Background and Aims: Up-to-date information is needed on hepatocellular carcinoma (HCC) diagnosis, stage, treatment, and survival. Methods: Of > 2000 patients with a new diagnosis of HCC in 2023 in the US Veterans Health Administration, a random subsample of 194 confirmed HCC cases were selected for a structured medical record review by expert hepatologists. Results: Among 194 confirmed HCC cases in 2023, mean age was 73 years, and only 56.7% had cirrhosis diagnosed before HCC, while 12.9% had cirrhosis diagnosed after HCC and 22.2% did not have cirrhosis. Stage at diagnosis was T1 in 17.5%, T2 in 42.3%, and beyond T2 in 40.2%. Early-stage diagnosis (T1 or T2) was more common in the following groups: cirrhosis diagnosed before HCC (70.9%), HCC diagnosed by screening (86.3%), high performance status (73.0%), receipt of Veterans Affairs (VA) primary care (63.3%), or VA liver care (72.6%). Among 147 of 194 patients (75.8%) who received HCC-directed treatments, the most common, first-line treatment was Y-90 radioembolization (28.6%), followed by ablation (21.1%), transarterial chemoembolization (20.4%), systemic therapy (17.0%), surgical resection (7.5%), and external beam radiation (5.4%). Mortality (29.9% at 1 year, 44.8% at 2 years) was lower in those with early-stage diagnosis, diagnosis via screening, Child-Turcotte-Pugh class A, Model for End-Stage Liver Disease ≤ 10, absence of cirrhosis, cured hepatitis C virus, receipt of curative treatments, VA primary or liver care, and good performance status. Conclusion: These results highlight the importance of HCC screening and engagement in liver care for early HCC diagnosis, curative treatment, and improved survival while demonstrating the feasibility of a national quality improvement program for addressing persistent gaps in the HCC screening, diagnosis, and treatment.

INTRODUCTION:Antibiotic overuse and subsequent antibiotic resistance lead to worse infection outcomes in cirrhosis. Secondary spontaneous bacterial peritonitis prophylaxis (SecSBBPr) is associated with higher SBP recurrence, but impact on non-SBP infections is unclear. METHODS:We studied patients with cirrhosis and SBP who were given SecSBPPr or not between 2009 and 2019 in 2 complementary national cohorts (Veterans Affairs Corporate Data Warehouse [VA-CDW] and non-VA TriNetX). Development of total non-SBP infections and specifically urinary tract infections (UTIs), bacteremia, pneumonia, and C. difficile using validated codes over 2 years was compared between those on SecSBPPr vs not. Multivariable regression for non-SBP infections was performed. RESULTS:VA-CDW: Of 4,673 veterans with index SBP, 2,539 (54.3%) were started on SecSBPPr. In total, 1,406 (30.1%) developed non-SBP infections (13.5% UTI, 12.4% pneumonia, 8.5% bacteremia, and 6.8% C. difficile ). On multivariable regression, SecSBPPr was significantly associated with any non-SBP infection (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.10-1.44, P < 0.0001) and UTI (OR 1.21, 95% CI 1.01-1.45, P = 0.036). TriNetX: Of 6,708 patients with index SBP, 3,261 (48.6%) were started on SecSBPPr. In total, 1,932 (28.8%) patients developed non-SBP infections (13.4% UTI, 12.9% pneumonia, 8.6% bacteremia, and 5.9% C. difficile ). On multivariable regression, SecSBPPr was significantly associated with any non-SBP infection (OR 1.33, 95% CI 1.12-1.59, P < 0.0001), UTI (OR 1.35, 95% CI 1.07-1.71, P = 0.010), pneumonia (OR 1.35, 95% CI 1.06-1.72, P = 0.017), and bacteremia (OR 1.47, 95% CI 1.10-1.97, P = 0.009). DISCUSSION:In 2 diverse US-based national cohorts of patients with cirrhosis and SBP, use of SecSBPPr was associated with a higher risk of non-SBP infections, especially urinary tract infections.

This practice recommendation serves as an update to the 2023 AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease (NAFLD), now known as metabolic dysfunction-associated steatotic liver disease (MASLD), and provides implementable guidance on patient selection for treatment, consideration of comorbidities, and monitoring of treatment safety and efficacy of semaglutide. FDA-indication and Practice Recommendation: The Wegovy formulation, whose main ingredient is semaglutide, received accelerated FDA approval in August 2025 for treating MASH with moderate-to-advanced fibrosis (consistent with stages F2-F3 fibrosis), based on interim results of the phase 3 ESSENCE trial where 72 weeks of 2.4 mg/week subcutaneous injection resulted in achievement of both primary histologic endpoints: (1) resolution of MASH without worsening of fibrosis (62.9% vs. 34.3% placebo, p <0.001) and (2) ≥1 stage reduction in liver fibrosis without worsening of MASH (36.8% vs. 22.4% placebo, p <0.001); final approval awaits long-term outcomes. Patient Selection: Candidates should have MASH with stage 2-3 fibrosis, identified using non-invasive tests (NITs) such as VCTE (8-15 kPa), MRE (3.1-4.4 kPa), or ELF (9.2-10.5), rather than liver biopsy, which is impractical and unnecessary for most patients. In those with VCTE (15-20 kPa), MRE (4.4-5 kPa), or ELF (10.5-11.3), an individualized decision to treat should be based on exclusion of cirrhosis with another confirmatory NIT, or cross-sectional imaging excluding nodular-appearing liver contour and signs of portal hypertension, or a platelet count of <150,000/mm 3 . While semaglutide is not approved to treat patients with MASH cirrhosis (VCTE >20 kPa, MRE>5.0 kPa, ELF>11.3, and/or evidence of portal hypertension), those with compensated cirrhosis who are receiving semaglutide for another FDA-approved indication should be monitored carefully. Monitoring and Safety: Semaglutide showed a favorable hepatic safety profile in the ESSENCE trial, with no discontinuations due to liver enzyme elevations. Routine hepatic panels are recommended only as clinically indicated. The most common adverse events were gastrointestinal (nausea, diarrhea, constipation, vomiting), generally mild and transient; patient education and dose titration help improve tolerance. Clinicians should monitor for rare but serious risks, including acute kidney injury (from dehydration), symptomatic gallbladder disease, pancreatitis, thyroid C-cell tumors, retinopathy progression, and lean mass loss. Treatment Response and Concomitant Therapy: Lifestyle modification remains the cornerstone of MASLD/MASH management alongside semaglutide. Combination use of resmetirom with semaglutide 2.4mg/week has not been studied. While no NITs reliably predict histologic response at the individual patient level, reductions from baseline to 72 weeks of treatment suggest significant improvement in MASH resolution (ALT ≥17 U/L or ≥20%) and fibrosis improvement (VCTE LSM ≥30%; MRE LSM ≥20%; ELF ≥0.5). Non-response may be suspected if ALT or NITs worsen. The benefit is uncertain if a suboptimal response occurs, and may require an individualized approach and further follow-up.

Chen, Vincent L.; Morgan, Timothy R.; Rotman, Yaron; Patton, Heather M.; Cusi, Kenneth; Kanwal, Fasiha; Kim, W Ray Author Information

BACKGROUND:With changes in bacteriology and cirrhosis demographics, the impact of spontaneous bacterial peritonitis (SBP) on cirrhosis outcomes needs re-evaluation. AIM:Determine the importance of SBP on mortality and liver transplant (LT) across occurrence/recurrence and prophylaxis in a national cohort of Veterans with decompensated cirrhosis. METHOD:Veterans admitted with their first hepatic decompensation between 2009 and 2019 were evaluated for SBP development, and use of primary/secondary SBP prophylaxis (PSPr/SSPr) to determine the associations between SBP and interaction with mortality and LT. RESULTS:52,392 Veterans were included and followed for 7.51 ± 3.83 years, during which 77% died and 2.4% received LT. 16.7% developed one SBP episode, 2.3% two episodes and 0.8% ≥ 3 episodes. Patients on PSPr versus not showed a 24% higher mortality risk, those on SSPr versus not had a 5% increased mortality risk with first and 28% higher mortality risk with additional recurrences. SBPPr interacted with SBP episode number (1.4× PSPr and 1.76× for SSPr) for mortality but not LT. SBP cultures showed higher resistance with increasing SBP episodes (2nd vs. 1st: OR = 2.51, p < 0.001; ≥ 3 vs. 2nd: OR = 7.84, p < 0.001) and with SBPPr (PSPr vs. no prophylaxis: OR = 2.30; SSPr vs. no at first recurrence: OR = 3.70; SSPr vs. no at ≥ 2 recurrences: OR = 10.79, all p < 0.001). Despite documented resistance on PSPr, 82% of patients were continued on the same medication for SSPr, with similar rates of continuation after repeat infection while on SSPr. CONCLUSION:In a national cohort of newly decompensated cirrhosis Veterans, SBP increased mortality, which worsened with recurrence. SBP prophylaxis (primary or secondary) showed an interaction with higher mortality but not LT. Antibiotic resistance increased with SBPPr, but culture results were not followed while resuming/initiating SBPPr. Novel strategies to prevent SBP recurrence and mortality are needed.

INTRODUCTION:Goals of care discussions (GCDs) are recommended for patients with cirrhosis but rarely conducted. Since 2017, the Veterans Health Administration has provided a standardized note template that clinicians can use to document GCDs for Veterans with serious illness. We aimed to quantify the frequency and timing of GCDs in this population, along with the factors associated with GCDs and their content. METHODS:This retrospective cohort study identified Veterans with cirrhosis from January 2017 to July 2022 and captured GCDs until July 2023. We assessed the association between demographics, clinical factors, use of health services, and GCD documentation. We also examined contents of completed GCDs, time from GCD completion to death, and changes in GCD documentation rates after targeted quality improvement (QI) initiatives from May 2020 to May 2023. RESULTS:By July 2023, 29.8% of 167,727 Veterans with cirrhosis had a completed GCD. GCD completion was significantly associated with palliative care consultation (odds ratio [OR] 3.86, 95% confidence interval [CI] 3.69-4.03), liver-related hospitalization (OR 3.27, 95% CI 3.08-3.46), decompensated disease (OR 2.27, 95% CI 2.20-2.33), and higher Charlton Comorbidity Index (OR 1.22, 95% CI 1.17-1.26). GCD completion improved from 0.4% to 21.2% from May 2020 to May 2023 after targeted QI initiatives. Among those with completed GCDs, median time between first GCD and death was 37 days. Surrogate decision making (71.8%) and goals of care (64.9%) were common elements, but only half of Veterans were considered to have sufficient illness understanding (52.5%). DISCUSSION:GCD documentation increased over time in the context of targeted QI initiatives. Future interventions should be conducted earlier and address illness understanding.

Abstract Background Because cirrhosis is often unrecognized, we aimed to develop a stepwise screening algorithm for cirrhosis in the Veterans Health Administration (VHA) and assess this approach’s feasibility and acceptability. Methods VHA hepatology clinicians (“champions”) were invited to participate in a pilot program from June 2020 to October 2022. The VHA Corporate Data Warehouse was queried to identify Veterans with possible undiagnosed cirrhosis using Fibrosis-4 (FIB-4) ≥ 3.25 and at least one risk factor for liver disease (e.g., obesity), and generate an age-stratified sample. Champions at four sites reviewed charts to confirm eligibility and contacted Veterans to offer further evaluation with elastography. Feasibility was defined as protocol implementation with completion of at least one elastography test and acceptability was defined based on Veteran- and clinician-reported surveys. Participation in the program, patient outcomes, adaptations to the protocol, and implementation barriers were also assessed. Results Four sites were able to implement the screening protocol. Adaptations included type of outreach (primary care vs. hepatology, phone vs. mail) and type of elastography used. One site chose to refer patients with clear evidence of cirrhosis directly to hepatology (n = 12) rather than to elastography. Key implementation barriers included staffing, primary care provider (PCP) comfort with interpreting and communicating results, and appointment availability during the COVID-19 pandemic. Of 488 patients whose charts were reviewed, 230 were excluded from outreach based on predefined criteria (e.g., advanced cancer, prior or current referral to hepatology). Champions and PCPs attempted to contact 165 of 246 Veterans who were deemed eligible for evaluation with elastography. Among 53 Veterans who completed elastography, 22 (42%) had findings consistent with significant fibrosis and were referred to hepatology. Clinicians and Veterans reported high acceptability of the program on surveys (80% of Veterans who completed survey). Conclusions This pilot demonstrated the feasibility, acceptability, and challenges of a multisite approach to cirrhosis screening.

INTRODUCTION:Metabolic dysfunction-associated steatotic liver disease (MASLD), an increasing public health concern, remains challenging to diagnose and risk-stratify. We assessed the (i) prevalence of MASLD risk factors among veterans in Veterans Health Administration (VA) care, (ii) factors associated with MASLD diagnosis, and (iii) associations between MASLD diagnosis and receipt of care. METHODS:Veterans with MASLD risk factors, including obesity, prediabetes, diabetes, or dyslipidemia, were identified using International Classification of Diseases-10 codes and followed in 2019-2022. Multivariable logistic regression and propensity score-adjusted models identified demographic and clinical characteristics associated with a diagnosis of MASLD or cirrhosis and receipt of elastography, specialty care for liver disease, VA weight management (MOVE!) participation, and glucagon-like peptide-1 (GLP-1) analog prescriptions. RESULTS:Among approximately 9 million veterans, 4,159,699 (45%) had risk factors for MASLD and were included in further analysis. MASLD or cirrhosis was diagnosed in 6% of the at-risk cohort. At-risk Veterans diagnosed with MASLD were younger with more metabolic risk factors, increased rates of alcohol use disorder, and higher FIB-4 scores and alanine transaminase values. Over 1-year follow-up, 6% engaged in MOVE!, 9% had specialty care for liver disease, 3% were prescribed GLP-1 analogs, and 2% underwent staging elastography. MASLD diagnosis was significantly associated with receipt of MOVE!, specialty care consultation, and GLP-1 analog prescription. DISCUSSION:Few at-risk Veterans carried an MASLD diagnosis or had undergone staging elastography. Because MASLD diagnosis was associated with linkage to hepatology care and weight loss therapy services, implementation of population screening and management services for MASLD is critically needed.

Introduction: Antibiotic overuse and subsequent antibiotic resistance lead to worse infection outcomes in cirrhosis. Secondary spontaneous bacterial peritonitis prophylaxis (SecSBBPr) is associated with higher SBP recurrence but impact on non-SBP infections is unclear. Methods: We studied patients with cirrhosis and SBP who were given SecSBPPr or not between 2009-2019 in two complementary national cohorts [Veterans affairs corporate data warehouse (VA-CDW) and non-VA TriNetX]. Development of total non-SBP infections and specifically urinary tract infections (UTI), bacteremia, pneumonia, and C.difficile using validated codes over 2 years was compared between those on SecSBPPr versus not. Multi-variable regression for non-SBP infections was performed. Results: VA-CDW: Of 4673 Veterans with index SBP, 2539 (54.3%) were started on SecSBPPr. 1406 (30.1%) developed non-SBP infections (13.5% UTI, 12.4% pneumonia, 8.5% bacteremia and 6.8% C.difficile ). On multi-variable regression, SecSBPPr was significantly associated with any non-SBP infection (OR 1.26, 95% CI:1.10-1.44, p<0.0001) and UTI (OR 1.21, 95% CI:1.01-1.45, p=0.036). TriNetX: Of 6708 patients with index SBP, 3261 (48.6%) were started on SecSBPPr. 1932 (28.8%) patients developed non-SBP infections (13.4% UTI, 12.9% pneumonia, 8.6% bacteremia and 5.9% C.difficile ). On multi-variable regression, SecSBPPr was significantly associated with any non-SBP infection (OR 1.33, 95% CI:1.12-1.59, p<0.0001), UTI (OR 1.35, 95% CI:1.07-1.71, p=0.010), pneumonia (OR 1.35, 95% CI:1.06-1.72, p=0.017), and bacteremia (OR 1.47, 95% CI:1.10-1.97, p=0.009). Conclusions: In two diverse US-based national cohorts of patients with cirrhosis and SBP, use of secondary SBP prophylaxis was associated with a higher risk of non-SBP infections , especially urinary tract infections.

To the editor, Among hospitalized adults with cirrhosis and ascites, early paracentesis (performed within 24 h) is associated with reduced inpatient mortality, particularly among high-risk patients, such as those with acute kidney injury and/or HE.1,2 Failure to perform early paracentesis is associated with higher odds of acute kidney injury, transfer to the intensive care unit, and inpatient mortality. Despite the recommendation from the American Association for the Study of Liver Disease (AASLD) that patients with ascites from cirrhosis admitted to the hospital undergo a diagnostic paracentesis, even in the absence of signs and symptoms of infection, a recent study by Patel et al3 revealed a low rate (14.3%) of early paracentesis performed in this population in the Veterans Health Administration (VHA). To understand barriers to early paracentesis, we developed and emailed a 20-question survey to clinicians responsible for performing inpatient paracentesis in VHA. A total of 114 participants from 24 VHA hospitals completed the survey, including 84% physicians and 10% advanced practice providers, most of whom specialized in Internal Medicine (48%) and Interventional Radiology (22%). Most respondents (62%) were familiar with the AASLD recommendation for paracentesis but described barriers including time (51%), provider comfort (51%), and supervisor availability (29%). Only 16% had a designated procedure team, and only 15% reported a standard operating procedure for inpatient paracentesis at their facility. These findings suggest several potential strategies to increase early paracentesis completion (Figure 1). Education and training could address the confidence gap described by Internal Medicine providers who perform the bulk of these procedures and are likely the major referral source to Interventional Radiology. Availability of prepackaged paracentesis kits containing the necessary supplies in the emergency department and the wards may help address the time burden. Likewise, standardized order sets for patients admitted with ascites could increase efficiency and prompt providers to address numerous quality issues, including timely paracentesis. Further research into noninvasive means to exclude spontaneous bacterial peritonitis may be beneficial.FIGURE 1: Early paracentesis has been shown to improve multiple important metrics in patients with decompensated cirrhosis admitted to the hospital, including mortality. In the Veterans Health Administration, rates of paracentesis completion in the first 24 hours of admission remain low. Based on our survey of Veterans Health Administration providers, there are a number of potential interventions that may increase early paracentesis completion and thereby improve patient outcomes. Abbreviations: AKI, acute kidney injury; ICU, intensive care unit.In summary, the study by Patel and colleagues highlighted an important quality gap in cirrhosis care in the VHA. Our survey documents a lack of time and comfort as the major barriers to early paracentesis. We suggest strategies such as prepackaged paracentesis kits, availability of procedure teams and ascites care-specific order sets to drive improvement in this important patient care metric.

The Veterans Health Administration provides care to more than 100,000 Veterans with cirrhosis. This implementation evaluation aimed to understand organizational resources and barriers associated with cirrhosis care. Clinicians across 145 Department of Veterans Affairs (VA) medical centers (VAMCs) were surveyed in 2022 about implementing guideline-concordant cirrhosis care. VA Corporate Data Warehouse data were used to assess VAMC performance on two national cirrhosis quality measures: HCC surveillance and esophageal variceal surveillance or treatment (EVST). Organizational factors associated with higher performance were identified using linear regression models. Responding VAMCs (n = 124, 86