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Item Early predictors of outcomes of hospitalization for cirrhosis and assessment of the impact of race and ethinicity at safety-net hospitals(PLOS ONE, 2019-03-06) Mukthinuthalapati, V. V. Pavan Kedar; Akinyeye, Samuel; Fricker, Zachary P.; Syed, Moinuddin; Orman, Eric S.; Nephew, Lauren; Vilar-Gomez, Eduardo; Slaven, James; Chalasani, Naga; Balakrishnan, Maya; Long, Michelle T.; Attar, Bashar M.; Ghabril, MarwanBackground Safety-net hospitals provide care for racially/ethnically diverse and disadvantaged urban populations. Their hospitalized patients with cirrhosis are relatively understudied and may be vulnerable to poor outcomes and racial/ethnic disparities. Aims To examine the outcomes of patients with cirrhosis hospitalized at regionally diverse safety-net hospitals and the impact of race/ethnicity. Methods A study of patients with cirrhosis hospitalized at 4 safety-net hospitals in 2012 was conducted. Demographic, clinical factors, and outcomes were compared between centers and racial/ethnic groups. Study endpoints included mortality and 30-day readmission. Results In 2012, 733 of 1,212 patients with cirrhosis were hospitalized for liver-related indications (median age 55 years, 65% male). The cohort was racially diverse (43% White, 25% black, 22% Hispanic, 3% Asian) with cirrhosis related to alcohol and viral hepatitis in 635 (87%) patients. Patients were hospitalized mainly for ascites (35%), hepatic encephalopathy (20%) and gastrointestinal bleeding (GIB) (17%). Fifty-four (7%) patients died during hospitalization and 145 (21%) survivors were readmitted within 30 days. Mortality rates ranged from 4 to 15% by center (p = .007) and from 3 to 10% by race/ethnicity (p = .03), but 30-day readmission rates were similar. Mortality was associated with Model for End-stage Liver Disease (MELD), acute-on-chronic liver failure, hepatocellular carcinoma, sodium and white blood cell count. Thirty-day readmission was associated with MELD and Charlson Comorbidity Index >4, with lower risk for GIB. We did not observe geographic or racial/ethnic differences in hospital outcomes in the risk-adjusted analysis. Conclusions Hospital mortality and 30-day readmission in patients with cirrhosis at safety-net hospitals are associated with disease severity and comorbidities, with lower readmissions in patients admitted for GIB. Despite geographic and racial/ethnic differences in hospital mortality, these factors were not independently associated with mortality.Item Clinical characteristics and prognosis of hospitalized patients with moderate alcohol-associated hepatitis(Wiley Online Library, 2024) Gaurnizo-Ortiz, Maria; Nephew, Lauren D.; Vilar-Gomez, Eduardo; Kettler, Carla D.; Slaven, James E.; Ghabril, Marwan S.; Desai, Archita P.; Orman, Eric S.; Chalasani, Naga; Gawrieh, Samer; Patidar, Kavish R.Background and Aims Little is known about the clinical characteristics and prognosis of hospitalized patients with moderate alcohol-associated hepatitis (mAH) as compared to severe alcohol-associated hepatitis (sAH). Therefore, we aimed to describe the clinical characteristics and risk factors associated with mortality in hospitalized mAH patients. Methods Patients hospitalized with alcohol-associated hepatitis (AH) from 1 January 2010 to 31 December 2020 at a large US healthcare system [11 hospitals, one liver transplant centre] were retrospectively analysed for outcomes. Primary outcome was 90-day mortality. AH and mAH were defined according to NIAAA Alcoholic Hepatitis Consortia and Model for End-stage Liver Disease Score ≤ 20 respectively. Multivariable Cox regression analysis was performed to identify independent risk factors associated with 90-day mortality. Results 1504 AH patients were hospitalized during the study period, of whom 39% (n = 590) had mAH. Compared to sAH patients, mAH patients were older (50 vs. 48 years, p < 0.001) and less likely to have underlying cirrhosis (74% vs. 83%, p < 0.001). There were no differences between the two groups for median alcohol intake g/day (mAH 140.0 vs. sAH 112.0, p = 0.071). The cumulative proportion surviving at 90 days was 88% in mAH versus 62% in sAH (p < 0.001). On multivariable analysis, older age [HR 1.03 (95% CI 1.00–1.06), p = 0.020], corticosteroid use [HR 1.80 (95% CI 1.06–3.06), p = 0.030] and acute kidney injury (AKI) [HR 2.43 (95% CI 1.33–4.47), p = 0.004] were independently associated with 90-day mortality. Conclusions mAH carries a 12% mortality rate at 90 days. Age, AKI and corticosteroid use were associated with an increased risk for 90-day mortality. Avoidance of corticosteroids and strategies to reduce the risk of AKI could improve outcomes in mAH patients.Item Low socioeconomic status exacerbates unmet health-related needs in patients with autoimmune hepatitis(Wiley Online Library, 2024) Singleton, Carolyn; Carter, Allie; Baker, Brittany; Jones, Emma; Green, Kelsey; Lammert, Craig; Nephew, Lauren D.Diminished quality of life has been well characterized in patients with autoimmune hepatitis (AIH); however, the full spectrum of unmet needs is unclear. We hypothesized that there is a high burden of health-related unmet needs in patients with AIH, and this burden differs by socioeconomic status (SES). Methods Members of the Autoimmune Hepatitis Association were invited online and by email to complete a modified version of the Systemic Lupus Erythematosus Patient Needs Questionnaire. Demographic and clinical data were also captured. Low SES was defined as annual household income <30 k, education level below high school, or moderate–high concern for transportation, food or housing. Multivariable logistic regression assessed the association between unmet health-related needs and SES. Results There were 433 participants; 89.8% identified as women, 16.2% lived outside the US, and 25.6% were classified as low SES. Over 70% of respondents reported at least one moderate–high need in the health-related unmet need domains. In multivariable logistic regression, patients in the low-SES group reported significantly higher odds of unmet needs compared to the moderate–high-SES group: for adequate information about side effects (OR 1.64, 95% CI 1.06–2.53, p = 0.026), opportunity to speak with others with AIH (OR 2.34, 95% CI 1.50–3.66, p < 0.001), healthcare professionals acknowledging patient emotions (OR 2.41, 95% CI 1.56–3.74, p < 0.001) and being taken seriously by medical providers (OR 2.09, 95% CI 1.34–3.28, p = 0.001). There is a high burden of health-related unmet needs in all patients with AIH that is exacerbated by low SES.Item Comorbidity burden may be associated with increased mortality in patients with severe acute liver injury referred for liver transplantation(International Scientific Information, Inc., 2020-11-03) Steiner-Temnykh, Lindsey; Dakhoul, Lara; Slaven, James; Nephew, Lauren; Patidar, Kavish R.; Orman, Eric; Desai, Archita P.; Vilar-Gomez, Eduardo; Kubal, Chandrashekhar; Ekser, Burcin; Chalasani, Naga; Chabril, MarwanSevere acute liver injury (S-ALI) can lead to acute liver and multisystem failure, with high mortality and need for liver transplantation (LT); however, the burden and impact of liver disease and comorbid conditions are unknown.Item An Outbreak Presents an Opportunity to Learn About a Rare Phenotype: Autoimmune Hepatitis After Acute Hepatitis A(2020-11-01) S.-Are, Vijay; Yoder, Lindsay; Samala, Niharika; Nephew, Lauren; Lammert, Craig; Vuppalanchi, RajThere are rare instances where patients with acute hepatitis A virus infection subsequently developed autoimmune hepatitis. The diagnosis of autoimmune hepatitis in this setting is challenging. Furthermore, information on treatment with steroids or other immune suppressants, duration of therapy and possibility of treatment discontinuation is currently unclear. Here we report a case series of four patients with histology proven autoimmune hepatitis after hepatitis A virus infection. We describe the presenting features, diagnosis, treatment and long-term outcomes of these cases. This case series provides a insight into the clinical presentation and treatment of autoimmune hepatitis after hepatitis A infection with interesting take home points for clinical hepatologists.Item Racial and ethnic disparities in psychosocial evaluation and liver transplant waitlisting(2023-06-01) Deutch-Link, Sasha; Bittermann, Therese; Nephew, Lauren; Ross-Driscoll, Katherine; Weinberg, Ethan M.; Weinrieb, Robert M.; Olthoff, Kim M.; Addis, Senayish; Serper, MarinaHealth disparities have been well-described in all stages of the liver transplantation (LT) process. Using data from psychosocial evaluations and the Stanford Integrated Psychosocial Assessment, our objective was to investigate potential racial and ethnic inequities in overall LT waitlisting and not waitlisting for medical or psychosocial reasons. In a cohort of 2271 candidates evaluated for LT from 2014 to 2021 and with 1-8 years of follow-up, no significant associations were noted between race/ethnicity and overall waitlisting and not waitlisting for medical reasons. However, compared with White race, Black race (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.07-2.56) and Hispanic/Latinx ethnicity (OR, 2.10; 95% CI, 1.16-3.78) were associated with not waitlisting for psychosocial reasons. After adjusting for sociodemographic variables, the relationship persisted in both populations: Black (OR, 1.95; 95% CI, 1.12-3.38) and Hispanic/Latinx (OR, 2.29; 95% CI, 1.08-4.86) (reference group, White). High-risk Stanford Integrated Psychosocial Assessment scores were more prevalent in Black and Hispanic/Latinx patients, likely reflecting upstream factors and structural racism. Health systems and LT centers should design programs to combat these disparities and improve equity in access to LT.Item Learn, adapt, act: A pragmatic approach for intervening on disparities in hepatocellular carcinoma outcomes(2025-03) Walker, Tiana; Nephew, Lauren D.Item Severe hepatic encephalogaphy with mechanical ventilation may inform waitlist priority in acutve liver failure: A UNOS database analysis(Wiley Online Library, 2024) Ma, Jiayi; Slaven, James E.; Nephew, Lauren; Patidar, Kavish R.; Desai, Archita P.; Orman, Eric; Kubal, Chandrashekhar; Chalasani, Naga; Ghabril, MarwanPatients with acute liver failure (ALF) awaiting liver transplantation (LT) may develop multiorgan failure, but organ failure does not impact waitlist prioritization. The aim of this study was to examine the impact of organ failure on waitlist mortality risk and post LT outcomes in patients with ALF. Methods We studied adults waitlisted for ALF in the United Network for Organ Sharing (UNOS) database (2002–2019). Organ failures were defined using a previously described Chronic Liver Failure modified sequential organ failure score assessment adapted to UNOS data. Regression analyses of the primary endpoints, 30-day waitlist mortality (Competing risk), and post-LT mortality (Cox-proportional hazards), were performed. Latent class analysis (LCA) was used to determine the organ failures most closely associated with 30-day waitlist mortality. Results About 3212 adults with ALF were waitlisted, for hepatotoxicity (41%), viral (12%) and unspecified (36%) etiologies. The median number of organ failures was three (interquartile range 1–3). Having ≥3 organ failures (vs. ≤2) was associated with a sub hazard ratio (HR) of 2.7 (95%CI 2.2–3.4)) and a HR of 1.5 (95%CI 1.1–2.5)) for waitlist and post-LT mortality, respectively. LCA identified neurologic and respiratory failure as most impactful on 30-day waitlist mortality. The odds ratios for both organ failures (vs. neither) were higher for mortality 4.5 (95% CI 3.4–5.9) and lower for delisting for spontaneous survival .5 (95%CI .4–.7) and LT .6 (95%CI .5–.7). Cumulative organ failure, especially neurologic and respiratory failure, significantly impacts waitlist and post-LT mortality in patients with ALF and may inform risk-prioritized allocation of organs.Item Exception points and body size contribute to gender disparity in liver transplantation(2017-08) Nephew, Lauren D.; Goldberg, David; Lewis, James D.; Abt, Peter; Bryan, Mathew; Forde, Kimberly A.Background & Aims—Women are significantly less likely than men to receive a liver transplant and more likely to die on the waitlist. We investigated potential reasons for these disparities, including match run positions and declined organs due to small stature of female recipients. Methods—We analyzed data from the United Network of Organ Sharing registry of candidates placed on the waitlist from May 10, 2007 through June 17, 2013. Primary outcomes included: ranked in first position on a match run, having an organ declined while in first position, declining an organ while in first position because of size mismatch between donor and recipient (body surface area discordance), and death or becoming too sick for liver transplantation. Results—Among 64,995 patients on the waitlist for liver transplantation, 23.1% of men and 15.6% of women received exception points (P<.001). Women listed without exception points were less likely than men to be ranked first (odds ratio [OR], 0.93; 95% CI, 0.88–0.99). Women who achieved a first position were more likely to decline an organ than men (OR, 1.15; 95% CI, 1.06–1.26); this difference was reduced after we accounted for recipient body surface area (OR, 1.08; 95% CI, 0.98–1.19). Women with a single liver decline were more likely than men with a single liver decline to die or become too sick for transplantation (OR, 1.26; 95% CI, 1.12–1.41). The difference was reduced after we accounted for exception points (OR, 1.16; 95% CI, 1.12–1.21) and recipient body surface area (OR, 1.01; 95% CI, 0.96–1.06). Conclusion—In an analysis of data from the United Network of Organ Sharing registry, we found that women when compared to men on the waitlist for liver transplantation. are disadvantaged by an imbalance in exception point allocation and organ decline because of small stature.Item Clinical features of ileal pouch-anal anastomosis in African American patients with underlying ulcerative colitis(Blackwell Publishing Ltd, 2009-07-20) Moore, L; Tang, L; Lopez, R; Shen, BBackground: The prevalence of inflammatory bowel disease in African Americans appears to be increasing. The data on differences in disease behavior and severity between the races have been conflicting. Aim: To evaluate the effect of race on outcome and natural history of patients with ileal pouch-anal anastomosis. Methods: All African American patients with underlying ulcerative colitis and ileal pouch-anal anastomosis who were seen in our subspecialty Pouchitis Clinic from 2002 to 2008 were included. The control group consisted of Caucasian patients with ulcerative colitis and ileal pouch-anal anastomosis who were randomly selected from the same Pouch Registry at a ratio of 4:1. We compared pouch failure, Crohn’s disease of the pouch, and chronic pouchitis rates, as well as other 23 demographic and clinical variables between African American and Caucasian patients. Results: A total of 12 African American patients and 48 Caucasian patients were evaluated in this case-control study. There were no significant differences in the frequency of pouch failure, Crohn’s disease of the pouch, or chronic pouchitis between the African American and Caucasian groups. However, African American patients were found to have a significantly shorter duration of inflammatory bowel disease (11.5 years vs. 17.0 years, P = 0.024) as well as significantly shorter duration of pouch (1.5 years vs. 4 years, P = 0.02). African Americans were also less likely to have pancolitis at the time of colectomy (83% vs. 100%, P = 0.037). Conclusions: While there were no significant differences in pouch outcomes between the races, African American patients appeared to have more left-sided colitis at the time of colectomy, with a shorter duration of inflammatory bowel and ileal pouch. This finding suggests that the natural history of ulcerative colitis and disease course before and after restorative proctocolectomy may be different between these racial groups.