James F. Trotter, M.D.

Heimbach, J.K., Trotter, J.F., Pomposelli, J., Cafarella, M. and Noreen, S.M. (2021). “A Tale Full of Sound and Fury.” Liver Transpl 27(5): 624-626.

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In the current issue of Liver Transplantation, Chyou et al. present an analysis of the new acuity circle (AC) distribution model for liver transplantation in the United States.(1) The authors analyzed Organ Procurement and Transplantation Network (OPTN) data from the 6-month period prior to the adoption of the policy (August 8, 2019 to February 3, 2020) compared with the 6 months after the policy began (March 5, 2020 to August 31, 2020), excluding status 1A, pediatric, living donor transplants, and transplants performed within the month of February to allow for a 1-month “adjustment period.” They examined the number of transplants performed in the 2 periods, the variance in the median Model for End-Stage Liver Disease at transplant (MMaT) across donor service areas (DSAs), which is one of the metrics used to assess differences in access to transplantation based on geography, and the number of liver procurements that would be anticipated to require a flight (distance >100 miles between donor and transplant hospitals). [No abstract; excerpt from article].

Fallahzadeh, M.A., Hansen, D.J., Trotter, J.F., Everson, G.T., Saracino, G., Rahimi, R.S., Helmke, S., Boutte, J. and Asrani, S.K. (2021). “Predicting clinical decompensation in patients with cirrhosis using the Hepquant-SHUNT test.” Aliment Pharmacol Ther 53(8): 928-938.

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BACKGROUND: Early identification of risk for decompensation in clinically stable cirrhotic patients helps specialists target early interventions and supports effective referrals from primary care providers to specialty centres. AIMS: To examine whether the HepQuant-SHUNT test (HepQuant LLC, Greenwood Village, Colorado, USA) predicts decompensation and the need for liver transplantation, hospitalisation or liver-related death. METHODS: Thirty-five compensated and 35 subjects with a previous episode of decompensation underwent the SHUNT Test and were followed for a median of 4.2 years. The disease severity index (DSI) (range 0-50) was examined for association with decompensation in compensated patients; and liver transplantation, liver-related death, and the number and days of liver related hospitalisations in all. DSI prediction of decompensation was also evaluated in 84 subjects with compensated cirrhosis from the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis Trial (HALT-C) followed for a median of 5.8 years. RESULTS: At baseline, subjects with prior decompensation had significantly higher DSI than compensated subjects (32.6 vs 20.9, P < 0.001). DSI ≥24 distinguished the decompensated from the compensated patients and independently predicted adverse clinical outcomes (hazard ratio: 4.92, 95% confidence interval: 1.42-17.06). In the HALT-C cohort, 65% with baseline DSI ≥24 vs 19% with DSI <24 experienced adverse clinical outcomes (relative risk 3.45, P < 0.0001). CONCLUSIONS: The SHUNT test is a novel, noninvasive test that predicts risk of decompensation in previously compensated patients. DSI ≥24 is independently associated with risk for clinical decompensation, liver transplantation, death and hospitalisation.

Fallahzadeh, M.A., Hansen, D.J., Trotter, J.F., Everson, G.T., Saracino, G., Rahimi, R.S., Helmke, S., Boutte, J. and Asrani, S.K. (2021). “Predicting clinical decompensation in patients with cirrhosis using the Hepquant-SHUNT test.” Aliment Pharmacol Ther Feb 8. [Epub ahead of print].

Full text of this article.

BACKGROUND: Early identification of risk for decompensation in clinically stable cirrhotic patients helps specialists target early interventions and supports effective referrals from primary care providers to specialty centres. AIMS: To examine whether the HepQuant-SHUNT test (HepQuant LLC, Greenwood Village, Colorado, USA) predicts decompensation and the need for liver transplantation, hospitalisation or liver-related death. METHODS: Thirty-five compensated and 35 subjects with a previous episode of decompensation underwent the SHUNT Test and were followed for a median of 4.2 years. The disease severity index (DSI) (range 0-50) was examined for association with decompensation in compensated patients; and liver transplantation, liver-related death, and the number and days of liver related hospitalisations in all. DSI prediction of decompensation was also evaluated in 84 subjects with compensated cirrhosis from the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis Trial (HALT-C) followed for a median of 5.8 years. RESULTS: At baseline, subjects with prior decompensation had significantly higher DSI than compensated subjects (32.6 vs 20.9, P < 0.001). DSI ≥24 distinguished the decompensated from the compensated patients and independently predicted adverse clinical outcomes (hazard ratio: 4.92, 95% confidence interval: 1.42-17.06). In the HALT-C cohort, 65% with baseline DSI ≥24 vs 19% with DSI <24 experienced adverse clinical outcomes (relative risk 3.45, P < 0.0001). CONCLUSIONS: The SHUNT test is a novel, noninvasive test that predicts risk of decompensation in previously compensated patients. DSI ≥24 is independently associated with risk for clinical decompensation, liver transplantation, death and hospitalisation.

Heimbach, J.K., Trotter, J.F., Pomposelli, J., Cafarella, M. and Noreen, S.M. (2021). “A Tale Full of Sound and Fury.” Liver Transpl Jan 18. [Epub ahead of print].

Full text of this article.

In the current issue of Liver Transplantation, Chyou et al present an analysis of the new Acuity Circle (AC) distribution model for liver transplantation in the United States. (1) The authors analyzed Organ Procurement and Transplantation Network (OPTN) data from the six month period prior to the adoption of the policy (8/8/2019-2/3/2020), compared to the six months after the policy began (3/5/2020-8/31/2020), excluding status 1A, pediatric, living donor transplants, and transplants performed within the month of February to allow for a one-month “adjustment period.”

Terrault, N.A., Burton, J., Ghobrial, M., Verna, E., Bayer, J., Klein, C., Victor, D., Mohan, S., Trotter, J., Dodge, J., Niemann, C.U. and Rubin, R.A. (2020). “Prospective Multicenter Study of Early Antiviral Therapy in Liver and Kidney Transplant Recipients of HCV-Viremic Donors.” Hepatology Sep 14. [Epub ahead of print.].

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Organs from HCV-viremic donors have been used in HCV-uninfected recipients (D+/R-) but the optimal treatment approach has not been defined. We evaluated the kinetics of HCV infection post-transplant in D+/R- kidney (KT) and liver transplant (LT) recipients when a preemptive antiviral strategy was used. Six U.S. transplant programs prospectively treated D+/R- primary LT and KT recipients with sofosbuvir-velpastasvir for 12 weeks starting once viremia was confirmed post-transplant and the patient judged to be clinically stable including eGFR >30 ml/min. Primary endpoints were sustained virologic response at 12 weeks post-transplant (SVR12) and safety (assessed by proportion of treatment-related adverse and serious adverse events). Of 24 patients transplanted (13 liver of whom 2 had prior treated HCV infection, 11 kidney), 23 became viremic post-transplant. The median (IQR) time from transplant to start of antiviral therapy was 7.0 (6.0,12.0) vs. 16.5 (9.8,24.5) days and the median (IQR) HCV RNA level 3 days after transplant was 6.5 (3.9,7.1) vs. 3.6 (2.9,4.0) log(10) IU/mL in LT vs. KT recipients, respectively. By week four of treatment, 10/13 (77%) LT, but only 2/10 (20%) KT had undetectable HCV RNA (p=0.01). At the end of treatment, all LT recipients were HCV RNA undetectable, while three (30%) of the kidney recipients still had detectable, but not quantifiable, viremia. All achieved SVR12 (lower 95% CI bound 85%). Serious adverse events considered possibly related to treatment were antibody-mediated rejection, biliary sclerosis, cardiomyopathy and graft-versus-host-disease, with the latter associated with multiorgan failure, premature treatment discontinuation and death. We conclude that despite differing kinetics of early HCV infection in liver versus non-liver recipients, a preemptive antiviral strategy is effective. Vigilance for adverse immunologic events is warranted.