Algorithms to Identify Alcoholic Hepatitis Hospitalizations in Patients with Cirrhosis

Background Alcoholic hepatitis (AH) is a clinically diagnosed syndrome with high short-term mortality for which liver transplantation may be curative. A lack of validated algorithms to identify AH hospitalizations has hindered clinical epidemiology research. Methods This was a retrospective cohort study of patients with cirrhosis using Veterans Health Administration (VHA) data from 2008 to 2015. We randomly sampled hospitalizations based upon abnormal liver tests and administrative codes for acute hepatitis or alcohol-associated liver disease (ALD). Hospitalizations were manually adjudicated for AH per society guidelines. A priori algorithms were evaluated to compute positive predicted value (PPV) and positive likelihood ratio (LR+), and were tested in an external University of Pennsylvania Health System (UPHS) cohort. Results Of 368 hospitalizations, 142 (38.6%) were adjudicated as AH. AH patients were younger (55 vs. 58 years, p 85 U/L but 2, total bilirubin > 5 mg/dL) and administrative coding criteria yielded the highest PPV (96.4%, 95% CI 87.7-99.6) and the highest LR+ (43.0, 95% CI 10.6-173.5). Several algorithms demonstrated 100% PPV for definite AH in the UPHS external cohort. Conclusion We have identified algorithms for AH hospitalizations with excellent PPV and LR+. These high-specificity algorithms may be used in VHA datasets to identify patients with high likelihood of AH, but should not be used to study AH incidence

Impact of Race-Adjusted Glomerular Filtration Rate Estimation on Eligibility for Simultaneous Liver-Kidney Transplantation

Estimated glomerular filtration rate (eGFR) is adjusted for Black race in commonly used formulas. This has potential implications for access to simultaneous liver-kidney transplantation (SLKT) as qualifying criteria rely on eGFR. We performed a retrospective study of United Network for Organ Sharing national transplant registry data between February 28, 2002, and March 31, 2019, to evaluate the proportion of Black patients who would be reclassified as meeting SLKT criteria (as defined per current policies) if race adjustment were removed from 2 prominent eGFR equations (Modification of Diet in Renal Disease-4 [MDRD-4] and Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]). Of the 7937 Black patients listed for transplant during the study period, we found that 3.6% would have been reclassified as qualifying for chronic kidney disease (CKD)-related SLKT with removal of race adjustment for MDRD-4, and 3.0% would have been reclassified with CKD-EPI; this represented 23.7% and 18.7% increases in SLKT candidacy, respectively. Reclassification impacted women more than men (eg, 4.5% versus 3.0% by MDRD-4; P < 0.05). In an exploratory analysis, patients meeting SLKT criteria by race-unadjusted eGFR equations were significantly more likely to receive liver transplantation alone (LTA) compared with SLKT. Approximately 2.0% of reclassified patients required kidney transplantation within 1 year of LTA versus 0.3% of nonreclassified patients. In conclusion, race adjustment in eGFR equations may impact SLKT candidacy for 3.0% to 4.0% of Black patients listed for LTA overall. Approximately 2.0% of patients reclassified as meeting SLKT criteria require short-term post-LTA kidney transplantation. These data argue for developing novel algorithms for glomerular filtration rate estimation free of race to promote equity

External Validation of the VOCAL‐Penn Cirrhosis Surgical Risk Score in 2 Large, Independent Health Systems

Cirrhosis poses an increased risk of postoperative mortality, yet it remains challenging to accurately risk stratify patients in clinical practice. The VOCAL‐Penn cirrhosis surgical risk score was recently developed and internally validated in the national Veterans Affairs health system; however, to date this score has not been evaluated in independent cohorts. The goal of this study was to compare the predictive performance of the VOCAL‐Penn to the Mayo risk, Model for End‐Stage Liver Disease (MELD), and MELD‐sodium (MELD‐Na) scores in 2 large health systems. We performed a retrospective cohort study of patients with cirrhosis undergoing surgical procedures of interest at the Beth Israel Deaconess Medical Center or University of Pennsylvania Health System from January 1, 2008, to October 1, 2015. The outcomes of interest were 30‐day and 90‐day postoperative mortality. Concordance statistics (C‐statistics), calibration curves, Brier scores, and the index of prediction accuracy (IPA) were compared for each predictive model. A total of 855 surgical procedures were identified. The VOCAL‐Penn score had the numerically highest C‐statistic for 90‐day postoperative mortality (eg, 0.82 versus 0.79 Mayo versus 0.78 MELD‐Na versus 0.79 MELD), although differences were not statistically significant. Calibrations were excellent for the VOCAL‐Penn, MELD, and MELD‐Na; however, the Mayo score consistently overestimated risk. The VOCAL‐Penn had the lowest Brier score and highest IPA at both time points, suggesting superior overall predictive model performance. In subgroup analyses of patients with higher MELD scores, the VOCAL‐Penn had significantly higher C‐statistics compared with the MELD and MELD‐Na. The VOCAL‐Penn score (www.vocalpennscore.com) has excellent discrimination and calibration for postoperative mortality among diverse patients with cirrhosis. Overall performance is superior to the Mayo, MELD, and MELD‐Na scores. In contrast to the MELD/MELD‐Na, the VOCAL‐Penn retains excellent discrimination among patients with higher MELD scores

Discordance in categorization of acute-on-chronic liver failure in the United Network for Organ Sharing database

Studies regarding acute-on-chronic liver failure (ACLF) among liver transplant (LT) candidates from the United Network for Organ Sharing (UNOS) database are being used to inform LT policy changes worldwide. We assessed the validity of identifying ACLF in UNOS. We performed stratified random sampling among 3 US LT centers between 2013-2019 to obtain a representative patient sample across ACLF grades. We compared the concordance of ACLF classification by UNOS vs. blinded manual chart review, according to EASL-CLIF. Among 481 sampled LT registrants, 250 (52%) had no ACLF, 75 (16%) had ACLF grade 1, 79 (16%) had ACLF grade 2, and 77 (16%) had ACLF grade 3 per UNOS categorization. Concordance of ACLF grade by UNOS vs. chart review was: 72%, 64%, 56%, and 64% for no ACLF, grade 1, grade 2, and grade 3, respectively, with an overall Cohen’s kappa coefficient of 0.48 (95% CI 0.42–0.54). Absence of acute decompensation was the most common reason for overestimation, and discordant brain and respiratory failure categorization were the most common reasons for underestimation of ACLF by UNOS. In this retrospective multi-center study, ACLF categorization by UNOS showed weak agreement with manual chart review. These findings are informative for ongoing allocation policy discussions, highlight the importance of prospective studies regarding ACLF in LT, and should encourage UNOS reform. Acute-on-chronic-liver-failure (ACLF) is a specific and common form of liver failure associated with high death rates. Studies have been published using the United States transplant registry (UNOS) to identify and describe outcomes of transplant candidates and recipients with ACLF, and these data are driving policy changes for transplant allocation around the world, but nobody has shown whether these data are reliable. We found that UNOS was not categorizing ACLF in concordance or accurately when compared to chart review, which shows the need for UNOS reform and non-UNOS studies to appropriately inform policies regarding the transplantation of patients with ACLF. [Display omitted] •UNOS studies on ACLF are informing global transplant allocation policies, but the validity of these data is unknown.•We found that ACLF identified by UNOS is only weakly concordant with chart review.•Classification of acute decompensation and brain/respiratory failures are common sources of discordance.•These data highlight the importance of prospective studies regarding ACLF in LT and should encourage UNOS reform

Show me ECHO : ENDO ECHO-changing the landscape of endocrinology and diabetes care in Missouri

"The Extension for Community Health Care Outcomes (ECHO) Project utilizes telemedicine technologies to deliver care and education to rural and underserved areas. Show-Me ECHO is a replication of ECHO project. It's goal is to educate providers in underserved areas in order to enhance patient care and minimize health care costs. The Missouri Telehealth Network at the University of Missouri spearheads the Show-Me ECHO Project, consisting of 6 separate specialties: endocrinology, autism, chronic pain, hepatitis C, pediatric asthma, and dermatology. These 6 ECHO clinics are offered on a weekly or bi-weekly basis, and rural Missouri providers are all invited to participate in some or all of them. The benefits of ECHO to providers include no-cost CMEs, case-based learning, and valuable input from a multidisciplinary team including specialists in chronic diseases."--Background