It was a pleasure to join colleagues in Washington D.C. to discuss advances in Hepatology over the past year. While always an area of keen interest given the clinical implications, portal hypertension and acute on chronic liver failure (ACLF) continue to be bustling areas of active research and clinical advances.

Terlipressin was a major focus of discussion this year among portal hypertension topics. Optimal implementation of this recently FDA approved treatment for Hepatorenal Syndrome is an ongoing area of discussion. Multiple studies including post-hoc analyses from the CONFIRM trial and a new randomized clinical trial from India suggest that initiating treatment with terlipressin earlier in a patient’s course – with less severe renal failure -- may be helpful. 

Multiple other presentations focused on the appropriate relative grading of illness severity with respect to use of serum creatinine and anticipated changes with adoption of MELD 3.0.  Dr Mohammad Amin Fallahzadeh of Baylor College of Medicine reminded us that despite multiple changes to our estimates of renal function in cirrhosis, an ideal formula for all patients remains elusive and improvements are needed for appropriate and equitable access to dual liver-kidney listing.

Dr. Ruben Hernaez, also from Baylor College of Medicine, presented a MODEL for post-transplant mortality among patients with ACLF which brings, broader multicenter evidence to the conversation surrounding how to select the very sickest patients wisely. Preliminary results suggested good ability to assist with discrimination between generally acceptable and unacceptable post-transplant outcomes.  A web-calculator for this task is anticipated from the group.

Multiple studies using artificial intelligence methods to improve prediction of important outcomes were presented, including “DynaMELD” a much more comprehensive (and complex) model for predicting mortality in patients with cirrhosis. Significant improvements in predictive capacity were demonstrated and further refinements were discussed, with review of the practicality of implementation and limitations.

Paracentesis was again demonstrated to be a safe procedure, despite deranged measures of coagulopathy by Dr. Brittany Bromfield from the University of Pittsburgh. Use of resources preprocedure to correct presumed bleeding tendency was reduced after initiation of a TEG-based protocol when platelet count <20,000 or INR >4 (or chronic kidney disease or several alcoholic hepatitis). Rates of hemorrhage were very low, however questions remain about the true limits of the bounds for safety.

We look forward to more refinements on the issues above and new discoveries to discuss next year.