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As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.

Liver disease, of which liver cirrhosis is the most advanced stage, constitutes the fourth most common cause of life-years lost in men and women younger than 75 years in England, where mortality rates from liver disease have increased by 25% in the past decade. Alcohol consumption is the most common modifiable risk factor for disease progression in these individuals, but within the UK, there is substantial variation in the distribution, prevalence, and outcome of alcohol-related liver disease, and no equity of access to tertiary transplantation services. These revised recommendations were agreed by an expert panel convened by the UK Liver Advisory Group, with the purpose of providing consensus on referral for transplant assessment in patients with alcohol-related disease, and clarifying the terminology and definitions of alcohol use in liver injury. By standardising clinical management in these patients, it is hoped that there will be an improvement in the quality of care and better access to liver transplant assessment for patients with alcohol-related liver disease in the UK.

Primary biliary cholangitis (PBC) is a debilitating chronic liver disease that progresses to cirrhosis with attendant complications in a substantial proportion of patients. It is a major cause of liver-related morbidity and mortality in the United Kingdom (UK). The British Society of Gastroenterology (BSG) published guidelines on PBC management, which included key audit standards. Therefore, we propose the first UK-wide audit of the management of PBC, sanctioned by the BSG and the British Association for Study of the Liver (BASL), to benchmark NHS trusts and health boards against these audit standards as a guide to targeted improvement in the delivery of PBC-related health care.

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the ‘Grading of Recommendations Assessment, Development and Evaluation (GRADE)’ system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years’ time.

Introduction Current assumption in the published literature is that AAH is not dissimilar to other forms of ACLF; however, the clinical syndrome of AAH is unique, characterised by profound jaundice and immune dysfunction. Therefore, the outcomes of patients requiring organ support in this setting may differ from other forms of ACLD. Aim To determine whether the clinical outcomes of AAH patients with multi-organ failure admitted to ITU differ from those with other forms of ACLD. Method Single-centre retrospective study of consecutive patients admitted to ITU with AAH (AAH ITU) between 10/2014 and 07/2017. Two comparator cohorts were identified - patients with AAH hospitalised but not requiring ITU (non-ITU AAH); and patients with non-AAH ACLD admitted to ITU (non-AAH ITU). The diagnosis of severe AAH was made prospectively adhering to the STOPAH trial criteria, and confirmed retrospectively by two independent Hepatologists; 37% of AAH patients had the diagnosis confirmed histologically. Results 62 patients were diagnosed with severe AAH during the study period – at the time of hospital admission the median bilirubin was 319μmol/l and 63% had a Glasgow Alcoholic Hepatitis Score ≥9. 21/62 patients were admitted to ITU. AAH ITU patients were more likely to have CLIF-C ACLF (100% vs 80%, p=0.017), but had a similar SOFA score (p=0.064) and total number of organ supports (2 vs 2, p=0.447) to non-AAH ITU patients (n=70). The 90-day survival was 29% for the AAH ITU patients, compared with 90% and 60% for non-ITU AAH and non-AAH ITU patients, respectively (p Overall, 15% of AAH ITU and 56% of non-AAH ITU patients who received any organ support survived to hospital discharge. Of the AAH ITU patients with a CLIF-C ACLF grade of 3, 1 patient (8%) survived to discharge, compared with 8/23 (35%) non-AAH ITU patients. Of the AAH ITU patients who required 3 organ support (n=8), none survived to hospital discharge, compared with 6/18 (33%) non-AAH ITU patients. Conclusion Patients with AAH admitted to ITU do comparatively worse than non AAH patients receiving a similar level of organ support; and prognostic variables such as the CLIF-C ACLF score may not be as discriminatory in this cohort. As such, ceilings of care should be considered carefully and on an individual case basis.

Background Anticoagulation alone in acute, extensive portomesenteric vein thrombosis (PVT) does not always result in spontaneous clot lysis, and leaves the patient at risk of complications including intestinal infarction and portal hypertension. Aim To develop a new standard of care for patients with acute PVT and evidence of intestinal ischaemia. Methods We present a case series of patients with acute PVT and evidence of intestinal ischaemia plus ongoing symptoms despite initial systemic anticoagulation, who were treated with a thrombolysis protocol between 2014 and 2019. This stepwise protocol initially uses low-dose systemic alteplase, and in patients with ongoing abdominal pain, and no evidence of radiological improvement, is followed by local clot dissolution therapy (CDT) through a TIPSS. Outcomes and safety were assessed. Results Twenty-two patients were included. The mean age was 44.6 (standard deviation [SD] 16.0) years, and 64% had an identifiable prothrombotic risk factor. All patients had intestinal wall oedema and 77% had complete occlusion of all portomesenteric veins. Systemic thrombolysis was started 18.7 (SD 11.2) days after the onset of symptoms. 55% of patients underwent TIPSS insertion for CDT. At the end of treatment, symptoms resolved in 91% of patients and recanalisation in 86%. Only one patient required resection for intestinal ischaemia, and there were no deaths. Major complications occurred in two patients (9%). Conclusions Our stepwise protocol is effective, resulting in good recanalisation rates. It can be commenced early while organising transfer to a centre capable of performing local CDT.

Strategies to delay or avoid the long-term decline in renal function and progression to chronic kidney disease (CKD) in liver transplant recipients remain unclear. Our aim was to examine the change in estimated GFR (eGFR) from six months after liver transplantation, and to identify modifiable factors associated with a faster rate of decline. This was a single-center retrospective study of 97 patients who underwent elective liver transplantation and survived ≥ 5 yr. eGFR was estimated using the MDRD6-variable equation, and the annualized change in eGFR was determined using simple linear regression. The baseline eGFR was 75 mL/min/1.73 m(2) . Thereafter, eGFR declined at a mean rate of 1.08 mL/min/1.73 m(2) per year. 49% had a decline in renal function greater than the rate expected with aging. Decline in eGFR was an independent predictor of CKD by five yr post-transplant (p = 0.001). Multivariate modeling found a higher baseline eGFR (p < 0.001), female gender (p = 0.006), hypertension (p = 0.019), and dyslipidemia (p = 0.034) to be associated with a faster rate of decline in renal function. In conclusion, liver transplant recipients have a clinically relevant decline in eGFR from six months post-transplant. Prospective studies are required to examine the effects of aggressive blood pressure and lipid control on the development of CKD in this setting.

Liver retransplantation for late hepatic artery thrombosis (HAT) is considered the treatment of choice for select patients. Nevertheless, there is a paucity of data to aid decision making in this setting. The aims of this single-center study of patients listed for late HAT were (1) to determine variables associated with wait-list mortality, (2) to describe survival after retransplantation, and (3) to determine variables associated with mortality after retransplantation. Seventy-eight patients were diagnosed with late HAT (incidence = 3.9%). Of the 49 patients listed for retransplantation, 9 died on the waiting list and 36 were retransplanted. The estimated 1-year survival after listing for retransplantation was 53.7%. Only multidrug-resistant (MDR) bacteria-positive cultures were predictive of wait-list mortality (P = 0.01). After retransplantation, the estimated 1- and 5-year patient survival was 71.9% and 62.5%, respectively. Increasing Model for End-Stage Liver Disease score (overall P = 0.007), MDR bacteria-positive cultures (P = 0.047), and continued antibiotic therapy (P = 0.001) at the time of retransplantation were risk factors for post retransplant death. In conclusion, patients who undergo liver retransplantation for late HAT have satisfactory outcomes. However, the presence of active infection and MDR bacteria-positive cultures should be taken into account when risk stratifying such patients.

Renal dysfunction of acute liver failure (ALF) may have distinct pathophysiological mechanisms to hepatorenal syndrome of cirrhosis. Yet, the impact of perioperative renal function on posttransplant renal outcomes in ALF patients specifically has not been established. The aims of this study were (1) to describe the incidence and risk factors for chronic renal dysfunction following liver transplantation for ALF and (2) to compare renal outcomes with age-sex-matched patients transplanted for chronic liver disease. This was a single-center study of 101 patients transplanted for ALF. Fifty-three-and-a-half percent had pretransplant acute kidney injury and 64.9% required perioperative renal replacement therapy. After transplantation the 5-year cumulative incidence of chronic kidney disease (eGFR

Serum creatinine is an important prognostic indicator in patients on the liver transplant waiting-list, being a component of the Model for End Stage Liver Disease (MELD) score. However, creatinine is influenced by age, gender and race, and in this role may disadvantage some individuals. The Modification of Diet in Renal Disease (MDRD) estimated glomerular filtration rate (eGFR) takes into account these variables and may be a superior measure of renal function. Our aim was to examine whether the MDRD 4-variable, 5-variable and 6-variable eGFRs are superior to serum creatinine in predicting 3-month waiting-list mortality in patients with end-stage liver disease. This was a retrospective single-centre study of 427 adults listed for first liver transplantation. The median listing MDRD 4-variable, 5-variable and 6-variable eGFR was 69, 71 and 73 ml/min/1.73 m(2) , respectively. The median listing serum creatinine was 89 μm. MDRD 4-variable (P = 0.002), 5-variable (P0.001) and 6-variable eGFR (P0.001), and serum creatinine (P0.001), were all predictors of mortality on the transplant waiting-list. Of the three MDRD equations, the 6-variable eGFR was the better prognostic indicator. The substitution of 6-variable eGFR for serum creatinine did not improve the prognostic accuracy of the MELD (P = 0.825) and UK score for Patients with End-Stage Liver Disease (P = 0.781) scores. In conclusion the MDRD eGFR is comparable, but not superior to serum creatinine, in predicting death within 3 months of listing for liver transplantation.