Delayed referral for liver transplant evaluation worsens outcomes in chronic liver disease patients requiring inpatient transplant evaluation

BACKGROUND Indications to refer patients with cirrhosis for liver transplant evaluation(LTE)include hepatic decompensation or a model for end stage liver disease(MELDNa)score≥15.Few studies have evaluated how delaying referral beyond these criteria affects patient outcomes.AIM To evaluate clinical characteristics of patients undergoing inpatient LTE and to assess the effects of delayed LTE on patient outcomes(death,transplantation).METHODS This is a single center retrospective cohort study assessing all patients undergoing inpatient LTE(n=159)at a large quaternary care and liver transplant center between 10/23/2017-7/31/2021.Delayed referral was defined as having prior indication(decompensation,MELD-Na≥15)for LTE without referral.Early referral was defined as referrals made within 3 mo of having an indication based on practice guidelines.Logistic regression and Cox Hazard Regression were used to evaluate the relationship between delayed referral and patient outcomes.RESULTS Many patients who require expedited inpatient LTE had delayed referrals.Misconceptions regarding transplant candidacy were a leading cause of delayed referral.Ultimately,delayed referrals negatively affected overall patient outcome and an independent predictor of both death and not receiving a transplant.Delayed referral was associated with a 2.5 hazard risk of death.CONCLUSION Beyond initial access to an liver transplant(LT)center,delaying LTE increases risk of death and reduces risk of LT in patients with chronic liver disease.There is substantial opportunity to increase the percentage of patients undergoing LTE when first clinically indicated.It is crucial for providers to remain informed about the latest guidelines on liver transplant candidacy and the transplant referral process.

Improved hepatitis A and hepatitis B vaccination strategy is necessary for patients with chronic hepatitis C

Introduction Hepatitis C virus(HCV)is a major cause of chronic liver diseases.Hepatitis A virus(HAV)or hepatitis B virus(HBV)infection on pre-existing hepatitis C can lead to significant morbidity and mortality[1].The Advisory Committee on Immunization Practices(ACIP)recommends HAV and HBV vaccination for patients with chronic liver diseases[2,3].Best-practice advice from the American College of Physicians and the Centers for Disease Control and Prevention(CDC)also emphasized the importance of HBV vaccination for at-risk populations[4].The hepatitis B vaccine response,however,is generally lower among patients with chronic liver diseases,especially those with cirrhosis or older age[5,6].In this study,we reported that a high proportion of patients with chronic hepatitis C remained at risk of HAV or HBV infection at their referral to our tertiary Liver Center.