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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: Aminoglycosides are a group of broad-spectrum antibiotics, which have action especially against gram-negative bacteria. It is associated with nephrotoxicity in 10-20% of cases, a figure that increases in patients with liver cirrhosis. Amikacin is frequently used in sepsis, with little information about the risk of nephrotoxicity in cirrhosis. The aim was to determine the association between amikacin use and renal function deterioration in patients with liver cirrhosis and sepsis. Patients / Materials and Methods: Retrospective, observational, analytical study in patients with liver cirrhosis of any etiology, who required hospitalization for sepsis between 2017 and 2023, and who received antibiotic therapy. An increase in serum creatinine ≥ 0.3 mg/dl in the first 7 days of hospitalization was used as a marker of renal function deterioration. Clinical variables, renal failure and mortality were compared between patients who received amikacin and those who did not. Stata 13.0 was used for data analysis with a statistical significance of 0.05. Results and Discussion: In this study 228 patients were included, median age 65 years (54-70), 100 (44%) women, 70 received amikacin (31%). Renal function deterioration was present in 25 (36%) patients with amikacin and 33 (21%) without amikacin. In patients with initial serum creatinine > 2.0 mg/dl and in those with Child-Pugh C cirrhosis, the probability of developing renal function deterioration was higher in those who received Amikacin (OR 7.5; 95% CI 1.1 – 48.0, p= 0.031 and OR 2.51; 95% CI 1.06 – 5.97, p = 0.036, respectively). A comparative table of different subgroups is attached. Conclusions: The use of amikacin was associated with renal function deterioration in patients with liver cirrhosis and sepsis, mainly in Child-Pugh C cirrhosis and with initial serum creatinine > 2.0 mg/dl.

Conflict of interest: No Introduction and Objectives: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure that diverts portal blood flow to the hepatic vein with the aim of reducing portal hypertension, being an alternative for managing its complications, such as variceal gastrointestinal bleeding and ascites, in both cirrhotic and non-cirrhotic patients. Objetives: To characterize patients who underwent TIPS between January 2007 and July 2024 at the Hospital Clínico De la Universidad de Chile Patients / Materials and Methods: Observational, retrospective cohort study. 39 patients medical records who underwent the procedure during the specified period were reviewed. Results and Discussion: 39 patients were analyzed, 53.8% of whom were men, with an average age of 60.7 years. The procedure was performed in 51% (20/39) of the patients within a period of just 4 years (2019 to 2024). The main indication was secondary to variceal gastrointestinal bleeding (59%), followed by refractory ascites (36%). Additionally, 33.3% presented some degree of portal vein thrombosis, and 33.3% had reported hepatic encephalopathy episodes before the procedure. The average MELD Na score was 15.4. Only three patients experienced hemorrhagic complications related to the procedure, with one resulting in death. 53.8% reported some degree of hepatic encephalopathy after the procedure. One-year survival was analyzed, showing 47.4% in patients whose procedure was performed before 2019 versus 76.9% in the period between 2020 and 2023 (p 0.095). Four patients underwent transplants after TIPS, without complications. Conclusions: We have observed a progressive increase in the indication for TIPS over time at our center, with half of the cases concentrated in the last four years. In addition, survival outcomes appear to be better, probably due to improved patient selection and more timely indications. The procedure was safe, with a low rate of acute complications and an incidence of encephalopathy similar to that reported in the literature. Longer-term follow-up will allow us to verify its effectiveness in our population

Conflict of interest: No Introduction and Objectives: Infections are a frequent cause of decompensation in patients with liver cirrhosis (LC). Understanding local microbiology is important for the correct choice of antibiotics and achieving good clinical outcomes. Objective: To evaluate the microbiology of infections in patients with cirrhosis who were hospitalized in our institution between 2015 and 2022. Patients / Materials and Methods: A retrospective, observational, and analytical study of LC patients hospitalized for any reason between 2015 and 2022. Positive cultures in LC patients (1036 in total) were reviewed, focusing on blood cultures, ascitic fluid cultures, and other types (bronchial secretions, devices and pleural fluid). Urine cultures, non-infection-related episodes, and contamination cases were excluded. Clinical characteristics of patients in each episode, as well as antimicrobial resistance of each organism, were analyzed. STATA 13.0 was used for data analysis with significance set at < 0.05. Results and Discussion: A total of 494 episodes of positive cultures from 187 LC patients were included; median age was 61 years (20-81), with 62% male. In 41% of episodes, the patient was immunosuppressed, and 47% were on prophylactic antibiotics. Forty percent of cultures were blood cultures, 20% ascitic fluid, and 40% other types of cultures. The most frequently isolated microorganisms were Enterobacteriaceae and Gram-positive bacteria. Resistance to extended-spectrum beta-lactamases, Vancomycin, and carbapenemases was evaluated, with Vancomycin resistance being the most frequent, only evaluated in enterococci. Immunosuppression was significantly associated with antibiotic resistance (56% vs 25%; p=0.001), whereas prior use of prophylactic antibiotics did not show a significant association (40% in both groups). Conclusions: The results suggest the need for empirical therapies for our patients and emphasize the importance of rational antibiotic use.

Conflict of interest: No Introduction and Objectives: Milan criteria (MC) have been the standard for selecting candidates for liver transplantation (LT) for hepatocellular carcinoma (HCC). New strategies including alpha-fetoprotein with tumor number and diameter, such as the French alpha-fetoprotein model (FM) and Metroticket2.0 (MT), improve prediction of recurrence and prognosis. Objectives:To compare these three tools in terms of survival and tumor recurrence. Patients / Materials and Methods: A cohort study of 79 LT patients with HCC (2006-2020). Patients were divided by MC: within (WMC) and outside (OMC). They were reclassified using FM into low risk (LRFM) and high risk (HRFM), and with Metroticket2.0: ≥75% 5 year survival (MT≥75) and

Conflict of interest: No Introduction and Objectives: Metabolic dysfunction associated steatotic liver disease (MASLD) pathogenesis is multifactorial. Increasing evidence highlight the role of psychosocial stress in liver disease progression. However, psychological characteristics involved in stress response in MASLD has not been investigated. Objective: To assess psychosocial stress and its relationship with liver damage in patients with MASLD. Patients / Materials and Methods: A transversal, descriptive study, was performed in MASLD patients diagnosed by liver biopsy recruited from Gastroenterology Unit of HCUCH.Demographic and clinical data was recorded using RedCap platform. Psychological assessment was performed by questionnaires: Perceived Stress Scale-14 (PSS-14), Anxiety-Depression Survey (HADS), Coping Strategy Inventory (CSI), Quality of Life (QoL SF-36), and Hexaco-60. Liver function and liver damage was evaluated by blood test and imaging (echography, Fibroscan and magnetic nuclear resonance) respectively. Statistical analysis including t-test and chi-squared, were performed using GraphPad Prisma. Significance set at p

Conflict of interest: No Introduction and Objectives: Patients with cirrhosis and septic shock face a high mortality rate, reaching up to 40%. There is limited literature from Latin America on this condition and associated mortality variables. The aim was to describe mortality in patients with liver cirrhosis and septic shock and analyze the associated variables. Patients / Materials and Methods: A retrospective, observational, analytical study was conducted on patients with liver cirrhosis, who were diagnosed with septic shock, according to Sepsis-3 criteria, during their hospitalization in Hospital Clínico Universidad de Chile, between 2017 and 2023. A confidence level was set at 95% with a statistical significance of p = 0.05. Results and Discussion: A total of 68 patients with septic shock were included, with a mean age of 61 years; the majority were male (57%). The primary etiologies of cirrhosis were alcohol-related (31%) and metabolic-associated (27%). Most patients had a Child-Pugh score of B or C (95%). The 28-day mortality rate was 38%, and the one-year mortality rate was 54%. These patients experienced 74 episodes of septic shock. Of these, 61% were associated with healthcare-related infections, and in 47% a Gram-negative microorganism was identified. Significant variables associated with 28-day mortality included a history of hepatic encephalopathy, low platelet count at admission, elevated total bilirubin, and higher severity scores (SOFA, Meld-Na, CLIF-SOFA). One-year survival was significantly higher among patients who received a liver transplant (HR 0.11, 95% CI 0.01 – 0.86, p = 0.036) (Figure 1). Conclusions: Mortality among cirrhotic patients with septic shock in Chile is high and comparable to international cohorts. Liver transplantation reduces mortality in this patient group. Higher SOFA, Meld-Na, and CLIF-SOFA scores at admission are associated with increased mortality.

Introduction and Objectives: Acute-on-chronic liver failure (ACLF) is associated with reduced short-term survival, and liver transplantation is frequently the only therapeutic option. Nonetheless, the post-transplantation prognosis seems to be worse in ACLF patients. Materials and Methods: The databases of two university centers were retrospectively evaluated, and adult patients with cirrhosis who underwent transplantation between 2013 and 2020 were included. One-year survival of patients with ACLF was compared to that of patients without ACLF. Variables associated with mortality were identified. Results: A total of 428 patients were evaluated, and 303 met the inclusion criteria; 57.1% were male, the mean age was 57.1 ± 10.2 years, 75 patients had ACLF, and 228 did not. The main etiologies of ACLF were NASH (36.6%), alcoholic liver disease (13.9%), primary biliary cholangitis (8.6%) and autoimmune hepatitis (7.9%). Mechanical ventilation, renal replacement therapy, the use of vasopressors and the requirement of blood product transfusion during liver transplantation were significantly more frequent in ACLF patients. Among those recipients without and with ACLF, survival at 1, 3 and 5 years was 91.2% vs. 74.7%, 89.1% vs. 72.6% and 88.3% vs. 72.6%, respectively (p=0.001). Among pre-transplantation variables, only the presence of ACLF was independently associated with survival (HR 3.2, 95% CI: 1.46-7.11). Post-transplantation variables independently associated with survival were renal replacement therapy (HR 2.8, 95% CI: 1.1-6.8) and fungal infections (HR 3.26, 95% CI: 1.07-9.9). Conclusions: ACLF is an independent predictor of one-year post-transplantation survival. Importantly, transplant recipients with ACLF require the use of more resources than patients without ACLF.

Background & Aims: Model for End-Stage Liver Disease (MELD) score better predicts mortality in alcohol-associated hepatitis (AH) but could underestimate severity in women and malnourished patients. Using a global cohort, we assessed the ability of the MELD 3.0 score to predict short-term mortality in AH. Methods: This was a retrospective cohort study of patients admitted to hospital with AH from 2009 to 2019. The main outcome was all-cause 30-day mortality. We compared the AUC using DeLong's method and also performed a time-dependent AUC with competing risks analysis. Results: A total of 2,124 patients were included from 28 centres from 10 countries on three continents (median age 47.2 ± 11.2 years, 29.9% women, 71.3% with underlying cirrhosis). The median MELD 3.0 score at admission was 25 (20–33), with an estimated survival of 73.7% at 30 days. The MELD 3.0 score had a better performance in predicting 30-day mortality (AUC:0.761, 95%CI:0.732–0.791) compared with MELD sodium (MELD-Na; AUC: 0.744, 95% CI: 0.713–0.775; p = 0.042) and Maddrey’s discriminant function (mDF) (AUC: 0.724, 95% CI: 0.691–0.757; p = 0.013). However, MELD 3.0 did not perform better than traditional MELD (AUC: 0.753, 95% CI: 0.723–0.783; p = 0.300) and Age-Bilirubin-International Normalised Ratio-Creatinine (ABIC) (AUC:0.757, 95% CI: 0.727–0.788; p = 0.765). These results were consistent in competing-risk analysis, where MELD 3.0 (AUC: 0.757, 95% CI: 0.724–0.790) predicted better 30-day mortality compared with MELD-Na (AUC: 0.739, 95% CI: 0.708–0.770; p = 0.028) and mDF (AUC:0.717, 95% CI: 0.687–0.748; p = 0.042). The MELD 3.0 score was significantly better in predicting renal replacement therapy requirements during admission compared with the other scores (AUC: 0.844, 95% CI: 0.805–0.883). Conclusions: MELD 3.0 demonstrated better performance compared with MELD-Na and mDF in predicting 30-day and 90-day mortality, and was the best predictor of renal replacement therapy requirements during admission for AH. However, further prospective studies are needed to validate its extensive use in AH. Impact and implications: Severe AH has high short-term mortality. The establishment of treatments and liver transplantation depends on mortality prediction. We evaluated the performance of the new MELD 3.0 score to predict short-term mortality in AH in a large global cohort. MELD 3.0 performed better in predicting 30- and 90-day mortality compared with MELD-Na and mDF, but was similar to MELD and ABIC scores. MELD 3.0 was the best predictor of renal replacement therapy requirements. Thus, further prospective studies are needed to support the wide use of MELD 3.0 in AH.

Introduction and Objectives: Patients with nonalcoholic fatty liver disease (NAFLD) are at increased cardiovascular risk, and there is a higher prevalence of this disease in patients with coronary heart disease (CHD). However, the evidence in favor of NAFLD as a risk factor for CHD is scarce. This study aimed to determine the prevalence of NAFLD in patients with CHD and to assess whether significant CHD is associated with NAFLD and liver fibrosis. Materials and Methods: Observational, analytical study in adult patients with coronary angiography for suspected coronary artery disease between July 2021-July 2022. The number of affected coronary vessels and the presence of significant CHD (stenosis >50%) were determined. In addition, FibroScan® was performed to evaluate steatosis and liver fibrosis up to 6 months after the coronary study, considering the presence of fibrosis at F>0. Descriptive statistics, Fisher's exact test and logistic regression models were reported for inferential analysis. Results: Ninety-seven patients were included, 73% male, age 63 ± 10 years (Table 1). 71% presented significant CHD, with 37% multivessel disease (2 or more). The prevalence of NAFLD was 38%, with no differences between those with and without CHD (43% vs. 36%, p=0.646). In turn, 16% of patients presented some degree of fibrosis, linearly associated with the number of vessels involved (OR=1.8, p=0.022), with an even higher risk in patients with two or more vessels involved (OR=3.5, p=0.027). Conclusions: There is a high prevalence of NAFLD in patients with CHD, with no differences between patients with significant stenosis vs not. Patients with multivessel disease have higher odd of presenting some degree of fibrosis. Although the presence of confounders should be evaluated in other studies, these data support the search for NAFLD and fibrosis in patients with CHD.

Introduction and Objectives: The long-term impact of alcohol-related public health policies (PHP) on the burden of liver disease is unclear. This study aimed to assess the association between alcohol-related PHP and alcohol-related health consequences; 2. To develop an instrument to quantify the establishment of alcohol-related PHP in each country. Materials and Methods: We performed an ecological multi-national study including 169 countries. We recorded socio-demographic data and the presence of alcohol-related PHP in each country from the WHO Global Information System of Alcohol and Health (GISAH) in 2010. Data on alcohol-related health consequences was collected from the Global Burden of Disease database (between 2010-2019). We classified the WHO categories into five domains to design an instrument with criteria for a low, moderate, and strong establishment of PHP. We estimated an incidence rate ratio (IRR) using multilevel generalized linear models with a Poisson family distribution. The models were adjusted by population size, age structure, and gross domestic product. We also estimated a preparedness index using multiple correspondence analysis. Results: The table summarizes the final instrument. We included 169 countries; the median preparedness index was 54 [34.9-76.8]. The preparedness index was associated with lower alcohol-associated liver disease (ALD) mortality (IRR:0.25, 95%CI: 0.06-1.09, p=0.064), cancer mortality (IRR:0.22, 95%CI: 0.05-0.97, p=0.046), hepatocellular carcinoma (HCC) mortality (IRR:0.20, 95%CI: 0.04-0.95, p=0.043), and cardiovascular mortality (IRR:0.15, 95%CI: 0.04-0.61, p=0.008). There was also a trend to lower alcohol use disorder prevalence (IRR:0.25, 95%CI: 0.06-1.09, p=0.064). The highest linear associations were observed in the Americas and Africa, while Europe exhibits a nonlinear association. Conclusions: The preparedness index on alcohol policies is a valuable instrument to assess the establishment and strength of PHP. Those countries with a higher number of PHP had lower mortality due to ALD, cancer, HCC, and cardiovascular diseases. Our results strongly encourage the development and implementation of PHP on alcohol consumption worldwide.

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: Research on the “Alcohol-Harm Paradox” (AHP) investigates why low-income individuals have more alcohol-related harm despite lower alcohol consumption (AC). Possible explanations have been evaluated in Europe and the US, but data constraints make it difficult in Latin America (LATAM). This study aimed to design a strategy to study the AHP in LATAM's restricted-data context, recognize its strengths and limitations, and identify possible explanations in the Chilean experience. The AHP is expected to be explained by the unequal distribution of comorbidities, risk behaviors, consumption patterns, rurality, education, access to health, social capital, and mental health. Materials and Methods: We first evaluated our hypothesis at the individual level with data from the 2016-17 National Health Survey. We conducted logistic regression models to assess whether the hypothesized explanatory factors mediated the effect of AC on liver disease. Second, we aggregated at the municipal level registry data on deaths from alcohol-related liver disease (Ministry of Health Statistics) and survey data on AC and the hypothesized explanatory factors (National Drug Survey and National Survey of Socioeconomic Characterization) to test our hypothesis using mortality as the outcome of negative binomial regression models. Results: The first analysis suggests that the AHP exists among Chilean men and it is explained by the unequal distribution of metabolic syndrome, diabetes, obesity, smoking, heavy episodic drinking, rurality, education, social support, and depression. The second analysis reinforces these findings and highlights the explanatory potential of healthcare-access inequality (Figure 1). Conclusions: The proposed analyzes support our hypothesis in Chile. They can be replicated in other LATAM countries as an effective restricted-data strategy to start investigating the AHP. However, cross-sectional survey analyzes are limited by reverse causation and aggregate data analyses by ecological fallacy. Better access to administrative data with patient identifier is needed to generate accurate longitudinal evidence on the explanatory mechanisms.

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: Acute-on-chronic liver failure (ACLF) is a severe clinical entity with organ failures and high short-term mortality. To Date, few ACLF reports have been published in Latin America. This study aimed to characterize patients with ACLF, identifying triggers, organ failure, and survival at 30, 90, and 180 days compared to patients with decompensated cirrhosis without ACLF. Materials and Methods: Retrospective study of decompensated cirrhotic patients hospitalized (between 2017-2019) in three centers in Chile. We evaluated transplant-free survival using Kaplan-Meier curves and Cox-regression. Results: 398 patients were included, a median age of 65.3±11.7-year-old, 50.5% female, 91 (22.9%) presented ACLF (8% ACLF-1, 6.3% ACLF-2, 8.6% ACLF-3); 6.6% underwent liver transplantation. ACLF patients were younger (63.6 vs. 66.0 years; p=0.045), had higher MELD-Na scores (27 [23-32] vs. 17 [13-23]; p

Introduction and Objectives: In chronic pathologies, such as cirrhosis, information is essential for disease acceptance, adherence to treatment and prevention of complications. This study aimed to determine whether written information in patients with cirrhosis has an effect on the level of knowledge and treatment adherence and to evaluate possible factors associated with disease-related knowledge in cirrhosis. Materials and Methods: Longitudinal, analytical study. Adult outpatients with cirrhosis were included in July-December 2021. Self-completed survey with demographic, clinical information, disease-related knowledge with ''Cirrhosis Knowledge Questionnaire'' (1 - 7 points) and treatment adherence with Morisky-Green-Levine scale (Low, Medium, High) were assessed. History of complications and hospitalizations in the last two years were obtained from clinical records. Patients were provided with an educational brochure and after four months, the disease-related knowledge and treatment adherence were re-evaluated. Comparative analysis was performed with T Student or ANOVA. Multiple linear regression models were assessed to identify possible associated factors (p < 0.05). Results: We included 104 patients, 53% men, the median age of 64 years, and 80% of them with middle or higher education. The most frequent etiologies of cirrhosis were alcohol (27%) and non-alcoholic steatohepatitis (26%). The median level of disease-related knowledge was 3 (RIC 2 - 5). Forty-three percent of the patients answered >50% of the answers correctly. Bivariate and multivariate analyses of the disease-related knowledge are described in Table 1. Disease-related knowledge levels increased after delivery of written information at the 4-month follow-up (3.21 vs. 3.96; p=0.0007), but treatment adherence did not. Conclusions: Less than half of the patients answered > 50% of disease-related knowledge correctly. Higher educational levels, history of hospitalization and complications due to cirrhosis were associated with a higher disease-related knowledge level score. The provision of written information is associated with an increase in disease-related knowledge levels in patients with cirrhosis.

Non-alcoholic fatty liver disease (NAFLD) is a complex and heterogeneous disorder considered a liver-damaging manifestation of metabolic syndrome. Its prevalence has increased in the last decades due to modern-day lifestyle factors associated with overweight and obesity, making it a relevant public health problem worldwide. The clinical progression of NAFLD is associated with advanced forms of liver injury such as fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). As such, diverse pharmacological strategies have been implemented over the last few years, principally focused on metabolic pathways involved in NAFLD progression. However, a variable response rate has been observed in NAFLD patients, which is explained by the interindividual heterogeneity of susceptibility to liver damage. In this scenario, it is necessary to search for different therapeutic approaches. It is worth noting that chronic low-grade inflammation constitutes a central mechanism in the pathogenesis and progression of NAFLD, associated with abnormal composition of the intestinal microbiota, increased lymphocyte activation in the intestine and immune effector mechanisms in liver. This review aims to discuss the current knowledge about the role of the immune response in NAFLD development. We have focused mainly on the impact of altered gut-liver-microbiota axis communication on immune cell activation in the intestinal mucosa and the role of subsequent lymphocyte homing to the liver in NAFLD development. We further discuss novel clinical trials that addressed the control of the liver and intestinal immune response to complement current NAFLD therapies.

Alcoholic liver disease (ALD) is one of the leading causes of morbidity among adults with alcohol use disorder (AUD) worldwide. Its clinical course ranges from steatosis to alcoholic hepatitis, progressing to more severe forms of liver damage, such as cirrhosis and hepatocellular carcinoma. The pathogenesis of ALD is complex and diverse elements are involved in its development, including environmental factors, genetic predisposition, the immune response, and the gut-liver axis interaction. Chronic alcohol consumption induces changes in gut microbiota that are associated with a loss of intestinal barrier function and inflammatory responses which reinforce a liver damage progression triggered by alcohol. Alcohol metabolites such as acetaldehyde, lipid peroxidation-derived aldehyde malondialdehyde (MDA), and protein-adducts act as liver-damaging hepatotoxins and potentiate systemic inflammation. Additionally, ethanol causes direct damage to the central nervous system (CNS) by crossing the blood-brain barrier (BBB), provoking oxidative stress contributing to neuroinflammation. Overall, these processes have been associated with susceptibility to depression, anxiety, and alcohol craving in ALD. Recent evidence has shown that probiotics can reverse alcohol-induced changes of the microbiota and prevent ALD progression by restoring gut microbial composition. However, the impact of probiotics on alcohol consumption behavior has been less explored. Probiotics have been used to treat various conditions by restoring microbiota and decreasing systemic and CNS inflammation. The results of some studies suggest that probiotics might improve mental function in Alzheimer’s, autism spectrum disorder, and attenuated morphine analgesic tolerance. In this sense, it has been observed that gut microbiota composition alterations, as well as its modulation using probiotics, elicit changes in neurotransmitter signals in the brain, especially in the dopamine reward circuit. Consequently, it is not difficult to imagine that a probiotics-based complementary treatment to ALD might reduce disease progression mediated by lower alcohol consumption. This review aims to present an update of the pathophysiologic mechanism underlying the microbiota-gut-liver-brain axis in ALD, as well as to provide evidence supporting probiotic use as a complementary therapy to address alcohol consumption disorder and its consequences on liver damage.

Introduction: Alcohol-associated liver disease (ALD) is the leading cause of liver-related mortality in Latin-America, yet the impact of public health policies (PHP) on alcohol consumption and liver disease is unknown. Objectives: To assess the association between alcohol PHP, alcohol consumption, and cirrhosis in Latin-American countries. Methods: We performed an ecological multi-national study including 20 countries in Latin-America (628,466,088 inhabitants). We obtained country-level socio-demographic information from the World Bank Open Data source. Alcohol-related PHP data for countries in Latin-America were obtained from the World Health Organization (WHO) Global Information System of Alcohol and Health (GISAH). We used a fixed-effects model to estimate proportions and multiple linear regression models to examine the association between the number of PHP and outcomes (alcohol intake, and deaths due to cirrhosis & traffic injuries). Results: The prevalence of obesity was 27% and 26.1% among males and females, respectively. The estimated alcohol per capita consumption (APC) among the population 15 years old was 6.8 liters of pure alcohol (5.6 recorded and 1.2 unrecorded). The countries with the highest APC were Uruguay (10.8 liters), Argentina (9.8 liters), and Chile (9.3 liters). The overall prevalence of alcohol use disorders (AUD) was 4.9%. ALD was the main cause of cirrhosis in 64.7% of males and 40.0% of females. A total of 19 (95%) countries have at least one alcohol-related PHP on alcohol. The most frequent PHP were: limiting drinking age (95%), tax control (90%), alcohol and driving (90%), and government monitoring systems (90%)(Table). A higher number of alcohol-related PHP was associated with a lower odds of AUD (OR 0.83, 95%CI:0.73-0.94; p=0.004), lower mortality due to ALD (OR 0.18, 95%CI:0.07-0.46, p

Introduction: Autoimmune hepatitis can present in severe or fulminant acute form (SAH). Only 30-60% of these patients respond favorably to corticosteroids. There is no clarity on its indication and how to evaluate steroid therapy in SAH. Objectives: To evaluate the early response to corticosteroid treatment in patients with SAH (defined as bilirubin> 10 mg / dL or hepatic encephalopathy). Method: Retrospective study of 27 patients with SAH, who received corticosteroids, aged 44 years (20-74), 19 (70%) women. Non-responder (NR) was defined if the patient died or required liver transplantation. Results: 8 patients (30%) were NR, age 49 years (21-72). Bilirubin 22.7 (15-43), INR 2.52 (1.7-3.1), MELD-Na 31 (23-38), UKELD 64 (58-66). Responders (R): 19 (70 %), age 46 years (20 -74). Bilirubin 16 (10-32), INR 1.6 (1-2.8), MELD-Na 23 (17-30), UKELD 59 (54-62). The control at 3 days of R vs NR respectively was bilirubin 10.6 vs 20.3, MELD-Na 19 vs 31, (p

Introduction: Hepatic encephalopathy (HE) is the most common neuropsychiatric syndrome secondary to portal hypertension. It usually responds to medical treatment, but sometimes HE is refractory (RHE) to usual treatment. In some patients it may be important to consider management alternatives. Endovascular therapy (ET) could be a therapeutic option in selected cases that is performed with very low frequency and the evidence is scarce. Objectives: To present our experience in the management of RHE with ET. Methods: The pre and post-procedure clinical characteristics of 10 patients with RHE undergoing splenic vein embolization (n: 5) or porto-systemic bypass embolization (n: 5) between 2009-2019 were retrospectively analyzed. Results: 7/10 were men, average age 67 years (62-79), in 70% the cause of cirrhosis was NASH, the Child Pugh average score was B (8 points), (6-11) and MELD-Na was 13 points, (9-20), in 5 patients the ammonia prior to the procedure was 134 mmol / l (range: 90-180, VN

Introduction: Cirrhosis is a frequent cause of hospitalization and is the 3rd cause of death in adults in Chile. Objective: To describe the trend in hospitalizations and mortality of hospitalized patients with cirrhosis in Chile. Methods: Descriptive analysis of combination of cross-sections, regression models (STATA 15). Population data from the MINSAL-DEIS 2001-2018 hospital discharge databases (HD) were used. HD were identified by C by codes K70.3, K743, K745, K746 (ICD-10). Results: Between 2001-2018 there were 28,181 HD by cirrhosis. Mean age 60 years; 63% men. 19,174 (68%) were for cirrhosis not associated with alcohol (CNAA) and 9,008 (32%) for alcohol (CAA). 4,903 (17.4%) of the HD were as deceased; these decreased from 521 (20.7%) in 2001 to 178 (12.5%) in 2018. Mortality was higher in CAA (21.4% vs 15.5%). 3 periods with different trends in the rate of HD per C (x100,000) are identified: 2001-2007 decreased by 53%, from 16.2 (2,518 HD) to 8.5 (1,411); 2007-2013 decreased 28% reaching 6.1 (1,067 HD); 2013-2018 increased 24.6%, reaching 7.6% (1,424 HD). The decrease in the second period and the increase in the third period were 3 times greater in CNAA than in CAA. By sex and type of cirrhosis, the third-period increase in CAA / women began in 2017. Conclusion: There is an increase in HD due to cirrhosis from 2013, relevant and worrying information. Its cause should be investigated in future studies. The decrease in deceased HD may be due to better knowledge and management of the disease.

Introduction: Transarterial chemoembolization (TACE) is considered the therapy of choice in patients with intermediate stage hepatocellular carcinoma (HCC) who are not candidates for surgical resection or tumor ablation. There are discrepancies in the American and European consensus on the treatment of HCC in Child B stage patients, given it is associated with an increased risk of liver failure and death. Objective: To describe the experience of a University Center in the management of patients with HCC and cirrhosis Child B. Methods: Observational, retrospective study. 25 patients were included. Sociodemographic variables, aetiology of cirrhosis, HCC stage, treatment and associated decompensations were included. The analysis was carried out with descriptive statistics. Results: Of the patients, 14 women, 24% with MELD-Na ≥ 15 (15-20). 44% NASH, 20% HCV infection. 56% and 34% in stage A and B of Barcelona. 32% within the Milan criteria and 25% within San Francisco. After the TACE, 16% presented immediate complications, without associated mortality. At 6 months of follow-up, 36% presented an increase in MELD-Na by (2-6) points, 32% presented or increased ascites, 12% progressed to Child C. Survival at 6 months after chemoembolization was 76%. Conclusion: TACE was a safe procedure in patients with Child B, in terms of immediate complications, however, a considerable percentage presented deterioration of liver function at 6 months of follow up. This therapy in Child B patients should be evaluated individually case by case.

Introduction: Autonomic nervous system (ANS) dysfunction in patients with chronic liver disease (CLD) is associated with greater severity. Heart rate variability (HRV) allows the assessment of ANS, but its implementation is complex. Pupillary reactivity (PR) by automatic pupillometry (AP) also provides this information; however its usefulness in patients with CLD is unknown. Objectives: To validate the usefulness of PR in the evaluation of ANS in healthy subjects and patients with CLD through association with HRV. Methods: Cross-sectional study that includes healthy controls (n = 11) and patients with DHC (n = 26). ANS balance was determined by HRV by Holter rhythm of 5 minutes and RP by AP. HRV / RP of healthy subjects and with CLD, and correlation parameters of both measurements were compared. Results: Significant differences were found between both groups in the parameters of both HRV and RP, demonstrating an imbalance of the ANS in CLD patients. Differences were significant in 2 of 3 time parameters, in 2 of 3 frequency parameters in HRV and in 5 of 7 objectified by AP. The imbalance increases directly according to the Child stage (p

Introduction: Hepatocellular carcinoma (HCC) is the third leading cause of cancer death worldwide. Liver transplantation offers good results in its treatment, however the shortage of donors has forced the use of other therapies, such as transarterial chemoembolization (TACE), whose therapeutic scheme is not completely standardized. Objective: To evaluate the response to the first TACE, the indicators of success of the therapy and the decompensations associated with its use. Methods: Retrospective observational study. 76 patients were included. Variables such as sociodemographic, clinical and HCC stages were included. Response to TACE was assessed by post-treatment LIRADS classification. Descriptive statistics were used for the analysis. Results: 60% men, the median age was 64 years (51-81), 63% Child A, average MELD-Na 10 points. 33% associated with NASH. 47% of the patients reached non-viability after the first TACE, 30% required two TACE, 15% three TACE and 7% four TACE. 58% in Barcelona stage A, 43% within the Milan criteria and 60% within the San Francisco criteria. 6% presented decompensations after the 1st TACE. The characteristics of the patients who reached non-viability versus those who remained viable are presented in Table 1. Conclusion: Most patients require two TACEs to achieve tumor non-viability. The main indicators of response to TACE were tumor burden and MELD-Na score> 8.

Introduction: It has been observed people with low-income-level (IL). The aim of this study was to evaluate alcohol-associated liver disease (ALD) paradox in Chile. Methods: With data from the ENS 2016-17 (N=2,190; age 25-64) we constructed a logit regression model that estimated the effect hazardous AC (AUDIT≥8) on the probability of presenting ALD (GPT≥40 U/L). We focus on the interaction between hazardous AC and IL, controlling for the presence of metabolic syndrome (MS), diabetes mellitus (T2DM), obesity and tobacco. Results: The average AC was 39g of alcohol per week (13g women IL; 64g men, without differences by IL). In women, hazardous AC only increased ALD among those >IL who presented with obesity or MS in combination with T2DM (+36% obesity+MS+T2DM; pIL is likely associated with higher AC and more harmful consumption patterns.

Introduction: Abdominal ultrasound is the test of choice for the screening of liver steatosis (LS) however it has a poor performance (20%). Transient elastography (TE) through the Continuous Attenuation Parameter (CAP) has shown an adequate correlation with the degree of steatosis by liver biopsy. Objectives: To evaluate the concordance between abdominal ultrasound and CAP by TE for the diagnosis of LS. Methods: Observational study. 160 patients (age 53 ± 14 years, 66.2% women) referred for TE (FibroScan; Echosens). The main indication was non-alcoholic fatty liver disease (44.4%). A cutoff of 233 dB / m was defined for the diagnosis of CAP steatosis and cuts recommended by the manufacturer were used for staging the grade of LS. Clinical data and reports of abdominal ultrasounds performed in the 90 days prior to the examination were recorded. Statistical analysis by proportion of agreement and kappa index. Results: LS was diagnosed by ultrasound in 85 patients (53.1%) vs 92 patients (57.5%) by CAP. The proportion of concordance between both exams was 74.3%, with a kappa index of 0.529. In patients with LS diagnosed by CAP, 73.9% had a concordant diagnosis by ultrasound, increasing to 82.4% when considering only patients with moderate and severe LS by CAP. Conclusion: There is moderate concordance between CAP and ultrasound for the diagnosis of LS, which increases in moderate and severe steatosis. The CAP could be an alternative tool for the diagnosis of LS, with eventual greater precision in mild cases.

Introduction: Transient elastography (TE) is a non-invasive method for the evaluation of liver fibrosis. Up to 20% of measurements fail, possibly due to the choice of probe position. Objectives: To evaluate the use of ultrasound as a position guide (UPG) prior to TE to improve the measurement of liver stiffness (LS). Methods: Prospective study of 237 patients (age 54 ± 14 years, 69% women) referred for TE (FibroScan, Echosens). The main indication was non-alcoholic fatty liver disease (52.3%). 65.4% of the patients were overweight or obese. LS was measured in each patient according to the manufacturer's recommendations and at the same appointment, in UPG. Fibrosis staging sections recommended by the manufacturer were used. Statistical analyzes performed with chi-square and t-test (p

Introduction: Liver transplantation (LT) has improved the quality of life and survival of patients in advanced stages of chronic liver disease (CLD). In the last decade, an increase in non-alcoholic steatohepatitis (NASH) as an indication for LT has been evidenced worldwide. There is little up-to-date information regarding the characteristics of LT performed in our country. Objectives: To describe the clinical characteristics of LT performed at the Hospital Clínico de la Universidad de Chile in the last 6 years. Methods: Retrospective study. LT performed between September 2013 and September 2019 were included. Clinical data, aetiology of DHC and MELD-Na were recorded at the time of transplantation. Results: 145 LT were performed, 60.6% being men, the median age was 59 years (22-72 years). The main etiology of CLD was NASH (39.3%), followed by CLA attributed to alcohol (17.9%) and autoimmune hepatitis (7.6%). 33.1% of the patients had hepatocellular carcinoma (HCC), of which 54% were patients with NASH. The mean MELD-Na at transplantation was 22 ± 9 and the operational MELD 28 ± 5. Conclusions: In our center, NASH is the first indication for LT, as well as the etiology most frequently related to the presence of HCC. These data are consistent with projections estimated worldwide. This information reaffirms the need for successful strategies to prevent and reverse the progression of NASH.

Introduction: Hepatocellular carcinoma (HCC) is the most common malignant liver tumor. Liver transplantation (LT) is considered potentially curative, achieving a survival of 70% at 5 years and a tumor recurrence

Introduction: Infections are an important cause of morbidity and mortality in the first month after liver transplantation (LT). It is important to know the local microbiology involved and the resistance patterns, to guide treatment appropriately. Objective: To characterize infections in the first month after LT in patients from the Hospital Clínico de la Universidad de Chile. Methods: Retrospective study of clinical records of 70 consecutive LT between February 2016 and October 2018. Results: 20 infectious events in 16 patients (23%). In 75% it was possible to isolate agent. Eight (40%) were bacteria, 5 were fungi and 2 were viruses; 25% were bacteremia, 20% urinary tract, 20% pulmonary, 10% intra-abdominal, and 5% skin. The agents were: K. pneumoniae (2), S. epidermidis (2), E. faecium (1), C. freundii (1), E. coli (1), S. malthophilia (1). Candidas (4), Aspergillus (1), varicella zoster virus (1), respiratory syncytial virus (1). It was not possible to identify a focus in 4 patients. There was antimicrobial resistance in 7 (35%) of the cases, 3 being multi-resistant (2 due to K. pneumoniae and 1 due to S. epidermidis). 4 microorganisms showed antimicrobial resistance (E. coli, C. freundii, E. faecium, and C. glabatra). The infection was the cause of in-hospital mortality in 2 patients. Conclusion: Infections in the first month after LT are frequent in our center, the majority of bacterial origin, as reported by international series. More than 1/3 of the patients present an agent with antimicrobial resistance, which should be considered in the choice of empirical therapy.

Introduction: Fatty liver disease (FLD) alcoholic and non-alcoholic are prevalent conditions. The damage is determined by steatosis and steatohepatitis with or without fibrosis. There is little information on its role in the progression to significant fibrosis (SF) of chronic liver diseases (CLD) other than FLD. Objective: To describe the frequency of steatosis and steatohepatitis in liver biopsies of patients with CLD other than FLD. Methods: Observational, retrospective study with biopsies performed between 2015-2018. The presence and degree of steatosis, steatohepatitis and fibrosis were recorded according to the METAVIR scale; F3-F4 is considered SF. Results: 268 biopsies analyzed; 93 with FLD are excluded. 175 are included: 53% autoimmune hepatitis (AIH), 27% primary biliary cholangitis (PBC), 7% viral hepatitis (VH) and 13% others. 74% women; age 52 (18-82) years; 58% had steatosis and 46% had steatohepatitis; 67% fibrosis, which was SF in 61%. Steatosis/steatohepatitis/fibrosis according to etiology: AIH 34%/46%/69%; PBC 19%/9%/53%; VH 77%/15%/39%. When analyzing the presence of SF according to the presence of steatosis or steatohepatitis: in steatosis 36% vs 48% without steatosis; In steatohepatitis there were more SF (65% vs 36%; p = 0.004). According to aetiology SF/non SF: HAI 92%/38% (p = 0.001); PBC 20%/24%; VH 50%/22% (NS). Conclusion: There was a high frequency of steatosis and steatohepatitis in patients with CLD. The presence of steatohepatitis is associated with a higher degree of fibrosis in patients with CLD, particularly in AIH, which may have an impact on the evolution and treatment.

Introduction: Hospitalizations (H) and mortality by alcoholic hepatitis (AH) have increased in Europe and North America. In Chile we do not have published data. Objectives: To describe the trend in H and mortality of hospitalized patients with AH in Chile. Methods: Descriptive analysis of combination of cross-sections and regression models (STATA 15). Population data from MINSAL-DEIS 2001-2018 hospital discharge databases (HD) were used. HD by AH were identified by ICD-10 code K701. Results: Between 2001-2018 there were 5,678 HD per AH. Average age 50 years. The rate of HD per AH per million inhabitants increased from 12.8 in 2001 to 18.5 in 2018 (44%). A linear estimate suggests that the rate increases by 0.55 points per year. In the population of 20-40 years it stands out that in women it increased by 64%. The only group where the rate of HD per AH increase steadily over time (in the rest the increase was less and less). The proportion by sex remained stable in 83% men and 17% women. In both sexes, 10% HD deceased, although in men a clear upward trend is observed (+0.32% annually, with a minimum of 6.5% HD in 2001 and a maximum of 15.3% HD in 2017), while in women the upward trend shows fluctuations. Conclusions: In Chile in recent years there has been an increase in HD by AH. This increased incidence is reflected in higher mortality in patients hospitalized for AH. The increase in HD was more stable among women aged 20-40 years.

Introduction: Transient elastography (TE) and non-invasive scores such as FIB-4 are non-invasive methods to evaluate liver fibrosis. Objectives: To evaluate the concordance between TE and FIB-4 in the diagnosis of advanced fibrosis. Methods: Observational study. 185 patients (53 ± 14 years, 71.4% women) referred for TE (FibroScan, Echosens). The main indication was non-alcoholic fatty liver disease (46%). Fibrosis staging sections recommended by the manufacturer were used. Clinical data and laboratory tests performed in the 30 days prior to the study were recorded. FIB-4 cuts > 3.45 and