Veeral Ajmera

Background: Liver transplantation (LT) is curative for hepatocellular carcinoma (HCC) but requires timely referral. Comprehensive data on factors impacting LT referral and outcomes for HCC are limited. We evaluated social, system, and clinical factors associated with listing, LT, mortality, HCC stage at referral, and time from HCC diagnosis to referral. Methods: The California Liver Network is a consortium of 6 LT centers comprising >75% of adult LTs in California. Demographic, clinical, psychosocial, and social determinants of health and outcome data were collected for adults referred for LT. Multivariable regression identified factors associated with outcomes. Results: Of 9987 adults referred, 1573 (15.7%) had HCC. Median age was 63.3 years; 73% males, 40% Hispanic, and 26.1% Medicaid insurance. Median MELD was 12.7 (IQR 8–16), and median time from HCC diagnosis to LT referral was 124 days (IQR 32–410). In all, 10% were T1 and 70.5% were T2 at referral. Alpha-fetoprotein (AFP) (OR 0.99), HCC stage, Medicaid insurance (OR 0.55), LT site, and marital status (OR 1.90) were associated with listing. Transplantation was associated with HCC stage (OR 0.42) and LT site. Mortality was associated with MELD (OR 1.02), hypertension (OR 1.44), dialysis (OR 2.48), hepatic encephalopathy (OR 1.54), and portal vein thrombosis (OR 1.44). Referral at more advanced HCC stage was associated with male sex (OR 1.55), AFP (OR 1.01), Medicaid insurance (OR 1.40), primary language (OR 0.70), and prior HCC treatment type. Longer time to referral was associated with HCV/alcohol liver disease and prior HCC treatment type. Conclusions: In this multicenter study of adults with HCC, Medicaid insurance, LT site, HCC treatment history, and psychosocial factors were key determinants of HCC care cascade progression, identifying targets to improve LT access.

Background: Noninvasive tests are well validated in metabolic dysfunction–associated steatotic liver disease, but evidence in metabolic dysfunction and alcohol-associated liver disease (MetALD) and alcohol-associated liver disease (ALD) is limited. We evaluated noninvasive test–based clinical care pathways for fibrosis risk stratification in MetALD and ALD. Methods: This is a multinational, multicenter, cross-sectional study across 35 centers in 16 countries (2013–2025), including adults with MetALD or ALD. Fibrosis was assessed by liver biopsy and/or vibration-controlled transient elastography (VCTE). In biopsy-proven participants, we analyzed the sequential pathway (Fibrosis-4 [FIB-4] first, followed by VCTE for indeterminate FIB-4) to identify advanced fibrosis (≥F3). Diagnostic accuracy was assessed using the AUC. Results: Among 893 participants (41.3% MetALD and 58.7% ALD), the median age was 52 [43.0–61.0] years, and 79.4% were male. The estimated prevalence of advanced fibrosis was 45% (32.2% in MetALD and 54.0% in ALD). Participants with MetALD had a more dysmetabolic profile but lower fibrosis stages than ALD. Among biopsy-proven participants, FIB-4 AUC was 0.720, and VCTE AUC was 0.833. FIB-4 performed better in MetALD than ALD (AUC 0.773 vs. 0.540), while VCTE accuracy was similar across groups. In the sequential pathways, the false-negative rate for advanced fibrosis (misclassified as low risk) was 6.8% (4.9% MetALD and 11.3% ALD). Conclusions: In biopsy-proven patients, FIB-4 performance was acceptable in MetALD but substantially weaker in ALD. The standard 2-step pathway performed adequately in MetALD but missed a clinically meaningful proportion of advanced fibrosis in ALD.

Background: Behavioral alcohol use disorder therapy (bAUDT) is increasingly used to improve eligibility and outcomes for liver transplant (LT) among patients with alcohol-associated liver disease (ALD), especially as more centers consider LT for patients with Methods: RESOLVE-ALD is a multicenter retrospective cohort study including adults with ALD and Results: Among 545 patients analyzed (median sobriety time 79 days; 52.8% inpatient evaluations), 22.4% participated in bAUDT during LTE and 43% received LT. Prior alcohol-related illness (aOR=1.93, p =0.03) and heavier daily drinking (aOR=1.90, p =0.04) were associated with increased adjusted odds of bAUDT during LTE, while older age (aOR=0.41, p =0.006), underinsurance (aOR=0.42, p =0.01), and hospitalization during LTE (aOR=0.42, p =0.02) were associated with reduced adjusted odds. bAUDT participation during LTE significantly increased adjusted odds of LT waitlisting (aOR=3.40, p =0.006), but did not predict return to use pre- or post-LT. Conclusion: bAUDT is more common among patients with risk factors for return to use and with the medical and financial stability to participate in therapy. Although associated with increased waitlisting adjusted odds, bAUDT does not significantly predict return to alcohol use pre- or post-LT. Future research should explore optimal methods of integrating bAUDT into the LTE process to improve access and minimize barriers to LT.

INTRODUCTION: Alcohol-associated liver disease (ALD), including alcohol-associated hepatitis, is the leading cause of liver transplant (LT) in the United States, and acceptance of LT without a mandatory period of abstinence is increasing. However, some patients may achieve spontaneous recovery (SR) without LT. We evaluated predictors of mortality and SR among patients with ALD referred for early LT. METHODS: Recovery, survival, and outcomes-ALD is a retrospective cohort of adults with ALD and 3 /µL, 95%CI 1.01–1.08). DISCUSSION: Among patients with ALD and short-term abstinence, blood urea nitrogen and platelets are novel predictors of outcomes, along with INR. Using these predictors—or recalibrating existing model for end-stage liver disease coefficients—in this unique patient population may help refine medical selection criteria and improve utility and equity in access to early LT.