Search

Patients with cirrhosis account for 3% of intensive care unit admissions with hospital mortality exceeding 50%; however, improvements in survival among patients with acutely decompensated cirrhosis and organ failure have been described when treated in specialized liver transplant centers. Acute-on-chronic liver failure is a distinct clinical syndrome characterized by decompensated cirrhosis associated with one or more organ failures resulting in a significantly higher short-term mortality. In this review, we will discuss the management of common life-threatening complications in the patient with cirrhosis that require intensive care management including neurologic, cardiovascular, gastrointestinal, pulmonary, and renal complications.

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 and Aims Gastric antral vascular ectasia (GAVE) is typically treated by endoscopic thermal therapies. Endoscopic band ligation (EBL) has been reported in the treatment of GAVE with encouraging results. However, EBL is not widely used to this end. Methods We conducted a comprehensive search of several databases (inception to May 2021) to identify studies reporting on the use of EBL in the treatment of GAVE. A random-effects model was used to calculate the pooled rates; I2 values and 95% prediction intervals were calculated to assess the heterogeneity. Results Ten studies (194 patients) were included in the final analysis. The pooled rate of treatment responders with EBL in GAVE was 81% (95% confidence interval [CI], 62.2-91.7), and GAVE recurrence was 15.4% (95% CI, 4.5-41.3). The pooled mean number of treatment sessions required was 2.4 (95% CI, 2.2-2.7), and the number of bands used to achieve eradication per patient was 15.1 (95% CI, 10.7-19.4). The pooled mean difference of pre- to post-treatment hemoglobin was 1.5 (95% CI, .9-2.2; P = .001), pre- to post-treatment units of packed red blood cells transfused was 1.1 (95% CI, .4-1.9; P = .002), and pre- to post-treatment hospital length of stay was .5 days (95% CI, .1-.9; P = .01). The pooled rate of overall adverse events was 15.9% (95% CI, 10.4-23.7). Conclusions EBL demonstrated excellent clinical outcomes in the treatment of GAVE with minimal adverse events. Multicenter randomized controlled trials comparing EBL and other modalities as initial therapy are warranted.

Background Due to donor organ shortage, the number of patients listed for transplant greatly exceeds the supply of available heart allografts Recent approval of direct-acting antiviral (DAA) agents for HCV provides an opportunity to expand the donor pool through the use of organs from HCV NAT+ donors and offering highly-effective anti-HCV therapy to organ recipients who develop HCV infection Methods A heart transplant nurse coordinator identified an opportunity to increase donor pool by utilizing HCV NAT + donors The nurse coordinator researched and reviewed other national heart transplant programs’ experiences to support the model of accepting HCV NAT+ donors A review of our local Organ Procurement Organization (OPO) identified that approximately 4 to 6 HCV NAT+ donors may be available locally for transplant annually, with additional donors potentially available through distant procurement The nurse coordinator advocated for a change by first identifying a physician mentor and champion Next, key players needed to successfully launch the proposal were recruited as the core team Results A multidisciplinary task force was formed and included members from Transplant Infectious Diseases, Hepatology, Pharmacy, Cardiology, Cardiac Surgery, Quality, OPO, Administration and Risk Management The task force members conceptualized and executed a guideline for the use of HCV NAT+ donors The guideline addressed patient education, informed consent, co-infection testing, discharge treatment plan, therapy algorithm based on viral genotype, concomitant medications, financial support and outcome monitoring Next, patient consent form and practice guideline were approved by the hospital Patient Safety Committee and the transplant team Finally, the HCV NAT+ Protocol was fully implemented, 11 months after the initial decision to modify donor acceptance criteria Conclusion A nurse coordinator directed initiative for a major practice change was successfully implemented by collaborative coordination with key stakeholders in the Heart Transplant Program Quality and process improvement is an excellent way for a nurse coordinator to positively impact their program and patients This report identifies the resources and key steps needed to successfully implement guidelines for HCV NAT+ donor organ use in a heart transplant program.

LT.Multivariant analysis for recurrence identified only explant findings as a survival predictor. Conclusions: In this large single center experience of LT for HCC with a short median wait time from listing to LT, outcomes were at or better than the reported national experience. Tumor biology appeared to be the driver for both HCC recurrence and long-term survival. Transplanting patients for HCC who did not experience a prolonged wait pre-LT did not adversely impact their overall outcome.