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Reflections on Key Presentations at ACG 2021

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At the 2021 ACG Annual Scientific Meeting held in Las Vegas, key topics in presentations included insights for better clinical management of patients during the COVID-19 pandemic, more evidence of the surge in alcohol associated liver disease that has been observed since 2020, and finally, a preliminary report that suggested the potential benefits of fecal microbiota transplant as a treatment for hepatic encephalopathy depends on donor and recipient factors.

Dr. Hadi and colleagues reported on the efficacy and safety of COVID-19 vaccination in patients with cirrhosis. Their group performed a retrospective cohort study using the TriNetx research network to analyze COVID-19 vaccine safety and efficacy outcomes comparing those with cirrhosis and non-cirrhosis groups using propensity score matching. Three thousand sixty-three vaccinated cirrhosis patients were compared to 398,406 vaccinated noncirrhotic patients with no significant differences noted in vaccine adverse events of special interest as defined by the CDC. While higher 30-day all-cause hospitalization rates were higher in the cirrhotic patient cohort compared to the noncirrhotic patient cohort, there were no differences in the rate of new Covid diagnoses between those with cirrhosis and without cirrhosis (with less than 10 new Covid diagnoses being observed in the cirrhosis cohort post-vaccination). This report provides additional reassurance that mRNA vaccination for SARS-CoV-2 infection can be administered safely in those with chronic liver disease including those with cirrhosis and decompensated cirrhosis.

One of the major sequelae of the COVID-19 pandemic has been the surge in alcohol-associated liver disease. Dr. Ayushi Jain and colleagues from Ohio State University reported their experience in their alcohol -associated liver disease population, noting an increase in severity of those admitted for alcohol-associated liver disease complications. Two populations were reported; one with alcoholic hepatitis requiring admission and the other, alcoholic cirrhosis who also required admission. Comparing patients in the acute alcoholic hepatitis cohort during the years 2019 and 2020, they noted increased admissions for alcoholic hepatitis in 2020 (162 in 2020 versus 86 in 2019) although similar Maddrey scores at presentation were observed. During the pandemic in 2020, those with alcoholic hepatitis had higher rates of critical care needs and other complications including hepatic encephalopathy, gastrointestinal bleeding, pressor support and need for renal replacement. Lower rates of steroid administration to treat alcoholic hepatitis were also noted in 2020 during the pandemic though there were no differences in outcomes as defined by the Lille score between the 2 periods. 

Patients in the alcoholic cirrhosis cohort who required admission also had more severe outcomes in the 2020 pandemic cohort compared to 2019 including greater critical care needs. Higher MELD scores, higher rates of ascites at presentation, development of hepatorenal syndrome, SBP, as well as greater requirements for pressor support and dialysis were observed in those with alcoholic cirrhosis which contributed to higher mortality during the pandemic compared to the prior year.

These results mirror national trends as it was recently reported that higher rates of transplant listing and transplantation have been observed for alcohol associated liver disease during the pandemic. To address this surge in alcohol-associated liver disease more resources for harm reduction measures in addition to other medical and psychosocial support will be required, and in those with alcohol associated liver disease, transplantation via an exception pathway will remain an important option for selected individuals who are refractory to medical therapy. 

Hepatic encephalopathy remains a problematic issue for those with chronic liver disease with the mainstay of therapy being non absorbable sugars (lactulose) and antibiotics (rifaximin). Dr. Bloom and colleagues reported preliminary results of their work exploring the role of fecal microbiota transplant (FMT) in those with prior overt hepatic encephalopathy. In this open label trial, 5 healthy donors provided FMT to 10 patients, administered 5 times over a 3-week period. The primary outcome was change in Psychometric Hepatic Encephalopathy Score (PHES). PHES scores improved after 3, and 5 doses of F MT as well as 4 weeks after fifth dose. Two Bifidobacterium taxa which produce short chain fatty acids (B adolescentis and B angulatum) were associated with improvement in PHES scores and Bifidobacterium abundance was higher in the FMT responders than the non-responders over the study period. Another interesting observation was that 2 FMT responders lost the rifampicin/rifaximin resistance gene rpoB after FMT and this finding should be further explored in larger studies. Thus both donor and recipient characteristics appear to affect outcomes and Bifidobacterium may play an important role in improving hepatic encephalopathy when treated by FMT. Further studies are ongoing to evaluate this modality.

Dr. Kwo reports no conflicts of interest. 

Illustration by April Brust

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