INTRODUCTION:To use a large language model (LLM) to create accurate and useable summaries of patient records for clinicians triaging new hepatology referrals. METHODS:We developed a comprehensive list of data elements required to triage a new hepatology referral and engaged in an iterative prompt engineering process to instruct an LLM to extract relevant data from patient referral documents. The final prompt was used on 50 original patient records from June to July 2025 to generate corresponding artificial intelligence (AI) summaries, which were assigned to 2 providers to review and triage according to their usual process. We assessed time to triage original vs AI files and accuracy of the AI files. A linear mixed-effects model was used to determine an adjusted time ratio comparing the time to triage AI files vs original files. RESULTS:AI-generated summaries were significantly shorter than original files (median [interquartile range] 2 [2-3] vs 23 [10.2-38.8] pages, P < 0.001). AI summaries had high accuracy (median [interquartile range]: 94.6% [86.5%-97.3%]) with a low hallucination rate. Use of the AI summaries led to a 60% reduction in triage time (adjusted mean triage time of 37.2 seconds for AI files vs 94.2 seconds for original files, P < 0.001). DISCUSSION:The use of an LLM led to significantly reduced document length, maintained an appropriate level of accuracy, and led to a significant decrease in clinician time to review the patient record. Future steps involve creating a fully automated workflow that is integrated into the electronic health record for widespread use.

ABSTRACT Background In the United States (US), chronic hepatitis C virus (HCV) is the leading cause of hepatocellular carcinoma (HCC). Direct‐acting antivirals (DAAs) cure HCV and reduce HCC risk, but Medicaid DAA coverage varies across states. Aim We assessed whether Medicaid DAA access was associated with trends in HCC‐related deaths. Methods We analyzed CDC WONDER death certificate data (1999–2023) to assess HCC‐related mortality. US states were grouped based on Medicaid DAA prior authorization restrictions using the Hepatitis C: State of Medicaid Access scoring system: A+/A (n = 28), B (n = 11), and C/D (n = 12). We used NCI Joinpoint software to calculate the annual percentage change (APC) and average annual percent change (AAPC) in age‐adjusted death rate. State‐specific HCC crude death rates were analyzed before and after 2014, alongside changes in Medicaid DAA policies from 2014 to 2024. Results Before 2017, HCC‐related death rates were positive in group A + /A (APC 2.01, 1999–2017), group B (APC 3.40, 1999–2009), and group C/D (APC 2.04, 1999–2023). Age‐adjusted death rates became negative in group A+/A states (APC −0.19, 2017–2023), while death rates continued to be positive for group B states (APC 1.49, 2009–2023) and group C/D states (APC 2.04, 2017–2023). The AAPC (1999–2023) was lowest in group A + /A (1.46), followed by group B (2.28) and C/D (2.04). From 2014 to 2024 accessibility to DAAs improved. Conclusion Increased DAA access was associated with reduced HCC‐related death rates. Improved HCV treatment could contribute to decreased HCC incidence and recurrence, enhance linkage to subspecialty care, and prevent liver‐related decompensation.

Donation after circulatory death (DCD) livers increasingly use machine perfusion (MP). This study evaluates MP's impact on older DCD livers based on data from the United Network for Data Sharing, covering all first adult DCD liver transplants (2016-2025). The cohort, divided into pre-MP and MP eras (separated by the FDA approval of the first normothermic MP platform in 2021), showed accelerated growth in DCD liver transplants during the MP era. Donors ≥60 rose 7.8-fold, including donors ≥70 (a USA first). By 2025, DCD livers accounted for 43.2%, with 61.35% from donors ≥50. Normothermic regional perfusion (NRP) (3.0%-16.5%), NMP (2.1%-38.9%), and sequential NRP-NMP (0.1%-10.7%) increased significantly (p < 0.001). The MP era was associated with a decrease in median waitlist time from 112 to 62 days (p < 0.001). Early graft survival was similar across ages. For ages 50-59, 1- and 3-year survivals were 87.9%/78.4% pre-MP and 90.1%/78.8% in the MP era. For 60-69, survival was 85.0%/80.6% pre-MP and 90.0%/71.3% in the MP era. DCD LTs for ≥70 were limited to the MP era with 87.8% 1-year survival. Multivariable Cox regression showed that static cold storage (HR = 1.29), donor age 50-69 versus 18-49, and recipient age (HR = 1.01) increased the risk of graft loss after adjustment. MP is associated with an increased number of older DCD liver transplants and acceptable early graft survival.

Background. Hepatocellular carcinoma (HCC) treatment decisions are becoming increasingly complex as new treatment options emerge. Improved understanding of tradeoffs and patient preferences in treatment decisions will enhance patient–provider discussions, improve treatment development, and inform HCC treatment guidelines. We performed a qualitative study involving patients with HCC and medical providers to assess the role of patient preferences in HCC treatment choices. Methods. Patient participants included those with HCC seen within a single tertiary care center. Provider participants involved physicians and advanced practice providers who cared for patients with HCC from a single center. Baseline and posttreatment patient interviews were conducted by trained qualitative research experts, informed by semi-structured interview guides, and analyzed using thematic analysis with pilot-tested codebooks. Summaries included a narrative description of the themes and subthemes that emerged related to each code, and illustrative quotes were used to highlight each theme. Results. The baseline interview involved 30 patients with HCC (22 of whom participated in follow-up interviews) and 10 providers who cared for patients with HCC. Patients identified factors considered when making treatment decisions included provider confidence and experience, patient prior cancer experiences, other health issues, and faith. Providers primarily discussed the role of Barcelona Clinic Liver Cancer stage, liver function, performance status, and eligibility of liver transplantation in making treatment recommendations. There was general agreement among providers that there is a need to better understand the role of patient values to improve care for HCC. Limitations. Qualitative interviews were limited to patients and providers from a single center. Conclusions. This qualitative study provided information on the variety of values considered by both patients and providers in HCC treatment decisions and the importance of considering tradeoffs of efficacy, toxicity, and inconvenience/costs. Highlights Hepatocellular carcinoma (HCC) treatment decisions are often complex and may become increasingly so as new treatment options emerge. Improved understanding of tradeoffs and patient preferences in treatment decisions will enhance patient–provider discussions, facilitate patient-centered trials to develop new treatments, and inform HCC treatment guidelines. This qualitative study of patients and providers provided information on the values considered in HCC treatment decisions and the importance of considering the tradeoffs of efficacy, toxicity, and inconvenience/costs. These insights can be used to develop preference elicitation tools, perform large-scale preference elicitation surveys, and systematically assess and incorporate patient preferences into treatment decisions.

INTRODUCTION:Early (i.e., without mandated period of abstinence) liver transplant (LT) for alcohol-associated hepatitis is the fastest-growing indication for LT in the United States and Europe. Harmful alcohol use after LT is associated with poor outcomes, but the distinction of establishing abstinence after return to drinking (i.e., reabstinence) is understudied. This study aims to characterize the survival outcomes of achieving reabstinence after post-LT harmful alcohol use. METHODS:We analyzed early LT recipients from 12 US LT centers between 2006 and 2021. Post-LT alcohol use was characterized as harmful using criteria of "binge" (≥5 [men] or ≥4 [women] drinks in < 24 hours) or "frequent" (≥4 days in one week) by interview or phosphatidylethanol >20 ng/mL. Reabstinence was defined as ≥12 consecutive months without harmful alcohol use after harmful alcohol use. RESULTS:Among 347 LT recipients (64% male, median age 43, median Model for End-Stage Liver Disease-Sodium score 38) with median post-LT follow-up of 2.2 years (interquartile interval 1.1-3.6), 276 (80%) recipients had no evidence of harmful alcohol use, 35 (10%) recipients had reabstinence, and 36 (10%) recipients had continued harmful alcohol use without reabstinence. Five-year predicted survival, adjusted for age, sex, and Model for End-Stage Liver Disease-Sodium score, was lowest among LT recipients with continued harmful alcohol use (77%), but similar among those with no harmful use (93%) and reabstinence (94%). DISCUSSION:Achieving reabstinence after post-LT harmful alcohol use is associated with similar 5-year post-LT survival compared with those without evidence of post-LT harmful alcohol use. Our findings highlight the importance of early detection and treatment of post-LT alcohol use.

Kidney transplant is not only the best treatment for patients with advanced kidney disease but it also reduces health care expenditure. The management of transplant patients is complex as they require special care by transplant nephrologists who have expertise in assessing transplant candidates, understand immunology and organ rejection, have familiarity with perioperative complications, and have the ability to manage the long-term effects of chronic immunosuppression. This skill set at the intersection of multiple disciplines necessitates additional training in Transplant Nephrology. Currently, there are more than 250,000 patients with a functioning kidney allograft and over 100,000 waitlisted patients awaiting kidney transplant, with a burgeoning number added to the kidney transplant wait list every year. In 2022, more than 40,000 patients were added to the kidney wait list and more than 25,000 received a kidney transplant. The Advancing American Kidney Health Initiative, passed in 2019, is aiming to double the number of kidney transplants by 2030 creating a need for additional transplant nephrologists to help care for them. Over the past decade, there has been a decline in the Nephrology-as well Transplant Nephrology-workforce due to a multitude of reasons. The American Society of Transplantation Kidney Pancreas Community of Practice created a workgroup to discuss the Transplant Nephrology workforce shortage. In this article, we discuss the scope of the problem and how the Accreditation Council for Graduate Medical Education recognition of Transplant Nephrology Fellowship could at least partly mitigate the Transplant Nephrology work force crisis.

Abbas, Daniyal MD1; Fix, Oren K. MD, MSc2; Evon, Donna M. PhD2; Barritt, A. Sidney IV MD, MSCR2 Author Information

The coronavirus disease-2019 (COVID-19) pandemic has had a large impact on patients with chronic liver disease (CLD) and liver transplantation (LT) recipients. Patients with advanced CLD are at a significantly increased risk of poor outcomes in the setting of severe acute respiratory syndrome coronavirus 2 infection. The pandemic has also considerably altered the management and care that is provided to patients with CLD, pre-LT patients, and LT recipients. Vaccination against COVID-19 protects patients with CLD and LT recipients from adverse outcomes and is safe in these patients; however, vaccine efficacy may be reduced in LT recipients and other immunosuppressed patients.

The COVID-19 pandemic has had a remarkable impact on the field of liver transplantation. Increasing evidence demonstrates a minimal risk of transmission of SARS-CoV-2 from non-lung donors who test positive for SARS-CoV-2; however, the risks of donor-derived SARS-CoV-2 from liver donors are unknown. We present our experience with two cases in which a liver was transplanted successfully from a brain-dead donor with incidental SARS-CoV-2 infection. Both donors were asymptomatic SARS-CoV-2-positive with negative bronchoalveolar lavage polymerase chain reaction (BAL PCR) and mechanism of death unrelated to COVID-19. Both the recipients did well after transplant and went home with a well-functioning liver. One patient did get readmitted and was found to be SARS-CoV-2-positive; however, it was probably related to hospital exposure rather than donor-derived. SARS-CoV-2-positive donors in select cases may be used for organ donation and liver transplant is safe for recipients.

Content available: Audio Recording Before the coronavirus disease 2019 (COVID-19) pandemic, telemedicine played a small role in clinical care, largely because of regulatory restrictions imposed by Medicare, Medicaid, and private insurers. The COVID-19 pandemic created an immediate need for liberalizing these restrictions, and the implementation and use of telemedicine skyrocketed in a time of crisis. Despite the pandemic's ebbs and flows, telemedicine will remain an integral part of clinical care for the foreseeable future. Lessons learned from early in the pandemic will inform how we use telemedicine to best care for patients with liver disease. In this special issue of Clinical Liver Disease, we bring you eight articles written by experts in the fields of hepatology and telemedicine. We begin with an overview of telemedicine, where we are today, and how we arrived here. Two articles cover the practical aspects of operationalizing a telemedicine program, outlining the crucial components, workflows, and platforms for success. Telemedicine has the exciting possibility to help providers care for patients who have traditionally had difficulty accessing tertiary care in urban centers, but it also has the potential to widen existing disparities in the delivery of clinical care because of the need for specific technologies and technological competence. The next article covers these issues of telemedicine and health disparities. We then review the integration of education and telemedicine. As graduate medical education has had to pivot to use telehealth and telemedicine for didactic and clinical teaching, we have come to embrace the conveniences and benefits of virtual learning, along with its drawbacks. Next, we discuss the benefits and the risks of using telemedicine for liver transplant evaluations, those essential multidisciplinary assessments previously considered an in-person-only activity. Maintaining quality in our virtual visits and leveraging telemedicine for quality improvement are the topics for the next article. Finally, and perhaps most importantly, we are honored to have the perspectives of our patients on telemedicine during the pandemic and beyond. We hope our readers will learn and take inspiration from these articles on telemedicine and expand the capabilities of telemedicine in the care of patients with liver disease well beyond the pandemic.

Early liver transplantation (LT) for alcohol-associated hepatitis (AH) is the fastest growing indication for LT, but prediction of harmful alcohol use post-LT remains limited. Among 10 ACCELERATE-AH centers, we examined psychosocial evaluations from consecutive LT recipients for AH from 2006 to 2017. A multidisciplinary panel used content analysis to develop a maximal list of psychosocial variables. We developed an artificial intelligence model to predict post-LT harmful alcohol use. The cohort included training (N = 91 among 8 centers) and external validation (N = 25 among 2 centers) sets, with median follow-up of 4.4 (IQR 3.0-6.0) years post-LT. In the training set, AUC was 0.930 (95%CI 0.862-0.998) with positive predictive value of 0.891 (95%CI 0.620-1.000), internally validated through fivefold cross-validation. In the external validation set, AUC was 0.692 (95%CI 0.666-0.718) with positive predictive value of 0.82 (95%CI 0.625-1.000). The model identified specific variables related to social support and substance use as highly important to predict post-LT harmful alcohol use. We retrospectively developed and validated a model that identified psychosocial profiles at LT predicting harmful alcohol use post-LT for AH. This preliminary model may inform selection and post-LT management for AH and warrants prospective evaluation in larger studies among all alcohol-associated liver disease being considered for early LT.