Serum NGAL Is Superior to Cystatin C in Predicting the Prognosis of Acute-on-Chronic Liver Failure

Introduction and aim. Acute-on-chronic liver failure (ACLF) is a syndrome with high short-term mortality, and predicting the prognosis is challenging. This study aimed to compare the performance of neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C (CysC) in predicting the 90-day mortality in patients with hepatitis B virus (HBV)-associated ACLF (HBV-ACLF). Materials and methods. This prospective, observational study enrolled 54 patients with HBV-ACLF. The serum NGAL and CysC levels were determined. A multivariate logistic regression analysis was used to analyze the independent risk factors of mortality. Results. Serum NGAL, but not CysC, was found to significantly correlate with the total bilirubin, international normalized ratio, and model for end-stage liver disease (MELD). Serum NGAL [odds ratio (OR), 1.008; 95% confidence interval (CI), 1.004-1.012; P < 0.01], but not CysC, was an independent risk factor for developing hepatorenal syndrome. Moreover, NGAL (OR, 1.005; 95% CI, 1.001-1.010; P < 0.01) along with the MELD score was independently associated with the overall survival in patients with HBV-ACLF. Patients with HBV-ACLF were stratified into two groups according to the serum NGAL level at baseline (low risk: <217.11 ng/mL and high risk: ≥ 217.11 ng/mL). The 90-day mortality rate was 22.73% (5/22) in the low-risk group and 71.88% (23/32) in the high-risk group. Moreover, NGAL, but not CysC, significantly improved the MELD score in predicting the prognosis of HBV-ACLF. Conclusion. The serum NGAL might be superior to CysC in predicting the prognosis of HBV-ACLF with the normal creatinine level.     

MELD or MELD-Na as a Predictive Model for Mortality Following Transjugular Intrahepatic Portosystemic Shunt Placement

Background and AimThe model for end-stage liver disease (MELD) was originally developed to predict survival after transjugular intrahepatic portosystemic shunt (TIPS). The MELD-sodium (MELD-Na) score has replaced MELD for organ allocation for liver transplantation. However, there are limited studies to compare the MELD with MELD-Na to predict mortality after TIPS.MethodsWe performed a retrospective chart review of patients who underwent TIPS placement between 2006 and 2016 at our institution. The primary outcome was mortality, and the secondary outcomes sought to assess which variables could provide prognostic information for mortality after TIPS placement. We performed receiver operating characteristic (ROC) curve analysis to assess the performance of MELD and MELD-Na.ResultsThere were 186 eligible patients in the analysis. The mean pre-TIPS MELD and MELD-Na were 13 and 15, respectively. Overall, mortality after TIPS was 15% at 30 days and 16.7% at 90 days. In a comparison of the areas under the ROCs for MELD and MELD-Na, MELD was superior to MELD-Na for 30-day (0.762 vs. 0.709) and 90-day (0.780 vs. 0.730) mortality after TIPS. The optimal cutoff score for 30-day mortality was 15 (0.676–0.848) for MELD and 17 (0.610–0.808) for MELD-Na, whereas the optimal cutoff score for 90-day mortality was 16 (95% CI: 0.705–0.855) for MELD and 17 (95% CI: 0.643–0.817) for MELD-Na. There were 24 patients with high MELD-Na ≥17, but with low MELD <15, and 90-day mortality in this group was 8.3%.ConclusionsAlthough MELD-Na is a superior prognostic tool to MELD for predicting overall mortality in cirrhotic patients, MELD tended to outperform MELD-Na to predict mortality after TIPS.     

HBV相关慢加急性肝衰竭患者短期预后的影响因素分析

目的分析探究影响HBV相关慢加急性肝衰竭(HBV-ACLF)短期预后的危险因素。方法收集2009年1月—2019年12月西安交通大学第二附属医院收治的240例非肝移植HBV-ACLF患者的临床资料,按照入院后28 d和90 d存活情况进行分组(28 d:生存组164例,死亡组76例;90 d:生存组140例,死亡组100例)。收集患者发病诱因、肝功能指标、MELD评分、MELD-Na评分和出现的并发症等资料。计量资料用2组间比较采用Mann-Whithey U检验,计数资料2组间比较采用χ^2检验。根据ROC曲线,计算ROC曲线下面积(AUC),采用约登指数确定临界值,HBV-ACLF短期预后的危险因素分析采用logistic多因素回归分析。结果HBV-ACLF患者的诱因主要包括HBV自发激活(55.6%)、核苷类似物停药或耐药引起HBV激活(25.2%)等。依28 d存活情况分组,基线资料中年龄、PTA、NLR、血钠、MELD评分、MELD-Na评分、TBil水平2组间比较差异均有统计学意义(Z值分别为-2.400、-6.015、-5.070、-5.103、-5.044、-7.430、-6.637,P值均<0.05);依90 d生存情况分组,基线资料中年龄、PTA、NLR、血钠、MELD评分、MELD-Na评分、TBil、胆固醇水平2组间比较差异均有统计学意义(Z值分别为-2.205、-7.728、-3.335、-4.015、-6.053、-7.908、-6.655、-3.607,P值均<0.05)。logistic多因素回归分析显示,TBil>260.20 mmol/L、PTA<24.8%、NLR>5.63、血钠<130.8 mmol/L、MELD>17.84分、MELD-Na>25.1分是影响患者28 d生存的独立危险因素[OR(95%CI)分别为4.572(1.321~15.823)、8.934(3.026~26.374)、2.632(1.126~6.152)、27.467(6.113~123.423)、4.303(1.048~17.663)、3.453(1.614~7.387),P值均<0.05];TBil>260.20 mmol/L、PTA<25.5%、血钠<135.3 mmol/L、MELD>17.84分、MELD-Na>25.1分是影响患者90 d生存的独立危险因素[OR(95%CI)分别为5.148(1.918~13.822)、15.718(5.161~47.866)、10.080(3.244~31.323)、11.157(2.580~48.254)、4.391(2.057~9.372),P值均<0.05]。240例患者中160例(66.7%)90 d内发生感染,其中细菌感染140例、病毒感染12例,真菌感染8例。160例出现感染的患者其90 d病死率显著高于无感染的患者(46.3%vs 32.5%,χ^2=6.720,P=0.010)。240例患者中176例28 d内出现腹水,44例出现胸腔积液,36例发生急性肾损伤,60例发生肝性脑病,12例发生消化道出血,2组间急性肾损伤、Ⅲ~Ⅳ度肝性脑病、消化道出血所占比例比较差异均有统计学意义(χ^2值分别为64.088、29.811、7.797,P值均<0.05)。结论HBV-ACLF患者基线TBil、PTA、血钠、MELD评分、MELD-Na评分是影响患者28 d和90 d预后的独立危险因素。HBV激活引起的肝脏炎症坏死是ACLF的始动因素,而感染、急性肾损伤、肝性脑病和消化道出血是影响患者预后的主要的并发症。     

血清IL-8水平预测HBV相关慢加急性肝衰竭患者短期预后的临床研究

目的探讨血清IL-8水平用于评价HBV相关慢加急性肝衰竭(HBV related acute-on-chronic liver failure,HBVACLF)患者短期预后的临床价值。方法纳入2016年1月—2018年8月我院收住的HBV-ACLF患者110例,根据住院60 d内是否病死分为生存组(n=64)及病死组(n=46)。收集患者入院时临床资料并计算终末期肝病模型(model of endstage liver disease,MELD)评分,检测血清IL-8水平,使用ROC曲线分析血清IL-8水平用于评价患者短期预后的价值。结果病死组患者血清IL-8水平及MELD评分均显著高于生存组,差异有统计学意义(P均<0.05)。预测HBV-ACLF患者60 d病死情况时,IL-8的AUC为0.817,MELD评分的AUC为0.811,IL-8联合MELD评分预测60 d病死情况的AUC为0.841。入院时高IL-8水平(≥349.7 pg/ml)患者60 d总体生存率著低于低IL-8水平(<349.7 pg/ml)患者(36.4%vs.80.0%,Log-rank P<0.001)。结论血清IL-8水平作为评价HBV-ACLF患者短期预后指标具有较好的临床价值。     

Ohio solid organ transplantation consortium criteria for liver transplantation in patients with alcoholic liver disease

AIM To evaluate risk of recidivism on a case-by-case basis.METHODS From our center's liver transplant program,we selected patients with alcoholic liver disease who were listed for transplant based on Ohio Solid Organ Transplantation Consortium(OSOTC) exception criteria.They were considered to have either a low or medium risk of recidivism,and had at least one or three or more months of abstinence,respectively.They were matched based on gender,age,and Model for End-Stage Liver Disease(MELD) score to controls with alcohol-induced cirrhosis from Organ Procurement and Transplant Network data.RESULTS Thirty six patients with alcoholic liver disease were approved for listing based on OSOTC exception criteria and were matched to 72 controls.Nineteen patients(53%) with a median [Inter-quartile range(IQR)] MELD score of 24(13) received transplant and were followed for a median of 3.4 years.They were matched to 38 controls with a median(IQR) MELD score of 25(9).At one and five years,cumulative survival rates(± standard error) were 90% ± 7% and 92% ± 5% and 73% ± 12% and 77% ± 8% in patients and controls,respectively(Log-rank test,P = 0.837).Four(21%) patients resumed drinking by last follow-up visit.CONCLUSION Compared to traditional criteria for assessment of risk of recidivism,a careful selection process with more flexibility to evaluate eligibility on a case-by-case basis can lead to similar survival rates after transplantation.     

Older age is associated with increased early mortality after transjugular intrahepatic portosystemic shunt

Introduction & Aim. The role of age as a predictor of mortality after transjugular intra hepatic portosystemic shunt (TIPS) is controversial. Age has been found to be an important predictor of post-TIPS mortality in some, but not all, studies and is not a component of the MELD score. The purpose of this study was to compare the 90-day survival of subjects with cirrhosis age ≥ 70 years with younger subjects undergoing TIPS.Material and methods. A database of adult with cirrhosis undergoing TIPS from 2003-2011 was analyzed. The primary endpoint was survival 90-days post-TIPS. Survival was analyzed by the Kaplan-Meier method and proportional hazard modeling.Results. 539 subjects met study criteria. 474 (88%) were between the ages of 24-69 and 65 (12%) were age 70-89 years. The groups were similar with respect to the indication for TIPS, mean MELD score and distribution of MELD score. Survival 90-days post-TIPS was 60% in the older cohort compared with 85% in the younger cohort (p < 0.001). Proportional hazards modeling controlled for comorbidities identified age ≥ 70 and MELD score as predictors of early post-TIPS survival. The hazard ratio associated with age increased monotonically, became significant at age ≥ 70 years (HR 3.22; 95% CI 1.81-5.74; p < 0.001) and exceeded the effect of MELD on survival.Conclusions. Age ≥ 70 was associated with reduced survival within 90 days following TIPS. The findings from this study indicate that age is a relevant consideration in assessing the early mortality risk of TIPS.     

Novel Prognostic Models for Predicting the 180-day Outcome for Patients with Hepatitis-B Virus-related Acute-on-chronic Liver Failure

Background and AimsIt remains difficult to forecast the 180-day prognosis of patients with hepatitis B virus-acute-on-chronic liver failure (HBV-ACLF) using existing prognostic models. The present study aimed to derive novel-innovative models to enhance the predictive effectiveness of the 180-day mortality in HBV-ACLF.MethodsThe present cohort study examined 171 HBV-ACLF patients (non-survivors, n=62; survivors, n=109). The 27 retrospectively collected parameters included the basic demographic characteristics, clinical comorbidities, and laboratory values. Backward stepwise logistic regression (LR) and the classification and regression tree (CART) analysis were used to derive two predictive models. Meanwhile, a nomogram was created based on the LR analysis. The accuracy of the LR and CART model was detected through the area under the receiver operating characteristic curve (AUROC), compared with model of end-stage liver disease (MELD) scores.ResultsAmong 171 HBV-ACLF patients, the mean age was 45.17 years-old, and 11.7% of the patients were female. The LR model was constructed with six independent factors, which included age, total bilirubin, prothrombin activity, lymphocytes, monocytes and hepatic encephalopathy. The following seven variables were the prognostic factors for HBV-ACLF in the CART model: age, total bilirubin, prothrombin time, lymphocytes, neutrophils, monocytes, and blood urea nitrogen. The AUROC for the CART model (0.878) was similar to that for the LR model (0.878, p=0.898), and this exceeded that for the MELD scores (0.728, p<0.0001).ConclusionsThe LR and CART model are both superior to the MELD scores in predicting the 180-day mortality of patients with HBV-ACLF. Both the LR and CART model can be used as medical decision-making tools by clinicians.     

Hyperkalemia influences the outcome of patients with cirrhosis with acute decompensation (AD) and acute-on-chronic liver failure (ACLF)

IntroductionThe presence of hyperkalemia in different clinical scenarios has been described as a risk factor for mortality. Information about this electrolyte disorder in patients with cirrhosis is limited and there are no data in patients with acute-on-chronic liver failure (ACLF).AimThe aim of this study was to investigate whether hyperkalemia is a risk factor for mortality in patients with cirrhosis and acute decompensation (AD) with and without ACLF.MethodsWe performed an analysis of the Chronic Liver Failure Consortium CANONIC database in 1,314 consecutive patients admitted to 29 European centers with AD both with and without associated ACLF (294 and 1020 respectively). Hyperkalemia was defined as serum potassium ≥ 5.0 mEq/L. All patients had at least one valid measure of serum potassium from admission and/or through the whole hospitalization.Results1314 patients were admitted with AD and 294 of them had ACLF at admission. Prevalence of hyperkalemia was significantly higher in ACLF versus AD (22.4% and 8.6% respectively, p<0.001). Hyperkalemia was associated with an increased 90, 180 and 360-day mortality risk in ACLF compared to AD (HR 10 vs 2.3 at 90-day p<0.001, 8.9 vs 3.1 at 180-day, p<0.001 and 5.8 vs 3.8 at 360-day, p<0.001). In a multivariate analysis, the presence of hyperkalemia during admission was independently associated with 90-day mortality [HR 2.4 (1.7 – 3.4)]. Variability of potassium between two valid measures ≥ 0.9 mg/dl was always also associated with a higher mortality rate. Addition of hyperkalemia to MELD score (MELD-K model) improved the accuracy to predict 90-day mortality risk.ConclusionsHyperkalemia is an independent risk factor of mortality in patients with AD and ACLF. Addition of hyperkalemia to the MELD score improves diagnostic accuracy to predict 90-day mortality in patients with AD and ACLF.     

Long-Term Survival and Its Related Factors in Pediatric Liver Transplant Recipients of Shiraz Transplant Center,Shiraz, Iran in 2012

Background

Liver transplantation is considered as the standard treatment for both children and adults with end-stage liver diseases. Using this method, children who have no chance for life can live a much longer life .Shiraz Transplant Center is the major pediatric liver transplant center in Iran. Therefore, determining patients’ survival and its effective factors can help clinical programming for increasing such patients’ survival after liver transplantation.

Objectives

The present study aimed to investigate the survival of patients below-18-years-old undergoing liver transplantation and the factors affecting their survival.

Patients and Methods

The present historical cohort study was conducted on 392 patients below-18-year-sold who had undergone liver transplantation for the first time in the Namazi hospital liver transplant center, Shiraz, Iran between 2000 and 2011. In this study, 1-, 3-, 5-, and 10-year survival of the patients was assessed using Kaplan-Meier and life table methods. The effect of factors related to the recipients, donors, and the transplantation process on the patients’ survival was also investigated.

Results

According to the results, 1, 3, 5 and 10-year survival of patients was 73%, 67%, 66%, and 66%, respectively. Besides, 1 ,3, 5, and 10-year survival of the patients who survived 1 and 3 months after the transplantation was 84%, 78%, 77%, and 77% and 89%, 82%, 81%, and 81%, respectively. In the univariate analysis, age, patients’ weight at transplantation, initial diagnosis, PELD/MELD score, existence of post-transplant complications, and year of transplantation were found to be effective factors on the patients’ survival. In the multivariate analysis, only the type of graft, PELD/MELD score, and existence of post-transplant complications were the prognostic variables.

Conclusions

In this study, the patients’ survival rate was 73%, which is quite low compared to the survival rate reported in other studies. Although we only have a 12-year experience with pediatric liver transplantation, the survival rate has increased in our center through the recent years (2008-2011). However, the survival rate of the patients who had survived 3 months after the transplantation was 89% which is comparable to other studies. Overall, cholestatic diseases (biliary atresia was the most prevalent), type of transplantation (split), PELD/MELD score > 20, and existence of post-transplant complications increased the risk of death after the transplantation.     

Risk factors for mortality in patients with alcoholic hepatitis and assessment of prognostic models: A population-based study

BACKGROUND:

Severe alcoholic hepatitis (AH) is associated with a substantial risk for short-term mortality.

OBJECTIVES:

To identify prognostic factors and validate well-known prognostic models in a Canadian population of patients hospitalized for AH.

METHODS:

In the present retrospective study, patients hospitalized for AH in Calgary, Alberta, between January 2008 and August 2012 were included. Stepwise logistic regression models identified independent risk factors for 90-day mortality, and the discrimination of prognostic models (Model for End-stage Liver Disease [MELD] and Maddrey discriminant function [DF]) were examined using areas under the ROC curves.

RESULTS:

A total of 122 patients with AH were hospitalized during the study period; the median age was 49 years (interquartile range [IQR] 42 to 55 years) and 60% were men. Median MELD score and Maddrey DF on admission were 21 (IQR 18 to 24) and 45 (IQR 26 to 62), respectively. Seventy-three percent of patients received corticosteroids and/or pentoxifylline, and the 90-day mortality was 17%. Independent predictors of mortality included older age, female sex, international normalized ratio, MELD score and Maddrey DF (all P<0.05). For discrimination of 90-day mortality, the areas under the ROC curves of the prognostic models (MELD 0.64; Maddrey DF 0.68) were similar (P>0.05). At optimal cut-offs of ≥22 for MELD score and ≥37 for Maddrey DF, both models excluded death with high certainty (negative predictive values 90% and 96%, respectively).

CONCLUSIONS:

In patients hospitalized for AH, well-known prognostic models can be used to predict 90-day mortality, particularly to identify patients with a low risk for death.     

Model for end-stage liver disease underestimates mortality of patients with acute-on-chronic liver failure waiting for liver transplantation

Background and AimsPatients with acute-on-chronic liver failure (ACLF) show excess mortality in MELD-Na based organ allocation for liver transplantation (LT). Whether MELD-based allocation in the Eurotransplant region similarly underprioritizes ACLF patients is unknown.Methods428 patients listed for LT from 01/2010 to 02/2021 at a tertiary center in Germany were screened and 209 patients included as derivation (n = 123) and validation cohort (n = 86). Competing risk analysis for waitlist mortality and LT as competing events was performed.Results90-day waitlist mortality for patients with MELD < and ≥ 25 at baseline was 9% vs. 33%, respectively (p = 0.009). Competing risk analysis shows significantly higher 90-day waitlist mortality in patients listed with ACLF compared to those without ACLF (p = 0.021) in the low MELD stratum. Probability of LT was similar between the two groups (p = 0.91). In the high MELD group, 90-day waitlist mortality and rates of LT were not significantly different between patients with and without ACLF (31% vs. 20%, p = 0.55 and 59% vs. 60%, p = 0.72, respectively). Post-transplant survival was similar between patients with and without ACLF. This result was confirmed in the validation cohort.ConclusionMELD-based organ allocation in the Eurotransplant region underestimates waitlist mortality in patients with ACLF in lower MELD ranges.     

Risk Factors and Outcomes of Acute Kidney Injury in Patients With Hepatitis B Virus-Related Acute-on-Chronic Liver Failure

Background

Acute kidney injury (AKI) is common in patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF); however, few studies concerning the risk factors and recovery patterns of renal function have been published.

IL-32联合终末期肝病模型对HBV相关慢加急性肝衰竭患者预后的预测价值

目的探讨IL-32联合终末期肝病模型(MELD)对HBV相关慢加急性肝衰竭(HBV-ACLF)患者预后的预测价值。方法选取2015年1月-2018年12月在苏州大学附属第一医院住院的92例HBV-ACLF患者,根据确诊后3个月随访情况分为存活组(n=40)和死亡组(n=52)。采用酶联免疫吸附试验(ELISA)测定患者的血清IL-32水平。收集患者的临床资料,包括年龄、性别、合并基础疾病、主要并发症、WBC、PLT、红细胞比积(HCT)、TBil、ALT、AST、Alb、SCr、PT、INR、HBV DNA等。符合正态分布的计量资料2组间比较采用t检验,不符合正态分布的计量资料2组间比较采用Mann-Whitney U检验;计数资料2组间比较采用χ2检验;IL-32与其他变量进行Pearson相关性分析;采用二元logistic回归分析影响HBV-ACLF患者预后的独立危险因素;利用ROC曲线下面积(AUC)评价IL-32联合MELD评分对HBV-ACLF预后的预测价值,AUC的比较采用正态性Z检验。结果2组间HCT、PLT、TBil、SCr、PT、INR、HBV DNA、IL-32、MELD评分比较差异均有统计学意义(P值均<0.05);IL-32与TBil(r=0.952,P<0.001)、MELD评分(r=0.850,P<0.001)均呈显著正相关;IL-32(OR=1.137,95%CI:1.040~1.243,P=0.005)和MELD评分(OR=1.055,95%CI:1.001~1.109,P=0.025)是HBV-ACLF患者死亡的独立危险因素;IL-32联合MELD评分对HBV-ACLF患者预后的预测价值最高(AUC=0.992,95%CI:0.981~1.000),优于IL-32(AUC=0.984)和MELD评分(AUC=0.877),差异均具有统计学意义(Z值分别为2.265、3.182,P值均<0.05)。结论IL-32、MELD评分均能预测HBV-ACLF患者预后,两者联合则预测价值更高。     

抗病毒治疗对乙型肝炎病毒相关慢加急性肝衰竭患者预后的影响

目的 探讨影响乙型肝炎相关慢加急性肝衰竭( HBV - ACLF)患者90 d预后的因素及抗病毒治疗对HBV-ACLF患者90 d预后的影响.方法 回顾性分析2009年1月-2011年6月在我院住院治疗的HBV-ACLF患者112例,根据入组时是否采用抗病毒治疗分为非抗病毒治疗组54例和抗病毒治疗组58例.非抗病毒治疗组采用内科综合治疗,抗病毒治疗组在内科综合治疗基础上加用抗病毒药物治疗,比较两组患者临床特征、存活率、抗病毒治疗短期疗效及分析影响预后的因素.结果 治疗4周后,两组ALT均显著降低,胆碱酯酶(CHE)和HBV DNA转阴率提高(P＜0.05);治疗8周后,抗病毒治疗组TBil和MELD评分明显低于非抗病毒治疗组,而凝血酶原活动度(PTA)水平明显高于非抗病毒治疗组(P＜0.05).治疗90 d,抗病毒治疗组累积存活率明显高于非抗病毒治疗组(P=0.025).影响预后的独立危险因素为:HBeAg、肝性脑病、肝肾综合征、抗病毒治疗(P＜0.05).结论 抗病毒治疗可提高HBV-ACLF患者的90 d存活率,是HBV-ACLF内科治疗的有效方法之一;HBeAg阴性、肝性脑病、肝肾综合征也可降低HBV - ACLF患者的90 d存活率.     

Development and Validation of a Nomogram for 90-day Outcome in Patients with Hepatitis B Virus-related Acute-on-chronic Liver Failure

Background and AimsIt is challenging to predict the 90-day outcomes of patients infected with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) via prevailing predictive models. This study aimed to develop an innovative model to enhance the analytical efficacy of 90-day mortality in HBV-ACLF.MethodsIn this study, 149 HBV-ACLF patients were evaluated by constructing a death risk prediction nomogram. Bootstrap resampling and an independent validation cohort comprising 31 patients from June 2019 to February 2020 were assessed for model confirmation.ResultsThe nomogram was constructed by entering and identifying five factors (age, total bilirubin, prothrombin activity (PTA), lymphocyte (L)%, and monocyte (M)%. Healthy refinement was achieved from the nomogram analysis, where the area under the receiver operating characteristic curve was 0.864 for the training cohort and 0.874 was achieved for the validation cohort. There was admirable concordance between the predicted and true results in the equilibrium curve. The decision curve assessment revealed the useful clinical application of the nomogram.ConclusionsWe constructed an innovative nomogram and validated it for the prediction of 90-day HBV-ACLF patient outcomes. This model might help develop optimized treatment protocol recommendations for HBV-ACLF patients.     

Comparison of model for end-stage liver disease score with discriminant function and child-Turcotte-Pugh scores for predicting short-term mortality in Korean patients with alcoholic hepatitis]

BACKGROUND/AIMS: Alcoholic hepatitis is an acute or acute-on-chronic inflammatory syndrome associated with significant morbidity and mortality. Traditionally, Maddrey discriminant function (DF) score and Child-Turcott-Pugh (CTP) score have been used for stratifying the prognosis of alcoholic hepatitis. Recently, the model for end-stage liver disease (MELD) score has been applied to alcoholic hepatitis and some investigators consider MELD score as a better prognostic indicator for severe alcoholic hepatitis. Therefore, this analysis was aimed to compare MELD score with DF and CTP scores for predicting the short-term mortality in Korean patients with alcoholic hepatitis. METHODS: The medical records of patients hospitalized with alcoholic hepatitis between January 1, 1999 and December 31, 2004 at Hanyang University Guri-Hospital were analyzed retrospectively. RESULTS: Of the 138 medical records reviewed, 74 cases fulfilled the inclusion criteria (61 males and 13 females; mean age 47.1 years). Twelve patients (16.2%) died within 90 days after admission. Univariate analysis demonstrated that variables such as ascites, hepatic encephalopathy, splenomegaly, international normalized ratio, CTP, and DF scores were significantly correlated with increased 90-day mortality while MELD score was not. According to the multivariate analysis, only CTP score was statistically significant (p=0.012) while DF and MELD scores were not significant for predicting 90-day mortality. The survival analysis with Cox regression test showed higher DF and CTP scores, but not MELD score, significantly increased the risk of in-hospital mortality. CONCLUSIONS: This study demonstrates that DF and CTP scores are independent predictors of short-term mortality in patients with alcoholic hepatitis.     

The Effect of Tuberculosis on the Mortality of Cirrhotic Patients: A Population-Based 3-Year Follow-Up Study

Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium tuberculosis. It is still unknown if TB, like other infectious diseases contributes a poor prognosis in cirrhotic patients. The aim of this study was to investigate the impact of TB on the mortality of cirrhotic patients.National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify 434 cirrhotic patients with new diagnosis of TB between January 1, 2007 and December 31, 2007. The comparison group consisted of 4340 selected cirrhotic patients without TB in the same period by propensity score matching analysis.The 30-day, 90-day, 1-year and 3-year mortalities were 10.1%, 24.2%, 43.1%, and 63% in the TB group, and 7.9%, 15.5%, 31.2%, and 53.4% in the non-TB group. After Cox proportional hazard regression model adjusted by the patients’ gender, age, and comorbid disorders, the hazard ratios (HR) in cirrhotic patients with TB for 30-day, 30 to 90-day, 90-day to 1-year, and 1 to 3-year mortalities were 1.33 [95% confidence interval (CI) 0.97–1.83], 1.91 (95% CI 1.45–2.51), 1.46 (95% CI 1.16–1.84), and 1.10 (95% CI 0.88–1.37), compared to the non-TB group.In conclusion, TB is a risk factor for the mortality of cirrhotic patients. The effect focused on the 30-day to 1-year after diagnosis of TB.     

Delta MELD as a predictor of early outcome in adult-to-adult living donor liver transplantation

Background/AimsAn increased post-operative mortality risk has been reported among patients who undergo living donor liver transplantation (LDLT) with higher model for end-stage liver disease (MELD) scores. In this study, we investigated the effect of MELD score reduction on post-operative outcomes in patients with a high MELD (≥20) score by pre-transplant management.Materials and MethodsWe retrospectively analyzed 386 LDLT cases, and patients were divided into low-MELD (<20, n=293) vs. high-MELD (≥20, n=93) groups according to their MELD score at the time of index hospitalization. Patients in the high-MELD group were managed specifically according to a treatment algorithm in an effort to decrease the MELD score. Patients in the high-MELD group were further divided into 2 subgroups: (1) responders (n=34) to pre-transplant treatment with subsequent reduction of the MELD score by a minimum of 1 point vs. (2) non-responders (n=59), whose MELD score remained unchanged or further increased on the day of LDLT. Responders vs. non-responders were compared according to etiology, demographics, and survival.     

Cryptococcosis in patients with liver cirrhosis: Death risk factors and predictive value of prognostic models

BackgroundLiver cirrhosis is associated with immune deficiency, which causes these patients to be susceptible to various infections, including cryptococcus infection. Mortality in cirrhotic patients with cryptococcosis has increased. The present study was to explore the risk factors of mortality and the predictive ability of different prognostic models.MethodsForty-seven cirrhotic patients with cryptococcosis at a tertiary care hospital were included in this retrospective study. Data on demographics, clinical parameters, laboratory exams, diagnostic methods, medication during hospitalization, severity scores and prognosis were collected and analyzed. Student's t test and Mann-Whitney test were used to compare characteristics of survivors and non-survivors at a 90-day follow-up and cerebrospinal fluid (CSF) manifestations of cryptococcal meningitis. Multivariate Cox regression analysis was used to identify the independent risk factors for mortality. Kaplan-Meier curves were used to analyze patient survival. Receiver operating characteristic (ROC) curves were used to evaluate the different prognostic factors.ResultsThe 30- and 90-day survival rates were 93.6% and 80.9%, respectively, in cirrhotic patients with cryptococcosis. Cryptogenic liver diseases [hazard ratio (HR) = 7.567, 95% confidence interval (CI): 1.616-35.428, P = 0.010], activated partial thromboplastin time (APTT) (HR = 1.117, 95% CI: 1.016-1.229, P = 0.022) and Child-Pugh score (HR = 2.146, 95% CI: 1.314-3.504, P = 0.002) were risk factors for 90-day mortality in cirrhotic patients with cryptococcosis. Platelet count (HR = 0.965, 95% CI: 0.940-0.991, P = 0.008) was a protective factor. APTT (HR = 1.120, 95% CI: 1.044-1.202, P = 0.002) and Child-Pugh score (HR = 1.637, 95% CI: 1.086-2.469, P = 0.019) were risk factors for 90-day mortality in cirrhotic patients with cryptococcal meningitis. There was significant difference in the percentage of lymphocytes in CSF between survivors and non-survivors [60.0 (35.0-75.0) vs. 95.0 (83.8-97.2), P < 0.001]. The model of end-stage liver disease-sodium (MELD-Na) score was more accurate for predicting 30-day mortality both in patients with cryptococcosis [area under curve (AUC): 0.826, 95% CI: 0.618-1.000] and those with cryptococcal meningitis (AUC: 0.742, 95% CI: 0.560-0.924); Child-Pugh score was more useful for predicting 90-day mortality in patients with cryptococcosis (AUC: 0.823, 95% CI: 0.646-1.000) and those with cryptococcal meningitis (AUC: 0.815, 95% CI: 0.670-0.960).ConclusionsThese results showed that cryptogenic liver diseases, APTT and Child-Pugh score were associated with mortality in cirrhotic patients with cryptococcosis and cryptococcal meningitis. MELD-Na score was important for predicting 30-day mortality, and Child-Pugh score was critical for predicting 90-day mortality.     

血清胱抑素C联合总胆红素对慢加急性肝衰竭患者短期预后的预测价值

目的探讨血清胱抑素C(CysC)联合总胆红素(TBil)对乙型肝炎相关慢加急性肝衰竭(HBV-ACLF)患者短期预后的预测价值。方法入选2012年1月至2016年1月在西京消化病医院住院且资料完整的HBV-ACLF患者,统计患者入院24 h内的一般资料、各项临床检测指标、Child-Turcotte-Pugh评分(CTP评分)、终末期肝病模型评分(MELD评分),所有患者均随访90 d,根据转归分为生存组和死亡组,Logistic多因素回归分析影响患者预后的独立危险因素。结果 162例患者中死亡78例,血清CysC、TBil是影响HBV-ACLF患者生存的独立危险因素。血清CysC与血肌酐(Cr)、MELD评分呈正相关,Spearman相关系数分别为0.400、0.416,均P0.01。联合血清CysC与TBil组成的预后模型(PM)的ROC曲线下面积(AUC)为0.833,其早期预测HBV-ACLF患者90 d死亡与否的价值高于CTP评分、MELD评分(P0.05)。高危组(PM≥3.07)90 d生存率为23.8%,低危组(PM3.07)为79.3%(P0.01)。结论血清CysC联合TBil建立的预后模型是一个简单易用的评分模型,且对HBV-ACLF患者90 d病死率的预测作用优于CTP和MELD评分。