Kymberly D. Watt

Liver transplantation after share 35: Impact on pretransplant and posttransplant costs and mortality.

Share 35 was implemented in 2013 to direct livers to the most urgent candidates by prioritizing Model for End‐Stage Liver Disease (MELD) ≥ 35 patients. We aim to evaluate this policys impact on costs and mortality. Our study includes 834 wait‐listed patients and 338 patients who received deceased donor, solitary liver transplants at Mayo Clinic between January 2010 and December 2014. Of these patients, 101 (30%) underwent transplantation after Share 35. After Share 35, 29 (28.7%) MELD ≥ 35 patients received transplants, as opposed to 46 (19.4%) in the pre–Share 35 era (P = 0.06). No significant difference in 90‐day wait‐list mortality (P = 0.29) nor 365‐day posttransplant mortality (P = 0.68) was found between patients transplanted before or after Share 35. Mean costs were

Long-term outcomes of patients undergoing simultaneous liver transplantation and sleeve gastrectomy

3,049 (P = 0.30),

Differing Impact of Sarcopenia and Frailty in Non-Alcoholic Steatohepatitis (NASH) and Alcoholic Liver Disease (ALD)

5226 (P = 0.18), and

The Reality of De Novo Malignancy: Sadly, Not Fake News

10,826 (P = 0.03) lower post‐Share 35 for the 30‐, 90‐, and 365‐day pretransplant periods, and mean costs were

Poor survival after liver retransplantation: Is hepatitis C to blame?

5010 (P = 0.41) and

Transplantation in the alcoholic patient.

5859 (P = 0.57) higher, and

Mortality while awaiting liver retransplantation : Predictability of MELD scores

9145 (P = 0.54) lower post‐Share 35 for the 30‐, 90‐, and 365‐day posttransplant periods. In conclusion, the added cost of transplanting more MELD ≥ 35 patients may be offset by pretransplant care cost reduction. Despite shifting organs to critically ill patients, Share 35 has not impacted mortality significantly. Liver Transplantation 23:11–18 2017 AASLD.

Recurrent or De Novo Allograft Steatosis and Long-Term Outcomes After Liver Transplantation

Obesity is increasingly common before and after liver transplantation (LT), yet optimal management remains unclear. The aim of this study was to analyze the long‐term outcomes for obese patients undergoing LT, including a noninvasive weight loss program and combined LT and sleeve gastrectomy (SG). Since 2006, all patients referred for LT with a body mass index (BMI) ≥35 kg/m2 were enrolled. Patients who achieved weight loss (BMI <35) underwent LT alone, and those who did not underwent simultaneous LT + SG. Analysis of long‐term outcomes for patients ≥3 years posttransplant was performed. Since 2006, there were 36 in the weight loss intervention (LT cohort) and 13 in the LT + SG cohort with >3 years of follow‐up, whereas overall, a total of 29 patients underwent LT + SG. Patients in the LT cohort had less severe obesity at enrollment (40.0 ± 2.7 vs. LT + SG cohort 46.0 ± 4.5; P < 0.001). In the LT cohort, 83.3% (30 of 36) achieved >10% loss in total body weight (TBW) pre‐LT. Three years posttransplant, 29.4% of patients in the LT cohort maintained >10% loss in TBW, whereas 100% of the LT + SG patients did (P < 0.001). Patients who underwent LT + SG maintained a significantly higher percentage of total body weight loss after 3 years of follow‐up (LT cohort 3.9 ± 13.3% vs. LT + S G cohort 34.8 ± 17.3%; P < 0.001). Patients in the LT + SG also had a lower prevalence of hypertension, insulin resistance, and hepatic steatosis and required fewer antihypertensive medications and lipid agents at last follow‐up. Conclusion: Whereas weight loss before transplantation was achieved by obese patients, weight regain was common in the LT cohort. Combined LT + SG resulted in more effective and more durable weight loss, as well as fewer metabolic complications at last follow‐up. (Hepatology 2018).

Su1426 EUS-GUIDED CORE LIVER BIOPSY USING A 22G FORK-TIP NEEDLE WITH STANDARD SUCTION TECHNIQUE OFFERS A SAFE AND RELIABLE CORE LIVER TISSUE ACQUISITION: A PROSPECTIVE BLINDED TRIAL IN NONALCOHOLIC FATTY LIVER DISEASE

Sarcopenia and frailty are commonly encountered in patients with end‐stage liver disease and are associated with adverse clinical outcomes, including decompensation and wait‐list mortality. The impact of these entities in patients with differing disease etiologies has not been elucidated. We aim to ascertain the change in their prevalence over time on the wait list and determine their impact on hospitalization, delisting, and wait‐list survival, specifically for patients with nonalcoholic steatohepatitis (NASH) and alcoholic liver disease (ALD). Adult patients who were evaluated for their first liver transplant from 2014 to 2016 with a primary diagnosis of NASH (n = 136) or ALD (n = 129) were included. Computed tomography scans were used to determine the presence of sarcopenia and myosteatosis. Frailty was diagnosed using the Rockwood frailty index. Patients with NASH had a significantly lower prevalence of sarcopenia (22% versus 47%; P < 0.001) but a significantly higher prevalence of frailty (49% versus 34%; P = 0.03) when compared with patients with ALD at the time of listing. In patients with NASH, sarcopenia was not associated with adverse events, but a higher frailty score was associated with an increased length of hospitalization (P = 0.05) and an increased risk of delisting (P = 0.02). In patients with ALD, univariate analysis showed the presence of sarcopenia was associated with an increased risk of delisting (P = 0.01). In conclusion, sarcopenia and frailty occur with differing prevalence with variable impact on outcomes in wait‐listed patients with NASH and ALD.

Mo1452 - Short and Long-Term Patient and Graft Outcomes after Liver Transplantation for Primary Sclerosing Cholangitis in the New Era of Transplantation

De novo malignancy (DNM) in liver transplantation recipients (LTRs) is a leading cause of longterm mortality. DNM can be at least partly attributed to infection with oncogenic viruses and to the loss of immunogenic surveillance in the setting of immunosuppression. In this issue of Liver Transplantation, Rademacher et al. report their experience in 1616 adult LTRs who were prospectively followed for up to 3 decades (median follow-up approximately 14 years). In a predominantly Caucasian population, 16.5% of recipients developed DNMs, which included solid organ tumors (59%) followed by skin tumors (26%) then hematologic malignancy (15%). The 10-year probability of developing a DNM was 12.9%, somewhat lower than what had been reported previously (up to 20%22%). Although more than half of the DNMs in this study were solid organ tumors, the skin cancer rate was well below previously published rates, impacting the overall DNM rate. The exclusion of high-grade colon dysplasia in this study also affects comparison of incidence rates. Variability in reported DNM incidence in different studies may reflect varying environmental exposures, specific immunosuppressive regimen, or diverse genetic predisposition. Additionally, retrospective data undoubtedly fail to capture 100% of cancers. Thus, reported incidence rates should be regarded as the lower end of the spectrum. In the current study, the authors confirm that the risk for any DNM was higher in patients with advanced age, as in other studies. A surprising observation was an apparent lower risk in patients with primary sclerosing cholangitis (PSC). While the authors astutely highlight that the low rate of smoking in this PSC cohort could contribute to lower DNM risk, this difference could also be explained by fewer patients with PSC and possibly different prevalence of inflammatory bowel disease (IBD) or colectomies that were not evaluated in the current study. Changing indications for LT will also affect cancer incidence rates. Patients with chronic hepatitis C virus (HCV) were at higher risk for posttransplant lymphoproliferative disorder but at lower risk for solid organ malignancies. The current era of DAAs and HCV eradication will likely see this risk diminish, but increased anticipated longterm survival may see increased rates of other malignancies. Because the HCV-infected recipients underwent transplantation prior to 2006, one can assume they were viremic, and recurrence of HCV can be implicated in the lymphoma risk. Rademacher et al. affirm the observation previously noted by Tjon et al. that cyclosporine-based immunosuppression increased the risk for DNM, particularly for solid organ tumors. The data presented are confusing, however, as a univariate analysis of a subset of patients receiving prolonged tacrolimusor cyclosporine-based regimen support this link, but once corrected for other risk factors (in the Supporting Table) the opposite is true. Additionally, when comparing calcineurin inhibitor (CNI) effects over 28 years of follow-up, care must be taken to account for era effect and dosing. Higher CNI dosing is related to increased risk, as shown by Carenco et al., whereas high tacrolimus trough levels (> 8 ng/mL during the first year and > 7 ng/mL during the 3 years after transplant) were associated with de novo solid organ tumors. Aguiar et al. recently reported that LT recipients who were switched from a CNI-based regimen to mycophenolate mofetil monotherapy had a lower risk for developing DNM. Higher level immunosuppression and CNI-based immunosuppression are clearly implicated in an increased risk of DNM. Consistent findings from this and similar studies are that malignancies such as lung cancer, oropharyngeal cancers, gastrointestinal cancers (in other studies with Abbreviations: CNI, calcineurin inhibitor; DNM, de novo malignancy; HCV, hepatitis C virus; LTR, liver transplantation recipient; PSC, primary sclerosing cholangitis.