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Background Statins may be protective in severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 infection. The aim of the current study was to evaluate the effect of in-hospital statin use on 28-day mortality rates and intensive care unit (ICU) admission among patients with SARS-CoV-2, stratified into 4 groups: those who used statins before hospitalization (treatment continued or discontinued in the hospital) and those who did not (treatment newly initiated in the hospital or never initiated). Methods In a cohort study of 1179 patients with SARS-CoV-2, record review was used to assess demographics, laboratory measurements, comorbid conditions, and time from admission to death, ICU admission, or discharge. Using marginal structural Cox models, we estimated hazard ratios (HRs) for death and ICU admission. Results Among 1179 patients, 676 (57%) were male, 443 (37%) were >65 years old, and 493 (46%) had a body mass index ≥30 (calculated as weight in kilograms divided by height in meters squared). Inpatient statin use reduced the hazard of death (HR, 0.566; P=.008). This association held among patients who did and those who did not use statins before hospitalization (HR, 0.270 [P=.003] and 0.493 [P=.04], respectively). Statin use was associated with improved time to death for patients aged >65 years but not for those ≤65 years old. Conclusion Statin use during hospitalization for SARS-CoV-2 infection was associated with reduced 28-day mortality rates. Well-designed randomized control trials are needed to better define this relationship.

Patients with cirrhosis and ascites experience frequent hospital admissions, leading to poor quality of life and high healthcare costs. Monitoring weight is a component of ascites care and telemonitoring may improve outcomes and costs. Goals We aimed to evaluate the cost and outcomes of current care compared to a telemonitoring system for ascites. Study We developed a decision-analytic model that examined 100 simulated patients over a 6-month horizon. We compared usual care to a new telemonitoring program, which we estimate costs $50,000/6 months. The cost of standard of care for 100 patients with cirrhotic ascites over a 6-month period is $167,500 more expensive than telemonitoring. By varying parameter probabilities by ± 10% and outcome costs by ± 20%, we found that standard of care remains more expensive than care with a telemonitoring intervention by $9400 to $340,200 per 6-month period. Standard of care leads to 9 more admissions (range 4 to 12) than a telemonitoring intervention, while telemonitoring leads to 9 more outpatient visits (range 6 to 9) and 28 additional outpatient large volume paracenteses (LVPs) (range 17 to 28). With more and less expensive telemonitoring interventions, standard of care remained more expensive. With 50% adherence to the intervention, standard of care was $89,848 more expensive. In almost all probability and cost scenarios, a telemonitoring intervention is cost-saving for the management of cirrhotic ascites. Using hospital admissions as a surrogate for quality of care, patient outcomes are improved primarily though more proactive medical intervention and more LVPs.

Social media (SoMe) can be an effective professional tool for the gastroenterologist or trainee. SoMe can support a gastroenterologist's efforts to brand themselves, network, learn, educate, and advocate for patients. SoMe for professional use should be approached with specific aims in mind, in order to optimize impact and productivity.

The practice of transplanting hepatitis C (HCV)-infected livers into HCV-uninfected recipients has not previously been recommended in transplant guidelines, in part because of concerns over uncontrolled HCV infection of the allograft. Direct-acting antivirals (DAAs) provide an opportunity to treat donor derived HCV-infection, and should be administered early in the post-transplant period. However, evidence on the safety and efficacy of an immediate DAA treatment approach, including how to manage logistical barriers surrounding timely DAA procurement, are required prior to broader use of HCV-positive donor organs. We report the results of a trial in which fourteen HCV-negative patients underwent successful liver transplantation from HCV-positive donors. Nine patients received viremic (nucleic acid testing (NAT)-positive) livers, and started a 12-week course of oral glecaprevir-pibrentasvir (GP) within 5 days of transplant. Five patients received livers from HCV antibody-positive non-viremic donors and were followed using a reactive approach. Survival in NAT-positive recipients is 100% at a median follow-up of 46 weeks. An immediate treatment approach for HCV NAT-positive liver transplantation into uninfected recipients is safe and efficacious. Securing payer approval for DAAs early in the post-transplant course could enable need-based allocation of HCV-positive donor organs irrespective of candidate HCV status, while averting chronic HCV allograft infection.

BackgroundTechnology represents a promising tool to improve healthcare delivery for patients with cirrhosis. We sought to assess utilisation of technology and preferred features of a digital health management tool, in patients with an early readmission for decompensated cirrhosis.MethodsWe conducted a cross-sectional study of patients readmitted within 90 days for decompensated cirrhosis. A semistructured interview obtained quantitative and qualitative data through open-ended questions.ResultsOf the 50 participants, mean age was 57.6 years and mean (range) model for end stage liver disease was 22.7 (10–46). Thirty-eight (76%) patients own a Smartphone and 62% have regular access to a computer with internet. Thirty-nine (78%) patients would consider using a Smartphone application to manage their cirrhosis. Forty-six (92%) patients report having a principal caregiver, of which 80% own a Smartphone. Patients were interested in a Smartphone application that could communicate with their physician (85%), send medication notifications to the patient (65%) and caregiver (64%), transmit diagnostic results and appointment reminders (82%), educate about liver disease (79%), regularly transmit weight data to the doctor (85% with ascites) and play a game to detect cognitive decline (67% with encephalopathy). Common themes from qualitative data include a desire to learn about liver disease and communicate with providers via digital tools.ConclusionAmong patients with cirrhosis with an early readmission for decompensation, most have Smartphones and would be willing to use a Smartphone to manage their disease. Future digital health management tools should be tailored to the use patterns and preferences of the patients with cirrhosis and their caregivers.

Fecal microbiota transplantation (FMT) is an emerging therapy for recurrent or refractory Clostridioides difficile infection and is being actively investigated for other conditions. We describe two patients in whom extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli bacteremia occurred after they had undergone FMT in two independent clinical trials; both cases were linked to the same stool donor by means of genomic sequencing. One of the patients died. Enhanced donor screening to limit the transmission of microorganisms that could lead to adverse infectious events and continued vigilance to define the benefits and risks of FMT across different patient populations are warranted.

Accurate prediction of outcomes for alcohol-associated hepatitis (AH) is critical, as prognosis determines treatment eligibility. Computed tomography (CT) features may provide prognostic information beyond traditional models. Our aim was to identify CT features that predict outcomes in AH. We studied 108 patients retrospectively with definite or probable AH, who underwent admission abdominal CT. A radiologist blinded to outcome evaluated eight CT features. The primary outcome was 90-day mortality. Twenty-five (23.2%) patients died within 90 days. While traditional prognostic tools, including Maddrey discriminant function (DF), predicted 90-day mortality (OR 1.01 [1.00, 1.03], P = 0.02), abdominal CT findings were also accurate predictors. On abdominal CT, patients with severe AH had larger volume of ascites (moderate/large volume: 34.0 vs. 8.2%, P

Background & Aims The surge in unhealthy alcohol use during the COVID‐19 pandemic may have detrimental effects on the rising burden of alcohol‐associated liver disease (ALD) on liver transplantation (LT) in the US. We evaluated the impact of the pandemic on temporal trends for LT including ALD. Approach & Results Utilizing data from United Network for Organ Sharing, we analyzed waitlist outcomes in the US through March 1, 2021. In a short‐period analysis, patients listed or transplanted between June 1, 2019 and February 29, 2020 were defined as the “pre‐COVID” era and after April 1, 2020 were defined as the “COVID” era. Interrupted time‐series analyses utilizing monthly count data from 2016‐2020 were constructed to evaluate rate change for listing and LT prior to and during the COVID‐19 pandemic. Rates for listings (P=0.19) and LT (P=0.14) were unchanged during the pandemic despite a significant reduction in the monthly listing rates for HCV (‐21.69%, P

Introduction There are no available low-burden, point-of-care tests to diagnose, grade, and predict hepatic encephalopathy (HE). Methods We evaluated speech as a biomarker of HE in 76 English-speaking adults with cirrhosis. Results Three speech features significantly correlated with the following neuropsychiatric scores: speech rate, word duration, and use of particles. Patients with low neuropsychiatric scores had slower speech (22 words/min, P = 0.01), longer word duration (0.09 seconds/word, P = 0.01), and used fewer particles (0.85% fewer, P = 0.01). Patients with a history of overt HE had slower speech (23 words/min, P = 0.005) and longer word duration (0.09 seconds/word, P = 0.005). Discussion HE is associated with slower speech.

Background & Aims Chronic liver disease (CLD) represents a major global health burden. We undertook this study to identify the factors associated with adverse outcomes in patients with CLD who acquire the novel coronavirus-2019 (COVID-19). Methods We conducted a multi-center, observational cohort study across 21 institutions in the United States (US) of adult patients with CLD and laboratory-confirmed diagnosis of COVID-19 between March 1, 2020 and May 30, 2020. We performed survival analysis to identify independent predictors of all-cause mortality and COVID-19 related mortality, and multivariate logistic regression to determine the risk of severe COVID-19 in patients with CLD. Results Of the 978 patients in our cohort, 867 patients (mean age 56.9 ± 14.5 years, 55% male) met inclusion criteria. The overall all-cause mortality was 14.0% (n = 121), and 61.7% (n = 535) had severe COVID-19. Patients presenting with diarrhea or nausea/vomiting were more likely to have severe COVID-19. The liver-specific factors associated with independent risk of higher overall mortality were alcohol-related liver disease (ALD) (hazard ratio [HR] 2.42, 95% confidence interval [CI] 1.29–4.55), decompensated cirrhosis (HR 2.91 [1.70–5.00]) and hepatocellular carcinoma (HCC) (HR 3.31 [1.53–7.16]). Other factors were increasing age, diabetes, hypertension, chronic obstructive pulmonary disease and current smoker. Hispanic ethnicity (odds ratio [OR] 2.33 [1.47–3.70]) and decompensated cirrhosis (OR 2.50 [1.20–5.21]) were independently associated with risk for severe COVID-19. Conclusions The risk factors which predict higher overall mortality among patients with CLD and COVID-19 are ALD, decompensated cirrhosis and HCC. Hispanic ethnicity and decompensated cirrhosis are associated with severe COVID-19. Our results will enable risk stratification and personalization of the management of patients with CLD and COVID-19. Clinicaltrials.gov number NCT04439084

BackgroundStatins may be protective in viral infection and have been proposed as treatment in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection.ObjectiveWe evaluated the effect of statins on mortality in four groups hospitalized with (SARS-CoV-2) infection (continued statin, newly initiated statin, discontinued statin, never on statin).DesignIn a single center cohort study of 1179 patients hospitalized with SARS-CoV-2 infection, the outcome of death, Intensive Care Unit (ICU) admission or hospital discharge was evaluated. Patients’ statin use, laboratory data, and co-morbidities were determined via chart review and electronic health records. Using marginal structural models to account for timing of statin initiation and competing risks, we compared the likelihood of severe outcomes in the four statin exposure groups.SettingAcademic medical center in the United StatesParticipantsPatients hospitalized with SARS-CoV-2 infectionMeasurements28-day mortality, ICU admission, or dischargeResultsAmong 1179 patients, 360 were never on a statin, 311 were newly initiated on a statin, 466 were continued on a statin, and 42 had a statin discontinued. In this cohort, 154 (13.1%) patients died by 28-days. With marginal structural model analysis, statin use reduced the hazard of 28-day mortality (HR 0.566 [CI 0.372, 0.862], p = 0.008). Both new initiation of statins (HR 0.493 [CI 0.253, 0.963], p=0.038) and continuing statin therapy reduced the hazard of 28-day mortality (HR 0.270 [CI 0.114, 0.637], p=0.003). Sensitivity analysis found that statin use was associated with improved mortality for patients > 65 years, but not for patients 65 years or younger.LimitationObservational designConclusionStatin therapy during hospitalization for SARS-CoV-2 infection, including new initiation and continuation of therapy, was associated with reduced short-term mortality.

We respectfully disagree with your interpretation of the lag in serum alanine aminotransferase (ALT) elevations behind aspartate aminotransferase (AST) elevations in patients with COVID-19. Specifically, you suggest that this lag reflects a dissociation between ALT and AST elevations and therefore implies a non-hepatic source of AST elevation.

Patients with cirrhosis and ascites experience frequent hospital admissions, leading to poor quality of life and high healthcare costs. Monitoring weight is a component of ascites care and telemonitoring may improve outcomes and costs. Goals We aimed to evaluate the cost and outcomes of current care compared to a telemonitoring system for ascites. Study We developed a decision-analytic model that examined 100 simulated patients over a 6-month horizon. We compared usual care to a new telemonitoring program, which we estimate costs $50,000/6 months.The cost of standard of care for 100 patients with cirrhotic ascites over a 6-month period is $167,500 more expensive than telemonitoring. By varying parameter probabilities by ± 10% and outcome costs by ± 20%, we found that standard of care remains more expensive than care with a telemonitoring intervention by $9400 to $340,200 per 6-month period. Standard of care leads to 9 more admissions (range 4 to 12) than a telemonitoring intervention, while telemonitoring leads to 9 more outpatient visits (range 6 to 9) and 28 additional outpatient large volume paracenteses (LVPs) (range 17 to 28). With more and less expensive telemonitoring interventions, standard of care remained more expensive. With 50% adherence to the intervention, standard of care was $89,848 more expensive.In almost all probability and cost scenarios, a telemonitoring intervention is cost-saving for the management of cirrhotic ascites. Using hospital admissions as a surrogate for quality of care, patient outcomes are improved primarily though more proactive medical intervention and more LVPs.

BACKGROUND AND AIMS: Coronavirus disease 2019 (COVID-19) leads to elevated liver biochemistries in approximately half of patients on presentation. To date, data are limited regarding the trend of liver biochemistries over the course of illness. We aimed to evaluate the trend, etiology, and outcomes associated with liver biochemistries in COVID-19. APPROACH AND RESULTS: A total of 60 patients with COVID-19 were admitted between March 21 and March 28, 2020. The mean age was 57 years, 65% were male, and 28% were Hispanic. At the study conclusion, 6 patients were deceased, 28 were discharged, and 26 remained admitted. Patients who remained admitted were followed for a median of 12 days. Of 60 patients, 41 (69%) had at least one abnormal liver biochemistry on admission. Median aspartate aminotransferase (AST) was higher than alanine aminotransferase (ALT) at admission (46 vs. 30 U/L) and during the hospital course. Aminotransferases rose above normal in 54 (93%) patients, whereas alkaline phosphatase and total bilirubin elevations were rare. Ten (17%) patients developed aminotransferases more than 5 times the upper limit of normal. AST highly correlated with ALT throughout the illness course (r = 0.97; P

Objectives Hepatic encephalopathy (HE) is associated with hospital readmissions and mortality. We sought to determine whether cognitive testing and stool frequency at discharge predicted 30-day readmission or death in cirrhotic patients admitted with overt HE. Methods We approached consecutive inpatients with cirrhosis and overt HE when they were within 48 hours of discharge. Patients underwent cognitive tests, including Psychometric Hepatic Encephalopathy Score (PHES), and stool frequency was documented. Chart review identified Model for End-Stage Liver Disease-sodium (MELD-Na) and the presence of non-HE extrahepatic organ failures. Cox proportional hazards models were used to evaluate predictors of time to the primary composite outcome of hospital readmission for HE or death within 30 days, censoring for liver transplantation. Results Of 51 patients consented and enrolled, 14 patients met the primary composite outcome. In unadjusted Cox models, 4 variables predicted HE readmission or death: MELD-Na (hazard ratio [HR] 1.10 [1.01-1.20], P = 0.03), respiratory failure (HR 4.26 [1.47-12.35], P = 0.008), total number of HE extrahepatic organ failures (HR 1.79 [1.12-2.88], P = 0.02), and score on a PHES subtest, Number Connection Test A (per 30 seconds; HR 1.25 [1.06-1.47], P = 0.01). PHES and 24-hour stool frequency did not predict the primary outcome. When controlling for MELD-Na, respiratory failure predicted the primary outcome (HR 3.67 [1.24-10.86], P = 0.02). Conclusion Cognitive testing and stool frequency at discharge did not predict poor outcomes in patients admitted with HE, while respiratory failure appeared to be a strong predictor.

Hepatic encephalopathy (HE) is a devastating complication of cirrhosis with an increasing footprint in global public health. Although the condition is defined using a careful history and examination, we cannot accurately measure the true impact of HE relying on data collected exclusively from clinical studies. For this reason, administrative data sources are necessary to study the population burden of HE. Administrative data is generated with each health care encounter to account for health care resource utilization and is extracted into a dataset for the secondary purpose of research. In order to utilize such data for valid analysis, several pitfalls must be avoided—specifically, selecting the particular database capable of meeting the needs of the study’s aims, paying careful attention to the limits of each given database, and ensuring validity of case definition for HE specific to the dataset. In this review, we summarize the types of data available for and the results of administrative data studies of HE.

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) surveillance rates are suboptimal in clinical practice. We aimed to elicit providers’ opinions on the following aspects of HCC surveillance: preferred strategies, barriers and facilitators, and the impact of a patient’s HCC risk on the choice of surveillance modality. METHODS: We conducted a web-based survey among gastroenterology and hepatology providers (40% faculty physicians, 21% advanced practice providers, 39% fellow-trainees) from 26 U.S. medical centers in 17 states. RESULTS: Of 654 eligible providers, 305 (47%) completed the survey. Nearly all (98.4%) of the providers endorsed semi-annual HCC surveillance in patients with cirrhosis, with 84.2% recommending ultrasound ± alpha fetoprotein (AFP) and 15.4% recommending computed tomography (CT) or magnetic resonance imaging (MRI). Barriers to surveillance included limited HCC treatment options, screening test effectiveness to reduce mortality, access to transportation, and high out-of-pocket costs. Facilitators of surveillance included professional society guidelines. Most providers (72.1%) would perform surveillance even if HCC risk was low (≤0.5% per year), while 98.7% would perform surveillance if HCC risk was ≥1% per year. As a patient’s HCC risk increased from 1% to 3% to 5% per year, providers reported they would be less likely to order ultrasound ± AFP (83.6% to 68.9% to 57.4%; p

Background Coronavirus disease 2019 (COVID-19) is associated with elevated liver biochemistries in approximately half of hospitalized patients, with many possible etiologies. Aim To assess agreement on the etiology of abnormal liver biochemistries and diagnostic recommendations in COVID-19. Methods Twenty hepatology consultations were reviewed by three senior hepatologists who provided a differential diagnosis and diagnostic recommendations. Kappa agreement on the primary etiology was calculated. Results Kappa agreement between hepatologists on the primary etiology of elevated liver biochemistries was 0.10 (p = 0.03). Agreement was greater around drug-induced liver injury 0.51 (p

INTRODUCTION: Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is common and can be associated with severe clinical consequences, including portal hypertension, cardiac failure, and encephalopathy. However, there are no reliable clinical predictors of hepatic involvement and its associated complications, limiting appropriate identification of these patients. In this work, we define the utility of serum ammonia and liver biochemical tests (LFTs) in predicting hepatic HHT involvement and its complications. METHODS: We performed a retrospective study examining a well-characterized cohort of patients with HHT. Clinical characteristics, laboratory tests, liver imaging, transthoracic echocardiography assessment of right ventricular systolic pressure (RVSP), and history of other HHT-related outcomes were assessed. Patients were followed for the development of encephalopathy. RESULTS: Of 45 patients with definite HHT, 18 (40%) had elevated ammonia levels. An elevated ammonia associated with the presence of hepatic arteriovenous malformations (AVMs) on imaging (P < 0.03) and when combined with elevated liver tests increased the sensitivity for hepatic AVMs by 18% (55% for LFTs vs 73% for LFTs plus ammonia). Furthermore, an elevated serum ammonia in patients with HHT associated with an elevated RVSP (>35 mm Hg), providing an 80% sensitivity and 71% specificity for predicting the presence of pulmonary hypertension. In contrast, there was no association with an elevated serum ammonia and encephalopathy over a total of 859 months of follow-up. DISCUSSION: Elevated ammonia in a cohort of patients with HHT was associated with the presence of hepatic AVMs and elevated RVSP, but no other complications of HHT, including encephalopathy.

INTRODUCTION Ammonia levels are used to assess hepatic encephalopathy, but their levels are highly variable in clinical practice. METHODS We studied factors associated with variation in ammonia values in cirrhotic patients without previous hepatic encephalopathy and healthy volunteers (HVs). RESULTS Ammonia increased by 12% and 18% at 1 and 2 hour, respectively, after a protein meal in 64 cirrhotic patients (P < 0.001). In 237 HVs, ammonia levels varied significantly between sites (P < 0.0001). New site-specific ammonia upper limits based on HV levels using a strict analysis protocol differed from routinely used values. Correlation between paired fresh samples was high (r = 0.83) but modest between fresh and frozen samples (r = 0.62). DISCUSSION Sample handling, processing, and protein intake impact ammonia levels across sites.

Background Ascites, or accumulation of abdominal free fluid, develops in two-thirds of patients with cirrhosis. Ascites is painful and, if inadequately managed, can lead to life-threatening complications, including spontaneous bacterial peritonitis and kidney failure. Body weight is an effective proxy for ascites volume; therefore, monitoring daily weights is recommended for optimal ascites management. At present, patients with ascites rarely proactively alert providers of significant weight gains, and there are no widely available technologies specifically designed for ascites monitoring. Objective The objective of this pilot study is to assess the feasibility of a smartphone app to manage outpatient ascites. Methods In this feasibility study, cirrhotic patients with significant ascites requiring specialist management are identified through an inpatient hepatology consult census and outpatient referrals. Each candidate is sent home with a Bluetooth-connected scale, which transmits weight data to the PGHD Connect Smartphone App, and then via the cloud into the electronic medical record (EMR). Weights are monitored every weekday by study staff and alerts are sent to providers if their patients’ weight changes by ≥5lbs within a week or from the weight documented at discharge. The primary outcomes are percentage of study enrollment days when weight data was successfully transmitted into the EMR and percentage of weight alerts to which providers responded. Results Seventy-eight cirrhotic patients were identified as requiring active management of ascites. Of these patients, 8 did not own a smartphone, 23 were encephalopathic, and thus were excluded; another 1 declined to participate, and 3 were consented but subsequently withdrawn due to physical limitation or death prior to hospital discharge. Each patient is enrolled in the program for 28 days. Of the 16 patients currently enrolled, 5 (31%) are male, mean age is 60.9 years (SD 11.1), 13 (81%) were enrolled as inpatients, 8 (50%) have non-alcoholic steatohepatitis cirrhosis, 4 (25%) alcohol-associated cirrhosis, and 2 (12.5%) viral cirrhosis. At this interim analysis, transmission of weight data into the EMR has successfully occurred on 70% of study enrollment days. Patients experienced technology issues during 10% of days enrolled. Of the total 20 weight alerts to date, 12 (60%) were triggered by weight loss ≥5lb in one week, 7 (35%) by weight gain ≥5lb in one week, and 1 (5%) by weight gain ≥5lb since discharge. Providers responded to 13 (65%) of the weight alerts within 24 hours. Of the 13 alerts with a provider response, 7 (54%) were followed by a call or email to the patient to discuss care, 4 (31%) a scheduled appointment, 4 (31%) a change in diuretic dosage, 3 (23%) scheduling for paracentesis (procedure to remove ascites fluid), and 3 (23%) further laboratory workup. To date, there have been 13 readmissions. Conclusions On the basis of our interim analysis, we demonstrate feasibility of a martphone app to facilitate ascites management. We report encouraging rates of patient and provider engagement. This innovation shows promise in enabling early intervention and enhancing quality of life in cirrhotic patients. Future studies will investigate the efficacy of mobile health technology to improve outcomes in this population.