Fertility is often impaired in adolescents and women with cirrhosis, but it is rapidly restored after liver transplantation (LT). Early and unplanned pregnancies confer increased risks to maternal, fetal, and graft health, underscoring the need for reproductive counseling. However, data on reproductive practices or counseling in the LT setting are limited. An anonymous online Qualtrics (Provo, UT) survey was sent to transplant patients and providers to gauge knowledge and practices surrounding contraception and pregnancy. Eligible participants included transplant patients aged 14‐45 years and their transplant providers. Patient response was 50.0% (74/148), 14 of whom were pre‐LT patients and 60 of whom were post‐LT patients. Counseling occurred in 37% of patients prior to transplant and 82% after transplant. Most patients (86%) considered family planning a high priority in their transplant care. Contraception‐ and pregnancy‐specific counseling was provided by LT providers in 60% and 44% of patients, respectively. The most desired mode of counseling by patients was in‐person discussion with an LT provider (89%). Despite most post‐LT patients receiving counseling, only 41% used contraception during the first year after LT, of whom 32% relied on high failure methods. Of the 31/43 (72.1%) provider responses, 96% voiced interest in additional reproductive education. Most providers (90%) correctly advised that patients delay pregnancy during the first year after LT, although misconceptions about safety of estrogen and intrauterine devices were selected by 53% and 42%, respectively. Some favored resources by providers were educational pamphlets in clinic (88%) and automated note templates to prompt family planning inquiry (72%). Transplant patients and providers have key deficiencies in their knowledge of contraception and corresponding practices. Most post‐LT patients receive counseling, yet contraception practices are inadequate for preventing unplanned pregnancy. Discussion with transplant providers was the most favored counseling modality by patients, underscoring our critical role in optimizing post‐LT reproductive care.

Background. Frailty has emerged as a critical determinant of mortality in patients with cirrhosis. Currently, the United Network for Organ Sharing registry only includes the Karnofsky Performance Status (KPS) scale, which captures a single component of frailty. We determined the associations between frailty, as measured by the Liver Frailty Index (LFI), and KPS with waitlist mortality. Methods. Included were 247 adult patients with cirrhosis listed for liver transplantation without hepatocellular carcinoma from February 2014 to June 2019, who underwent outpatient assessments using the LFI and KPS within 30 days of listing. “Frail” was defined using the established LFI cutoff of ≥4.4. Competing risk models assessed associations between the LFI and KPS with waitlist mortality (death/delisting for sickness). Results. At a median 8 months follow-up, 25 (10%) patients died/were delisted. In this cohort, median Model for End-Stage Liver Disease-Sodium was 17, LFI was 3.9 (interquartile range 3.4–4.5), and KPS was 80 (interquartile range 70–90). In multivariable analysis, LFI (sub-hazard ratio 1.07, per 0.1 unit; 95% confidence interval, 1.01-1.12) was associated with waitlist mortality while KPS was not (sub-hazard ratio 1.00, per 10 units; 95% confidence interval, 0.78-1.29). Conclusions. Our data suggest that frailty, as measured by the LFI, may be more appropriate at capturing mortality risk than KPS and provide evidence in support of using the LFI more broadly in clinical transplant practice in the outpatient setting.

Acute‐on‐chronic liver failure (ACLF) is a condition in cirrhosis associated with organ failure (OF) and high short‐term mortality. Both the European Association for the Study of the Liver‐Chronic Liver Failure (EASL‐CLIF) and North American Consortium for the Study of End‐Stage Liver Disease (NACSELD) ACLF definitions have been shown to predict ACLF prognosis. The aim of this study was to compare the ability of the EASL‐CLIF versus NACSELD systems over baseline clinical and laboratory parameters in the prediction of in‐hospital mortality in admitted patients with decompensated cirrhosis. Five NACSELD centers prospectively collected data to calculate EASL‐CLIF and NACSELD‐ACLF scores for admitted patients with cirrhosis who were followed for the development of OF, hospital course, and survival. Both the number of OFs and the ACLF grade or presence were used to determine the impact of NACSELD versus EASL‐CLIF definitions of ACLF above baseline parameters on in‐hospital mortality. A total of 1031 patients with decompensated cirrhosis (age, 57 ± 11 years; male, 66%; Child‐Pugh‐Turcotte score, 10 ± 2; Model for End‐Stage Liver Disease [MELD] score, 20 ± 8) were enrolled. Renal failure prevalence (28% versus 9%, P < 0.001) was more common using the EASL‐CLIF versus NACSELD definition, but the prevalence rates for brain, circulatory, and respiratory failures were similar. Baseline parameters including age, white cell count on admission, and MELD score reasonably predicted in‐hospital mortality (area under the curve, 0.76). The addition of number of OFs according to either system did not improve the predictive power of the baseline parameters for in‐hospital mortality, but the presence of NACSELD‐ACLF did. However, neither system was better than baseline parameters in the prediction of 30‐ or 90‐day outcomes. The presence of NACSELD‐ACLF is equally effective as the EASL‐CLIF ACLF grade, and better than baseline parameters in the prediction of in‐hospital mortality in patients with cirrhosis, but not superior in the prediction of longer‐term 30‐ or 90‐day outcomes.

Frailty has commonly been defined as a distinct biologic state of decreased physiologic reserve and increased vulnerability to health stressors that predispose individuals to adverse health outcomes. 1 As originally conceptualized in the field of geriatrics, frailty is a multidimensional construct that encompasses physical as well as psychological factors. A number of instruments have been developed in the field of geriatrics to operationalize the multidimensionality of this construct; however, in patients with cirrhosis, instruments used to measure frailty have largely focused on the physical aspects of frailty. 2 Our team developed the Liver Frailty Index from a cohort of patients with cirrhosis awaiting liver transplantation that includes hand grip strength, chair stands, and balance testing. 3 While we have demonstrated that the Liver Frailty Index accurately captures the construct of physical frailty, little is known of its association with psychological contributors to health outcomes. One psychological construct that has been recognized to be associated with frailty in noncirrhotic populations is resilience. 4-8 Resilience is a modifiable quality that describes an individual's capability to thrive

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INTRODUCTION: Women with cirrhosis listed for liver transplant have increased waitlist mortality compared with men, but the reasons for this disparity is not well-established. We hypothesized that women with cirrhosis have different comorbidities and reasons for hospitalizations than men - and explored this hypothesis in a large, multi-center cohort of inpatients with cirrhosis. METHODS: Our cohort included patients with cirrhosis hospitalized non-electively, prospectively enrolled at 4 academic medical centers 1/2013-2/2017. Data collected included comorbidities, reasons for admission, cirrhosis complications, medications, hospital course, and outcomes. Readmission and mortality rates were compared between women and men using logistic regression. RESULTS: Of the 674 hospitalized patients with cirrhosis, 256 (38%) were women. Median age was 56 years; 75% were non-Hispanic White. Women were less likely than men to have cirrhosis from alcohol (34% vs 26%, P < 0.001), and more likely to have NASH (22% vs 15%, P < 0.001). Women and men had similar cirrhosis complications, liver-related medications, MELD (20 vs 20, P = 0.36), and Child-Pugh (9 vs 10, P = 0.36) scores. Women were more likely to have certain non-liver related comorbidities, including insulin-dependent diabetes (23% vs 14%, P = 0.002) and connective tissue disease (4% vs 1%, P = 0.004), as well as to require non-opiate pain medications (14% vs 7%, P = 0.008) or antidepressant/sleep aids (38% vs 28%, P = 0.005). Overall infection rates on admission were similar between women and men (27% vs 22%, P = 0.19), but women were more likely than men to have UTIs (14% vs 4%, P < 0.001) and less likely to have SBP (6% vs 11%, P = 0.04). Rates of other decompensating events were similar between women and men, including GI bleeding, renal dysfunction, and volume overload (P for all > 0.05). There were no differences between women and men in 30d (11% vs 13%, P = 0.60) or 90d (22% vs 27%, P = 0.18) mortality. In logistic regression, female gender was not associated with increased 30d mortality (OR 0.88, 95% CI 0.54-1.43, P = 0.60) or 90d readmission (OR 1.06, 95% CI 0.75-1.48, P = 0.76). CONCLUSION: Although women and men hospitalized with cirrhosis have similar severity of liver disease, they differ by their etiologies of cirrhosis, non-liver related comorbidities, infectious complications, and patterns of medication use. Future studies should further explore the role that these non-liver-related factors play in contributing to well-established gender disparities in waitlist outcomes.

INTRODUCTION: Over 30% of female liver transplant patients are reproductive age. Fertility is quickly restored following transplant and unplanned pregnancy is common. Data on reproductive counseling in transplant patients are lacking. METHODS: Women ages 14-45 years who were listed, or with previous liver transplant (n=147) at an academic medical center were invited to complete an online survey in 2018. Questions explored contraception/pregnancy counseling, patient counseling preferences, and contraception use after transplant. RESULTS: Fifty (34%) women completed the survey, including 11 pre- and 39 post-transplant patients. Median age was 33 years; 76% were white, 20% Hispanic. Most (79%) reported reproductive counseling as “very important” to their post-transplant care, although 71% reported insufficient counseling received. Among pre-transplant women (n=11), 4 reported never discussing future pregnancy, 2 were advised never to conceive, and 3 were informed that pregnancy after transplant was impossible. During pre-transplant years only 14/38 (36%) received any counseling, of whom only 56% described counseling received as sufficient. While counseling after transplant was more common (74%), only 47% (18/38) of women reported contraception use in the first year post-transplant, including 22% using high failure methods including condoms, withdrawal, or rhythm. Women's reported preferences for counseling included discussion with transplant providers (92%), referral to women's health (67%), and handouts (31%). CONCLUSION: Reproductive counseling is inconsistent in liver transplant patients, despite patient interest, and the majority used no contraception. Given maternal and fetal risks of unplanned pregnancies, systems-based interventions that optimize women's preferred means of counseling should be implemented in this medically complex population.

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