Explore the vast range of titles available.

Pain management in patients with cirrhosis is a difficult clinical challenge for health care professionals, and few prospective studies have offered an evidence-based approach. In patients with end-stage liver disease, adverse events from analgesics are frequent, potentially fatal, and often avoidable. Severe complications from analgesia in these patients include hepatic encephalopathy, hepatorenal syndrome, and gastrointestinal bleeding, which can result in substantial morbidity and even death. In general, acetaminophen at reduced dosing is a safe option. In patients with cirrhosis, nonsteroidal anti-inflammatory drugs should be avoided to avert renal failure, and opiates should be avoided or used sparingly, with low and infrequent dosing, to prevent encephalopathy. For this review, we searched the available literature using PubMed and MEDLINE with no limits.

BACKGROUND: Liver transplantation (LT) using organs donated after cardiac death (DCD) is increasing due, in large part, to a shortage of organs. The outcome of using DCD organs in recipients with hepatits C virus (HCV) infection remains unclear due to the limited experience and number of publications addressing this issue. OBJECTIVE: To evaluate the clinical outcomes of DCD versus donation after brain death (DBD) in HCV-positive patients undergoing LT. METHODS: Studies comparing DCD versus DBD LT in HCV-positive patients were identified based on systematic searches of seven electronic databases and multiple sources of gray literature. RESULTS: The search identified 58 citations, including three studies, with 324 patients meeting eligibility criteria. The use of DCD livers was associated with a significantly higher risk of primary nonfunction (RR 5.49 [95% CI 1.53 to 19.64]; P=0.009; I 2 =0%), while not associated with a significantly different patient survival (RR 0.89 [95% CI 0.37 to 2.11]; P=0.79; I 2 =51%), graft survival (RR 0.40 [95% CI 0.14 to 1.11]; P=0.08; I 2 =34%), rate of recurrence of severe HCV infection (RR 2.74 [95% CI 0.36 to 20.92]; P=0.33; I 2 =84%), retransplantation or liver disease-related death (RR 1.79 [95% CI 0.66 to 4.84]; P=0.25; I 2 =44%), and biliary complications. CONCLUSIONS: While the literature and quality of studies assessing DCD versus DBD grafts are limited, there was significantly more primary nonfunction and a trend toward decreased graft survival, but no significant difference in biliary complications or recipient mortality rates between DCD and DBD LT in patients with HCV infection. There is insufficient literature on the topic to draw any definitive conclusions.

Background. Features of nonalcoholic fatty liver disease (NAFLD) have yet to be described in the Canadian First Nations (FN) population. The aim of this study was to compare the prevalence, severity, and outcome of NAFLD in FN versus non-FN patients at an urban, tertiary care centre. Methods. Adults with NAFLD and no additional liver disease were identified in a prospectively derived database at the University of Manitoba. Demographic, clinical, laboratory, imaging, and histologic data were analyzed. Results. 482 subjects fulfilled diagnostic criteria for NAFLD, including 33 (7%) FN. Aside from rural residence, diabetes and cholestasis being more common in FN patients, the ages, gender distributions, clinical and radiologic features, and liver enzyme/function test results were similar in the two cohorts. Noninvasive tests of fibrosis (APRI and NAFLD fibrosis scores) were also similar in the two cohorts. There were no significant differences in liver enzyme or function tests in either cohort after approximately three years of follow-up. Conclusion. Compared to the prevalence of FN persons in the general population of this study site (10–15%), FN patients were underrepresented in this NAFLD population. The severity and progression of liver disease in FN patients appear to be similar to those in non-FN patients.

BACKGROUND: Transient elastography (TE) is a safe and effective technology to noninvasively assess hepatic fibrosis in patients with numerous liver conditions. TE is not readily available to all Canadians, and data regarding how this technology is incorporated into clinical practice are lacking. OBJECTIVE: To describe TE practices in Canada, and to identify strategies to optimize access and usage. METHODS: All Canadian centres with TE devices were invited to complete a survey after obtaining purchasing data from the national distributor of the device. Descriptive statistics were generated. RESULTS: Forty-two devices were available in Canada as of January 2015. Seventy-one percent are used in academic settings, 74% are hospital based and 26% are in private clinics. The test is performed by trained nurses in 48% of centres, physicians in 19%, technicians in 9.5% and by any member of the health care team in 19%. Nineteen percent of centres provide satellite clinics to perform the test. While the majority of the centres perform the test at no additional cost to patients, 29% charge a variable fee. CONCLUSION: In Canada, most TE devices are used in academic and/or hospital-based settings, thus limiting access to this technology to many patients. A sizeable minority of centres mandate patients pay variable out-of-pocket fees. Satellite clinics offered by some centres could increase access, but are not widespread. The lack of uniformity with TE practices in Canada suggests that a national policy is needed.

Background Candidacy for liver transplantation is determined through standardized evaluation. There are limited data on the frequency and reasons for denial of trans-plantation after assessment; analysis may shed light on the short-term utility of the assessment. We sought to describe the frequency and reasons for ineligibility for liver transplantation among referred adults. Methods We studied all prospectively followed recipient candidates at a single centre who were deemed unsuitable for liver transplantation after assessment. Inclusion criteria were age 18 years and older and completion of a standard liver transplantation evaluation over a 3-year period. Patients were excluded if they had a history of prior assessment or liver transplantation within the study period. Demographic and baseline clinical data and reasons for recipient ineligibility were recorded. Results In all, 337 patients underwent their first liver transplantation evaluation during the study period; 166 (49.3%) fulfilled inclusion criteria. The mean age was 55.4 years, and 106 (63.9%) were men. The 3 most common reasons for denial of listing were patient too well ( n = 82, 49.4%), medical comorbidities and/or need for medical optimization ( n = 43, 25.9%) and need for addiction rehabilitation ( n = 28, 16.9%). Conclusion Ineligibility for transplantation after assessment was common, occurring in nearly half of the cohort. Most denied candidates could be identified with more discriminate screening before the resource-intensive assessment; however, the assessment likely provides unforeseen positive impacts on patient care.