Chronic hepatitis B (CHB) infection is a significant risk factor for developing hepatocellular carcinoma (HCC). As HCC is associated with significant morbidity and mortality, screening patients with CHB at a high risk for HCC is recommended in an attempt to improve these outcomes. However, the screening recommendations on who to screen and how often are not uniform. Identifying patients at the highest risk of HCC would allow for the best use of health resources. In this review, we evaluate the literature on screening patients with CHB for HCC, strategies for optimizing adherence to screening, and potential risk stratification tools to identify patients with CHB at a high risk of developing HCC.

Medical assistance in dying (MAiD) has been a legally approved practice in Canada since 2016. Only recently have patients undergoing MAiD also been considered as donors for liver transplantation (LT). This study aimed to evaluate a case series of LT outcomes for recipients with MAiD donors and was paired with a systematic literature review of studies assessing the efficacy of MAiD-associated liver donation. A retrospective chart review of patients registered within the LT Registry at London Health Sciences Centre (LHSC) in London, Ontario, Canada, that had received MAiD donor LT was conducted to develop a case series. Descriptive statistics were produced based on available patient outcomes information. The systematic review included euthanasia due to MAiD being a term exclusive to Canada. Case series had a 100% 1-year graft survival rate, with 50% of patients experiencing early allograft dysfunction but having no significant clinical outcome. A single case of postoperative biliary complication was reported. Median warm ischemic time ranged from 7.8–13 minutes among case series and literature reviews. Utilization of donation after circulatory death allografts procured after MAiD appears to be promising. Mechanisms associated with potential impact in postoperative outcomes include relatively lower warm ischemic time relative to donation after circulatory death Maastricht III graft recipients.

Introduction: Patient, clinician, and system‐related barriers may affect adherence to hepatocellular carcinoma (HCC) surveillance programmes. The impact of a dedicated automated recall HCC surveillance programme on retention rates in patients eligible for screening is unknown. We aimed to describe and evaluate a large HCC surveillance programme in a publicly funded healthcare system. Methods: Data were collected from January 1, 2013, to December 31, 2022, from a retrospective cohort of subjects enrolled in a publicly funded automated recall semi‐annual surveillance programme as per the American Association for the Study of Liver Disease HCC guidance in the Calgary Health Zone (~1.6 million), Canada. Patients were excluded if there was incomplete data or did not meet indications for surveillance. Cox regression was used to identify predictors of non‐retention to surveillance. Results: A total of 7269 patients were included. The median was age 55.5 years (IQR: 45.5–63.8), 60% were male, 46% were of Asian descent, 51% had HBV infection, and 36% had cirrhosis (35% alcohol‐related). Median follow‐up was 4.9 years (IQR: 1.5–7.2). Overall, 52% ( n = 3768) of patients were retained in the surveillance programme, while 8.3% ( n = 603) left for potential medical reasons, and 40% ( n = 2898) were lost in follow‐up. The median time in the programme for those lost in follow‐up was 0.81 years (IQR: 0.0–2.8) compared to 6.75 years if retained (IQR: 5.6–8.6; p < 0.001). In multivariable Cox regression analysis, HCV aetiology (HR 1.41; CI 1.23–1.62, p < 0.01), African ethnicity (HR 1.20, CI 1.02–1.42, p = 0.03), and cirrhosis (HR 1.16, CI 1.05–1.28, p < 0.01) increased risk of dropout. On interaction analysis, Hepatitis B amongst cirrhotic patients also increased risk of dropout (HR 1.48, CI 1.05–2.07, p = 0.02). Conclusion: A dedicated automated recall HCC surveillance programme has a high retention rate in a large multi‐ethnic cohort of patients while identifying certain marginalised patient populations, such as those with viral liver disease, cirrhosis, or African ethnicity, as particularly vulnerable to loss to follow‐up.

Length of stay (LOS) is a significant contributor to overall patient outcomes for patients undergoing liver transplantation. This study documents a quality improvement project aiming to reduce the median post-transplant LOS for liver transplant patients. We instituted five Plan–Do–Study–Act cycles with the goal of reducing LOS by 3 days from a baseline median of 18.4 days over 1 year. Balancing measures such as readmission rates ensured any decrease in stay was not associated with significantly increased patient complications. Over the 28-month intervention period and 24-month follow-up period, there were 193 patients discharged from hospital with a median LOS of 9 days. The changes appreciated during quality improvement interventions carried over to sustained improvements, with no significant variability in LOS postintervention. Discharge within 10 days increased from 18.4% to 60% over the study period, with intensive care unit stay decreasing from a median of 3.4–1.9 days. Thus, the development of a multidisciplinary care pathway, with patient engagement, led to improved and sustained discharge rates with no significant differences in readmission rates.

Introduction: Choosing Wisely Canada (CWC) Hepatology published recommendations in 2017 aiming to reduce low-value care and testing, including serum ammonia tests for hepatic encephalopathy (HE) and transfusion of blood products for minor invasive procedures. We explored the impact of these recommendations in reducing rates of low-value testing and care. Methods: We included all medicine inpatients from 23 hospitals in Ontario, Canada from the GEMINI database between April 2015 and March 2022. Weekly rates of low-value care were measured before and after the CWC Hepatology recommendations (19 July 2017). Interrupted time-series regression models were used to assess time trends for rates of low-value care. Subgroup analysis was completed on hospitalisations under hepatology or gastroenterology services. Results: Of 59 155 patients identified with liver disease, 17 906 developed HE and 11 676 cirrhosis patients underwent minor invasive procedures. In the HE cohort, there was no immediate change in the rate of ammonia tests with recommendations, but the overall rate decreased by 0.002 tests per hospitalisation per week (95% CI −0.00413 to −0.000009). With recommendations, we observed an increase in the rate of 0.242 (95% CI 0.010 to 0.474 transfusions/hospitalisation), but no significant difference in the rate change nor in the rate of platelet and vitamin K transfusions. There was no significant change in the rate of platelet and vitamin K transfusions. Hospitalisations under hepatology or gastroenterology services also did not have a change in rates of low-value care overall, except for ammonia tests where the rate decreased by 0.012 tests (95% CI −0.0177 to −0.00626 tests/hospitalisation) per week after recommendations. Conclusions: The CWC recommendations were associated with a reduction in the rate of serum ammonia tests, but not with transfusion of blood products. Thus, there remains an opportunity to reduce low-value care and application of clinical guidelines.

Chronic hepatitis B (CHB) is the leading cause of hepatocellular carcinoma (HCC) globally. We described and evaluated the outcomes of patients with CHB‐HCC in Canada. In this retrospective cross‐sectional cohort study, data were analysed from CHB mono‐infected subjects seen between 1 January 2012 and 31 December 2022, and entered the Canadian Hepatitis B Network Registry. Descriptive analysis and chi‐squared modelling were used to compare cohorts, followed by multivariable survival analysis regarding survival post‐diagnosis. Statistical analyses were completed in R version 2.2. Of the 6711 patients with CHB who met inclusion criteria, 232 (3.5%) developed HCC. Compared with the CHB cohort, the majority of CHB‐HCC cohort were male, SEA and HBeAg negative and born in endemic area (80% vs. 56%, 73% vs. 55%, 84% vs. 54%, 64% vs. 40% and all p < 0001). Overall, median HBV DNA level was log 2.54 (IQR: 0–4.04). Advanced liver disease, defined as minimum Fibrosis stage F3, was seen in 9.4% of overall cohort, but 92% of HCC cohort. At diagnosis, median tumour size was 2.5 cm (IQR: 1.7–4.0) and mean tumour number was 1.33 (SD: 1.33), with 81% of patients BCLC 0‐A. Fifty‐three per cent of patients were diagnosed with HCC as part of surveillance protocols. The survival rate after HCC diagnosis was 78.7%, during the median follow‐up of 52.9 months (IQR: 17–90). In multivariable analysis, survival was significantly correlated with diagnosis through the screening programme. In this large cohort of patients with CHB‐HCC, the majority of patients were detected with early‐stage HCC and received treatment with curative intent, resulting in strong survival rates.