Good afternoon everybody and welcome to the AASLD ILTS transport course live question answer session. I'm Jim Finlay and with my co-moderators program chairs Kim Watt and Dennis Balchi will be moderating these questions. Hopefully you've had a chance to review the course prior to joining us. We have the presenters here. What we're going to be doing this afternoon is approaching it in terms of the three sessions. So we'll have the presenters for the session one up first half an hour approximately half an hour for the second session and half an hour for the third session. So we'll be just dealing with the presenters from each session in the three different groups. If you've got your screens up in terms of asking questions on the right side of the screen there should be two tabs a Q&A tab and a chat tab. Submit questions in the Q&A tab and please indicate which speaker you're addressing the question to and also if you can address the questions to the speakers in the session we're currently dealing with that would make it a lot easier from our point of view. We'll do our best to get through as many questions as we can. Also you can use the chat tab to engage with other attendees and share resources while the session is going on. If we don't get a chance to answer your question you can use the TLM DX system to connect with the presenters outside of this session. So let's get started with the session one presenters who should be all up on the screen just now and if you recall session one was about enhancing access to transplantation. So I think one of the things that struck me with that was the ProCon debate at the end about social media and we've heard some good things social media can do and some bad things that social media is doing already and I think my first pick on that to both of the presenters of the ProCon would be social media is out there it's doing these good and bad things at the moment. How can we influence what's going on? We may say we really don't want that to be happening but can't have any say over it at all. Whitney do you want to start? Yes. Am I starting or am I doing something? I thought you were going to. No it's a great question. You know the debate is on how far can we go and if we really want to keep taking this additional steps I think that we have to engage more as a transplant community in social media. To me that would mean more than our own Facebook, Twitter accounts. It would mean really taking on some sort of a site or a chat room where donors and recipients can interact and engage and I think that it's in that forum that we would have a moderator like a moderate have the role of a moderator to control that environment but that's kind of my question for everybody is are you ready for something like that? You can't necessarily stop people from saying things. You cannot allow them to post it or you can delete it or you can be sitting there really micromanaging everything that somebody says. That's a really big responsibility and I think a lot of the things that come up some people might feel comfortable with and some people might not so it's just a whole new it's a whole new world out there that we would really have to navigate and we'd have to be really adept to figuring out what's real and what's not real and we'd really be responsible for those postings and those interactions. Nazia do you have any thing to add? Yeah I do. I think that first of all thank you very much for starting and I think that you know that we want it or not social media is out there and you saw both from my presentation and Dr. Jackson presentation that a lot of people spending a horrendous amount of time on social media and that's the the future we cannot avoid it but we can use it in a beneficial way to approach the issue of liver transplantation and live donation and navigate it in a way that it would be beneficial. One of the things for example that I believe would be very helpful and certainly in Toronto we started to look into this is that to ensure that if someone is going to post online or create a social media page for public appeals that there is some guidance from our program we have created guidance for how to go to social media how to approach them and also have a champions that could navigate that and that champion is someone who has been a anonymous donor, non-directed donor themselves and they can help navigate the issue around the posting and the information that is out there and that is certainly very helpful to avoid many misleading information such as etiology of liver disease, how serious is someone's health and some of the issue that Dr. Jackson brought up during her presentation. I do agree though as a community that you know I think a lot of the misinformation that Whitney sort of mentioned in her talk is really it's going to dissuade a lot of potential altruistic donors or non-directed type of donors that I think you know we need to make a collective effort at dissuading all the myths and all of the misinformation that's out there. Is there a plan or a process to do that sort of thing? I'll ask you Whitney. Well I saw that Mayo Clinic has like frequently you know misunderstood issues about live donation and that's actually one of the websites that comes up first when I searched for it. I don't know if I'm just you know they kind of are predicting what I want to see or not but that definitely I thought was like a great a great way to tackle it however Mayo got the most hits to become the first one that that's on my search. Yeah I don't I don't know how to combat those myths that are out there. The biggest things that we can do are build trust with our community and you know a reputation they say hard-earned easy to lose. So we have to build trust with the community, have information that's out there and I don't know that there is a I mean look at what's happening in the world right now with you know everything that's going on in the election even. I don't know that you can always police things and always shut things down. I think that that trust and that educational message is probably the most important one which is why I think that our role is really to keep yes absolutely our donors are going to be our recipients are going to be out there recruiting donors whether we're involved or not. Our role is certainly for education. Advertising will always be out there but should we really push it to that next level of helping those interactions those donors and recipients find each other and I don't know that we're there yet. I don't know that we have a platform that we can trust yet. And certainly none of this probably applies to Mark's talk which is more on living donor in sort of extreme cases or very sick patients. Any other thoughts by Mark or Nazia on this living donor option or living donor issue? You know the other thing I'll just mention is social media doesn't end up being a huge source of donors for our program. I certainly think that the word gets out there that way and it's a tool but I can think of three people who were not related to a recipient who did a directed donation through social media in the past three years. So a lot of things even our non-directed population doesn't seem to come to us from social media. I'm sure that they use social media that they get a lot of education from there but it doesn't tend to be a huge source of donors for us. Yeah I think it's probably more like the individual person posts their thing and then someone meets them through and then they're no longer technically not directed you know. The individuals use it more. Is that more your findings too Nazia? Well again you know each program is a little bit different. We know and I talked a little bit about during my presentation that in the past some of the public appeals has been helpful to raise a lot of donors for others that ultimately decided to donate to other recipients and they remain interested and that seems to be still a little bit the situation that they come forward for a specific person who went for a public appeal and that could be a famous or not famous person but that has raised some interest that remained in those donors to continue to pursue with donation with other potential recipients. All right so we've got a question here for Marina Serper. Can we try that? Sorry Jim I interrupted you. Go ahead. You go ahead and do Marina's question because I know that she's got to run off and take care of sick patients right now. So Dr. Serper, how do you use HVPG for further stratification in a patient with cardiac cirrhosis on biopsy, no portal hypertension, venous pressure gradient below five, good liver function, no cirrhosis complications? Do you do a heart liver or just a heart? So in the Penn experience you know the short answer is for this patient if it's cirrhosis even if it's well compensated cirrhosis it's a liver heart and you know data are quite limited but there have been reports where you know the envelope has been pushed and I'm sure this is not uniform across centers but there has been delayed recovery, prolonged morbidity after a heart liver in cases of cirrhosis. It is survivable and I don't have the data because we don't have good national data on this at all but at least what I can tell you from our experience and we've done a fair amount of heart livers is that we've kind of learned that any cirrhosis even no matter how well compensated even in the absence of significant portal hypertension it just puts a lot of the cardiac operation puts a lot of strain on the liver. There is a lot in terms of infectious complications that can be seen so the short answer here any cirrhosis is a heart liver. Where we do use HVPG is in cases where sometimes the liver can look nodular if there's passive congestion for example with Fontan single ventricle physiology and we can use HVPG to help guide us sometimes but we don't use it to make decisions with concomitant cirrhosis. How about Sameet do you want to weigh in on the kidney side of things similar type of scenario? Yeah it was very interesting so just last week I had one patient who was a 40 year old being you know who had heart disease and he had cirrhosis. In that case we suggested you know that he needs combined heart liver if he eventually gets to that but then in the same week I had somebody with you know undergoing for kidney and we said you know what this person does not have portal hypertension I think we're okay with a you know kidney transplant alone. So it's interesting like you know the data is used differently for different organs and I think it's just the amount of effort into a combined heart liver as compared to a simultaneous liver kidney. Moving on a little keeping on the living donor front a question for Dr. Cattrell. When you decide to do a living donor for one of these critically ill patients is there ever issues with the speed required to work up the donor? Pardon me is there what? Is there any issues with the time required to work up the donor given the critical illness of the potential recipient? In our program a typical donor workup takes about four to six weeks mostly for logistical reasons but in times of crisis we can work up a donor within 24 hours. So it's the time really depends on the level of illness and the recipient but you know to date it has not been a problem working up somebody in a quick quickly. As a follow-up on that I mean do you think there's more potential for like donor follow-up with a you know high speed workup over 24 hours? That hasn't been a problem I mean we have a we spent a lot of time with the donors, with different members of the team meet with the donor. We try to put them, we try to do it in a way that puts them, well, you know, the problem with this situation, it is a high pressure situation for the donor and they know what the alternative is. If they don't act, they know the recipient, their loved one will likely die. So we certainly recognize it is a high pressure situation. It is coercive by nature, but we do spend quite a bit of time with them, educating them as best we can to make them feel comfortable with whatever decision they make in the end. We always offer the possibility of opting out. We understand the situation that they're in, and if they're not feeling comfortable, we get the impression that they're not comfortable, we will sway them to not donate. So we're very cognizant of that situation. We have a couple of questions for Dr. Berenger. So one of them here is a patient whose pre-transplant surface antibody titer is satisfactory and receives a core positive liver, surface antigen negative. After a year or two post-transplant, if surface antibody is satisfactory, would you stop antiviral prophylaxis? So in short, how long would you keep a core antibody positive person on antiviral? If the recipient is surface antibody positive. So I think after two years, the amount of immunosuppression, the intensity of immunosuppression that the patient is on is probably much lower. So the risk is already not very high for the baseline, even without any prophylaxis, the risk of developing de novo HBV is relatively low in those who are, in the recipients who are surface antibody positive. In fact, in our own center, because the risk is relatively low in those patients, we sometimes don't even use prophylaxis and we follow these patients with strict monitoring. But I would definitely, it's a very good option to stop antivirals after two years because they're on low immunosuppression. They're no longer under steroid therapy, which as we know is being associated with a reactivation of HBV. So I think it's, this is a good strategy. Is there a surface antibody level you'd want to see? I don't think there's data to suggest that you have a cutoff to say, okay, you can stop in these patients, at least that I'm aware of. But I would say that again, I think in the patients, if you don't, if you forget about these patients being liver transplanted, if we think about reactivation of patients who are COVID positive under immunosuppression, chemotherapy, the reactivation is significantly lower when you stop steroids and you're just under tacrolimus monotherapy or microphenolate monotherapy. And generally speaking, these patients are under significantly low immunosuppression two years from transplantation. And would you do anything different if the, let's say you're treating rejection and they're needing pulse steroids or even thymoglobulin, then would you, you'd probably have to remember these guys were core antibody positive if you need to pay attention to that, right? Yes, I think you need to pay attention to these things. I think that the problem with these patients, it's so easy to leave them under prolonging antiviral prophylaxis with lamivudine with very, very few side effects, even in the longterm. We have, we forget that they're on these antiviral drugs in the longterm and it's much easier then to monitor them very strictly. Right. How about if you gave a surface antigen positive graft, do you have any kind of surveillance program? Like this is still a HCC risk now, right? So I've not seen much on that. Your thoughts? I don't think we have a lot of experience in the West. I think most of the experience comes from the Asian countries because of the epidemiology, HPV in this, they have a lot of surface antigen positive patients. I mean, they have much more anti-core positive donors but they also have quite a lot of surface antigen positivity in the general population. So the practice of using this surface antigen positive organs is mostly the data that I have reviewed really comes from Asian countries. There's also some papers coming from Italy, interesting papers. And they all end up saying that the results are equal to those observed in recipients receiving surface antigen negative grafts but that we still need to look for potential consequences in the longterm, such as HCC development. So it's kind of the last sentence of all these reports that I have been reading. But overall, they all suggest that the results are quite good. We have not been using this surface antigen positive grafts. I mean, you need to make sure that they have no fibrosis, that they're good quality livers but there are experiences in Asian countries even with using grafts from HBS antigen donors. Like donors. So somebody else, oh, sorry, go ahead. Yeah. Okay, I have a quick question for Dr. Ketrell. Those recipients that have high math scores frequently they're acute and chronic patients or former liver failure patients. And while they are in the ICU or being prepped for transplant and the donor is being prepared, as you said, maybe in a day's time, fast-tracked, do you have a threshold when you say the potential benefits of the operation does not outweigh the risks for the donor and how do you calculate this risk? As I, I think I mentioned in the talk, I mean, if there's any question about whether a recipient will survive a deceased donor transplant, we won't offer a living donor transplant. So sometimes it can be very difficult to finding when it's futile, but fortunately we've been successful today in trying to identify some of the patients that would not likely survive a transplant with a living donor. So as far as the living donor is concerned, the risk is going to be the same. I mean, but as I mentioned also in my talk, the fallout of a bad outcome when the recipient can be pretty severe for some donors. So that's something we have to be very wary of. Some of the worst experiences that we've seen are in donors who have, where the recipient has died shortly after the transplant or have had a bad outcome with the graft which has had to be replaced. So it's tragic for everyone actually when that happens. Yeah, absolutely. And as you pointed out, the long-term outcomes, especially the psychological outcomes for the donors are the worst cohort for those donors who have lost their recipients in the immediately post-operatively. So we try to be, you know, it's always a debate between the team. It's not an easy decision making. Do you have a cutoff GRWR for the recipient? Well, it's, you know, one of the things that's becoming more challenging is even in the patients who don't have high MELD scores, we're seeing with the NASH population, they have a relatively low MELD scores, but they're actually quite sick with a lot of comorbidities. And in many ways, I find them more challenging than some of the other classic high MELD patients that we were concerned about. So if somebody is quite ill, where they need a lot of liver mass to begin with, so the cutoff would be around one, I would say. I mean, right now our cutoff is probably around 0.7 to 0.8 in most cases. But in the sicker patients, preferably higher than that. So we have another question from Marina Serper. Would you offer, I'm guessing it's combined liver, heart and a patient with a normal HVPG, but a biopsy showing uniform F4 versus someone with a biopsy of F3? Yeah, so, you know, I think if you have, you know, patchy fibrosis, if there's any question, if things are on the border, this is when we use that, you know, what we call the peak liver protocol. So we basically allocate, we take the liver and the heart. We have a backup liver recipient at all times, and then our surgeons go in. And at the time of median sternotomy, you extend the incision, you take a look at the liver, and then they make the decision, how does the liver look? And does the recipient liver in fact need to be explanted? And so we always have a backup. So these are, and I'll be honest with you, this is not from my personal experience, but from the surgeon's experience, just asking them. It has been just a handful of cases, less than five, where we have not transplanted the liver in a peak liver case. So most cases that are even on the border at our center have turned into simultaneous heart liver. And reallocating those organs, is that legit? Well, that's another discussion. I mean, we have a backup recipient, you know, and I don't wanna use the term liver in a bucket, but that's what some people call it. Right now you have a liver and you really need to make sure that you're able to use that liver if you don't think you need it. So we have a backup recipient in those cases. Interesting. Marina Berenguer, there's another question for you on using a core positive liver in a patient with Delta. Patients with Delta, and we have a few here in Spain. Like, I mean, we are in the Mediterranean basis. We have the Delta patients, I would never, for instance, use a surface antigen positive liver in a Delta recipient. And I think also using an anti-core positive donor in a Delta recipient is not the best of the situations. I don't think it's completely prohibited. If you are in a very emergent situation, I think we have very good anti-virals against HPV. And you, generally speaking, you manage HPV and in doing so, Delta won't be a problem. But there've been cases of progression of Delta in the graft despite the good control of HPV. So I think it's a good strategy not to use anti-core positive grafts and more surface antigen positive grafts in Delta recipients. Question for Dr. Rosserani, about the kidneys. Certainly doing kidney transplants, the habit, and you mentioned this in your talk, the body habitus of people who look like they've got NAFLD is increasing. Do you have any sense of how robust the workup for patients who are being primarily worked up for a kidney transplant is for coincident with non-alcoholic fatty liver disease? No, I think as of now, it probably is non-existent. We tend to just think about Hep B and Hep C, but really haven't paid NAFLD and NASH as much, given as much thought. And if you look at some of the long-term studies, seems like the risk factors for somebody not doing well, who we thought would do well, is age and diabetes. And so I have a feeling that eventually we may need to have that kind of shift. Even the other day, same thing. I had a patient with normal LFTs who had, on kidney transplant alone, workup was found to have cirrhosis. And then what do you do? Endoscopy showing varices, so we called that off. But yeah, I think we may need to introduce something to help with that, whether it's an ultrasound or something at least to start off with, or some non-invasive markers. Do you have any data that, there's always this tossed around HVPG less than 10 to go ahead and safely just do a kidney alone. Is that just some random, I feel okay about that number type of thing? Or is there data around that? I don't think there's an absolute cutoff, is my guess. Like the other day also clinically what we did is we scoped the patient. She was found to have varices, so that was it. And so we stopped there. But absolute cutoff, I don't know. But if you look at sort of the easel and the KDCO conference, they suggested less than 10. Marina, you're on. Yeah, following the problem with the endoscopy sometimes, when you have these very small varices that sometimes it's not always that easy to say these are varices from the hyperploidal hypertension. And I'm always a little bit nervous about the endoscopy to make decisions. That's why I think the portal pressure measurement is sometimes better than the scoping when you have these near normal endoscopies. I understand. Like this one, I actually got somebody else to say, hey, this person, what do you think? And they're like, you know, these are real varices. But more than that, I think even if we, let's say get that patient through the transplant, we still don't know what's going to happen to them three years out, five years out. And so I would still say stop at that point, at least for me. Okay, I think we're running up towards the end of our first session here. So a lot of interesting discussion around the topics presented. I'd like to thank everybody for being here and doing the discussion. And then we'll be back in a couple of minutes with the presenters from the second session. Thank you very much. And welcome back, everybody. We now have the presenters from the second session, which was, as you recall, perioperative risk assessment and management. So we will be discussing that for the next 30 minutes or so. Do we have any questions? We have a question from Dr. Izzi. First question is for Dr. Izzi. The question is, what is the possibility of reversal of cirrhotic cardiomyopathy after liver transplant? This is an excellent question. So the data about the possibility of reversal of cirrhotic cardiomyopathy according to the new diagnostic criteria after transplant are very limited. So there are two studies that evaluated the reversal of EE prime after transplant, and one of them showed that it doesn't change, and the other one showed it actually worsened. There are three studies that evaluated left atrial volume index as a surrogate of diastolic dysfunction or cirrhotic cardiomyopathy in this patient population. Two of them showed it actually worsens after transplant, and one of them showed it remains the same. In our study that's under review that I just mentioned in the presentation, there were 22 patients with cirrhotic cardiomyopathy who happened to have echocardiography after transplant for clinical indications. Only six of them had the reversal of cirrhotic cardiomyopathy. So these are all, you know, limited studies with small numbers, but so far there's insufficient evidence to suggest reversal post-transplant based on the new criteria. Now back in the days when they were going to be based on QT prolongation regardless of echo, yes, the QT seemed to get better after transplant, but if we go by the actual echo, there's insufficient evidence to suggest that, but we're now, you know, studying it at a, you know, at a larger population, and hopefully by the next meeting we'll have an answer for that. And just following up with that, I think one of the things you presented was that looked like one-year outcomes, so late outcomes are more associated with cirrhotic cardiomyopathy than early outcomes. Do you have any data to say whether the presence of cirrhotic cardiomyopathy is any more better at predicting late outcomes than just general cardiovascular risk? I'm sorry, the line was breaking. Can you repeat the question? Oh, so late outcomes appear to be associated with cirrhotic cardiomyopathy rather than early outcomes. Do you have any data looking at whether those late outcomes are better predicted by cirrhotic cardiomyopathy? Is there, or would just using traditional cardiovascular risk factors give you the same predictive power, or is it a different group of patients? That's a great question. So actually in our study, because of concerns that these could be just reflective of the development, let's say, of hypertension or diabetes or other risk factors in these patients post-transplant, so was that the effect of cirrhotic cardiomyopathy or, you know, these other risk factors? So we did control, again, this is a small patient sample of 141 patients, but we did, when we did control for hypertension or diabetes, still cirrhotic cardiomyopathy was a risk factor for later decompensation or later cardiovascular disease, regardless of the hypertension or diabetes status. They did have an impact, but it's an independent impact of each other. Okay, thank you. There's a question that was in here for Dr. Tandon, so you can unmute yourself in preparation. What is the model for reimbursement for both pre- and post-liver transplant for palliative care, which might be different in the U.S. than Canada, so it might help. Yeah, I'm sure it is actually quite different, so it'd be great if one of the U.S. docs could chime in on the U.S. model, but certainly, I think post-transplant is going to be evolving as far as the model of coverage as we get more and more used to non-cancer palliative care being a part of management, but for us anyways in Canada, it is covered under our healthcare insurance with supplemental benefits, etc., for hospice, etc., so in the United States, I'm pretty sure hospice is covered by Medicare, is my understanding. Yeah, I think so, and I'm the last person to actually fully understand reimbursement stuff because I tend to think like a Canadian, but I think all you'd need is an actual indication, you know, a valid indication, and it should be covered by insurance, I would think, because it is symptom control management, and they have a subspecialty designation for that, so I have to think it would be reimbursed. Do you see a role for maybe increasing palliative care consultation or ongoing care using telemedicine? Do you think this whole COVID opening the doors for telemedicine might actually be advantageous for the palliative care world of this? I actually think it's advantageous across cirrhosis care. I mean, it's got advantages and disadvantages. Obviously, we've been thrown into it, and we're learning how to roll with it, but we need to increase access more broadly, especially in a country like Canada, where we've got so many huge, huge country, rural and remote citizens who don't get the same access to care, so I think virtual care delivery does open up care delivery to those citizens as well. Yeah, I just sort of see that palliative care being a particularly useful avenue to be able to do continued care and optimizing kind of the symptom control care through virtual means, whether it's video or telephone visit, I think it should be a definite pickup on that. For sure, and safely, obviously, with COVID, you know, we don't want to put our patients at risk. Right, exactly. We had a question here for Mitra. Do you think there is a special subgroup of patients in whom MARS or any of the other devices might help to bridge them to transplant, i.e. those with the very high bilirubin, or what special subgroup of patients may benefit the most? That's a great question. I think it's a hard question to answer. You know, a lot of these studies with MARS, pretty much all of them, except actually, there was one, I saw an abstract on from the US group on ALF patients where it was a positive trial with MARS, but if we look at the CLF group, there's been four studies, they've been all negative studies. Yes, it, you know, reduces the cranium and bilirubin, because that's what the device is made to do. But what they did see, actually, if they broke it down to ACLF, you know, one, two, three, in the one and two, those patients who had, you know, more than four sessions of MARS, in the first 10 days, there was a statistical difference between the two groups, but then it got lost by very quickly. So I think there is a role, I think, like, you know, we have this debate with just dialysis and outside of liver patients, when do you start? I think if you start these devices earlier, the question is when is early, really, for these patients that you may see a benefit so earlier before they end up with four or five, you know, organ failures. The use of MARS, the problem is that, again, it's a device that most centers really in the, in the US, there's very few that it's a very expensive device, the filters are extremely costly. So unless there are studies that will show, you know, a benefit for ACLF, I think for now, it's hard to judge when to start these. But I think there is a role, I just don't know what level, you know, of a bilirubin or ACLF to start these patients on. The data has been negative. Again, for ALF, the former study was also a negative trial. But you know, most of these patients with ALF who get MARS, when they're randomized, they quickly get transplanted. So the study and with MARS and acute liver failure, at least, patients were transplanted within 16 hours. I mean, that doesn't even happen in the US. These are European studies. In the US, it takes just like two days to get even a social work and, you know, get insurance, you know, approval. But again, there is an abstract from the US. It's retrospective with Jody Olson and Dean Karvelas is the senior author for that. It's an abstract I saw this morning. And they looked at their retrospective US studies in patients with ALF who got MARS treatment, and there was a survival benefit. And these were patients, they didn't get transplanted very quickly, like the European studies. So maybe there is a benefit in these patients. Do you think that the bilirubin going down is really just sort of a false advertising? I mean, it's clearing the bilirubin, but it's not, it's not affecting the source of the bilirubin, right? The liver failure? Exactly. And I think bilirubin is kind of like, you know, BUN or creatinine is, you know, the creatinine comes down, but it's not really a marker of these toxins that really exist. I think bilirubin is just something you can measure. But what happens to the rest of these, you know, bile acids and toxin, I think it's a question. And again, I think once you have multi-organ failure, now is it two, three, four, is it too late that no matter what you do, it's not going to make a difference. And I think this is one of the limitations of the studies, either it's too late or the patients get transplanted. So you can't even get the effect of the treatment. And does it have any effect on INR? Because we just recently had a MARS patient whose INR went from super detection, like unable to quantify to at least being detectable. And the only difference was MARS, but we were surprised that INR was affected at all. It's interesting. Not that I know of, it's usually about the bilirubin, you know, the creatinine and things like that, urea, ammonia level, but INR is not, did the patient do well? Could it be that the liver was getting better or just suddenly became normal? Very definitely not. No, we just transplanted her the other day, so I'll find out if she's doing well now, but yeah, it was just interesting. I've not seen MARS actually lower an INR before, so I thought I'd ask you. Okay. We have another question for Panita. One of the studies in your excellent presentation suggested palliative care is associated with an increased survival. Any thoughts about the rationale or mechanism of that? Yeah, that's a really good question. So that was the TEML study in non-small cell cancer. We don't have any such studies in cirrhosis yet, but as I recall, the authors hypothesized that the survival benefit was potentially related to a better control of symptoms and improvement in quality of life. And so patients may be more than engaged with their care overall and one can, with the remarkable low quality of life that we have in our patients and the high symptom burden, I think that may be a possibility in our patients as well. Okay. And we have a question for Dr. Balchi. How do you manage the port-a-cable shunt over time in small for size system? I think this is maybe asking like further down the line, rather than interoperatively. Do you go to IR? Do you go in surgically again? Well, first of all, I should say port-a-cable shunts are not very popular in the living donor liver transplant community. Most of the Asian centers avoid port-a-cable shunts. Rather, as I have tried to mention in my presentation, prefer a stepwise approach, starting with spinig artery ligation, then might go for spinaectomy. And even after those measures, which potentially cause dramatic decrease in portal hyperperfusion and portal pressures, then might go for port-a-cable shunt in very small grafts. One group has some data that has been recently published. It came from India, the Medanta group that we're studying. And they use polychiable shunts for very small livers like GRW are less than 0.7 with portal pressure over 15 millimeter mercury. And actually, calibrating those shunts are critical. And following them up also is important. And as soon as their duty is over, they could be controlled or they could be closed, if you will, by operation or by intervention rate. Both ways are possible. I think it depends on center experience. But probably more than 90% of living donor liver transplants will not require a portal chelation. And Dr. Izzi, do you think cirrhotic cardiomyopathy, is it, you know, we've got this new definition now for diastolic dysfunction, which of course has multiple causes. How do we separate out cirrhotic cause from diabetic patient, you know, other diastolic dysfunction causes? That's a great question. And it's really hard to answer. Because there's really no, you know, no way that we know of at this point to discern like, is this diastolic dysfunction from the liver or from, you know, diastolic dysfunction or obesity. Even for the cataracts for diastolic dysfunction in these patients versus general population, we actually for these criteria, we use the cut-offs that are, that had been used in general population and apply them to our general population. So we don't have an objective way to discern is this from, you know, diabetes or from, you know, having cirrhosis. One way that we may, you know, or something that I can foresee in the future using MRI based analyses to discern that given that patients with cirrhosis, they can have myocardial fibrosis and, you know, increased myocardial inflammation, which may not be seen to that extent in patients with diabetes, but that's, you know, 10 steps down the road. But as of now, there is no way to discern that. Great question. Maybe arguably it's the long-term change, right? The ones that continue to have trouble post transplant might not necessarily be cirrhotic driven or they're worsened by cirrhosis, but there's a baseline problem that's causing cardiomyopathy. That's very true. But at the same time, what we know from the cardiac literature, you know, cardiac fibrosis, for example, that develops in patients with aortic stenosis or other cardiac etiologies may not reverse. So if we think that cardiac fibrosis, or based on the available data, cardiac fibrosis is part of the cirrhotic cardiomyopathy pathophysiology, it's not inconceivable that it may not reverse down the road. So you're not off the hot seat yet, because someone else just sent in a question for you. So is there a point of no return, like a futility cutoff to transplanting patients with severe cardiomyopathy? So I think that would be mostly based on ejection fraction. You know, so if they're just the systolic dysfunction component of their cirrhotic cardiomyopathy below 50%, that would be very discouraging from proceeding with transplant. Now for the diastolic dysfunction, let's say, you know, as you know, like diastolic dysfunction has grade one, two, and three. What if somebody has grade three? Do we proceed or not proceed with transplant? There are no data to say we shouldn't proceed. And we're actually evaluating this now, but as of now, we can't say we should hold off. Maybe the patient would need extensive post-transplant echocardiographic surveillance to make sure that there's no further worsening in their cardiac function, or there's no evolution of the diastolic dysfunction into systolic dysfunction and decline in EF that may warrant initiation of guideline-directed therapy or anti-remodeling agents. But that surveillance could be considered post-transplant. But, you know, I wouldn't say that diastolic dysfunction at this point is prohibitive of transplant, regardless of how severe it is. Yeah, I think… I was going to say, Jim, as an anesthesiologist, can you… I think there's older data looking at some of the older diastolic dysfunction parameters, which suggests that at least, you know, one in two, you know, one in two out of four doesn't seem to cause an issue. But once you get up, as Izzy was suggesting, to the higher levels of dysfunction, there did seem to be some correlation with worsened outcomes in some smaller, older studies. What remains to be seen is because these were using measures which were quite preload-dependent, you could get a different measurement pre, post-withdrawal of ascites, etc., would be how the new measures pan out with that. And really, since, you know, these are fairly recent additions to diastology literature, we really don't know how it's going to play out in cirrhosis at this point. But I think there is some, at least, previous signal that higher levels of diastolic dysfunction may be associated with worse, again, longer-term outcomes rather than… we're always focusing on short-term outcomes in anesthesia, but it seems to be the longer-term outcomes that were worse. What about additive stuff, Jim, as far as being the one behind the curtain there? If you've got some element of diastolic dysfunction and then you throw in some AFib or, you know, some other added cardiac assault intra-op, are there sort of too many additive… what's the point of too many additive factors? It can potentially make the intraoperative course more difficult. There… I think there's really very little, as he said, in terms of pure diastolic issues that would make you think, no, we shouldn't be going ahead with this. Obviously, you know, the usual take care with fluids and fluid shifts, etc. However, it'd be more looking at the other factors involved. And I don't know that there's ever any patient I've seen that's sort of like, wow, this is really bad diastolic dysfunction in addition to something else. It's usually something else that's going to make you say no, like, for example, systolic function or a bad valvular problem, rather than the diastolic dysfunction per se, should be manageable. And I think a lot of the times patients who've got bad diastolic dysfunction have it secondary to not sort of cardiomyopathy, but other cardiovascular issues that we're way more familiar with and way better at saying yes or no, depending on the severity of them. All right. So, the added question to this from a listener is, Dr. Izzi, do you wait for a good donor in candidates with severe cardiomyopathy? So, there are no data to support yes or no, but anecdotally, I've seen our anesthesia colleagues, you know, when they see diastolic dysfunction, especially if it's grade two or three, they really prefer a good donor. And Jim can, you know, jump in here. We always prefer good donors. I think the surgeons do too. Any comments? Yeah, I would like to follow up with this. Actually, what Kimberly has said, more further complicating issues like for cardiomyopathy plus, let's say, pulmonary hypertension. You know, we surgeons, we don't know too many parameters, but in the preoperative period, we would like to know the pulmonary artery pressure and now this cardiomyopathy that has always been known to a certain extent as an influence during the operation that we all focus first in the preoperative period. What will be the interplay between the level of cardiomyopathy and pulmonary artery pressure? This question goes for Izzi. And how would you manage this interoperatively? Would you change anything or would you ask your surgeons to change their surgical technique, like avoid total cable clamping? So regarding your first question regarding pulmonary hypertension and cardiomyopathy, it's actually an excellent question because right now one of the most common causes of pulmonary hypertension is actually diastolic dysfunction. And diastolic dysfunction is the hallmark of cirrhotic cardiomyopathy. So these patients can, you know, can conceptually be at higher risk of pulmonary hypertension even after transplant if the diastolic dysfunction persists. You know, regarding your second question, our preliminary data do not suggest that patients with cirrhotic cardiomyopathy need higher pressure support or, you know, increased IV fluid requirements. But again, these are preliminary and, you know, we'll see what the final data show. But so far, it doesn't seem that diastolic dysfunction requires increase, you know, increase in pressure support during the surgery. I have to say that, you know, if you, you know, if you, if you're getting a not great organ and, you know, there is a higher risk of reperfusion syndrome, that conceptually, you know, it will affect, you know, it will have a larger impact on patients with diastolic dysfunction. Yeah, I mean, I can maybe add in terms of the pulmonary hypertension. Yeah, diastolic dysfunction can lead to pulmonary hypertension, but it's not the, it's not the pulmonary hypertension that we worry about with portal pulmonary hypertension in that it's secondary to elevated filling pressures, rather than actual vasoconstriction and remodeling, and as such, should be more able to be dealt with during a transplant than portal pulmonary hypertension. Okay, is there a time point that you stop the surgeons to not to push the heart and heart too much in your operating group? Jim always tells our surgeons to, to avoid blood loss and fluid shifts. So, I mean, we do the majority of our transplants piggyback, our surgeons do the majority of piggyback, and we, in the past with pulmonary hypertension, portal pulmonary hypertension, we had done some with vena vena bypass in an attempt to decrease the changes in preload, etc. More recently, we've continued to do them with piggyback technique and have been equally as successful or unsuccessful as you are with those patients. I see one additional question in here for Panita. So, given anxiety and depression among patients with end-stage liver disease and in view of the goals of palliative medicine, is palliative, are palliative care providers expected to prescribe anti-anxiety or antidepressant medications? Great question. So, I think, I think overall, I mean, it's the symptom burden that we all need to take on as a team. And that team involves the family physicians who are probably more skilled in actually the anti-anxiety, antidepressant kind of therapies. But it involves really recognizing that there's a problem and someone starting to do the screening. So, getting that role clarity around who's doing what, whether that becomes us gaining some more skills in that, whether it's the primary care docs, whether it's the palliative care physicians, I think we're going to need to learn more as we go and really define that according to the local context of what's acceptable within wherever you're practicing. But yes, someone needs to start screening and someone needs to start managing these symptoms for sure. Great. I am not seeing any additional questions. And we're just about running out of time for this part of the Q&A. So, I think, again, I would like to thank the presenters for answering the questions and some excellent questions they are. We'll step aside for a second here and then be back with the session three presenters in a couple of minutes. Thank you. And we're back. And now we have the presenters from the third session. This was the session titled the 10 years after transplant. So a variety of different talks here. And we think have some questions, this already. Yeah, I think first up for Dr. Wagner, you showed evidence that CNI reduction or elimination can improve EFGR, but is there any similar evidence that it produces cardiovascular risk? That's a great question, Jim. First of all, I hope everyone's having a great meeting and is enjoying the course and the discussion this afternoon. So even though I think we have some reasonable evidence, pretty good evidence, quality evidence that CNI reduction improves EGFR and can reduce progression to CKD in these patients, we actually have no evidence in liver transplantation that it actually links to a reduction in cardiovascular outcomes. There was a recent meta-analysis in the Cochrane database that came out at least for steroid-free immunosuppression, so not specifically CNI reduction that did show that there was a trend towards a reduction in hypertension. There is a trend in reduction of incident new onset diabetes after transplant with steroid-free regimens, but there is no other high quality data that's out there looking at this question. For those that are out there, fellows, people who are new in this world, it's a great area of investigation to actually see if these therapies actually move the needle on cardiovascular risk. Yeah, there's at least some theoretical evidence. We use sirolimus and stents in reducing cardiac proliferation, but actually ticrolimus itself has some effect, not nearly as much as sirolimus in some of the antiproliferative stuff, so it might not, as far as at least atherosclerotic disease, it might not have quite as much of a benefit in reducing TAC, but hard to know necessarily with cyclosporine or other immunosuppressants. So the follow-up to that question, Lisa, was we have so much to do as hepatologists in order to manage transplant recipients, immunosuppression, graft function, cancer prevention, kidney function, and now you're saying all these cardiovascular risks, what are some of your possible solutions that have come up in your research to address this critical issue? That's a great question. I'm sure I'm not gonna invent more time for everybody during their now e-visits where we're trying to cram all this stuff in in these follow-up of these long-term patients. And I think this comes to sort of what I said at the end, is that there are a lot of proposed care models and ways that we could do a better job of sort of redesigning our long-term post-transplant care that doesn't even just apply to cardiovascular risks, it also applies to malignancy prevention and all these other things like Kim talked about. The reality is I personally, and from the data and the studies that we've done here at Northwestern, I don't think the answer is that the hepatologist should be managing everything all the time long-term, but that means that we need to shift our framework and be thinking about how we can do a better job of communicating and integrating long-term care, whether it's through the primary care provider, whether there is potentially a role, especially early on after transplant, there has been talk about having well-trained mid-level providers that we could do a better job of leveraging to help us manage, especially in that first year, like we showed. If we can reduce that blood pressure, we can do better intensive management of cardiovascular risks, then, you know, and we could sort of supervise and help in that way, and then in our visits be more focused on the immunosuppression and the graft function and those sort of things as hepatologists, those are potential solutions, those are costly, those are system-wide things that our institutions have to agree to fund and pay for. So there's probably a role for better virtual integrated health networks utilizing our primary care doctors and our consultants in a better way. And I just wanna reiterate that, that that is one of the most important things we as the hepatologists and providers need to empower the general practitioner, the general internist at home, that, you know, seeing us once a year for diabetic care is not good diabetic care. A, B, and C once a year. So, you know, we absolutely need to be empowering them. You know, most general practitioners probably panic when they see a transplant recipient and we just need to say, hey, statins are okay, all right? Choose an oral hypoglycemic, don't use insulin, you know, that kind of, we just need to educate for sure, and that's something we need to do a lot better of. Yeah, agreed. All right, Dr. Joshi, you're on the hot seat. So how does one engage with a young adult who is non-adherent? So I think it's important to establish the reasons for non-adherence. It's never one sort of single reason alone. I think in my presentation, I highlighted some of the risk factors for non-adherence, which, you know, can relate to socioeconomic factors, to disease related factors. So I think it's about just opening a dialogue, having those conversations, and then, you know, breaking down those potential barriers to sort of patients coming forward. And then you adapt accordingly. So I think being quite flexible, adapting clinics to suit young adults. So evening clinics, yeah, some of the talks earlier talking about social media, I think there's a fine medium where you can engage with young adults as well. They're more susceptible or persuaded by social media. So all these things are important in trying to identify the reasons for non-adherence and then sort of moving forward with them. So it's a tough one. And I think, you know, we'll all see non-adherence in all aspects of our care. It's not just young adults, it's all of our patients at some point. There was a follow-up to that question as well. Would you consider re-transplanting a young adult that's non-adherent? Yikes. Tough question. That is a tough question. What I would say, again, it comes back to, well, why are they non-adherent? You know, young adults, they, you know, have different ways of, you know, sort of using information. They've got higher risk behaviors. They tend to use sort of reward rather than consequence as how they sort of, you know, go through some of their sort of problems that they see and face. So that's not a yes or no answer. I don't think anybody can say yes or no off one bat, but it's about engaging with that young adult, trying to determine why they're non-adherent and then moving forward. And I think, again, in my talk, I really emphasized the need for multidisciplinary care. It's not just the hepatologist, it's the social worker, it's the psychologist. I can't overestimate, you know, underestimate the role of the psychologist in care for this group. And again, you know, I'm an adult physician. I'm not a pediatrician. You know, the need for psychology in adult care as well, you know, is really needed. Dr. Gupta? Yeah, thank you. That's a great question. Not an easy answer. But in addition to what Deepak just said, you know, connecting with them is important, but one thing I would say not to do is keep stressing that take your medicine, take your medicine. At some point, at least the young teens, again, it depends if you're dealing with, you know, 23, 24 year old versus you are dealing with a little bit of a defiant oppositional 16, 17, 18 year old, I've seen that that's always counterproductive. So the way I approach it with my patients is I'll tell them, you know, I understand it's very hard to take medications. I understand sometimes you don't feel like it. And that seems to resonate. And then slowly you build a rapport. I'm not saying it's not a foolproof strategy by no means, but I think that is very helpful, what Deepak said, you know, connecting with them, not sort of preaching or being judgmental. I think those two, if we can really avoid that, actually connects us much better to the patient. As far as re-transplanting, as you saw in my talk, the main point as a pediatrician or as a pediatric hepatologist I want to make is, you know, we have to give these teens and young adults a chance. I mean, remember we were teenagers once and you know, what all we did at that time, the brain is not fully developed. The cognitive, there are cognitive delays. Executive functioning is not developed in 24. You know, there's still risk-taking. How can we deny that patient from a second chance at life? But we have to set some boundaries. It should never be given without discussion because then they don't realize the value of it. So we always set boundaries. We always set things like you have to show adherence, it seems. I would liken it similar to how we, not we, but adult hepatologists do it with alcoholics. So I'm always in favor of giving them a second chance at transplant, but I would also say we should not do it just as a matter of fact. We should discuss with them and set expectations, really. Since you're answering questions, Nitika, one more for you. What would you suggest for a small program that don't have the resources that Atlanta Children's has in terms of setting up a transition program? And how hard is it to convince administration that such a thing is worth doing? I'm still continuing to do that. I'm still trying to continue my administration that it is important. Because this is a little twilight area. The pediatric hospitals think, well, they're going to be out of our system. The adult hospitals, they form a drop in the bucket, but they are our patients. And so yes, it did take convincing, but I think as compared to where we were in 2011 when we started our program, I think there is much more awareness. The fact that we are discussing this topic today in this course is a testament to the fact is a testament to the fact that people are paying more attention. So I think convincing the administration has become a little bit easier. You can never make a business model for it. That's the part of the problem, but you can make a humanitarian model for it. That's required. How do we set up a program if you have less resources? I have to say that my team really helped me. I mean, it was not something I could have done by myself, but if you had to, even your interaction one-on-one with the patient, because we see them for a long period of time. We always see our patients at least every six months. We never do annually. And now with telemedicine, I'm just ecstatic because our non-adherent patients, the ones who don't like coming, I can reach them on their cell phones in their rooms. And then I can comment on, hey, this is your room. It looks great. So I think it's opened up a whole new area for me personally and with frequent touch bases. So yes, it'd be hard to build a program, but we can still prepare them one-on-one. We can still teach them how to take ownership of their own care. We can still teach them, talk to them instead of their parents. I think that's one of the biggest things. If you can talk to the young adult or teen and get them to answer your questions and get them to ask proactive questions about their care, I think that is a big achievement. We actually did a study which is currently under review for publication, which really showed that we had a patient who was on track for a great college and had great GPA and SAT scores, had been transplanted four times, but did not know what she was transplanted for. So these things, and which was a shocker when we did the survey, that was the last person I expected to get that answer from. She didn't know she was transplanted first for biliary atresia. So I think education and getting them to talk and ask questions, we can do that one-on-one. We don't need a whole lot of preparation. It's that one-on-one connection, but we have to start early. We start late, then you can make a difference. So I would suggest, it would be great to have a team, but there's something we can do one-on-one with the patients we see. Each of us can do that. Okay. Okay. There is a question for Kim and Lisa. Oh. Take it away, Denz. All right. And now, obesity is being shown to be associated with malignancy development and cardiovascular disease. What are the best strategies against weight gain post-liver transplant? Do you want to go, Lisa? I think Kim goes first, or Lisa. All right, Kim goes first. Well, I think whoever asked the question already posed the answer is avoiding the weight gain, certainly dealing with their weight before transplant, if at all possible. The idea of sleeve gastrectomies and that kind of stuff can happen in the morbidly obese, which you can prevent steatosis and diabetes post-transplant. I don't know any data yet on those types of patients, whether we avoid malignancies. But certainly avoidance of weight gain is the critical part. Everybody gains weight after transplant. Some people need to, some people overshoot. A lot of people overshoot, but transplant is not a cure for overweight and it is not a cure for the obese. So they're only going to get more overweight or become obese. So we need to have strategies upfront to avoid weight gain. And the best strategies for that are challenges. So we don't have data on upfront weight gain strategies. And so obviously having your dieticians, talking to people upfront, warning them about weight gain, I threaten them. We're looking at a couple of different studies on weight gain, but we don't have any of them complete yet. So I don't know if Lisa, if you guys have a specific approach to avoiding weight gain. Yeah, it's such an important thing. I think that, I mean, this goes right back to what we said before, and I was just even listening to Nikita and Deepak talk as well. I mean, this is very much right. Talking about counseling and behavior change and actually making sure that we're not just yelling at patients, like you gotta eat less, you gotta lose weight, you shouldn't do this, you shouldn't do that. Nobody likes that, nobody responds to that. So what we have found really helpful is that we, at least in our NASH program in particular, refer all of our patients, if possible, to a health behavior psychologist in addition to the nutrition piece, right? So that you're addressing both the nutrition arm of things and the sort of what to eat, but also the why behind everybody's turning to food, especially a lot of these patients also have addiction history, whether it's to food or other addictive things. And now you've told them they can't drink alcohol, they can't smoke, they can't do any of these other things, and food becomes a comfort. It's also really hard. Obviously, we all know that. Post-transplant, it's very isolating. It's especially isolating now in COVID for them, there's a lot of time at home, there's a lot of time being sedentary. So the more that you can, again, ask for help, it's a theme sort of across the board, we're not in this alone, we have incredible access to different practitioners and people, especially now with telemedicine, a lot of these services are now available to be at least administered via telemedicine. And so getting people involved early, and not taking the entire responsibility of all of the behavioral follow up and the frequent appointments that need to happen to address those things, and just trying to be a little bit more of the driver of the bus and sort of helping to navigate people through that first year by hooking them up with people who are experts in those areas, I think has been a successful strategy for us. Yeah, I think trying to identify people ahead of time who are probably most likely to gain weight and might need more than just a, you know, four or six month follow up, maybe they to have kind of virtual contact, or something, you know, and as the weeks go along, and in preparation to, you know, whether it's diet strategies, behavioral medicine, whatever, but I do think we we need to be a lot more engaging and trying to prevent the weight gain that happens for all of the downstream complications, because they're all very definitely related to that initial phase of weight gain. Yep. So I think that's the one thing like the sleeve gastrectomy studies do show us is if you can actually have weight loss after transplant, you don't get near as much diabetes, hyperlipidemia, steatosis, which, of course, you know, translates five, six, eight years down the road when you start seeing the heart disease and the malignancies start to kick in. So I think we need to avoid for sure. There's another question in here for Nikita, I think, right? Yeah, pediatric physicians see much more frequently in the liver transplant clinics, as you've mentioned, every six months, is that something you'd recommend when they go to adult clinic? Or should we treat them like adults? Oh, that's an excellent question. Thank you for asking that. Yes, I think we should treat them like adults. But we should see them a little bit more frequently. I mean, just imagine if you're seeing somebody who's 22 doesn't want to talk, you know, is having mood swings, has had a transplant for 18 years has a very complex history and shows up in your clinic. How are we going to build that rapport? You know, if you see them once a year, so what we do in our joint clinic, which I do with Dr. Ryan Ford, who's my adult hepatology counterpart, we try to and again, when I say try, because we are all busy and our clinics are full, but we try to see them more frequently in the beginning. And if they're stable patients, or if I know I'm telling him that, well, you know what, this is a very compliant patient, I think we can go six months or this patient has never missed a clinic appointment, we can go, you know, three months or never more than three to four months. So I think in the first year, it is very important to see them more frequently as you develop a relationship. I think it can be spaced. And this is not just my opinion. It's actually validated by data. We have data from our center, which is also under review, not published yet. But and it's similar to some of the other smaller studies, which showed that there is an increased mortality post transfer of these patients from pediatric to adult health care. They invariably show up in the ER, they don't follow up. It's because they just haven't had that relationship. And they are like, dear, second headlines, because they most of the times don't like the adult setup who wants to grow up, nobody wants to grow up, you know. So it's there. So, so it's very important, I think that they should be seen a little bit more frequently. But it's not for the rest of their lives, of course. But I think the highest risk period is the first two years, we showed that about 50% of the patients who had died within the five years had died within the first two years. So it is very critical that these are seen, they're seen more often. And then you can, we've actually transferred patients who had a great history. And then three months later, I hear from my adult colleague that, you know, had some issues like actually truancy. And I was like, are you talking about are we talking about the same patient? So things change. So it's very important. Again, I'm sorry, I'm saying that again and again. But I think it's very important that we see these patients more frequently in the beginning, then you would see any other stable patients, get to know them, develop a relationship, and then they can be phased out. But yes, we should treat them like adults. Deepak? Yeah, I think I'd just like to emphasize what Nitika has just said, I think it depends on the individual. You've got to be flexible. But also remember, it's not just you know, you as the hepatologist, you have other members of the team. So, you know, it might be that they want to follow up with your social worker, your psychologist in a couple of weeks. And then, you know, it just allows them to get more used to the adult system, the adult way. And we are very different. I'm still asked, you know, you know, when will I see the pediatric consultant? And I know you're just seeing me. So it's slowly, slowly. And it just, you know, really depends on the individual case. Okay, we've a couple of questions for Dr. Prasad now. First one, is there a time point after liver transplant where you would contradict traveling abroad because the low rate of response to vaccines? Absolutely excellent question. So it's a moving target. And one of the important things to take into account is that all travel is not the same and every transplant is not the same. So the first piece is that we have the ability to provide surrogate immunity in short of vaccines. And so in many cases where travel is absolutely necessary in short order, or exposure is unavoidable in shorter after transplant, we can use immunoglobulin for protection IVIG. And so that is one thing that can be done. What degree of protection that provides for some of the travel associated infections is variable. Because remember the immunoglobulin that you give your patient by and large, it's from your community. So you can't expect by giving somebody an IVIG dose that they're now going to be protected against cholera if they're in the Western hemisphere and traveling to an environment where they'll be exposed. The other piece that's important with respect to the vaccines is that more recent data has actually demonstrated that we do see reasonably protective immune response, for example, with influenza vaccine as short as one month post transplant. So while I wouldn't deploy a live virus vaccine in those situations, things like a flu shot, which honestly is actually probably the most important vaccine you give anybody before they travel, if they're traveling during the flu season, can be done within a month. So it's one where you want to kind of think about what is the immunosuppression regimen that was used, the induction regimen. What does that mean in regards to the suppression of the patient's immune function? What kind of treatment did they have prior to transplant? If this is somebody who got immune hepatitis, who might've had Rituxan previously, that is a much different picture than somebody who is a LANEX erotic, but a different approach. So really pull in your transplant ID colleagues on that front and put their feet to the fire because there's no one answer to everybody. Okay. And a second question for you. How early is it safe to travel abroad for post liver transplant recipients in areas where access to a transplant center may be difficult and where you've thought of some preventive measures for traveler's diarrhea? I guess that's two questions. So I'll do the second part first. There are fairly well-developed approaches that are used in travel medicine in general, and specifically within transplant in regards to having patients travel with some antibiotic in case they were to develop say traveler's diarrhea, et cetera. Much of that is extrapolated from the non-immunocompromised host. And what I, what I take issue with that is in my immunocompromised patients, I don't worry so much about your standard traveler's diarrhea. That's a risk. And we want to be careful about that, but where it's absolutely imperative for transplant patients to take so much greater care about exposure is exposure to an acquisition of non-standard traveler's diarrhea type pathogens, your cyclospora, your, your other parasitic etiologies infection, which can create fairly persistent infection, which are very difficult to get rid of, particularly in the more immunocompromised host, especially when you're early post transplant. So while we do have people travel with a course of quinolone, et cetera, I do really hammer home the importance of appropriate safety precautions, avoiding eating raw vegetables or making sure you're thoughtful about where the water supply is coming from, because I'm not so worried about the bacterial etiologies. Those are manageable in most of those environments. It's the kind of more chronic etiologies of diarrhea that are a problem. As far as safety of travel, I think one of the things that COVID has really highlight has put, you know, put a lot of spotlight on is that almost no matter where you travel, depending on your resources, you do have the ability to communicate back with your own center and to be able to get in touch with care. And it's important to set those kinds of communication pathways up. Now, if I've got somebody who's going somewhere where they're not going to have access to any kind of telecommunications, yeah, that that's a big red flag to me. That's one where you've got to know it's an important reason you're traveling. You're in the best shape to be doing that. And then we've got a lot of plans in place to do so safely. We've had members of the military who have transplanted, we've gotten that, but they have the backup when they're doing that. So there's no specific window. I do like by and large, if, you know, if you can wait three months, that's a bare minimum for me. But if you have to travel in that one to three month window, it's a lot of planning and how do we, you know, who do we communicate with? Also remember transplant's done worldwide now. There's so many centers, so many places people can get in touch with where there's somebody who knows how to help. Yeah, I had a sort of separate question myself, but Nikita or Nitika, you kind of brought it up yourself. So I'm going to pose it to Deepak. But using virtual consults, I think with the adolescent and young adult group probably is just a huge advantage, I got to think, you know, as far as just you're connecting at kind of a little bit more on their level, you know, it's kind of more like their little personal device and now you're a part of it. So is this something that's growing or obviously it's growing in the COVID era, but is it something you find particularly useful in your transition patients? Yeah, so I think if there's been one positive of the COVID-19 pandemic in the UK, it's been that a lot of the red tape around using telemedicine, sort of online sort of, you know, platforms, it's all been broken down. And for once, things have been speeded through very quickly. So we've been engaging more and more with patients, we can follow them up much quicker. You know, we don't have the geographical area we need, you know, that you guys cover in the US, but it's still an issue. 50 miles is a lot for some people coming up to see us in clinics. So just engaging them, like Natika said, in their sort of own personal environment, they don't feel threatened by a clinical room, by curtains, it's made it so much easier. And I think, again, they are more willing to participate with us, it doesn't stop them, you know, taking a day off school, taking a day off their work. And it's just so flexible. The biggest problem is us now, because we're, you know, stuck in clinic, we can only do it at a certain time. So I think we need to evolve as well. Yeah, I think that's a huge evolution for medicine in general. So Lisa, hotspot for you, how do we get statins into the water of our transplant patients, they need it for malignancy, they need it for cardiac disease? What do we do to get people to start prescribing these things? Well, I mean, there's two things. Number one, you said it before, Kim, that we have to empower the primary care doctors to feel comfortable. And one of the things that did come out of our research that we've done in our focus groups is the biggest thing that we had that was identified by both primary care doctors within our Northwestern network, and those who are in the community, is they didn't have a clear sense of who they could reach out to with quick, simple questions about drug drug interactions, they didn't trust their own pharmacists, or even some of their own pharmacists who weren't familiar with transplant drugs would sort of hedge on recommendations. So the biggest missing piece in a lot of linkage to care is utilizing our transplant pharmacy team. And I would say that our heart transplant colleagues have done this to a better degree. And there's actually been some nice literature in the heart transplant world sort of dovetailing off of what right cardiology has already done in terms of heart failure, follow ups, and discharge and following these patients frequently with touch points with whether it's nursing care or pharmacy care to touch base on how patients are doing symptomatically, they've transitioned that to heart transplant follow up as well. And so if we can just create some simpler decision trees where we give the power to our transplant pharmacists to prescribe and send so that we approve and make it more automated as opposed to relying on us to make a decision. And this goes for you know, statin medications, blood pressure management, I mean, some of these things that we know are just these low hanging fruits that we're just not doing and it's time constraints, it's too many competing interests, too many things that are going through our brains, the more automated we can make it, the easier it's going to be as more of an opt out system on our end. So I think that's probably the best way to address it from a system level. Great answer. Okay, just as a comment, the audience comment here, Jim, did you want to share that with everyone? Yeah, you can certainly you know, there's a comment about the stars will network for excellence and pediatric transplant, which is based in Pittsburgh, several initiatives, one of which is transition of care, and the suggestion that programs who are interested in might want to reach out to them. So that's, I think, Nitika is part of you're actually involved with that program. Correct? Yeah. So that's it. So eight centers, eight or nine centers, and you know, can reach out to anybody. And we are heading the TOC initiative with transfer of care. So hopefully good data to come from that. Okay, good. I think with that, we're coming to the end of this question and answer session, part three of three. Again, I'd just like to thank everybody for their participation, both the presenters, moderators and the audience for sending in some excellent questions, which have stimulated the debate. A couple of housekeeping reminders at the end, if you didn't have a chance to view all the presentations, or if they were so wonderful, we'd like to see them again. They're still going to be up there until February the 21st 2020. So you have plenty time to review. At the end of this, at the end of the meeting, attendees will receive information about how to get their certificates of attendance or CMEs or their mock points. That's it. I'd just like again to thank everybody and say thank you very much for great presentations, great discussion and great transplant course overall. Thank you. Yes, thank everybody. Yep, really great talks. Thanks.

liver transplantation care

access to transplantation

cirrhotic cardiomyopathy

post-transplant care

social media for transplant recruitment

liver-heart transplants

palliative care

MARS therapy

portacaval shunts

diagnosing cirrhotic cardiomyopathy

telemedicine for young patients

medication adherence