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The corona virus disease 2019 (COVID‐19) pandemic has had a wide‐ranging impact on the clinical practice of medicine and emotional well‐being of providers. Our aim was to determine the impact of the COVID‐19 pandemic on practice and burnout among hepatology providers. From February to March 2021, we conducted an electronic survey of American Association for the Study of Liver Diseases (AASLD) members who were hepatologists, gastroenterologists, and advanced practice providers (APPs). The survey included 26 questions on clinical practice and emotional well‐being derived from validated instruments. A total of 230 eligible members completed the survey as follows: 107 (47%) were adult transplant hepatologists, 43 (19%) were adult general hepatologists, 14 (6%) were adult gastroenterologists, 11 (5%) were pediatric hepatologists, 45 (19%) were APPs, and 9 (4%) were other providers. We found that 69 (30%) experienced a reduction in compensation, 92 (40%) experienced a reduction in staff, and 9 (4%) closed their practice; 100 (43%) respondents reported experiencing burnout. In univariate analysis, burnout was more frequently reported in those ≤55 years old (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2‐4.2), women (OR, 2.2; 95% CI, 1.3‐3.7), nontransplant hepatology (OR, 2.0; 95% CI, 1.1‐3.3), APPs (OR, 2.7; 95% CI, 1.4‐5.1), and those less than 10 years in practice (OR, 1.9; 95% CI, 1.1‐3.3). In multivariable analysis, only age ≤55 years was associated with burnout (OR, 2.3; 95% CI, 1.1‐4.8). The most common ways the respondents suggested the AASLD could help was through virtual platforms for networking, mentoring, and coping with the changes in practice due to the COVID‐19 pandemic. Conclusion: The COVID‐19 pandemic has had a substantial impact on the clinical practice of hepatology as well as burnout and emotional well‐being. Women, APPs, and early and mid‐career clinicians more frequently reported burnout. Identified strategies to cope with burnout include virtual platforms to facilitate networking and mentoring.

ABSTRACT IMPACT: Many who suffer from end-stage organ disease do not qualify for solid organ transplantation because of obesity; however, bariatric surgery offers the potential to render select patients transplant-eligible, and in some cases, may lead to weight loss that is sufficient to reverse end-stage organ disease. OBJECTIVES/GOALS: As obesity prevalence grows, more end-stage organ disease patients will be precluded from transplant. Numerous reports suggest bariatric surgery in end-stage organ disease may help patients achieve weight loss sufficient for transplant listing, though the published data are limited. METHODS/STUDY POPULATION: We performed a systematic review/meta-analysis of studies of bariatric surgery to achieve solid organ transplant listing. RESULTS/ANTICIPATED RESULTS: Among 82 heart failure patients, 40.2% lost sufficient weight for listing, 29.3% were transplanted, and 8.5% had sufficient improvement with weight loss they no longer required transplantation. Among 28 end-stage lung disease patients, 28.6% lost sufficient weight for listing, 7.1% were transplanted, and 14.3% had sufficient improvement following weight loss they no longer required transplant. Among 41 cirrhosis patients, 58.5% lost sufficient weight for listing, 41.5% were transplanted, and 21.9% had sufficient improvement following weight loss they no longer required transplant. Among 288 end-stage/chronic kidney disease patients, 50.3% lost sufficient weight for listing and 29.5% were transplanted. DISCUSSION/SIGNIFICANCE OF FINDINGS: Small sample size and publication bias are limitations; however, bariatric surgery may benefit select end-stage organ disease patients with obesity that precludes transplant candidacy.

Introduction: Recurrence of HCV infection in patients with chronic hepatitis C virus (HCV) at the time of liver transplantation is nearly universal and reduces the likelihood of graft and patient survival. Materials and methods: We evaluated outcomes of 17 patients (16 with HCV genotype 1 and 1 with genotype 4) who received up to 12 or 24 weeks of ledipasvir/sofosbuvir plus ribavirin prior to or up to the time of liver transplant in the SOLAR-1 and SOLAR-2 trials. In all patients, HCV RNA was < 15 IU/mL prior to transplant. At screening, 6 patients were Child-Pugh-Turcotte (CPT) class B and 11 were CPT class C. Seven patients underwent transplant prior to completing assigned treatment, with 4 treated for < 12 weeks. The primary endpoint was posttransplant virologic response 12 weeks after transplant (pTVR12) in patients with HCV RNA < 15 IU/mL at their last measurement prior to transplant. Results: Overall, 94% (16/17) achieved pTVR12. All who achieved pTVR12 received at least 11 weeks of treatment. The single patient who did not achieve pTVR12 discontinued study drug on day 21 and underwent liver transplant the following day. The patient had HCV RNA < 15 IU/mL at post-transplant week 2 but died 15 days post-transplant because of multi-organ failure and septic shock. Conclusion: Among a small population of HCV patients with decompensated cirrhosis, virologic response to ledipasvir / so-fosbuvir plus ribavirin prior to liver transplantation was maintained after transplantation, even if treatment was stopped early. Administration of ledipasvir / sofosbuvir plus ribavirin before liver transplant can prevent post-transplant HCV recurrence.

Introduction. Men have higher risk for hepatocellular carcinoma (HCC) than women. Pre liver transplant (LT) alpha fetoprotein (AFP) levels strongly predict post LT HCC recurrence. Though women with HCC have higher AFP, the contribution of AFP level by gender to post LT HCC recurrence is unknown.Material and methods. In this UNOS-based, retrospective cohort study we investigate sex differences in HCC recurrence among LT recipients with MELD exception between 2006-2010. Covariates include race, disease etiology, co-morbidities, AFP at listing and LT, tumor burden, loco-regional therapy, and donor risk index. HCC recurrence was assessed by competing risks regression.Results. Of the eligible cohort (n = 5,002) included 3,872 men and 1,130 women. HCC recurred in 258 men (7%) and 66 women (6%). Median listing AFP was higher in women than men (14 vs. 11 ng/dL, p < 0.001). While no sex difference in overall HCC recurrence was detected (HR 0.9, 95% CI 0.7-1.2, p = 0.38), there was a strong interaction between gender and AFP on recurrence risk (p = 0.02). HCC recurrence was nearly three times higher in women (HR 4.2, 95% CI 2.2-8.2, p < 0.001) than men (HR 1.5, 95% CI 1.1-2.1, p = 0.02) with AFP at LT between 101-500 ng/dL.Conclusion. This study reveals novel sex differences in post LT HCC recurrence, which was nearly three times higher in women than men with high AFP at LT. Pre-LT AFP levels appear to carry a different prognosis in women than men, and a subset of female LT recipients may benefit from more intensive HCC surveillance after LT.

OBJECTIVES/SPECIFIC AIMS: Nonalcoholic fatty liver disease (NAFLD) is the most common cause of liver disease in the United States and increases risk for cirrhosis and liver cancer. Identifying modifiable risk factors for NAFLD could allow better targeting of prevention programs. Insulin resistance (IR) plays a significant role in the development and progression of NAFLD. IR is also an important precursor to the development of type 2 diabetes (T2DM). However, the development and duration of IR during young adulthood and its association with NAFLD and T2DM in midlife is unclear. To test whether trajectories of IR using homeostatic model assessment (HOMA-IR) change throughout early adulthood are associated with risk of prevalent NAFLD and T2DM among persons with NAFLD in midlife independent of current or baseline HOMA-IR. METHODS/STUDY POPULATION: Participants from the CARDIA study, a prospective multicenter population-based biracial cohort of adults (baseline age 18–30 years), underwent HOMA-IR measurement (≥8 h fasting and not pregnant) at baseline (1985–1986) and follow-up exam years 7, 10, 15, 20, and 25. At Year 25 (Y25, 2010–2011), liver fat was assessed by noncontrast computed tomography (CT). NAFLD was defined as CT liver attenuation

The treatment of hepatitis C has evolved over the past decade, and a combination of interferon (IFN), pegylated or standard type, and ribavirin is now acknowledged as the therapy of choice. Questions remain, however, about the duration of treatment and which patients are the most likely to benefit from therapy. Cost effectiveness analyses (CEAs) have been employed to answer these questions. Before the results can be interpreted appropriately, however, clinicians must make themselves aware of the underlying assumptions and the nature of the ‘reference’ case. Moreover, certain parameters, including quality-of-life evaluations, may not be easily translated from one jurisdiction to another. The costs and benefits of treatment are often very sensitive to such factors as patient age, viral load, histological severity and the viral genotype. Randomized controlled clinical trials, and the CEAs on which they are based, have shown that combination therapy is more cost effective than IFN monotherapy, and that both are cost effective compared with no treatment. Ongoing research on the use of pegylated IFN, weight-adjusted dosing of ribavirin, and the treatment of relapsers and nonresponders will provide valuable data that could be incorporated into future CEAs. Health care resources are vast, but not limitless. Therefore, health care providers need to become aware of how best to allocate resources to the general population. CEAs can facilitate this process by determining which treatment strategies are likely to yield the greatest clinical benefits without excessive expenditures.