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.

Hepatic myelopathy (HM) is a rarely reported disorder characterized by progressive spastic paraparesis due to impaired corticospinal tract function in the setting of cirrhosis or portosystemic shunting. HM has not to date been recognized as a Model for End-Stage Liver Disease (MELD) exception for transplantation. Outcomes for a small number of patients from Europe and Asia who have undergone liver transplantation (LT) for HM suggest a potential neurological benefit, especially with earlier transplantation. We report the first use of MELD exception points for the condition of HM to enable early LT resulting in the reversal of marked spastic paraparesis. Our patient, whose myelopathy had markedly progressed without further hepatic decompensation, underwent LT 14 months after the diagnosis of HM with an adjusted MELD score of 30, which was granted as a United Network for Organ Sharing exception. After LT, there was significant neurological improvement as the patient progressed from wheelchair dependency to full ambulation. We reviewed the literature of other HM patients who had undergone LT. With our patient, there were in all 15 reported cases of LT in individuals with HM. LT can lead to a marked improvement in HM, particularly in the earlier clinical stages of the disorder. Early LT can be accomplished, as in our case, by the submission of an appeal for a MELD upgrade. Liver Transpl 16:818-826, 2010. (C) 2010 AASLD.