Long-term survival and clinical outcomes following direct-acting antiviral (DAA) treatment in HCV decompensated cirrhosis in Brazil: a real-world study

IntroductionThe outcomes regarding portal hypertension-related complications and infections after HCV cure in decompensated cirrhosis are scarcely reported. We aimed to identify the predictors of survival and to evaluate the frequency of decompensation events of cirrhosis, including hepatocellular carcinoma (HCC), portal hypertension complications and infections in a cohort of decompensated cirrhotic with sustained virological response (SVR) in a real-world scenario.Patients and methodsThis was a prospective study in consecutive HCV-infected patients with decompensated cirrhosis who achieved SVR after direct-acting antiviral (DAA) treatment. At baseline, clinical and laboratory data were recorded. Patients were followed until development of outcomes regarding further decompensation, death, or liver transplant. A Cox-regression analysis was performed and survival curves were constructed using the Kaplan Mayer method.ResultsOne hundred and thirty patients (age 60 ± 9 years, 64% female, 70% genotype 1) were included and followed-up through three years. SVR was associated with a lower prevalence of ascites and an improvement in Child-Pugh and MELD scores. One and three-year probability of transplant-free survival was 93% and 66%, respectively. Variables related to three-years survival were MELD < 11 (HR 1.24, 95% CI 1.13-1.37) and absence of ascites (HR 2.03, 95% CI 0.99-4.13) after the end of treatment (91% versus 37% in patients with ascites and a higher MELD, p < 0.001).ConclusionsDecompensated cirrhotics with SVR and a low MELD without ascites have an excellent long-term prognosis. On the contrary, those with higher MELD and ascites have a low probability of survival even in the short term and might be evaluated for liver transplantation.     

Longitudinal assessment of prognostic factors for patients with hepatorenal syndrome in a tertiary center

Introduction  

Hepatorenal syndrome (HRS) is one of the serious complications in patients with advanced cirrhosis and ascites. In tertiary centers, most patients were classified as having type 1 HRS for their rapid progressive diseases. However, no significant predictors have been assessed previously for patients with type 1 HRS. In addition to the initial model of end-stage liver disease (MELD) scores and biochemistry parameters, we want to further investigate the prognostic importance of changes in MELD scores and biochemistry parameters over time for patients with type 1 HRS.     

Relative adrenal insufficiency in the non-critically ill patient with cirrhosis: A systematic review and meta-analysis

Background & Aims

Characterization of relative adrenal insufficiency (RAI) in cirrhosis is heterogeneous with regard to studied patient populations and diagnostic methodology. We aimed to describe the prevalence and prognostic importance of RAI in non-critically ill patients with cirrhosis.

Methods

A systematic review and meta-analysis was performed using MeSH terms and Boolean operators to search five large databases (Ovid-MEDLINE, ScienceDirect, Web of Science, Cochrane Library and ClinicalTrials.gov ). The population of interest was patients with cirrhosis and without critical illness. The primary outcome was the pooled prevalence of RAI as defined by a peak total cortisol level <18 μg/dl, delta total cortisol <9 μg/dl or composite of the two thresholds in response either a standard-dose or low-dose short synacthen test. Odds ratios and standardized mean differences from random-effects models estimated important clinical outcomes and patient characteristics by adrenal functional status.

Results

Twenty-two studies were included in final analysis, comprising 1991 patients with cirrhosis. The pooled prevalence of RAI was 37% (95% CI 33–42%). The prevalence of RAI varied by Child–Pugh classification, type of stimulation test used, specific diagnostic threshold and by severity of illness. Ninety-day mortality was significantly higher in patients with RAI (OR 2.88, 95% CI 1.69–4.92, I2 = 15%, p < 0.001).

Conclusions

Relative adrenal insufficiency is highly prevalent in non-critically ill patients with cirrhosis and associated with increased mortality. Despite the proposed multifactorial pathogenesis, no studies to date have investigated therapeutic interventions in this specific population.     

Algorithm for Screening of Adrenal Function in Stable Patients with Cirrhosis

Introduction and aimsAdrenal insufficiency (AI) is common in patients with cirrhosis. We aimed to assess the presence of AI in stable patients with cirrhosis using the gold-standard insulin tolerance test (ITT) and to propose an algorithm for screening AI in these patients.Material and methodsWe studied 40 stable patients with cirrhosis. We determined the basal total (BTC) and peak cortisol (PTC) levels. Using the ITT, we defined AI as a serum PTC < 18 ng/dL at 30 min after insulin-induced hypoglycemia. We assessed the diagnostic accuracy of BTC in different stages of liver disease to discriminate between those with NAF and AI.ResultsOf the 40 patients, 24 (60%) presented with AI. Child-Pugh and MELD scores differed between the NAF and AI groups (Child-Pugh: NAF 7.2 ± 1.7 vs. AI 8.8 ± 2.4, p = 0.024 and MELD: NAF 9.9 ± 2.5 vs. AI 14.9 ± 6.3, p = 0.001). The BTC level was lower in patients with AI than in those with NAF (7.2 ± 2.4 vs. 12.5 ± 5.2, p < 0.001). A BTC value <10.0 |ig/dL had a 96% sensitivity (negative predictive value: 90%) for identifying AI. This cutoff value (BTC <10.0 |ig/dL) provided 100% specificity (positive predictive value: 100%) in patients with advanced liver disease (Child-Pugh >9 or MELD >12).ConclusionAn algorithm including the use of BTC and the severity of liver disease may be a useful and simple method for assessing adrenal function in stable patients with cirrhosis.     

Evaluation of the increase in model for end-stage liver disease (DeltaMELD) score over time as a prognostic predictor in patients with advanced cirrhosis: risk factor analysis and comparison with initial MELD and Child-Turcotte-Pugh score

BACKGROUND/AIMS: The model for end-stage liver disease (MELD) has been used to prioritize cirrhotic patients awaiting liver transplantation. The change in MELD score over time (DeltaMELD) may have additional prognostic value. We investigated the ability of DeltaMELD to predict the outcome of advanced cirrhosis and prospectively assessed the factors associated with increasing DeltaMELD. METHODS: Risk factors were determined in 58 prospectively followed-up patients. The predictive power of DeltaMELD, initial MELD and Child-Turcotte-Pugh (CTP) score was compared by using c-statistic in 351 patients. RESULTS: Ascites (P=0.020) and hepatic encephalopathy (P=0.023) were significantly associated with increasing MELD score at 3 months. The area under receiver operating characteristic (ROC) curve for DeltaMELD/month was 0.779 compared with 0.718 for MELD (P=0.130) and 0.528 for CTP score (P<0.001) at 6 months; the area was 0.822, 0.744 and 0.528, respectively (P=0.018 and <0.001, respectively) at 12 months. DeltaMELD/month >2.5 was the only significant prognostic predictor at 6 (odds ratio: 9.8, P<0.001) and 12 months (odds ratio: 16.3, P<0.001) in multivariate logistic analysis. CONCLUSIONS: Increasing MELD score is associated with the onset of ascites and encephalopathy. DeltaMELD is superior to initial MELD and CTP scores to predict intermediate term outcome in patients with advanced cirrhosis.     

Serum zonulin levels in patients with liver cirrhosis: Prognostic implications

BACKGROUND Increased gut permeability and bacterial translocation play an important role in liver cirrhosis. Zonulin is a recently recognized protein involved in the disintegration of the intestinal barrier.AIM To investigate possible differences in serum zonulin levels among patients with different cirrhosis stages and their potential prognostic implications.METHODS Consecutive cirrhotic patients who attended our liver clinic were included in the study. Serum zonulin levels, clinical, radiological and biochemical data were collected at baseline. Patients who accepted participation in a regular surveillance program were followed-up for at least 12 mo.RESULTS We enrolled 116 cirrhotics [mean Child-Turcotte-Pugh(CTP) score: 6.2 ± 1.6;model for end-stage liver disease score: 11 ± 3.9]. The causes of cirrhosis were viral hepatitis(39%), alcohol(30%), non-alcoholic fatty liver disease(17%), and other(14%). At baseline, 53% had decompensated cirrhosis, 48% had ascites, and 32% had history of hepatic encephalopathy. Mean zonulin levels were significantly higher in patients with CTP-B class than CTP-A class(4.2 ± 2.4 ng/dL vs 3.5 ± 0.9 ng/dL, P = 0.038), with than without ascites(P = 0.006), and with than without history of encephalopathy(P = 0.011). Baseline serum zonulin levels were independently associated with the probability of decompensation at 1 year(P = 0.039), with an area under the receiving operating characteristic of 0.723 for predicting hepatic decompensation. Higher CTP score(P = 0.021) and portal vein diameter(P = 0.022) were independent predictors of mortality.CONCLUSION Serum zonulin levels are higher in patients with more advanced chronic liver disease and have significant prognostic value in identifying patients who will develop decompensation.     

Model for end‐stage liver disease,model for end‐stage liver disease‐sodium and Child–Turcotte–Pugh scores over time for the prediction of complications of liver cirrhosis

Background/Aims: There has been no report concerning the predictive capability of each scoring system in determining the development of complications of liver cirrhosis such as variceal bleeding and/or hepatic encephalopathy. Methods: We retrospectively studied 128 patients with liver cirrhosis [92 males; mean (standard deviation) 54.2 (11.2) years] admitted to our institution from March 2004 to April 2006. Seventy‐three patients (57.0%, group 1) were admitted because of complications of cirrhosis and 55 patients (43.0%, group 2) were admitted for causes unrelated to complications of cirrhosis. We calculated values for model for end‐stage liver disease (MELD), MELD‐sodium (MELD‐Na) and Child–Turcotte–Pugh (CTP) scores on admission and at 3 and 6 months before admission. Each delta score was defined as the difference in the scores of 3 and 6 months before admission. Results: The relative risk for complications in the patients with ΔMELD/3 months ≥1.35, ΔMELD‐Na/3 months ≥1.35 and ΔCTP/3 months ≥1 was 2.05 [95% confidence intervals (CI) 1.47–2.85, P<0.01], 2.04 (95% CI 1.45–2.88, P<0.01) and 1.98 (95% CI 1.39–2.81, P<0.01) respectively. The area under the receiver‐operating characteristic curves of ΔMELD/3 months, ΔMELD‐Na/3 months and ΔCTP/3 months for the occurrence of cirrhotic complications were 0.691, 0.694 and 0.722 respectively. A higher ΔMELD/3 months (≥1.35), ΔMELD‐Na/3 months (≥1.35) and ΔCTP/3 months (≥1) was associated with decreased survival. Conclusions: Delta model for end‐stage liver disease/3 months, ΔMELD‐Na/3 months and ΔCTP/3 months were clinically useful parameters for predicting the occurrence of cirrhotic complications.     

Development and validation of a prognostic model for patients with hepatorenal syndrome: A retrospective cohort study

BACKGROUNDHepatorenal syndrome (HRS) is a severe complication of cirrhosis with high mortality, which necessitates accurate clinical decision. However, studies on prognostic factors and scoring systems to predict overall survival of HRS are not enough. Meanwhile, a multicenter cohort study with a long span of time could be more convincing.AIMTo develop a novel and effective prognostic model for patients with HRS and clarify new prognostic factors. METHODSWe retrospectively enrolled 1667 patients from four hospitals, and 371 eligible patients were finally analyzed to develop and validate a novel prognostic model for patients with HRS. Characteristics were compared between survivors and non-survivors, and potential prognostic factors were selected according to the impact on 28-d mortality. Accuracy in predicting 28-d mortality was compared between the novel and other scoring systems, including Model for End-Stage Liver Disease (MELD), Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and Chinese Group on the Study of Severe Hepatitis B-Acute-on-Chronic Liver Failure (COSSH-ACLF). RESULTSFive prognostic factors, comprised of gender, international normalized ratio, mean corpuscular hemoglobin concentration, neutrophil percentage, and stage, were integrated into a new score, GIMNS; stage is a binary variable defined by the number of failed organs. GIMNS was positively correlated with MELD, CLIF-SOFA, and COSSH-ACLF. Additionally, it had better accuracy [area under the receiver operating characteristic curve (AUROC): 0.830] than MELD (AUROC: 0.759), CLIF-SOFA (AUROC: 0.767), and COSSH-ACLF (AUROC: 0.759) in the derivation cohort (P < 0.05). It performed better than MELD and CLIF-SOFA in the validation cohort (P < 0.050) and had a higher AUROC than COSSH-ACLF (P = 0.122).CONCLUSIONWe have developed a new scoring system, GIMNS, to predict 28-d mortality of HRS patients. Mean corpuscular hemoglobin concentration and stage were first proposed and found to be related to the mortality of HRS. Additionally, the GIMNS score showed better accuracy than MELD and CLIF-SOFA, and the AUROC was higher than that of COSSH-ACLF.     

The value of model for end-stage liver disease and Child–Turcotte–Pugh scores over time in evaluating the prognosis of patients with decompensated cirrhosis: experience in the Chinese mainland

Aim:  In addition to the model for end-stage liver disease (MELD) and Child–Turcotte–Pugh (CTP) score, the change in MELD score (ΔMELD) and CTP (ΔCTP) over time, as well as the modified CTP score, have been proposed as predictive factors for patients with advanced liver cirrhosis. We investigated the ability of the above scoring systems to predict the outcome of decompensated cirrhosis in the Chinese mainland.
Methods:  A cohort of 160 patients with advanced liver cirrhosis who were followed up were studied prospectively. Kaplan–Meier survival analysis was used to evaluate 3-month survival in categories ranked by MELD and ΔMELD, CTP, ΔCTP and modified CTP score respectively. The area under receiver operator characteristics curve (AUC) was used to determine the predictive abilities of these models for 3-month mortality. A multivariate logistic regression method was used to determine the factors associated with mortality.
Results:  Forty-five patients (28%) died within 3 months. The AUC of the ΔMELD (0.901) was significantly higher than that of the MELD score (0.828) and the CTP score (0.605) ( P  < 0.01). The differences remained significant between the AUC of the ΔCTP and CTP score, modified CTP and CTP ( P  < 0.01). The AUC of ΔCTP, modified CTP and MELD were not different from each other ( P  > 0.05). In multivariate analysis, MELD, CTP scores, ΔMELD, ΔCTP and modified CTP were independent predictors of 3-month mortality.
Conclusions:  ΔMELD, ΔCTP and modified CTP were clinically useful parameters for short-term prognostication of patients with decompensated cirrhosis.     

Applicability of MELD as a short-term prognostic indicator in patients with chronic liver disease: an Indian experience

Background: The model for end‐stage liver disease (MELD), which employs objective variables, statistical weighting and a continuous scale, has replaced the Child–Turcotte–Pugh (CTP) classification as the scoring system of choice in several liver transplant centers. However, the predictive ability of MELD has never been prospectively evaluated in India. The aim of this study was to examine the MELD score, the CTP score and the recently proposed modified CTP score in Indian patients with liver cirrhosis to determine their correlation and compare their prognostic significance for short‐term survival. Methods: A total of 76 patients with cirrhosis (mean age 46.97 years) were prospectively evaluated and followed up for 6 months. MELD score, CTP score and modified CTP score were calculated at baseline. The correlation between variables was evaluated by Pearson's correlation test. Receiver‐operating characteristic (ROC) curves were used to determine the cutoff values for each score with the best sensitivity and specificity in discriminating between patients who survived and those who died. Results: Alcoholic liver disease was the most common (50%) etiology of cirrhosis. MELD score and CTP score showed very good correlation (Pearson correlation r = 0.983). ROC curve showed area under curve (c‐statistics) for MELD score, CTP score and modified CTP score as 0.764, 0.804 and 0.817, respectively. Conclusion: The MELD score was not found to be superior to CTP score and modified CTP score for short‐term prognostication of patients with cirrhosis in this study.     

MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation

Important progress has been made recently regarding the pathogenesis and treatment of hepatorenal syndrome (HRS). However, scant information exists about factors predicting outcome in patients with cirrhosis and HRS. Moreover, the prognostic value of the model of end-stage liver disease (MELD) score has not been validated in the setting of HRS. The current study was designed to assess the prognostic factors and outcome of patients with cirrhosis and HRS. The study included 105 consecutive patients with HRS. Forty-one patients had type 1 HRS, while 64 patients had type 2 HRS. Patients with type 1 HRS not only had more severe liver and renal failure than type 2 patients, they also had greater impairment of circulatory function, as indicated by lower arterial pressure and higher activation of vasoconstrictor factors. In the whole series, the median survival was 3.3 months. In a multivariate analysis of survival, only HRS type and MELD score were associated with an independent prognostic value. All patients with type 1 HRS had a high MELD score (> or =20) and showed an extremely poor outcome (median survival: 1 mo). By contrast, the survival of patients with type 2 HRS was longer and dependent on MELD score (> or =20, median survival 3 mo; <20, median survival 11 mo; P < .002). In conclusion, the outcome of patients with cirrhosis and HRS can be estimated by using two easily available variables, HRS type and MELD score. These data can be useful in the management of patients with HRS, particularly for patients who are candidates for liver transplantation.     

Prevalence of Septic Events, Type 1 Hepatorenal Syndrome, and Mortality in Severe Alcoholic Hepatitis and Utility of Discriminant Function and MELD Score in Predicting These Adverse Events

We sought to assess prevalence, and utility of discriminant function (DF) and MELD score in predicting septic events (SE), type 1 hepatorenal syndrome (HRS), and short-term mortality in severe alcoholic hepatitis (AH). Charts of patients with AH (group 1) and cirrhosis without AH (group 2) were retrospectively reviewed. Severe AH, discriminant function (DF) ≥ 32 was treated with pentoxifylline. One hundred ninety-five patients were enrolled in the study and divided into 2 groups: group 1, n=99, and group 2, n=96. Of those with AH, 82% had a DF ≥ 32 at presentation. Group 1 patients had a higher prevalence of SE (38% versus 25%, P=.04), type 1 HRS (30% versus 9%, P=.0003), and short-term mortality (28% versus 7%, P=.0001). In patients with AH, a MELD score ≥20 (but not a DF ≥ 32) at presentation was an independent predictor of a SE (odds ratio [OR] 2.8 [1.0–7.9], P=.04), HRS (OR 4.0, 95% confidence interval [CI] 1.0–16.6, P=0.05), and short-term mortality (OR 6.4, 95% CI 1.1–37.6, P=.03). Kaplan-Meier survival curves confirmed that that a MELD ≥ 20 but not a DF ≥ 32 was associated with a poorer survival (P = .005 and .5, respectively). In conclusion, patients with severe AH have higher prevalence of SE, HRS, and short-term mortality compared to those with cirrhosis without AH. A MELD score ≥20 at presentation is an independent predictor of these adverse events in patients with AH who have been treated with pentoxifylline.     

Different scoring systems to predict 6-week mortality in cirrhosis patients with acute variceal bleeding: a retrospective analysis of 202 patients

Objective: Determine the optimal scoring system for evaluation of 6-week bleeding-related mortality in liver cirrhosis patients with acute variceal bleeding (AVB). Prediction effects of six scoring systems, AIMS65 score, Glasgow-Blatchford (GBS) score, full Rockall (FRS) score, the model for end-stage liver disease (MELD), the MELD-Na model and the Child-Turcotte-Pugh (CTP) score were analyzed in this study.

Methods: A total of 202 liver cirrhosis patients with AVB were enrolled between 1 January 2014, and 31 December 2014. All subjects were scored according to AIMS65, GBS, FRS, MELD, MELD-Na and CTP scoring systems on the first day of admission. The primary endpoint of the study was 6-week mortality. The prediction effect of these scoring systems for 6-week mortality was compared by ROC curve and the area under the curve (AUC).

Results: The scores of nonsurvival group evaluated by the AIMS65, GBS, FRS, MELD, MELD-Na and CTP (2.6?±?1.1, 12.9?±?2.7, 6.6?±?1.8, 26.9?±?6.5, 31.6?±?9.3, 9.6?±?2.2, respectively) were higher than those of the survival group (1.2?±?1.1, 10.2?±?3.4, 5.1?±?1.6, 21.0?±?6.4, 22.8?±?8.2, 7.7?±?2.0, respectively) (p?Conclusions: AIMS65 and MELD-Na scoring systems are recommended for evaluation of 6-week bleeding-related mortality in liver cirrhosis patients with AVB.     

miR-122在肝脏疾病调控中的作用研究进展

miRNA-122是MicroRNAs家族的一员,其在肝脏中高度特异性表达,参与肝脏的发育分化、基因表达调控和功能代谢,并与丙型肝炎病毒感染与肝癌的发生发展等密切相关。本文重点介绍miRNA-122在肝脏疾病调控中的作用研究进展。     

Serum cholesterol predicts transplant-free survival in cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt

BackgroundMalnutrition is frequent in patients with cirrhosis and has been associated with poor prognosis. The Model for End-stage Liver Disease (MELD) score was created to predict survival after Transjugular Intrahepatic Porto-systemic Shunt (TIPS) but lacks a nutritional parameter.AimsTo evaluate the prognostic value of serum cholesterol in patients with cirrhosis undergoing TIPS and to develop a prognostic score to predict survival.MethodsAn explorative cross-sectional study was conducted of cirrhotic patients undergoing TIPS from 2008 until 2019. Exclusion criteria were liver transplantation or hepatocellular carcinoma before TIPS. Risk analysis was used to compare survival according to clinical and analytical data. The diagnostic performance of serum cholesterol added to MELD was evaluated and confirmed in an external validation cohort.ResultsThe final cohort of 100 patients had a mean MELD score of 14±5 and cholesterol of 122±51 mg/dL. MELD (p < 0,05) and both cholesterol (p < 0,05) and low-density lipoprotein levels (LDL-C) (p < 0,05) were independent predictors of post-TIPS transplant-free survival with an optimal cut-off of 106 mg/dL for serum cholesterol. The combined MELD-cholesterol risk score improved diagnostic accuracy of each parameter separately, and this was confirmed in the external cohort.ConclusionSerum cholesterol and LDL-C are independent predictors of transplant-free survival in cirrhotic patients undergoing TIPS. The MELD-cholesterol score slightly improved prognostic accuracy.Lay SummaryAs an objective and easily measured indicator of both nutritional status and hepatic function, serum cholesterol could be useful to predict transplant-free survival in patients with cirrhosis undergoing TIPS. It can enable health care providers to identify high-risk patients and to optimize nutritional status before TIPS.     

Clinical course and prognostic factors of hepatorenal syndrome: A retrospective single-center cohort study

AIM: To investigate clinical and biochemical features of hepatorenal syndrome (HRS), to assess short and long-term survival evaluating potential predictors of early mortality.METHODS: Sixty-two patients with liver cirrhosis and renal failure, defined as a serum creatinine value > 1.5 mg/dL on at least two measurements within 48 h, admitted to our tertiary referral Unit from 2001 to 201, were retrospectively reviewed. Among them, 33 patients (53.2%) fulfilled the revised criteria of the International Ascites Club for the diagnosis of HRS. Twenty-eight patients were treated with combinations of terlipressin and albumin, two with dopamine and albumin, and three with albumin alone. No patients were suitable for liver transplantation. Complete response was defined as normalization of creatinine levels to less than 1.5 mg/dL, partial response as a decrease of at least 50% but not to less than 1.5 mg/dL, no response as no reduction in creatinine or a decrease of less 50% compared to pre-treatment values. All of the patients were followed up for at least 1 year until January 2013.RESULTS: HRS type 1 was diagnosed in 15 patients (45.5%). Hepatitis C virus infection was the primary etiology (69.6%), followed by alcohol (15.2%), and cryptogenesis (15.2%). Complete response to therapy was obtained in only 3 cases (9.1%) and partial response in 7 patients (21.2%). Median survival was 30 d (range: 10-274) without significant differences between type 1 and type 2 HRS. By univariate analysis, Child-Pugh class C (P = 0.009), presence of hepatocellular carcinoma (P = 0.04), low serum sodium (P = 0.02), high bilirubin values (P = 0.009) and high Model for End-stage Liver Disease (MELD) score (P = 0.03) were predictive factors of 30-d mortality. By multivariate analysis, only serum sodium < 132 mEq/L (OR = 31.39; P = 0.02) and MELD score > 27 (OR = 18.72; P = 0.01) were independently associated with a survival of less than one month.CONCLUSION: HRS still has a poor prognosis, even when vasoactive drug therapies are extensively used.     

Prognostic factors for patients with cirrhosis and kidney dysfunction in the era of MELD: results of a prospective study.

BACKGROUND/AIM: Hepatorenal syndrome (HRS) is associated with a poor prognosis. The incidence and prognostic impact of kidney dysfunction due to other causes in cirrhotic patients are less well known. The current study prospectively evaluated the incidence and the prognostic relevance of different etiologies of kidney failure in cirrhotic patients. METHODS: Eighty-eight consecutive patients with cirrhosis and serum creatinine > or =1.5 mg/dl were enrolled. The etiologies of kidney dysfunction were analyzed, and prognostic factors including Model for End-Stage Liver Disease (MELD) score were evaluated in a multivariate Cox model. RESULTS: HRS was present in 35 (40%) patients (15 HRS 1, 20 HRS 2), followed by renal parenchymal disease (23%), drug-induced kidney dysfunction (19%) and prerenal failure due to bleeding or infections (15%). HRS patients had a significantly higher MELD score and shorter survival. In addition to the MELD score, only HRS 1 was independently predictive for survival. HRS 2 patients had a similar outcome as patients with non-HRS kidney dysfunction. CONCLUSIONS: In patients with cirrhosis and renal failure, hepatorenal syndrome is associated with a worse prognosis than kidney dysfunction due to other conditions but only HRS type 1 has independent prognostic relevance in addition to the MELD score in these patients.     

MELD Score Does Not Discriminate Against Patients with Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a significant complication of cirrhosis and part of the CTP score. The UNOS database was queried for listings from February 2001 to February 2002 (CTP era) and February 2002 to February 2003 (MELD era). HE at listing, Grade III/IV HE at transplant, and 12-month posttransplant survival were compared. HE rate at listing was similar, whereas Grade III/IV HE at time of transplant was significantly lower in the MELD era. Waiting periods were shorter in the MELD era. Twelve-month posttransplant survival was lower in all patients with HE at listing (P < 0.0001) and for patients with Grade III/IV HE at transplant (P < 0.0001) in both eras. No significant change in posttransplant survival of HE patients was observed after MELD implementation. We conclude that (1) HE patients have worse posttransplant survival even after MELD; (2) MELD allows more rapid transplantation; and (3) rates of HE at listing have not changed since MELD implementation; however, rates of Grade III/IV HE at transplant have decreased.Presented at the Annual Meeting of the American Gastroenterological Association, Digestive Disease Week, New Orleans, Louisiana, May 2004.     

Albumin-Bilirubin (ALBI) as an accurate and simple prognostic score for chronic hepatitis B-related liver cirrhosis

BackgroundThe Albumin–Bilirubin (ALBI) score was developed to predict the long-term prognosis of hepatocellular carcinoma patients. We aimed to investigate the performance of ALBI for predicting severity and long-term prognosis of chronic hepatitis B-related liver cirrhosis (CHB-LC).MethodsCHB-LC patients were enrolled from two medical centers between 2011 and 2017. The prognostic performance of ALBI was evaluated and compared with Child-Turcotte-Pugh (CTP), model of end-stage liver disease (MELD) and MELD integrating sodium (MELD-Na) scores.ResultsThis study enrolled 398 CHB-LC patients and patients were followed up for a median of 33.9 (IQR 21.6–48.8) months. The ALBI (HR: 3.151, 95% CI: 2.039–4.869,P < 0.001) was identified as an independent predictor of liver-related mortality. The receiver operating characteristic curves (ROCs) analysis revealed that ALBI score (0.756, 0.745, 0.739, 0.767 and 0.765) was superior to MELD score (P < 0.05) and comparable with CTP score (P > 0.05) for predicting 2-year, 3-year, 4-year, 5-year and global mortality. The AUROCs of ALBI score were significantly higher than MELD-Na score(P < 0.05) for predicting 2-year, 3-year and 5-year mortality. Patients with lower ALBI grade had a significantly lower mortality than patients with higher ALBI grade (P < 0.05).ConclusionsALBI score accurately predicts the severity and long-term prognosis of patients with CHB-LC. The prognostic performance of ALBI score was superior to MELD and MELD-Na score.     

Correlation of HVPG Level with CTP Score,MELD Score,Ascites, Size of Varices,and Etiology in Cirrhotic Patients

Background/Aim:

This study intends to determine the correlation of a patient''s hepatic venous pressure gradient (HVPG) measurement with six factors: Child–Turcotte–Pugh (CTP) score, model for end-stage liver disease (MELD) score, presence of ascites, size of varices, presence of variceal bleeding, and an etiology of cirrhosis. The study also aims to identify the predictors of higher HVPG measurements that can indirectly affect the prognosis of cirrhotic patients.

Patients and Methods:

Thirty patients diagnosed with cirrhosis were enrolled prospectively and each patient''s HVPG level was measured by the transjugular catheterization of the right or middle hepatic vein. The wedged hepatic venous pressure (WHVP) and free hepatic venous pressure (FHVP) were measured using a 7F balloon catheter. The HVPG level was calculated as the difference between the WHVP and FHVP measurements.

Results:

The mean HVPG level was higher in alcoholic than in nonalcoholic cirrhosis (19.5 ± 7.3 vs 15.2 ± 4.5 mm Hg, P = 0.13). The mean HVPG was also higher in bleeders compared with nonbleeders (18.5 ± 5.3 vs 10.7 ± 3.1 mmHg, P = 0.001). Patients with varices had a higher mean HVPG level than those without varices (17.4 ± 5.8 vs 11.7 ± 3.9 mmHg, P = 0.04). The difference among the three categories of varices (small, large, and no varices) was statistically significant (P = 0.03). In addition, the mean HVPG level was higher in patients with ascites than in those without ascites (18.7 ± 4.7 vs 11 ± 5.3 mmHg, P = 0.002), and it was significantly higher in patients in CTP class C (21.8 ± 5.5 mmHg) as compared with those in CTP class B (16.9 ± 2.9 mmHg) and CTP class A (10.5 ± 4.1 mmHg; P ≤ 0.001).

Conclusion:

HVPG levels were significantly higher in patients in CTP class C as compared with those in CTP classes A and B, thereby indicating that an HVPG measurement correlates with severity of liver disease. A high HVPG level signifies more severe liver disease and can predict the major complications of cirrhosis.