Biliary complications after orthotopic liver transplantation (OLTx) have a high incidence with inherent risks. Given the rise of obesity and subsequent bariatric surgery, there are new challenges for management, particularly in the setting of bypass anatomy, which is not well described. Trans-gastric remnant endoscopic retrograde cholangiopancreatography (TG-ERCP) is a novel technique that could evolve into a primary tool for the diagnosis and treatment of biliary complications after OLTx. A 35-year-old female with a history of Roux-en-Y gastric bypass (RYGB), decompensated alcoholic cirrhosis, and a MELD of 40 underwent standard OLTx. The postoperative course was complicated by rising liver function tests and common bile duct (CBD) dilatation without graft biliary tree dilation. Due to her bypass anatomy, TG-ERCP was used to diagnose a biliary stricture which was treated with CBD stenting. A gastric remnant gastrostomy tube (G-tube) was placed as easy access for all interval ERCP interventions until stricture resolution. As metabolic dysfunction-associated steatotic liver disease becomes a larger transplant indication, centers will undoubtedly encounter more recipients with RYGB anatomy. When compared to alternative options, TG-ERCP should be the primary tool for the diagnosis and treatment of postoperative biliary complications, given its high success rate with fewer complications and graft vascular injuries. Future cohort-based studies are necessary to validate this approach and the proposed treatment algorithm.

Background: Kidney injury is common among liver transplant recipients. Equations estimating glomerular filtration rate were not developed in liver transplant recipients. Aim: To determine if GFR equations and 24-hour urine creatinine clearance accurately estimate GFR in liver transplant recipients. Methods: 30 subjects were enrolled within 6 months of transplant and obtained estimates of GFR. The iothalamate scan served as the gold standard and it was compared to GFR equations and 24- hour urine creatinine clearance. Results: The mean time to iothalamate scan was 110 + 50 days.The mean iothalamate GFR was 90 + 37 mL/min/1.73 m2. The GFR equations underestimated GFR with 47%-63% of estimates differing by more than 20% from the iothalamate GFR. Among the equations the CKD-EPI-Cys-Cr was the most accurate. 24-hour urine creatinine clearance both under and overestimated GFR, however it was the most concordant with the iothalamate scan in identifying subjects with GFR greater or less than 50 mL/min/1.73 m2. Conclusions: Within 6 months of liver transplant GFR equations and 24-hour urine collection do not accurately estimate GFR. 24-hour urine creatinine clearance may be the clinically most useful estimate of GFR because it most accurately identifies liver transplant recipients with GFR greater or less than 50 mL/min/1.73 m2.

Filsinger, Michael MPAS, PA; Russo, Mark W. MD; Levi, David M. MD; Pierce, Ruth RN; Casingal, Vincent MD; Eskind, Lon MD; deLemos, Andrew MD; Schmeltzer, Paul A. MD; Zamor, Philippe J. MD; Burick, Alexzandria PA-C Author Information

Health care has shifted to placing priority on quality and value instead of volume. Liver transplantation uses substantial resources and is associated with high readmission rates. Our goal was to determine if a protocol designed to reduce readmission after liver transplant was effective. We conducted a prospective study of a protocol designed to reduce readmission rates after liver transplantation by expanding outpatient services and alternatives to readmission. The 30‐day readmission rate 1 year after implementing the protocol was compared to the 30‐day rate for 2 years prior to implementation. Multivariate analysis was used to control for potential confounding factors. Over the study period, 167 adult primary liver transplants were performed with a mean biological Model for End‐Stage Liver Disease score of 21 ± 8. Fifty‐seven (34%) patients were readmitted. The most common reason for readmission was biliary complications (n = 13). The 30‐day readmission rate decreased from 40% before implementing the protocol to 20% after implementation (P = 0.02). In multivariate analysis, the protocol remained associated with readmission (odds ratio, 0.39; 95% confidence interval, 0.16‐0.92; P = 0.03). The mean length of stay after transplant was 13 ± 12 days preprotocol and 9 ± 5 days postprotocol (P = 0.09). Alternatives to readmission, including hospital lodging and observation status, were main factors in reducing readmission rates. If the most recent definitions of inpatient admission and observation status were applied over the entire study period, then the readmission rates preprotocol and postprotocol were 31% and 20% indicating that the revised definition of observation status accounted for 45% of the reduction in the readmission rate. Readmission after liver transplantation can be reduced without increasing length of stay by implementing a specifically designed protocol that expands outpatient services and alternatives to inpatient admission. Liver Transplantation 22 765–772 2016 AASLD.

BACKGROUND:Post-transplant hepatitis C is a major challenge after liver transplantation (LT). Antiviral therapy is associated with lower efficacy in the post-transplant setting.AIMS:The purpose of this study was to determine the safety and effect of intravenous interferon (IFN) during the anhepatic phase of LT on hepatitis C viral load.METHODS:Fifteen consecutive subjects undergoing liver transplant for hepatitis C cirrhosis were enrolled in the study, ten of which received study drug and five subjects served as controls. Cases received weight-based ribavirin and subcutaneous IFN at time of incision followed by intravenous IFN at the start of the anhepatic phase. Adverse events and viral levels were recorded. Repeated measures ANOVA was employed to test for differences over time, between the groups, and time by group interaction.RESULTS:All subjects had genotype 1 virus. Hepatitis C viral load was lower at week 4 in cases compared to controls (769,004 ± 924,082 IU/ml and 2,329,896 ± 3,731,749 IU/ml, respectively), but did not reach statistical significance (p = 0.50). Three subjects developed adverse events related to IFN including pulmonary edema, rejection, and neutropenia.CONCLUSIONS:Intravenous IFN administered during the anhepatic phase of liver transplant did not prevent graft reinfection and was associated with manageable adverse events. This regimen could be further studied if direct acting antiviral agents alone are insufficient for treating post-transplant hepatitis C.

GOALS:To describe our experience with coronary artery stenting and antiplatelet therapy in cirrhotic patients and compare rates of bleeding with a control group.BACKGROUND:Although there are data on cardiac evaluation and perioperative cardiac risk in cirrhotic patients, there is a paucity of information on outcomes in cirrhotic patients with coronary artery stents. Cirrhotic patients may be at increased risk for complications, including gastrointestinal bleeding as a result of antiplatelet therapy prescribed after stenting.STUDY:We performed a retrospective study of complications in cirrhotics that received a coronary artery stent followed by clopidogrel and aspirin prescribed to prevent stent occlusion. Cirrhotics with stents were compared with an age and sex-matched control group with cirrhosis without stents and not on aspirin.RESULTS:Among 423 cirrhotic patients who underwent liver transplant evaluation, 16 patients (3.8%) received a stent of which 9 underwent liver transplant. Two patients with varices (12.5%) in the stent group had fatal variceal bleeding and 2 controls (6.3%) had nonfatal variceal bleeding during follow-up while on antiplatelet therapy (P=0.86). There were no significant differences in transfusion requirements between the 9 liver transplant recipients with stents compared with the control group, P=0.69 for packed red blood cells.CONCLUSIONS:In our experience, it is safe for cirrhotic patients without varices to receive a coronary artery stent and for cirrhotic patients with coronary artery stents to be considered for liver transplantation. Larger prospective studies are needed to confirm these results and evaluate the risk of bleeding in cirrhotics with varices who receive coronary artery stents and antiplatelet therapy.

Purpose: Post transplant recurrent Hepatitis C continues to be a challenge after liver transplantation (LT). Primary aim of this pilot study was to determine the safety of IV Interferon (IFN) & Ribavirin (RBV) administered during anhepatic phase of LT & determine their effect on HCV RNA. Secondary aims included histologic response at 48 weeks post-transplant. Methods: 15 consecutive subjects undergoing LT for HCV cirrhosis were enrolled {10 cases (received IFN), 5- controls}. All cases received RBV 1000/1200 mg PO on call to OR, 5 MU IFN α-2b SQ at time of incision & 5 MU IFN α-2b IV at start of the anhepatic phase. Adverse events within 48 weeks post LT were recorded. HCV RNA levels were obtained pre-transplant, before & after anhepatic phase, at 12, 24, 48 & 96 hrs & at week 4, 8, 12, 24 & 48 post LT. IL28B status was recorded. All subjects underwent protocol liver biopsy at 48 weeks. Immunosuppression was protocol based and all but 2 received tacrolimus. Repeated Measures ANOVA was employed to test for differences over time, between the groups, and time by group interaction. Results: All but 1 subject were male & mean age was 51 years. All had genotype 1 virus & mean MELD of study group was 18 + 6.2 (no significant difference between cases & controls). IL28B differed significantly between the 2 groups (cases - 5 CT, 2 CC, 1 TT, 1 not available; controls - 3 TT, 1 CT, 1 not available, p<0.05). We previously reported the regimen to be safe with easily manageable adverse events (n=3 subjects) and a trend for lower HCV RNA at week 4 among cases compared to controls (p >0.07; ACG 2012 # S132). There was no significant difference in Hgb, ANC, creatinine, ALT and length of stay post LT between the 2 groups. We now report follow-up 48 week data on our primary and secondary end-points. No additional adverse events were observed. The trend towards lower HCV RNA observed at week 4 among cases was lost at week 48 [HCV RNA was similar among cases and controls at 48 weeks post LT (5,866,398 + 9,441,240 vs. 5,216,657 + 4,968,923 respectively); p>0.05]. No significant difference was observed in histologic stage/grade at 48 weeks [data available in all but 2 subjects (1 case and 1 control)] between the 2 groups- all controls- stage 0 fibrosis; cases: Five- no fibrosis, One- stage 1 fibrosis, Three- stage 2 fibrosis. Conclusion: This pilot study suggests that IV IFN administered during the anhepatic phase of LT appears to be safe. There was a trend towards lower HCV RNA at week 4 post-LT among cases, although no significant virologic/ histologic effect was noted at 48 weeks. This limited data support further study of this novel approach for preventing recurrent post-LT HCV, possibly involving direct acting antiviral agents in select IL28B sub-groups.

Acute liver failure (ALF) during pregnancy is very uncommon. Pregnancy-specific liver conditions like hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and acute fatty liver of pregnancy can cause ALF at term or postpartum, but, typically occur during the third trimester. Most of these patients recover spontaneously after delivery, but, on occasion, they require liver transplantation in the postpartum period. However, ALF during the first and second trimester of pregnancy requiring antepartum liver transplantation is rare. Only fifteen cases of liver transplantation during pregnancy have been reported, and very few occurred during the first trimester. We report a Woman who developed acute liver failure during the first trimester of pregnancy and underwent successful liver transplantation at 11-week gestation, followed by successful delivery of the fetus at 30 weeks. To our knowledge, this is the earliest case of successful liver transplantation during pregnancy followed by successful fetal outcome. We discuss management of the patient and fetus before, during, and after liver transplantation and review the literature on antepartum liver transplant in pregnancy.

Purpose: Background: Recurrent hepatitis C (HCV) is a major challenge post liver transplantation (LT). Early prophylactic antiviral therapy has not been beneficial & therapy ‘on demand' is associated with lower response rates. Aim: To determine the safety and effect on HCV RNA of interferon (IFN) & Ribavirin (RBV) administered during the anhepatic phase of LT. Methods: 10 consecutive subjects with HCV undergoing LT were enrolled in the treatment arm (cases). 5 consecutive subjects with HCV who did not receive treatment acted as controls. Treatment consisted of RBV 1000/1200 mg PO on call to OR and 5 MU IFN α-2b SQ at time of incision followed by 5 MU IFN α-2b IV at start of the anhepatic phase. HCV RNA levels were obtained pre-transplant, before & after anhepatic phase, at 12, 24, 48 & 96 hrs after transplant & at week 4. Daily CBC was followed pre-discharge & weekly. Immunosuppression was protocol based. Repeated Measures ANOVA was employed to test for differences over time, between the groups, & time by group interaction. Results: All subjects were genotype 1 & all but 2 received tacrolimus (TAC) based immunosuppression. Mean MELD was 21 +/- 3.5. 4 subjects had HCC while 1 each had hepatopulmonary syndrome & hyponatremia. 3 subjects had adverse events attributed to IFN- intra-op pulmonary edema after IV infusion that responded to medical intervention (definite), leucopenia needing granulocyte colony stimulating factor (probable) & acute rejection treated with steroid bolus & adding mycophenolate (possible; low TAC level). Mean HCV RNA and ALT at week 4 were lower in cases than controls (707,715 vs. 2,329,836 IU/ ml) & (52 vs. 73 U/L), but this difference was not statistically significant. During first 4 weeks, HCV RNA (see graph), hemoglobin & absolute neutrophil count were not significantly between the 2 groups. Post transplant length of stay was similar between 2 groups. Conclusion: In this pilot study, IFN administered during the anhepatic phase of LT, was associated with manageable adverse events. Week 4 HCV RNA & ALT levels were lower in cases than controls although the difference was not statistically significant. These data support further study of this novel approach for preventing recurrent hepatitis C post LT, including combination therapy with direct acting antiviral therapy. Disclosure: Dr. Russo - Consultant, Speakers Bureau: Merck, Consultant Speakers Bureau: Vertex.Figure: No Caption available.