Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.29367

The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases.

EASL-EASD-EASO Clinical Practice Guidelines for the Management of Non-Alcoholic Fatty Liver Disease

NAFLD is one of the most important causes of liver disease worldwide and will probably emerge as the leading cause of end-stage liver disease in the coming decades, with the disease affecting both adults and children. The epidemiology and demographic characteristics of NAFLD vary worldwide, usually parallel to the prevalence of obesity, but a substantial proportion of patients are lean. The large number of patients with NAFLD with potential for progressive liver disease creates challenges for screening, as the diagnosis of NASH necessitates invasive liver biopsy. Furthermore, individuals with NAFLD have a high frequency of metabolic comorbidities and could place a growing strain on health-care systems from their need for management. While awaiting the development effective therapies, this disease warrants the attention of primary care physicians, specialists and health policy makers.

/pdf/global-burden-of-nafld-and-nash-trends-predictions-risk-2rbbbzfuoo.pdf

Global burden of NAFLD and NASH: trends, predictions, risk factors and prevention

Since publication of the Society for Healthcare Epidemiology of America position paper on Clostridium difficile infection in 1995, significant changes have occurred in the epidemiology and treatment of this infection. C. difficile remains the most important cause of healthcareassociated diarrhea and is increasingly important as a community pathogen. A more virulent strain of C. difficile has been identified and has been responsible for more-severe cases of disease worldwide. Data reporting the decreased effectiveness of metronidazole in the treatment of severe disease have been published. Despite the increasing quantity of data available, areas of controversy still exist. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, and infection control and environmental management.

/pdf/clinical-practice-guidelines-for-clostridium-difficile-meg93r15my.pdf

Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)

We thank Giri et al for their interest in our recent manuscript.1 They raised some interesting points regarding our study sample and the generalizability of our proposed cutoffs for FIB4 and the NAFLD Fibrosis Score (NFS) in different patient populations.2 We agree that nonalcoholic fatty liver disease (NAFLD) is a dynamic disease that can improve over time with dietary change, exercise and weight loss and that these changes may have occurred in the time interval between the liver biopsy and entry into the cohort. The amount of weight loss that has been associated with improvement in the fibrosis stage is 10%.3 Unfortunately, no more than 10%– 12% of patients will successfully experience this degree of weight loss, even in the setting of a structured weightloss program.3,4 We expect that very few patients would experience substantial weight loss, therefore, few would be reclassified from having cirrhosis to lower fibrosis stages in the year between liver biopsy and cohort enrollment. Giri et al are correct in noting that older age and diabetes may influence the performance of FIB4 and NFS. However, we observed that the AUROC, sensitivity and specificity in the UK cohort were almost identical to the US cohort for FIB4 (0.87 vs 0.86, 0.78 vs 0.80 and 0.76 vs 0.78) and NAFLD fibrosis score (0.89 vs 0.84, 0.68 vs 0.70, and 0.89 vs 0.86) despite the UK cohort having an older mean age and higher prevalence of diabetes. PPV were slightly higher for NAFLD fibrosis score (0.46 in UK vs 0.35 in US) and similar for FIB4 (0.31 vs 0.29). Whilst some studies have reported decreased accuracy of FIB4 in patients with diabetes,5 FIB4 has been associated with an increased risk of liverrelated morbidity and mortality in a cohort of patients with an even higher prevalence of diabetes than in our study.6 In our derivation and validation cohorts, the mean BMI was 34–­35 kg/m2,­ with­most­ patients­ having­ BMI > 30­ and­ ~15% with BMI >40, which is representative of the general NAFLD population. Our study was not powered to investigate the performance of our cutoffs in subgroups such as patients with diabetes or class III obesity. We recognise age is an important predictor of cirrhosis in patients with NAFLD, and that accurate identification of highrisk patients is imperative. Shah et al7 reported a FIB4 cutoff of 1.3 as having 90% sensitivity to rule out cirrhosis. Our newly identified cutoff of 1.67 is in fact higher, yet lower than the suggested 2.0 cutoff in patients who are older than 65.8 Further work must be done to identify the most appropriate FIB4 cutoff in older patients, as the cutoff of 2.0 has not yet been wellvalidated. The use of a single cutoff, as proposed in our study, allows us to confidently rule out cirrhosis, but emphasises the need for additional testing to diagnose cirrhosis. Giri et al's comments highlight the need for further validation of our newly proposed cutoffs, particularly in patients older than 65, as well as those with diabetes and/or class III obesity.

Letter: non‐invasive prediction models to exclude cirrhosis in NAFLD—not everyone fits the mould. Authors' reply

<h3>Introduction</h3> Chronic Hepatitis C virus (HCV) infection is a major cause of morbidity and deaths worldwide. HCV treating teams in England have made steady progress towards the goal of eliminating HCV by 2025. However, HCV reinfection rates are high, particularly in North-East England, suggesting a significant reservoir of untreated infections. Contact tracing, a tool successfully used to identify and treat cases in other infectious diseases is not routine practice in HCV. Here we present the outcomes of an ‘HCV Test and Trace’ pilot scheme. <h3>Methods</h3> Individuals with recently acquired HCV infection or reinfection were invited to participate when they presented to our service for treatment. For those who agreed to participate, a Hepatitis C Trust peer worker approached them to invite potential contacts for HCV test using ‘dry blood spot’. To encourage participation, incentives (vouchers for a food outlet) were given to index individuals and contacts upon HCV testing. We collected data on uptake, HCV test results, treatment rates and reasons for declining. <h3>Results</h3> Between April 2022 and Jan 2023 (9 months), 241 individuals were invited to participate, of whom 118 (49%) agreed. The overall interim outcomes of the pilot are summarised in figure 1. To date, 24 (10% of all, 20% of those agreeing) have brought forward contacts for testing. A total of 88 contacts were identified and tested, averaging 3 or more contacts per participant. of these, 33 (38%) were HCV RNA positive indicating active HCV. To date, 10 have started antiviral treatment, 14 are awaiting assessment or treatment initiation, 7 persistent failed encounters, 1 pregnant and 1 spontaneous clearance. The most common reason for individuals declining participation was that they were no longer in contact with at risk individuals (69%). <h3>Conclusions</h3> Overall, about half of individuals with recent HCV infection or reinfection agreed to participate in a test and trace pilot scheme, but to date only 20% actually brought contacts forward. However, the frequency of active HCV among the contacts appears to be high at 38%. Work is ongoing to refine the pathway to increase uptake, testing and treatment rate. 

P297 What is the impact of a hepatitis C ‘test and trace’ pilot using peer workers?

Prognostic value of the Enhanced Liver Fibrosis (ELF) test to predict long-term outcomes in a NAFLD cohort with up to 35 years follow-up

Introduction Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution. Methods A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan–Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality. Results One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038). Conclusions Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.

Stuart McPherson

Papers

Letter: non‐invasive prediction models to exclude cirrhosis in NAFLD—not everyone fits the mould. Authors' reply

P297 What is the impact of a hepatitis C ‘test and trace’ pilot using peer workers?

Prognostic value of the Enhanced Liver Fibrosis (ELF) test to predict long-term outcomes in a NAFLD cohort with up to 35 years follow-up

Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease