Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a severe complication of advanced cirrhosis with high mortality and limited treatment options. Terlipressin is currently the only FDA-approved therapy for HRS, though recurrence is common upon discontinuation in patients without access to liver transplantation. Transjugular intrahepatic portosystemic shunt (TIPS) may provide definitive treatment for HRS-AKI in nontransplant candidates or in the setting of prolonged waitlists. This case illustrates the safety and success of terlipressin prior to TIPS for definitive treatment of HRS-AKI in a nontransplant candidate.

Acute kidney injury (AKI) and chronic kidney disease (CKD) are common conditions among patients with cirrhosis whose development is associated with increased morbidity and mortality. Recurrent episodes of AKI within this population can ultimately lead to CKD, while patients with underlying CKD are in turn more likely to experience AKI. Determining the etiology of kidney dysfunction in the setting of cirrhosis is often challenging given the considerable limitations of currently available diagnostic tools. Ongoing research into the role of novel serum and urine biomarkers may allow for more timely diagnosis and treatment of kidney injury among patients with cirrhosis. This review provides an overview of kidney dysfunction in cirrhosis with a focus on the role of these emerging biomarkers for diagnosis of AKI and CKD.

Suboptimal patient-provider relationship is a significant contributor to healthcare disparities. Minority populations report fewer favorable interactions, which may lead to poorer outcomes and engagement in care. Patients with chronic diseases are especially at risk. We aimed to study perceptions of healthcare providers and experience among those with cirrhosis. The nationally representative database, All of Us, was queried. The primary outcome was “favorable healthcare experiences,” defined as whether providers asked for opinions, demonstrated respect, and were easy to understand. The secondary outcome was “unfavorable healthcare experiences,” defined as whether patients felt they were treated with less courtesy, received poorer service, or not listened to. We compared the experience between income levels and other demographic variables. Multivariable logistic regression was adjusted for a priori covariates. 5753 patients with cirrhosis were included with a mean age of 58. The majority were male (51

Chronic hepatitis B (CHB) is a major cause of liver-related morbidity and mortality in the United States. Patients with CHB require long-term antiviral treatment and consistent follow-up, but often face numerous barriers to accessing care and medications. In this study, we used the Medicare Part D database and the Rural-Urban Continuum code to explore specialty and geographic characteristics of healthcare providers that manage Medicare patients with CHB. Between 2013 and 2021, more than 7000 prescribers prescribed over 2.4 million 30-day prescriptions of these CHB therapies, of which 2 million (85%) were in metropolitan counties. The number of 30-day prescriptions increased by 5.4% annually. The number of prescriptions by GI increased by 12.5% a year and prescriptions by APPs increased by 12.2% a year, while prescriptions by ID decreased by 14.0% annually. In non-metropolitan counties, APPs experienced -5% APC between 2013 and 2021, and PCPs experienced -12.5% APC between 2016 and 2021. In this study, we found that there has been a noticeable shift in the specialties prescribing medications for patients with hepatitis B. Gastroenterologists and APPs became significantly more involved as prescribers. The increase in APP management of patients with CHB is a welcoming development, especially in light of the physician workforce shortage. It is important to create solutions such as co-management to ensure that patients with CHB receive consistent care without further contributing to supply-demand mismatch in gastroenterology.

Background. A major contributor to increased healthcare spending in the United States is drug pricing, as US drug prices are nearly 3× higher than those in other countries. This cross-sectional study aimed to investigate current global price differences in liver transplant medications and provide potential cost savings for Medicare Part D if international reference pricing was adopted. Methods. Publicly available drug formularies for Canada, the United Kingdom, Japan, France, Germany, Italy, and Australia were used to collect 2024 prices for 8 commonly used liver transplant medications (mycophenolate mofetil, mycophenolate sodium, sirolimus, tacrolimus, Advagraf, Envarsus, everolimus, and cyclosporine). US prices were obtained from UptoDate’s 2024 listed representative average wholesale prices and Medicare Part D’s drug prices from 2022. Results. The average US wholesale price and Medicare spend for originator liver transplant medications were 4.1× and 6.8×, respectively, the average originator prices in G7 countries and Australia. Adopting the average global originator drug price per dose may lead to an estimated $26 141 463 in cost savings per year to Medicare. The average US wholesale price and Medicare spend for generic liver transplant medications were 2.76× and 3.75×, respectively, the global average generic prices. Adopting the average global generic drug price per dose may lead to an estimated $363 538 474 in cost savings per year to Medicare. Conclusions. This study demonstrates the significantly greater financial burden that liver transplant patients in the United States face compared with liver transplant patients in 7 other major industrial countries. Future adoption of international reference pricing may help bridge this pricing disparity.

Over the past several years, there has been a wealth of new data pertaining to the management of complications of cirrhosis, resulting in several important updates to best practices and consensus guidelines. Despite these advancements and numerous recent targeted quality initiatives, hospitalizations resulting from complications of cirrhosis remain frequent, costly and associated with poor patient outcomes. An emphasis on evidence-based management of hospitalized patients with decompensated cirrhosis has the potential to decrease readmission rates and length of stay while improving overall patient outcomes. Herein, we provide an updated, evidence-based overview of the optimal inpatient management of the most frequently encountered complications associated with cirrhosis.

Continuous treatment with rifaximin 550 mg (hereafter rifaximin) is associated with lower hospitalization rates in patients with hepatic encephalopathy (HE); however, access barriers may exist. This study assessed gaps in rifaximin access and the impact of treatment gaps, particularly those resulting from claim rejections, on hospitalizations and healthcare costs among patients with HE in the United States. The IQVIA PharMetrics® Plus database linked with Longitudinal Access and Adjudicated Data (2015–2022) were used to identify adults with HE who had ≥ 1 paid rifaximin prescription fill. Rifaximin treatment gaps were assessed during the 12-month period from the first observed attempt at receiving rifaximin (index date). Adjusted number of overt HE (OHE) hospitalizations and healthcare costs were compared over the 6 months following the index date between Cohort 1, who had no gap due to claim rejection and had < 7 days of treatment gap due to other reasons, and Cohort 2, who had ≥ 1 rejection gap or had ≥ 7 days of non-rejection gap. During the year following the index date, 94.7

BACKGROUND:Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death in the United States and globally. The Asian American, Native Hawaiian, and Pacific Islander (AANHPI) population has often been studied as one homogenous cohort despite its heterogeneity. We aim to understand differences in treatment modality and mortality among AANHPI patients with early-stage HCC. METHODS:The National Cancer Database was queried between 2004 and 2019. Patients with early-stage HCC eligible for liver transplantation (LT) were included. AANHPI patients were further disaggregated into subgroups, and non-Hispanic White (NHW) patients were included as reference. χ 2 was used for categorical variables and the Student t test was used for continuous variables. Survival curves were generated using Kaplan-Meier estimates. RESULTS:A total of 3039 (8.5%) AANHPI and 32,845 (91.5%) NHW were included. Among the AANHPI, 1368 (45.0%) were East Asian (EA), 1229 (40.4%) were Southeast Asian (SEA), 302 (9.9%) were South Asian (SA), and 140 (4.6%) were Native Hawaiian and other Pacific Islander (NHPI). Compared with NHW, AANHPI patients were less likely to undergo LT but had lower mortality. When disaggregated, SA patients were more likely to receive LT (HR: 2.70), and SEA (HR: 1.43) and NHPI (HR: 1.90) patients had higher mortality when compared with EA, all P <0.01. CONCLUSIONS:AANHPI with early-stage HCC had better survival as a cohort. However, when disaggregated, there were notable disparities among different subgroups. AANHPI represents an incredibly diverse group of individuals, and it is imperative for physicians, researchers, and policy makers to appreciate the true heterogeneity of this population.

ABSTRACT Enhanced recovery after surgery protocols have been shown to reduce length of stay in transplant patients. The purpose of our study was to evaluate the impact of a standardized protocol in liver transplant recipients (LTR) on length of stay (LOS) and delirium during the index hospitalization post‐LT. Elements of the protocol included reduced intraoperative corticosteroids (from methylprednisolone 1000 to 250 mg), conversion of steroid taper to be administered once‐daily instead of BID, optimal end‐of‐case intraoperative extubation, multimodal analgesia, early removal of surgical drains, implementation of dietary and physical therapy plans and education for multidisciplinary providers and patients about expected LOS. The primary outcome was post‐LT LOS. Secondary outcomes included incidence of delirium, ICU LOS, rejection at 60 days and readmission within 30 days of discharge. A total of 125 LTRs were included. Baseline characteristics were similar between groups. The median LOS was 12 days (IQR, 9–19) and 10 days (IQR, 8–15) in the pre‐ and post‐implementation groups, respectively ( p = 0.025). ICU LOS was 2.9 (IQR, 2.1–4) and 2.7 (IQR, 1.9–3.7) in the pre‐ and post‐implementation groups, respectively ( p = 0.525). In the pre‐ and post‐implementation groups, the incidence of delirium was 17 (25.8%) and 5 (8.6%), respectively ( p = 0.013). The incidence of treated rejection at 60 days was 3% (0.0–10.1) and 5.2% (2.9–15.2) in the pre‐ and post‐implementation groups, respectively ( p = 0.550). Implementation of a Fast Track protocol in a high acuity LTR was feasible and safe and was associated with a reduction in LOS.