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Conflict of interest: No Introduction and Objectives: Background: Severe alcohol-associated hepatitis (AH) is considered a common precipitant of acute-on-chronic liver failure (ACLF). This study aims to characterize the association between AH and ACLF, focusing on mortality across different ACLF grades. Patients / Materials and Methods: Multicenter prospective cohort study. We included patients admitted with severe AH between 2015–2022. The main outcome was mortality by ACLF grade during admission. The analysis included survival analysis using Cox regression. We adjusted multivariable models based on the main predictors of mortality observed in prior studies. Results and Discussion: We prospectively included 646 patients from 24 centers and 8 countries. Age 49.9±11.7 years, 85.1% of men and 64.4% had a previous diagnosis of cirrhosis. Median MELD at admission was 25 [20-31] points, 46.5% of patients were treated with corticosteroids, and only 2.2% underwent liver transplantation (LT). Around 67.4% of patients fulfilled ACLF criteria: 10.1% grade 1, 19.2% grade 2, and 38.1% grade 3. The most frequent organ dysfunctions were 76.2% liver, 40.8% brain, 43.2% coagulation, 29.6% renal, 29.4% circulatory, and 18.9% lung failure. Survival at 180 days was 77.8% (95%CI: 72.1-82.6%) in those without ACLF grade 3 and 28.0% (95%CI: 20.5–36.0%) in those with ACLF grade 3 (p

Conflict of interest: No Introduction and Objectives: Hypothermic machine perfusion using ECMO devices has emerged as a promising technique to enhance the viability of marginal liver grafts. This study aims to present the clinical outcomes of a series of 100 liver grafts subjected to this advanced preservation methods. Patients / Materials and Methods: A prospective analysis between October 2022 and May 2024 was conducted on 100 consecutive liver perfusion cases involving hypothermic perfusion with an ECMO device, followed by a subgroup comparison of regular and marginal grafts. Post-transplantation, key outcomes such as liver functionality, early complications, and overall survival were monitored in all patients. Statistical analyses included T-tests and Fisher's exact tests to evaluate differences in means and frequencies between groups. Results and Discussion: Three grafts were discarded due to severe steatosis. The patient cohort had a mean MELD Na score of 29.0 ± 8.72. The one-year survival rate was 82.7%. The major complication was infectious, observed in 57.7% of cases. The mean ICU and hospital stay was 10.98 ± 14.29 and 28.24 ± 24.78 days, respectively. Eighty-one liver grafts were categorized as regular (83.5%) and 16 as marginal (16.4%). Vascular complications were significantly more frequent in marginal grafts compared to regular grafts. No statistically significant differences in other clinical outcomes were observed between the regular and marginal graft groups (Table 1). Conclusions: The findings suggest that hypothermic perfusion using ECMO devices facilitates the safe utilization of marginal liver grafts. While the overall clinical outcomes are promising and comparable to international standards, the high incidence of infectious complications and extended ICU and hospital stays highlight significant areas for improvement. These challenges appear to be more related to the severity of the patient's conditions, as indicated by the elevated average MELD Na score, rather than the quality of the grafts. Therefore, hypothermic perfusion represents a viable strategy for expanding liver graft selection criteria in transplantation.

Conflict of interest: No Introduction and Objectives: Pts with ACLF should be assessed for liver transplant (LT) due to the high mortality without LT (28-day mortality: grade 1 = 14.6%, 2 = 32%, 3 = 78.6%). There is a survival benefit for ACLF grades 2-3 with LT (85-89% at 3-months and 70-80% at 3-years). Grade 2, and specially grade 3 ACLF pts remain a challenge for LT teams. New scoring systems (eg. SALT-M) have been developed to assist decision-making. There is limited data on this topic in Chile and Latin America. Aim: To characterize ACLF pts who underwent LT in our center between January 2020 and March 2024. Patients / Materials and Methods: Observational retrospective study. Clinical and laboratory data were collected. The cohort was divided into 3 groups based on ACLF grade. We calculated ACLF scores and assessed outcomes at 28-days and 3-months after LT. Results and Discussion: A total of 100 LT were performed between January 2020 and March 2024. 31 pts (31%) had ACLF before LT. Table 1 shows general data of ACLF LT pts. Alcohol and autoimmune were the most frequent etiologies. Infection was the most frequent extrahepatic comorbidity before and after LT (80.7% and 93.6% respectively). Length of stay (LOS) was influenced by the grade of ACLF, with grade 3 patients having the longest ICU stay (20.92 days). 28-day and 3-month survival rates were 90.3% and 87.1%, respectively. Only grade 3 ACLF LT pts showed a difference between 28-day and 3-month survival. Multi organ dysfunction syndrome (MODS) was the main reported cause of death (75%). Conclusions: Short term outcomes were consistent with national and international data. Infections were the main complication before and after LT. SALT-M score correlates with ACLF severity but would not have changed the decision to perform LT. A prolonged LOS is expected in ACLF LT pts.

Over the last decade, metabolic-associated fatty liver disease (MAFLD) has become an important public health issue worldwide. In many countries, MAFLD has become the most common cause of chronic liver disease. On the contrary, hepatocellular carcinoma (HCC) mortality is rising. Liver tumors have become the third cause of cancer mortality worldwide. HCC is the most frequent liver tumor. While the burden of HCC related to viral hepatitis is declining, the prevalence of MAFLD-related HCC is rising rapidly. Classical screening criteria for HCC consider cirrhotic, advanced fibrosis, and viral hepatitis patients. Metabolic syndrome with liver involvement or MAFLD is associated with a higher risk of HCC development, even in the absence of cirrhosis. The question about the cost effectiveness of surveillance for HCC in MAFLD is yet not fully answered. There are no guidelines that address the question of when to start or how to define the population who can benefit of surveillance for HCC in MAFLD patients. This review aims to revise the evidence of HCC development in MAFLD. It hopes to be a step closer to defining screening criteria for HCC in MAFLD.

Introduction and Objectives: Although most cases of HCC occur in patients with advanced liver disease and there are effective screening methods, health policies aimed at preventing and detecting HCC are not often on the agenda of government initiatives and policies. This study aimed to explore HCC-related population-wide public health policies, treatment availability, epidemiological surveillance, and awareness campaigns in the Americas. Materials and Methods: We conducted a 43-item survey about HCC among experts from 12 countries. Questions were classified into four categories: policies and civil society (18 questions), clinical guidelines (5 questions), epidemiology (7 questions), and care management (13 questions). The survey was administered using an electronic form in May 2022. Data was collected in a spreadsheet, revised by two independent reviewers, and contrasted with governmental institutions. Results: We obtained 22 responses from 15 out of the 18 countries targeted. A total of 7 (47%) countries had a written national cancer strategy or action plan. Only 4 (27%) countries had a specific written national HCC strategy or action plan, including Argentina, Brazil, Mexico, and the United States. These same four countries also had national clinical guidelines on HCC. HCC is managed by various providers, including Hepatologists (80%), Oncologists (80%), Gastroenterologists (60%), Surgeons (47%), and Palliative medicine (20%). There were important differences in the availability of treatments among countries in the Americas (Figure). Of note, 60% of countries had liver transplantation available for HCC, but only 67% of them had this therapy outside the capital city. Nine (60%) countries had a national disease registry that included HCC. However, only Brazil (7%) had governmental funded awareness campaigns on HCC prevention or screening. Conclusions: Implementation of public health policies on HCC is scarce in the Americas. Important differences in treatments were observed across countries, especially in curative therapies. Our results strongly encourage developing public health policies on HCC in the Americas.

Introduction and Objectives: Severe alcohol-associated hepatitis (AH) is an entity with high morbidity and mortality; however, data in Latin America is limited. We aimed to characterize patients hospitalized for AH in a multinational cohort in Latin America. Materials and Methods: Multicenter prospective cohort study. We included patients admitted with severe AH between 2015-2022. Sociodemographic and clinical information was recorded. The analysis included survival analysis using Kaplan-Meier curves. This study was approved by the institutional ethics committee. Results: 470 patients from 24 centers (8 countries: Mexico, Chile, Argentina, Brazil, Peru, Bolivia, Colombia, and Ecuador) were included. Age 49.8 ± 10.6 years, 85.6% of men and 45% had a previous diagnosis of cirrhosis. Median MELD at admission was 26.9 [22-32] points. 26.5% met SIRS criteria and 34.3% had an acute kidney injury (AKI) on admission. Only 36.8% of patients were treated with corticosteroids. Survival at 30 days was 75.0% (95%CI: 70.1-79.3%) and 62.8% (95%CI: 57.1-68.0%) at 90 days. A total of 191 (45.8%) patients presented infections, 31.4% at admission and 24.9% during hospitalization. The most frequent locations of community-acquired infections were respiratory (33.5%), urinary (32.1%), spontaneous bacterial peritonitis (14.9%), and skin (10.5%), while the most frequent pathogens were Escherichia coli (40%), Klebsiella pneumoniae (12%), and Enterococcus (6%). The presence of infection at admission was associated with a decreased survival at 90-days (66.9% versus 48.1%, p=0.0002). AKI at admission was also associated with decreased survival at 90-days (86.8% versus 51.3%, p

Introduction and Objectives: Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Still, there are epidemiological and clinical data in Latin America. In Chile, this is the first study regarding HCC with a significant number of patients. This study aimed to obtain and analyze clinical and epidemiological data of Chilean patients with HCC. Materials and Methods: Multicenter study from 12 Chilean hospitals that have members of the Chilean Association of Hepatology as members of their staff. Clinical records from 2015-2021 were included. Kaplan-Meier survival curves and Cox regression analysis were obtained. Results: We obtained data from 856 patients with HCC from 12 different centers. Median age 67 years old; 58.7% male. Cirrhosis is present in 91.2% (779) of cases. Main risk factors reported: fatty liver 47.9%(410), alcohol 19.6% (68), viral 12.2%(104) and autoimmune 3.5% (30). The median MELD score was 11.7 (CI95% 11,4-12). 38% (322) were diagnosed during surveillance; this was associated with earlier BCLC stage (OR 2,6; CI95%1,9-3,4). BCLC stages at diagnosis were 0; 8,2%(69), A: 38,5%(326), B:29,9%(253), C: 15,4%(130) and D: 8,2%(69). The main initial treatments were TACE, ablation, resection, liver transplant and sorafenib in 27,4%(226), 19,3%(159), 11,4%(94), 8%(66) and 5,5%(45), respectively. 53,4%(452) pts were in Milan Criteria at diagnosis. 9,1%(78) patients got a liver transplant. Five-year survival was 24% (CI95%20-28). The main factors associated with survival are depicted in Figure 1. Conclusions: Fatty liver was remarkably the main risk factor reported for HCC in our Chilean cohort. This is a worrisome number since NAFLD is on the rise worldwide, and especially in Latin America. Surveillance is key for early detection. The liver function defined by Child-Pugh and HCC stage using BCLC staging is strongly associated with survival. Liver transplant is still a scarce treatment resource.

Introduction and aim: The MELD score has been established as an efficient and rigorous prioritization system for liver transplant (LT). Our study aimed to evaluate the effectiveness of the MELD score as a system for prioritization for LT, in terms of decreasing the dropout rate in the waiting list and maintaining an adequate survival post-LT in Chile. Materials and methods: We analyzed the Chilean Public Health Institute liver transplant registry of candidates listed from October 15th 2011 to December 31st 2014. We included adult candidates (>15 years old) listed for elective cadaveric LT with a MELD score of 15 or higher. Statistical analysis included survival curves (Kaplan–Meier), log-rank statistics and multivariate logistic regression. Results: 420 candidates were analyzed. Mean age was 53.6 ± 11.8 years, and 244 were men (58%). Causes of LT included: Liver cirrhosis without exceptions (HC) 177 (66.4%); hepatocellular carcinoma (HCC) 111 (26.4%); cirrhosis with non-HCC exceptions 102 (24.3%) and non-cirrhotic candidates 30 (7.2%). LT rate was 43.2%. The dropout rate was 37.6% at 1-year. Even though the LT rate was higher, the annual dropout rate was significantly higher in cirrhotic candidates (without exceptions) compared with cirrhotics with HCC, and non-HCC exceptions plus non-cirrhotic candidates (47.9%; 37.2% and 24.2%, respectively, with p = 0.004). Post-LT survival was 84% per year, with no significant differences between the three groups (p = 0.95). Conclusion: Prioritization for LT using the MELD score system has not decreased the dropout rate in Chile (persistent low donor's rate). Exceptions generate inequities in dropout rate, disadvantaging patients without exceptions.

Introduction and aim: In 2008 the International autoimmune hepatitis (AIH) Group proposed the simplified diagnostic criteria for this disease. The original cohort study was performed in 11 international centers, but validation studies are scarce in Latin-America. The aim of this study is validate these criteria in Hispanic patients. Material and methods: A retrospective cohort of patients undergoing percutaneous liver biopsy and follow-up of at least 12 months was recruited from a Chilean University hospital. Patients with previous immunosuppressive therapy and liver transplant recipients were excluded. The diagnostic accuracy was analyzed using as gold standard the clinical course during long-term follow-up. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) and area under the ROC curve (AUROC) were calculated. Results: Four hundred eighty one patients were evaluated, 294 were included. 218 (74.15%) were female, mean age 48.5 (± 12.3) years, mean follow-up 34 (± 18) months. 66 patients had AIH or overlap syndrome (22.45%), 96 (32.65%) non-alcoholic steatohepatitis, 40 (13.61%) primary biliary cholangitis, 31 (10.54%) hepatitis C, 8 (2.72%) hepatitis B, 53 (18.02%) other etiologies. The AUROC for AIH simplified criteria was 0.976. Using a cutoff ≥ 6 and ≥ 7 points, the sensitivity was 86.4% and 54.6%; specificity, 98.7% and 99.6%; PPV, 95% and 97.3%; and NPV, 96.2% and 88.6%, respectively. Conclusion: Simplified criteria for the diagnosis of AIH have a high accuracy in our Chilean-Hispanic cohort. The female gender is strongly associated to AIH and could help in difficult cases. Further studies with a prospective design are necessary to confirm these observations.

The use of calcineurin inhibitors (CNI) after liver transplantation is associated with post-transplant nephrotoxicity. Conversion to myc-ophenolate mofetil (MMF) monotherapy improves renal function, but is related to graft rejection in some recipients. Our aim was to identify variables associated with rejection after conversion to MMF monotherapy. Conversion was attempted in 40 liver transplant recipients. Clinical variables were determined and peripheral mononuclear blood cells were immunophenotyped during a 12-month follow-up. Conversion was classified as successful (SC) if rejection did not occur during the follow-up. MMF conversion was successful with 28 patients (70%) and was associated with higher glomerular filtration rates at the end of study. It also correlated with increased time elapsed since transplantation, low baseline CNI levels (Tacrolimus ≤ 6.5 ng/mL or Cyclosporine ≤ 635 ng/mL) and lower frequency of tacrolimus use. The only clinical variable independently related to SC in multivariate analysis was low baseline CNI levels (p = 0.02, OR: 6.93, 95%, CI: 1.3-29.7). Mean baseline fluorescent intensity of FOXP3+ T cells was significantly higher among recipients with SC. In conclusion, this study suggests that baseline CNI levels can be used to identify recipients with higher probability of SC to MMF monotherapy. Clinicaltrials.gov identification: NCT01321112.

Hepatic involvement in primary amyloidosis is an infrequent challenge to the hepatologist. Although usually asymptomatic, amyloidosis may have unusual manifestations. Liver biopsy is an important diagnostic tool for this condition. Herein, we report three cases of portal hypertension related to primary hepatic amyloidosis, one of them in the form of acute liver failure.