Patients with primary sclerosing cholangitis (PSC) are at increased risk of bacterial cholangitis due to biliary strictures and bile stasis. A subset of PSC patients suffer from repeated episodes of bacterial cholangitis, leading to frequent hospitalizations and impaired quality of life. Although PSC waitlist candidates with bacterial cholangitis frequently receive exception points, and/or are referred for living donor transplantation, the impact of bacterial cholangitis on waitlist mortality is unknown. We performed a retrospective cohort study of all adult PSC waitlist candidates listed for initial transplantation from February 27, 2002 to June 1, 2012 at the University of Pennsylvania and the University of Colorado-Denver. Over this period, 171 PSC patients were waitlisted for initial transplantation. Prior to waitlisting, 38.6% (66/171) of patients had a history of bacterial cholangitis, while 28.0% (44/157) of those with at least one MELD update experienced cholangitis on the waitlist. During follow-up, 30 (17.5%) patients were removed from the waitlist for death or clinical deterioration, with 46.7% (14/30) developing cholangiocarcinoma. Overall, 12/82 (14.6%) waitlist candidates who ever had an episode of cholangitis were removed for death or clinical deterioration, compared with 18/89 (20.2%) without cholangitis (P=0.34 comparing two groups). No patients were removed due to bacterial cholangitis. In multivariable competing risk models, a history of bacterial cholangitis was not associated with an increased risk of waitlist removal for death or clinical deterioration (subhazard ratio=0.67; 95% CI: 0.65-0.70, P<0.001). In summary, PSC waitlist transplant candidates with bacterial cholangitis do not have an increased risk of waitlist mortality. The data call into question the systematic granting of exception points or referral for living donor transplantation due to a perceived risk of increased waitlist mortality.

Hepatitis C virus (HCV) infection recurs universally in patients who are viremic at liver transplantation and likely accounts for the diminished post-transplant graft and patient survival. We evaluated whether undetectable HCV RNA pre-transplant improves graft and patient survival after transplantation. Cases, defined by HCV listing diagnosis and positive HCV antibody, were selected from the Scientific Registry of Transplant Recipients database and further grouped as HCV RNA-positive (n=4978) or negative (n=445) based upon pre-transplant testing. Controls were non-HCV recipients (n=2995). RNA-negative cases had significantly better 5-year graft (72% vs. 64%) and patient (79% vs. 69%) survival than RNA-positive cases (p<0.01 for both), and similar survival as controls (Graft: 72% vs. 74%, Patient: 79% vs. 80%; p>0.05 for both). Non-proportional hazards modeling of RNA-positive cases identified a subgroup with rapid progression leading to early graft loss and death. Multivariable analyses confirmed that a positive HCV RNA prior to transplantation was a significant independent predictor of graft loss and death. In conclusion, HCV patients who have undetectable RNA at the time of liver transplantation experience improved long-term graft and patient outcomes. We speculate that the post-transplant survival of HCV recipients could be improved by safe and tolerable pre-transplant antiviral strategies.

An acceptable SVR rate is achievable in a safety net patient population. Addressing the barriers to care will be paramount when using direct-acting antivirals.

Background and Aim Associations between pre-liver transplantation (pre-LT) BMI and post-LT survival are well described; however, there are few data assessing associations between the commonly observed post-LT BMI changes and survival. We investigated the impact of early post-LT BMI change on post-LT patient and graft survival. Methods Using UNOS data, we identified 2,968 adult primary LT recipients who were not overweight pre-LT, BMI >16 to ≤25 kg/m2, and who had BMI recorded at 2-years post-LT. Delta BMI was defined as the BMI difference from pre-LT and 2-years post-LT. Recipients were grouped into three categories: BMI Gain (increase >1 BMI point), BMI Loss (decrease >1 BMI point), and BMI Stable (maintained BMI within 1 point). Associations between Delta BMI and patient and graft survival were evaluated using Kaplan Meier and multivariable Cox regression analyses. Results BMI Gain was common (54%) and associated with significantly greater 5-year patient and graft survival (90% and 89%, respectively), compared to recipients who had either BMI Loss (77% and 74%, respectively, p<0.0001 for both) or BMI Stable (83%, p=0.04 and 82%, p=0.007, respectively). In multivariable analyses, increasing Delta BMI was inversely associated with risk for death and graft loss (HR 0.89 [95% CI 0.86–0.91], p<0.001; and HR 0.88 [95% CI 0.86–0.91], p<0.001, respectively). Conclusion This study of a large national liver transplant database demonstrated that post-LT BMI gain was associated with better patient and graft survival, whereas BMI loss was associated with reduced patient and graft survival.