by Agatston. Sixty-two patients were included. 37.1% had alcohol-related liver disease and 27.4% had NASH cirrhosis. Mean CAC score was 261.1±SD, 463.84. Alcohol-related liver disease, male gender, and hypertension were significantly associated with CAC score >100 and only alcohol-related liver disease was associated with CAC score >300. In logistic regression, patients with alcohol-related liver disease had more than sixfold increase in risk of having CAC scores >100 and 300 (OR 6.14, and 6.70, respectively). Alcohol-related liver disease, male gender, and hypertension were significantly associated with an increased CAC score >100. However, alcohol-related liver disease was the only factor associated with CAC score >300.

Patient selection in liver transplantation for hepatocellular carcinoma

: Liver transplantation is the best therapy for selected patients with unresectable hepatocellular carcinoma (HCC). The worldwide incidence of the disease and the success of liver transplantation have produced a high demand, which has led different countries to adopt heterogeneous policies to allocate deceased donor livers for these patients. Even though tumor burden is the criteria with strongest evidence, there is continuous evolution of the interaction of factors that can improve the prediction of disease recurrence and long-term survival, such as tumor size, number of nodules, tumor volume, cancer-related symptoms, alpha fetoprotein serum level, imaging studies, pretransplant biopsy, response to liver-directed therapies and waiting time. In this manuscript, we summarize recent literature on the selection criteria of candidates with HCC undergoing liver transplant evaluation around the world. We review the evidence behind deceased donor liver allocation systems in different countries and the current role of living donor liver transplantation (LDLT). The largest studies come from United Network for Organ Sharing (UNOS) and European databases, however, there is high-impact data coming from Eastern countries with high HCC incidence and high-volume transplant centers, such as China, India, Japan, and South Korea. Soon, a slow shift towards transplant survival benefit in combination with overall survival may be observed in the allocation policies around the world.

S3272 Prevalence of Colonic Adenomas in Cirrhotic Patients Undergoing Pre-Transplant Evaluation: A Meta-Analysis and Systematic Review

INTRODUCTION: Multiple studies have suggested that the risk of advanced adenomas and colorectal cancer is not only higher in liver transplant patients, but also significantly increases post transplantation, particularly due to their immunocompromised state. As it stands, CRC screening recommendations in low to moderate risk liver transplant candidates are the same for those of the general population. This study aims to analyze the literature on the prevalence of adenomas in liver cirrhosis patients undergoing colonoscopy screening as part of their pre-transplant evaluation. METHODS: A systemic review was conducted in PUBMED, Embase, PubMed Central and ScienceDirect databases from inception through May 2020. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird and pooled event rates were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques. RESULTS: Eleven studies with a total of 4223 patients with cirrhosis undergoing liver transplant evaluation were included in this analysis. The pooled event rate for any adenoma was 21.2% (95% CI, 16.9%–26.2%), whereas the pooled event rate for advanced adenoma was 5.6% (95% CI, 2.7%–11.4%). The pooled event rate for adenocarcinoma was 0.7% (95% CI, 0.03%–1.7%), most of which were successfully resected endoscopically. CONCLUSION: This study suggests a considerable prevalence of adenomatous polyps and advanced lesions in this high-risk patient population, and hence, colonoscopy should be performed for every transplant candidate within the frame of the current ACG recommendations. Additionally, our results call for further risk-matched prospective studies to examine the need for earlier endoscopic surveillance in this cohort of patients.Figure 1.: Forrest plot, pooled event rate of any adenoma in cirrhotic patients undergoing transplant evaluation.Figure 2.: Forrest plot, pooled event rate of advanced adenomas in cirrhotic patients undergoing transplant evaluation.Figure 3.: Forrest plot, pooled event rate of adenocarcinoma in cirrhotic patients undergoing transplant evaluation.

Spotlight on Impactful Research: Utilization of Aspirin and Statin in Management of Coronary Artery Disease in Patients With Cirrhosis Undergoing Liver Transplant Evaluation.

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-reading-frankul a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-interview-frenette an interview with the author Answer questions and earn https://www.wileyhealthlearning.com/Activity/7036138/disclaimerspopup.aspx.

Non-selective beta blocker use is associated with improved short-term survival in patients with cirrhosis referred for liver transplantation

BackgroundRecent evidence cautions against the use of non-selective beta-blockers (NSBB) in patients with refractory ascites or spontaneous bacterial peritonitis while other data suggests a survival benefit in patients with advanced liver disease. The aim of this study was to describe the use and impact of NSBB in patients with cirrhosis referred for liver transplantation.MethodsA single-center cohort of patients with cirrhosis, who were referred and evaluated for liver transplantation between January and June 2012 were studied for baseline characteristics and clinical outcomes. Patients were grouped according to the use of NSBB at initial evaluation, with the endpoint of 90-day mortality.ResultsSixty-five (38%) of 170 consecutive patients evaluated for liver transplantation were taking NSBB. Patients taking NSBB had higher MELD and Child Pugh score. NSBB use was associated with lower 90-day mortality (6% vs. 15%) with a risk adjusted hazard ratio of 0.27 (95%CI .09–0.88, p = .03). Patients taking NSBB developed acute kidney injury (AKI) within 90 days more frequently than patients not taking NSBB (22% vs 11%), p = 0.048). However, this was related to increased stage 1 AKI episodes, all of which resolved. Twelve (27%) of 45 patients with > 90 day follow up discontinued NSBB, most commonly for hypotension and AKI, had increased subsequent MELD and mortality.ConclusionsNSBB use in patients with cirrhosis undergoing liver transplant evaluation is associated with better short-term survival. Nevertheless, ongoing tolerance of NSBB in this population is dynamic and may select a subset of patients with better hemodynamic reserve.

95 Prevalence of Intrapapillary Mucinous Neoplasm in Patients With Chronic Kidney Disease

INTRODUCTION: The prevalence of intraductal papillary mucinous neoplasm (IPMN) in the general population ranges from 3.3%–9.8%. In patients undergoing liver transplant evaluation, overall prevalence is documented to be 6.6%. So far, the suggested risk factors for IPMN include diabetes, family history of pancreatic adenocarcinoma, and tobacco use. We aim to study the prevalence and risk factors for IPMN formation in patients with chronic kidney disease (CKD). METHODS: We performed a retrospective cross-sectional study of patients with CKD who had MRIs of the abdomen performed between the dates of 1/2018 and 12/2018. Independent chart review was conducted and various demographic, clinical, and imaging metrics were extracted. Overall, the prevalence of IPMN was calculated. A student's t-test and chi-square test were used to compare the IPMN group to non-IPMN group. RESULTS: A total of 400 patients were reviewed. The total prevalence of IPMN in CKD patients was 13.7% (55/400). In 68% of the study patients, the MRI was done for a kidney transplant evaluation. The average age of patients in the study was 58 ± 14 years, 59% were male and 52% patients were on dialysis. Diabetes and Hypertension accounted for 26% and 45% of CKD respectively. In patients with IPMNs, the average size was 10 ± 5.7 mm; 45% were located in the head, 33% in the body and 22% in the tail. Notably, 16% were main duct IPMNs, 80% were side branch IPMNs and 4% patients had mixed (MD + SB) IPMNs. Amongst the patients with IPMNs, 7.5% of patients had associated high-risk features and were referred for endoscopic ultrasound. Comparison of the IPMN group to non-IPMN group is shown in Table 1. IPMNs were most commonly observed in elderly patients. Gender, dialysis status, etiology of CKD, smoking and alcohol intake did not seem to impact the prevalence of IPMN in CKD patients. CONCLUSION: Patients with CKD have a higher prevalence of IPMNs than the general population. We further aim to confirm this interval data with our age and gender matched control group without CKD.

Application of Prescription Drug Monitoring Program to detect underreported controlled substance use in patients evaluated for liver transplant.

Presurgical controlled substance use predicts postoperative complications, increased readmissions, and mortality. We aimed to examine if a Prescription Drug Monitoring Program (PDMP) would detect underreported controlled substance use in patients undergoing liver transplant evaluation. We performed a retrospective cohort study at a tertiary referral center of patients undergoing liver transplant evaluation in 2017. PDMP reviews were performed on all 360 patients and urine drug screen (UDS) results were reviewed when available to evaluate dispensed controlled substances. These results were compared to the patient's self-reported medication list at evaluation to identify any underreporting. The primary outcome was the number of self-reported controlled substance discrepancies on the medication list identified by PDMP and UDS at the time of evaluation. Among the 360 patients, 87 (24%) had a discrepancy where PDMP revealed a controlled substance prescription that the patient did not report on their medication list. Seventy-seven (67/87) of these discrepancies involved opiates. Of the 360 patients, 219 (61%) had a negative UDS, but 70 (32%) of these patients had at least one controlled substance listed on PDMP. PDMP is a promising screening tool when used in conjunction with the UDS for detecting underreported controlled substance use in liver transplant candidates.

03:18 PM Abstract No. 210 Association between modified BALAD score and locoregional therapy response in transplant waitlist patients with hepatocellular carcinoma: prospective, observational analysis at a high-volume transplant center

The BALAD score, a risk index combining threshold values for bilirubin, albumin, α-fetoprotein (AFP), des-γ-carboxy prothrombin (DCP), and Lens culinaris agglutinin-reactive α-fetoprotein (AFP-L3), has been useful in predicting survival and recurrence risk in hepatocellular carcinoma (HCC). This study seeks to correlate BALAD score with durable locoregional treatment response to doxorubicin-eluting bead transarterial chemoembolization (DEB-TACE). A single-center, prospective analysis was performed on patients undergoing liver transplant evaluation with HCC who were selected for down-staging or bridge-to-transplantation LRT with DEB-TACE. Blood was collected immediately prior to DEB-TACE in all patients. Plasma levels of AFP, DCP, and AFP-L3 were measured using the μTASWako i30 autoanalyzer. DEB-TACE was performed with 100-300μ LC beads mixed with 50mg Doxorubicin to near-complete stasis. Tumor response to DEB-TACE was calculated by mRECIST at 30-day and 3-month follow-up imaging. Cohort demographics were median age of 60, 69% male, 78% hepatitis C cirrhosis etiology, 88% within Milan criteria with an average MELD-Na score of 10. Median BALAD components were as follows: bilirubin 1.5 mg/dL, albumin 3.2 g/dL, AFP 7 ng/mL, AFP L3% 8, and DCP 2.8 ng/mL. Median follow up imaging for durable tumor response was 112 days. Fifty-percent of cohort had a complete response to DEB-TACE. Univariate analysis revealed BALAD score was associated with response to DEB-TACE (P=0.04), with 73% of patients with BALAD ≥ 2 not responding to DEB-TACE. BALAD component analysis revealed tumor biomarker thresholds poorly modeled to the dataset. The BALAD biomarker cutoffs were modified from AFP 400ng/mL to 20ng/mL, AFP-L3% from 15% to 10%, and DCP 1.9ng/mL to 7.5ng/mL decreasing the corresponding P-value (0.04 to 0.02) between BALAD and treatment response. Waitlist dropout after DEB-TACE for patients with modified-BALAD ≤ 1 was 5%. By combining metrics for liver synthetic function with biomarkers of HCC aggressiveness, the BALAD can identify HCC resistance to embolization therapy and risk of waitlist dropout.

Utilization of aspirin and statin in management of coronary artery disease in patients with cirrhosis undergoing liver transplant evaluation.

Coronary artery disease (CAD) assessment is a vital part of liver transplantation (LT) evaluation, as it allows for identification and medical optimization prior to transplantation. Although aspirin and statins are standard of care for CAD, they are not universally used in cirrhosis due to concerns about adverse events. Per protocol, coronary angiography was performed as part of the LT evaluation in all patients over the age of 50 years or with CAD risk factors, even if they were younger than 50. Optimal CAD medical management was defined as the use of both statin and aspirin, unless a contraindication was documented. Impact of these medications on hepatic decompensation, renal function, gastrointestinal bleeding, and need for transfusion was evaluated. CAD was detected in 84/228 (36.8%) patients. Lipid profile was similar in patients with and without CAD. In patients with CAD, statins were started in 19 (23%), while aspirin was used in 30 (36%) patients. In patients with obstructive or multivessel CAD, statin therapy was used only in 41% and 65%, respectively. Statins were more likely to be prescribed in patients with diabetes (32% versus 15%, P = 0.05) and history of dyslipidemia (38% versus 15%, P = 0.02). Use of statin therapy was not linked to hepatic decompensation, hospitalization, or rise in Model for End-Stage Liver Disease (MELD). Similarly, use of aspirin therapy was not associated with increased risk acute variceal hemorrhage, gastrointestinal bleeding, or worsening anemia. In conclusion, in decompensated cirrhosis, lipid profile alone is unable to risk stratify patients with CAD. Statin and aspirin appear to be safe. However, they are significantly underutilized for the management of CAD in this patient population. Liver Transplantation 24 872-880 2018 AASLD.

Coronary artery disease in decompensated patients undergoing liver transplantation evaluation.

Coronary artery disease (CAD) is an important contributor to morbidity and mortality in patients undergoing liver transplantation (LT). However, the current literature is limited by sampling bias and nondefinitive assessment of CAD. The current study examines the prevalence of CAD via per protocol coronary angiography and its relationship to etiology of liver disease in patients undergoing liver transplantation evaluation (LTE). Data on 228 patients were prospectively collected who had coronary angiography as part of LTE between 2011 and 2014. Coronary angiography was done in all patients age ≥50 years or with CAD risk factors. CAD was defined as any coronary artery stenosis, whereas stenosis ≥ 70% in distribution of 1 or 3 major coronary arteries was considered as single- or triple-vessel disease. CAD was detected in 36.8% of patients, with the highest prevalence among nonalcoholic steatohepatitis (NASH) patients with cirrhosis (52.8%). Prevalence of single-vessel disease was higher among patients with NASH compared with hepatitis C virus (HCV) and alcoholic cirrhosis (15.1% versus 4.6% versus 6.6%; P = 0.02). Similarly, patients with NASH were more likely to have triple-vessel disease when compared with HCV and alcoholic cirrhosis (9.4% versus 0.9% versus 0%; P = 0.001). While adjusting for traditional risk factors for CAD, only NASH as etiology of liver disease remained significantly associated with CAD. Complications from diagnostic coronary angiography or percutaneous coronary intervention were low (2.6%). In conclusion, patients undergoing LTE have a high prevalence of CAD, which varies widely depending on etiology of liver cirrhosis. The procedural complications from coronary angiography are low. Liver Transplantation 24 333-342 2018 AASLD.

CORRELATION BETWEEN ECHOCARDIOGRAPHIC PULMONARY ARTERY PRESSURE ESTIMATES AND RIGHT HEART CATHETERIZATION MEASUREMENTS IN PATIENTS UNDERGOING LIVER TRANSPLANT EVALUATION: A SINGLE CENTER STUDY

Background: Pulmonary hypertension is a major adverse outcome indicator in patients undergoing liver transplant evaluation. We aim to examine the correlation between pulmonary artery systolic pressure calculated from echocardiography (ePASP) and measurement from right heart catheterization (cPASP)