Background/aims
Community-based assessment and management of chronic liver disease (CLD) in people who are homeless (PWAH) remains poorly described. We aimed to determine prevalence/predictors of chronic liver disease (CLD) in PWAH and assess performance of non-invasive hepatocyte fibrosis and injury markers.

Methods
The Vulnerable Adult LIver Disease (VALID) study provided a “one-stop” liver service based at homeless hostels. Our primary outcome was the prevalence of clinically significant hepatic fibrosis (CSHF) (liver stiffness measurement (LSM) ≥ 8kPa).

Results
Total individuals recruited were 127, mean±SD age 47±9.4 years, 50% (95% CI 41%-59%) and 39% (95% CI 31%- 48%) having alcohol dependence and a positive HCV RNA respectively. CSHF was detected in 26% (95% CI 17%-35%), independent predictors being total alcohol unit/week (OR 1.01, 95% CI 1.00-1.02, p=0.002) and HCV RNA positivity (OR 2.93, 95% CI 1.12-7.66, p=0.029). There was moderate agreement between LSM and Enhanced Liver Fibrosis (ELF) score (kappa 0.536, p<0.001) for CSHF as assessed by LSM ≥8kPa. Those with CSHF had significantly higher levels of IFN-γ (p=0.002), IL-6 (p=0.001), MMP-2 (p=0.006), ccCK-18 (p<0.001) and ELF biomarkers (p<0.001), compared to those without CSHF. Service uptake was ≥95%. Direct acting antiviral (DAA) treatment completion was 93% (95% CI 77%-99%), sustained virological response (SVR) being 83% (95% CI 64%-94%).

Conclusion
There is a significant liver disease burden from HCV and alcohol in PWAH. Non-invasive hepatocyte fibrosis and injury markers can help in identifying such individuals in the community. Despite a challenging cohort, excellent service uptake and high DAA-based SVRs can be achieved.

Background/aims: We performed a systematic review and meta-analysis addressing community-based assessment and treatment of hepatitis C virus (HCV)-related liver disease, injecting drug use (IDU) and alcohol use amongst people who are homeless (PWAH).

Methods: Using systematic review methodology, databases were searched (MEDLINE/ EMBASE/CINAHL) for studies combining PWAH, HCV-related liver disease and community assessment until December 2019. Studies with a sample size > 30, with PWAH constituting at least 30% of the cohort were included and a quality assessment performed. Pooled estimates of key indicators were analysed using meta-analysis.

Results: We identified 39 studies (n=13,918), 37 categorised as poor quality (Newcastle-Ottawa Scale). Prevalence of homelessness ranged between 30%-100% (37 studies). Eight studies provided all of the following: HCV screening, alcohol/substance use/liver fibrosis assessment and HCV treatment. No study provided interventions for alcohol use, with two providing opioid substitution treatment. Alcohol use prevalence (24 studies) was 4%-97%, being 59% (95% CI 20%-92%) in four studies that included only PWAH. Recent IDU prevalence (16 studies) was 7%-73%, being 21% (95% CI 17%-26%) in four studies that included only PWAH. HCV seroprevalence (25 studies) was 2.5% - 58%; in 13 studies that included only PWAH, this was 20% (95% CI 12%-30%). Prevalence of F4 fibrosis (nine studies) was 6%-28%, being 7% and 16% in two studies that included only PWAH. Direct acting antiviral-based intention-to-treat sustained virological response (SVR) rates (five studies) were 82%-92%, being 92% in the one study that included only PWAH. In the only two randomised controlled trials (RCT) identified, community-based interventions (mental health/peer mentor) significantly increased linkage to care (p=0.04), HCV treatment (p=0.005) and SVR rates (p=0.018).

Conclusion: The burden from alcohol/IDU and HCV, and consequently liver disease in PWAH needs addressing. RCT trials assessing community-based interventions to improve liver health in PWAH are needed.

Context
Palliative care remains suboptimal in end-stage liver disease (ESLD).

Objectives
We report qualitative outcomes from the REDUCe study. We aimed to explore and contrast experiences/perceptions/care pathways of patients with refractory ascites due to ESLD randomised to either palliative long-term abdominal drains (LTAD) (allows home drainage) versus large volume paracentesis LVP) (hospital drainage).

Methods
Concurrent embedded qualitative study in a 12-week feasibility randomised controlled trial. Telephone interviews were conducted, data being recorded, transcribed verbatim and analysed using applied thematic analysis, considered in terms of a pathway approach towards accessing healthcare. Quantitative outcomes were collected (IPOS, SFLDQoL, EQ-5D-5L, ZBI-12).

Results
Fourteen patients (six allocated LTAD and eight LVP) and eight nurses participated in the qualitative study. The patient journey in the LVP group could be hindered by challenges along the entire care pathway, from recognising the need for drainage to a lengthy wait in hospital for drainage and/or to be discharged. These issues also impacted upon caregivers. In contrast, LTADs appeared to transform this care pathway at all levels across the patient’s journey by removing the need for hospital drainage. Additional benefits included personalised care, improved symptom control of ascites, being at home and regular support from community nurses. Nurses also viewed the LTAD favourably though expressed the need for additional support should this become standard of care.

Conclusions
Patients and nurses expressed acceptability of palliative LTAD in ESLD and preference for this approach in enabling care at home. Proceeding to a definitive trial is feasible.

Background
Palliative care remains suboptimal in end‐stage liver disease.

Aim
To inform a definitive study, we assessed palliative long‐term abdominal drains in end‐stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison.

Methods
A 12‐week feasibility nonblinded randomised controlled trial comparing large‐volume paracentesis vs long‐term abdominal drains in refractory ascites due to end‐stage liver disease with fortnightly home visits for clinical/questionnaire‐based assessments. Study success criteria were attrition not >50%, <10% long‐term abdominal drain removal due to complications, the long‐term abdominal drain group to spend <50% ascites‐related study time in hospital vs large‐volume paracentesis group and 80% questionnaire/interview uptake/completion.

Results
Of 59 eligible patients, 36 (61%) were randomised, 17 to long‐term abdominal drain and 19 to large‐volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long‐term abdominal drain group vs large‐volume paracentesis group) were 0 (0‐1) vs 4 (3‐7); week 12 serum albumin (g/L) and serum creatinine (μmol/L) were 29 (26.5‐32.5) vs 30 (25‐35) and 104.5 (81‐115.5) vs 127 (63‐158) respectively. Total attrition was 42% (long‐term abdominal drain group 47%, large‐volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites‐related costs and percentage study time in hospital were lower in the long‐term abdominal drain group, £329 (253‐580) vs £843 (603‐1060) and 0% (0‐0.74) vs 2.75% (2.35‐3.84) respectively. Self‐limiting cellulitis/leakage occurred in 41% (7/17) in the long‐term abdominal drain group vs 11% (2/19) in the large‐volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long‐term abdominal drains could transform the care pathway.

Conclusions
The REDUCe study demonstrates feasibility with preliminary evidence of long‐term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation.

Objective ‘Sensible on Strength’ (SoS), a local public health initiative, is aimed at reducing high-strength beer and cider availability. The objective of this study was to assess its impact on local hospital admissions with alcohol-related liver disease (ALD) and on drinking behaviour.
Design This was a retrospective cohort study in patients admitted with decompensated ALD, 3 years before and 3 years after the introduction of the SoS initiative.
Hospital records of 143 index admissions with decompensated ALD were reviewed. Outcomes measures were the severity of liver disease on admission and mortality (inpatient and long-term), and change (if any) in alcohol drinking behaviour.
Results Comparing patients admitted in both phases, there were no significant differences in liver prognostic scores, liver-related complications, length of stay and inpatient/long-term mortality (p>0.05). However, the SoS initiative was associated with a 33% move away from beer and cider consumption (36.3% vs 54.0%; p=0.034), but without a significant change in units of alcohol consumed. The Model for End-stage Liver Disease (MELD) score was the only independent predictor of inpatient mortality (odds ratio 1.25; p=0.025).
Conclusion Despite having no apparent impact on the clinical spectrum of local ALD admissions, it is conceivable that longer follow-up is needed to determine the true impact of this initiative.

Background and aims
The incidence and mortality from end‐stage liver disease is increasing, with a minority eligible for liver transplantation. Ascites is the commonest complication of end‐stage liver disease and large volume paracentesis (LVP) the accepted management strategy where refractory to medical treatment. In malignant ascites, permanent indwelling peritoneal catheters (PIPC) are an established palliative intervention. The aims are to describe available data using permanent indwelling peritoneal catheters in refractory ascites due to end‐stage liver disease.

Methods
Using systematic review methodology, databases were searched (MEDLINE, EMBASE, CINAHL [The Cumulative Index to Nursing and Allied Health Literature], Google Scholar and Cochrane Database of Systematic Reviews from inception‐March 2018), for studies combining ascites and palliative care. Inclusion and exclusion criteria were applied to results.

Results
Following initial and updated searches, 225 studies were identified for full text review, 18 were eligible for final analysis. The studies displayed heterogeneity in design, reported on different indwelling catheters and were overall of low quality. Only one pilot randomised controlled trial was identified, of PIPC versus LVP, recruiting one patient into each arm. Technical insertion success was 100%, with low rates of non‐infectious complications (<12%), none life threatening. Rates of bacterial peritonitis were not unacceptably high (12.7%), considering this was an end‐stage liver disease population and only a minority utilising long‐term prophylactic antibiotics. Only one study attempted quality‐of‐life assessments; none addressed potential health economic benefits.

Conclusions
Despite lack of well‐designed studies, preliminary data suggests low significant complication rates; however safety and efficacy of permanent indwelling peritoneal catheters in end‐stage liver disease remains to be confirmed. Further prospective randomised controlled trials are warranted, potentially translating permanent indwelling peritoneal catheters into improved palliative care in end‐stage liver disease.

Liver disease is now the third most common cause of premature death in the UK, with chronic viral hepatitis being an important contributory factor. Often the diagnosis of chronic liver disease is only made when patients present late in the disease trajectory. This underscores the importance of near patient testing and linkage into care. The need for community based models for liver disease is in line with the recently commissioned National Liver report, which calls for assessment and treatment of high-risk individuals in the community.

In this manuscript our objectives are to discuss the need for community services for individuals with hepatitis C virus (HCV) infection and give an overview of the different community models for HCV. Finally we describe our experiences in setting up a successful nurse led service for screening, stratification and treatment of HCV related liver disease at a substance misuse service. We highlight the important stages of this process including engaging with stakeholders, obtaining funding and service set up. We also explore the obstacles and challenges faced and summarise our key recommendations. A brief summary of interim clinical outcomes is also presented.