ABSTRACT Aims Liver transplantation is often curative for patients with cirrhosis; however, some patients subsequently develop cirrhosis in the transplanted graft, either due to recurrence of the original cause of liver disease or development of a new type of liver disease (de novo). Here, we examined patients who developed recurrent or de novo cirrhosis after undergoing liver transplantation for cirrhosis. Methods We examined consecutive adult liver transplant patients who underwent liver transplantation for cirrhosis and were followed between January 1, 1987, and December 31, 2023, at our institution. Patients transplanted for indications other than cirrhosis, including acute liver failure, were excluded. Patients with active hepatitis C virus infection at the time of transplantation were excluded from the primary analysis. Cirrhosis after transplant was defined by histology demonstrating bridging fibrosis or the presence of clinical complications of portal hypertension. In the evaluation of mortality risk, propensity score matching was used to compare liver transplant recipients with and without cirrhosis after liver transplant, and survival was assessed using Kaplan–Meier analysis. Results In total, 937 unique patients were included; 107 (11.4%) developed cirrhosis subsequent to transplantation with a median (interquartile range) time to cirrhosis of 7.8 (8.3) years after transplant. In total, 89 of 107 (83.2%) patients developed the same liver disease that caused cirrhosis initially and led to transplantation. Autoimmune hepatitis (16/55, 29.1%) and primary biliary cholangitis (11/52, 21.2%) most commonly recurred after liver transplantation. Overall, de novo cirrhosis occurred in 18/937 (1.9%) of all patients, accounting for 16.8% (18/107) of patients who developed cirrhosis, most commonly due to chronic rejection (9/18) or metabolic dysfunction‐associated steatohepatitis (4/18). Patients with cirrhosis after transplant had a significantly lower survival rate at 20 years (50.6% vs. 70.7%, hazard ratio: 1.77; 95% confidence interval: 1.09–2.88; log‐rank test; p < 0.05) after liver transplantation compared to those without cirrhosis after transplant. Conclusion Cirrhosis after transplant is uncommon, but when it occurs, it is most often due to recurrence of the primary liver disease, with the highest recurrence rates observed in patients with autoimmune hepatitis and primary biliary cholangitis. De novo cirrhosis is most commonly associated with chronic rejection or metabolic dysfunction‐associated steatohepatitis. Patients developing cirrhosis after transplant have reduced long‐term survival.

The American Board of Internal Medicine Research Pathway (ABIM RP) is designed to train physician-scientists by shortening postgraduate clinical training and increasing research time. We surveyed ABIM RP graduates to understand career trajectories, research engagement, and barriers to physician-scientist retention in academic research careers. We performed an anonymous, structured, web-based survey of 700 ABIM RP current and former trainees (2011-2022). We received 105 survey responses (97 RP graduates). The survey queried about demographics, training background, career outcomes, research involvement, and perceived barriers to retention in physician-scientist careers. Responses were stratified by trainee status, gender, and Medical Scientist Training Program (MSTP) participation, and select results were compared to test for statistical associations. Most respondents (79%) remained in academia, with 61% engaged in research-dominant roles. More MSTP graduates held research-focused academic positions than non-MSTP graduates. The most commonly reported barriers to sustaining research careers were funding instability, financial concerns, and lack of protected research time. Although many of the trainees in the ABIM RP who completed the survey remained in academia, systemic barriers such as funding instability and gaps in institutional support persist. Strategies to enhance financial stability, protected research time, and mentorship appear to be necessary to enhance physician-scientist career retention.

MASH is a leading cause of liver transplantation. Here, we investigated formoterol, a long-acting β2 adrenergic receptor agonist (LABA), in MASH. Mice treated with a high-fat diet (HFD) for sixteen weeks developed liver steatosis and were treated with formoterol or vehicle for four weeks. Steatosis largely resolved following formoterol treatment. To investigate mechanism, we evaluated mitochondrial biogenesis and found in HFD mice treated with formoterol versus vehicle that: PGC1α levels and electron transport chain components were significantly higher; mitochondrial number was increased; and lipids were decreased. Human HepaRG liver cells were then exposed to free fatty acids and/or formoterol. Formoterol attenuated lipid accumulation and increased ATP-linked basal and maximal respiration. Finally, a retrospective analysis of 59,644 patients with MASH showed that patients taking LABAs had fewer complications of advanced liver disease and lower mortality. Together, these data raise the possibility that LABAs, especially formoterol, could be a novel MASH treatment.

Background and Aim:Studies on the duration of vasoconstrictors after endoscopic variceal ligation (EVL) for acute variceal bleeding (AVB) have shown varying results. The present network meta-analysis compared the effectiveness of vasoconstrictors after EVL based on the therapy duration. Materials and Methods:The electronic databases of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus were searched from inception to March 2024 for randomized studies comparing the duration of vasoconstrictors in AVB after EVL (Group 1: ≤24 hours, Group 2: >24 to ≤72 hours, Group 3: >72 to ≤120 hours). Rebleeding and mortality risk were analyzed using pairwise and network meta-analyses. Results:Eleven studies (n=1,066) met the inclusion criteria. Rebleeding rates varied from 0-38% in Group 1, 2-12% in Group 2, and 0-26% in Group 3. There was no difference in the risk of rebleeding in Group 1 (risk ratio [RR]: 1.36, 95% confidence interval [CI]: 0.48-3.52) or Group 2 (RR: 1.34, 95% CI: 0.42-4.54), compared to Group 3. Similarly, there was no difference either in 5-day mortality risk among the groups (RR: 0.66, 95% CI: 0.09-2.52 and 1.08, 95% CI: 0.15-6.43 for Groups 1 and 2, respectively, vs. Group 3) or 30-day mortality risk (RR: 1.18, 95% CI: 0.51-2.51 and 0.98, 95% CI: 0.36-2.52 for Groups 1 and 2, respectively, vs. Group 3). Conclusion:The current network meta-analysis provides no evidence to support the use of vasoconstrictors following EVL. These data suggest that vasoconstrictors can be stopped early after EVL, facilitating early discharge from the hospital.

The U.S. Multi-Society Task Force (USMSTF) updated its 2020 guidelines to recommend less frequent post-polypectomy surveillance, yet premature colonoscopies remain common. Since the guidelines were published 5 years ago, we hypothesized that adherence has improved over time. We also aim to identify factors associated with non-adherence. This was a multicenter retrospective cohort study of 452 patients. 1st surveillance colonoscopies performed between 2020 and 2025 were included. Findings from pathology reports for both index and first surveillance colonoscopies were recorded. We considered follow-up after identifying hyperplastic polyps (HPs), low-risk adenomas (LRAs), or high-risk adenomas (HRAs) (the most advanced lesion was considered to be the lesion for which surveillance was indicated). Procedures performed more than 6 months earlier or later than recommended were defined as early or late, respectively. Early surveillance occurred in 58

Laparoscopic liver biopsy (LLB) provides a way to obtain liver tissue samples under direct visual inspection of the liver surface. It complements percutaneous liver biopsy (PLB) for complex or high-risk cases where PLB cannot be performed. Clinical practices for LLB vary across centers due to the lack of international standards. To improve the procedural quality and diagnostic efficiency of LLB, a multidisciplinary panel of 45 international experts from 6 continents, including hepatology, hepatobiliary surgery, gastrointestinal surgery, and metabolic and bariatric surgery, developed this consensus statement through three rounds of a modified Delphi process. This consensus covers clinical application scenarios, high-risk clinical scenarios, preoperative preparation, surgical procedures, complication management, and discharge and quality management. It aims to promote the standardization, safety, and rational clinical application of LLB; support the management of complex cases; and facilitate the appropriate implementation of this important diagnostic procedure.

PURPOSE OF REVIEW:Albumin plays a central role in maintaining circulatory and endothelial homeostasis through its oncotic and nononcotic effects. In cirrhosis, reduced concentration and impaired function of albumin contribute to circulatory derangements, renal dysfunction, and infection risk. While albumin is firmly established in certain settings such as spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and large-volume paracentesis (LVP), its broader use in cirrhosis remains controversial and incompletely defined. We aim to integrate up to date guidance on the use of albumin in cirrhosis, and to highlight areas where evidence remains limited or evolving. RECENT FINDINGS:Evidence from randomized trials and meta-analyses highlights both established and emerging roles of albumin in cirrhosis. Albumin has demonstrated clear benefit after LVP, where it reduces postprocedural circulatory dysfunction, renal impairment, and hyponatremia compared with other plasma expanders. In HRS, albumin serves as an indispensable therapeutic backbone, enhancing the efficacy of vasoconstrictors and improving rates of renal reversal, yet its independent role remains incompletely defined. In SBP, co-administration of albumin with antibiotics reduces renal failure and improves short-term survival, establishing it as standard of care. In acute kidney injury (AKI) outside of HRS, current guidelines recommend the use of albumin as part of an initial volume challenge in many forms of AKI to aid diagnosis and potentially promote renal recovery, although the timing of its use differs among guidelines. SUMMARY:Albumin is a cornerstone therapy in the management of decompensated cirrhosis and its clinical complications. While its role is well defined in HRS, SBP, and post-LVP, higher-quality evidence is needed to refine its use in other settings, particularly in AKI.

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease with inflammatory bowel disease (IBD) present in 60–80

INTRODUCTION:We hypothesized that SGLT-2 inhibitors (SGLT-2is) may have beneficial effects on portal hypertension in patients with cirrhosis. METHODS:Using TriNetX, we identified adults with cirrhosis treated with SGLT-2is. Patients prescribed SGLT-2is within 12 months of a cirrhosis diagnosis were examined (vs. no treatment). Three subgroups were examined: MASH cirrhosis, alcohol-associated cirrhosis, and "other" cirrhosis. To control for liver disease severity/etiology, propensity score matching (PSM) incorporating 47 variables was performed within each subgroup. RESULTS:PSM resulted in a total of 10,976 cirrhosis patients (compensated and decompensated together; 5488 each SGLT-2i/control), composed of three matched subgroups (MASH (6052); alcohol (2864); other (2060)). After matching, baseline characteristics were similar in patients prescribed SGLT-2is and controls. Patients receiving SGLT-2is developed significantly fewer new portal hypertensive complications, including ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome (any portal hypertensive complication risk; MASH: HR 0.73, 95%CI 0.64-0.83; alcohol: HR 0.58, 95%CI 0.49-0.68; other: HR 0.60, 95%CI 0.47-0.76; all P < 0.001). The complication with the greatest reduction was ascites. In sensitivity analyses of decompensated cirrhosis patients, the development of a new portal hypertension complication was lower in those prescribed SGLT-2is. Patients prescribed SGLT-2is had a reduced risk of all-cause mortality (MASH: HR 0.57, 95%CI 0.49-0.66; alcohol: HR 0.65, 95%CI 0.55-0.77; other: HR 0.49, 95%CI 0.39-0.62; all P < 0.001). CONCLUSION:Cirrhosis patients prescribed SGLT-2is had decreased portal hypertensive complications and increased survival compared to those not receiving SGLT-2is.

BACKGROUND:During the COVID-19 pandemic, there was an increase in alcohol consumption. Here, we investigated COVID-19's impact on alcohol-associated hepatitis (AH) and alcohol-associated cirrhosis (AC) outcomes. METHODS:Data from HCA's Enterprise Data Warehouse were examined (1/1/18 - 12/31/22). Patients aged > 18 years admitted for AH or AC were included. Pre- COVID-19 (2018-2019) and COVID-19 (2021-2022) time frames were evaluated. Statistical analyses were performed to evaluate LOS, discharge disposition, and mortality. RESULTS:Of the 3177 patients with AH and AC, 1752 were admitted during COVID-19 (AH: 815, AC: 937). Patients in both groups were predominantly male (AH: 68%, AC: 72%) and White (AH: 73%, AC: 79%), with patients in the AH group being younger than those in the AC group (49 vs. 56 years). During COVID-19, 369/815 (45%) patients in the AH group and 447/937 (48%) patients in the AC group were diagnosed with COVID-19. In patients with AH, those diagnosed with COVID-19 had a 2.4-day longer LOS (OR: 2.36, p < 0.001), a 39% decreased likelihood of home discharge (OR: 0.61, p < 0.05), and a 223% increase in mortality (OR: 2.23, p < 0.05), compared to patients with AH, but without COVID-19. In patients with AC, those with COVID-19 had a 2.2-day longer LOS (OR: 2.19, p < 0.001), though discharge disposition and mortality were not significantly affected by a COVID-19 diagnosis. CONCLUSIONS:Patients with COVID-19 and AH or AC had longer LOS. Mortality was increased in AH but not AC, perhaps reflecting greater acuity and severity of AH than AC.