Influential factors of prognosis in lamivudine treatment for patients with acute‐on‐chronic hepatitis B liver failure

Background and Aims: Chronic hepatitis B virus (HBV) infection is a major global health issue, and the prognosis of patients with HBV‐associated acute‐on‐chronic hepatic failure (ACLF) is extremely poor. In this study, the efficacy of lamivudine was investigated in patients with ACLF. The effects of HBV DNA load and its related factors on the prognosis were also further explored. Methods: A matched retrospective cohort study using data on ACLF patients derived from our hospital database was conducted. One hundred and thirty patients receiving lamivudine were selected into the lamivudine treatment group with another 130 without lamivudine treatment studied as control. They were matched for sex, age and imaging finding with the lamivudine treatment group. All the patients were followed up for 3 months and the survival rates were compared. The influential factors on the mortality were studied by the Cox proportional hazards model. Results: The cumulative survival rates of patients in the lamivudine group were higher than those of the control group (χ² = 9.50, P = 0.0021). The mortality of patients in the high virus load group (71/95, 74.7%) was higher than that of those in the low virus load group (15/29, 51.7%) (χ² = 5.536, P = 0.019). For patients with a Model for End‐Stage Liver Disease (MELD) score of 20–30 by week 4, the mortality of those with HBV DNA that was undetectable or declined for more than 2 log₁₀ (2/12, 16.7%; 18/40, 45.0%) was lower than that of those with a less than 2 log₁₀ decline (18/23, 78.3%) (χ² = 10.106, P = 0.001). In the Cox proportional hazards model, for patients with a MELD score of 20–30, treatment method (P = 0.002), pretreatment HBV DNA load (P = 0.007) and decline of HBV DNA load during therapy (P = 0.003) were independent predictors; for those with a MELD score of above 30, MELD score (P = 0.008) was the only independent predictor. Conclusion: Lamivudine can significantly decrease the 3‐month mortality of patients with a MELD score of 20–30, and a low pretreatment viral load and rapid decline of HBV DNA load are good predictors for the outcome of the treatment.     

ADAMTS13 activity may predict the cumulative survival of patients with liver cirrhosis in comparison with the Child-Turcotte-Pugh score and the Model for End-Stage Liver Disease score

Aim: Decreased plasma ADAMTS13 activity (ADAMTS13:AC) results in accumulation of unusually large von Willebrand factor multimers and platelet thrombi formation. Our aim was to evaluate whether ADAMTS13:AC is a prognostic marker in patients with liver cirrhosis. Methods: Plasma ADAMTS13:AC and its related parameters were examined in 108 cirrhotic patients. Results: ADAMTS13:AC decreased as the severity of liver disease increased (means: controls 100%, Child A‐cirrhotics 79%, Child B‐cirrhotics 63%, and Child C‐cirrhotics 31%). ADAMTS13:AC markedly decreased in the cirrhotics with hepatorenal syndrome, refractory ascites and hepatic encephalopathy. The cumulative survival time was the shortest (median: 4.5 months) in the cirrhotics with severe to moderate ADAMTS13:AC deficiency (<3–25%), followed by those with mild ADAMTS13:AC deficiency (25–50%), and was the longest in those with normal activity (>50%). In contrast, based on the Child‐Turcotte‐Pugh (CTP) score, Child C‐cirrhotics had the worst survival, but the survival probabilities did not differ between Child A and B cirrhotics. Based on the Model for End‐Stage Liver Disease (MELD) score, the survival was the worst for the cirrhotics in the fourth quartile, but it was not different among cirrhotics in the first three quartiles. Cox proportional‐hazards regression analysis showed that ADAMTS13:AC and serum albumin were independent factors affecting the survival. Conclusions: ADAMTS13:AC concomitantly decreases as the functional liver capacity decreases. This activity may be a useful prognostic marker that is equal or superior to the CTP score and the MELD score to predict not only the short‐term prognosis but also the long‐term survival of the cirrhotic patients.     

Serum sodium and hydration status predict transplant-free survival independent of MELD score in patients with cirrhosis

Background and Aim: Serum sodium may have prognostic value in addition to the model for end‐stage liver disease (MELD) score for prediction of early mortality in patients listed for liver transplant. In patients with cirrhosis, over‐hydration is a common feature but its prognostic value has not been evaluated. This study examines the independent prognostic significance of MELD, serum sodium and hydration status on long‐term survival in patients with cirrhosis. Methods: Serum sodium and hydration (total body water as a percentage of fat‐free mass) were measured in 227 consecutive cirrhotic patients (146 male, 81 female; median age 49 years, range 19–73 years; median MELD score 13, range 6–36). Patients with hepatocellular carcinoma or listed for liver transplantation at the time of initial assessment were excluded. A competing risks Cox proportional hazards analysis was performed to evaluate the influence of MELD, sodium and hydration on risk of death or transplant. Results: Median follow‐up was 52 (range 4–93) months. Serum sodium and hydration were each associated with reduction in time to death or transplant on univariate analysis (sodium: hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.87–0.94, P < 0.0001; hydration: HR 1.20, 95% CI 1.10–1.30, P < 0.0001). On multivariate analysis, MELD, serum sodium and hydration were independently predictive of death or transplant (MELD: HR 1.12, 95% CI 1.06–1.19, P < 0.0001; sodium: HR 0.93, 95% CI 0.87–0.99, P = 0.04; hydration: HR 1.17, 95% CI 1.02–1.33, P = 0.02). Conclusions: In non‐waitlisted patients with cirrhosis, serum sodium is predictive of transplant or death independent of MELD score.     

Evidence-based incorporation of serum sodium concentration into MELD

BACKGROUND & AIMS: Serum sodium (Na) concentrations have been suggested as a useful predictor of mortality in patients with end-stage liver disease awaiting liver transplantation. METHODS: We evaluated methods to incorporate Na into model for end-stage liver disease (MELD), using a prospective, multicenter database specifically created for validation and refinement of MELD. Adult, primary liver transplant candidates with end-stage liver disease were enrolled. RESULTS: Complete data were available in 753 patients, in whom the median MELD score was 10.8 and sodium was 137 mEq/L. Low Na (<130 mEq/L) was present in 8% of patients, of whom 90% had ascites. During the study period, 67 patients (9%) died, 243 (32%) underwent transplantation, 73 (10%) were withdrawn, and 370 were still waiting. MELD score and Na, at listing, were significant (both, P < .01) predictors of death within 6 months. After adjustment for MELD score and center, there was a linear increase in the risk of death as Na decreased between 135 and 120 mEq/L. A new score to incorporate Na into MELD was developed: "MELD-Na" = MELD + 1.59 (135 - Na) with maximum and minimum Na of 135 and 120 mEq/L, respectively. In this cohort, "MELD-Na" scores of 20, 30, and 40 were associated with 6%, 16%, and 37% of risk of death within 6 months of listing, respectively. If this new score were used to allocate grafts, it would affect 27% of the transplant recipients. CONCLUSIONS: We demonstrate an evidence-based method to incorporate Na into MELD, which provides more accurate survival prediction than MELD alone.     

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.     

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.     

Development of a survival evaluation model for liver transplant recipients with hepatocellular carcinoma secondary to hepatitis B

AIM： To develop a model using easily obtainable, objective, verifiable preoperative parameters, to help evaluate post transplant survival probability for hepatocellular carcinoma （HCC） patients with hepatitis B.
METHODS： We retrospectively examined a cohort of 150 consecutive primary cadaveric liver transplants with HCC in our center over 6 years. Thirteen preoperative biochemical parameters and six tumor-related factors were analyzed to identify their correlation with post transplant survival using the Cox proportional-hazards regression model. The predictive power of a new model and the model for end stage liver disease was compared by the receiver operating characteristic curve.
RESULTS： In univariate analysis, the factors significantly associated with post transplant survival were serum concentrations of albumin, total bilirubin, alkaline phosphatase, alpha-fetoprotein, γ-glutamyltransferase, aspartate aminotransferase, sodium, tumor diameter and the number of tumor nodules. MuLtivariate analysis showed alpha-fetoprotein, serum sodium, alkaline phosphatase and the number of tumor nodules were significantly associated with the post transplant outcome. Based on the four variables, we established a new model with a c-statistic of 0.72 which was significantly greater than 0.50 （P = 0.001）, and the c-statistic of MELD was 0.59 （P = 0.146）.
CONCLUSION： The new model based on four objective tumor-related parameters has the capacity to evaluate the risk of post transplant mortality for HCC patients with hepatitis B.     

肝硬化患者血清钠特点及含钠终末期肝病模型对预后的判断价值

目的 分析终末期肝硬化患者的血清钠特点与患者生存状况和门静脉高压并发症之间的关系,比较终末期肝病模型(MELD)及其含钠模型对预后的判断价值.方法 选取我院2005年6月至2010年10月失代偿期肝硬化患者的住院资料进行登记和随访.将血清钠水平按≤125 mmol/L、＞ 125 ～＜135 mmol/L和≥135 mmol/L进行分级,分析不同血清钠水平肝硬化患者的生存情况及与肝硬化门静脉高压相关并发症的关系,并分析Child-Pugh分级与血清钠水平的相互关系.利用Kaplan-Meier方法分析不同血清钠水平患者的生存率变化,利用接受者工作特征(ROC)曲线下面积比较MELD与MELD-Na和iMELD判断患者生存不同时间的准确性.组间均数的比较用t检验或方差分析,率的比较用x2检验,ROC曲线下面积的比较采用正态性Z检验.结果 至随访期截止,共有467例患者被纳入本研究.总体低钠血症(血清钠＜ 135 mmol/L)发生率为50.54％ (236/467),其中死亡患者低钠血症发生率为66.81％ (155/232),生存患者为34.47％ (81/235),差异有统计学意义(x2=9.73,P＜0.01).血清钠≤125 mmol/L、＞125 ～＜135 mmol/L和≥135 mmol/L患者的病死率分别为86.00％ (43/50)、60.10％ (110/183)和33.76％ (79/234),差异有统计学意义(P＜ 0.01).Child-Pugh A、B、C级患者的血清钠水平分别为(138.80±4.42)mmol/L、(135.30±6.66) mmol/L和(131.18±7.53) mmol/L,各组间差异均有统计学意义(P值均＜0.05).肝性脑病、肝肾综合征和自发性腹膜炎的发病率因血清钠水平的下降而升高(r值分别为-0.213、-0.342和- 0.142,P值均＜0.05),腹水量也随血清钠水平的降低而增加(P＜0.01),而消化道出血的发生则与血清钠水平无明显关系(r=0.40,P＞0.05).MELD、MELD-Na和iMELD模型在判断患者3个月预后方面无明显差异(P＞ 0.05),而在判断患者6个月和1年预后方面,MELD-Na和iMELD优于MELD(P值均＜0.05).结论 低钠血症与终末期肝病患者的预后及相关并发症发生有一定的关系.MELD与钠相结合后,可以提高MELD判断患者预后的能力.     

Selecting an optimal prognostic system for liver cirrhosis: the model for end‐stage liver disease and beyond

In comparison with the Child–Turcotte–Pugh (CTP) system, recent studies suggested that the model for end‐stage liver disease (MELD) may more accurately predict the survival for patients with cirrhosis. In the US, the liver allocation system was changed in 2002 from a status‐based algorithm utilizing CTP scores to one using continuous MELD severity scores as a reference system in prioritizing adult patients on the waiting list. Direct evidence that demonstrates the benefits of MELD is the fact that the mortality rates of transplant candidates on the waiting list have remarkably decreased after the implementation of the MELD. The MELD score is closely associated with the degree of portal hypertension as reflected by the hepatic venous pressure gradient. Hyponatraemia occurs as a result of advanced cirrhosis, and a serum sodium (Na) level <126 mEq/L at the time of listing for transplantation is a strong independent predictor of mortality. Several MELD‐derived prognostic models that incorporate serum Na into calculation have been proposed in the hopes of further improving the MELD's prognostic accuracy. Additionally, serum parameters such as creatinine and international normalized ratio are subject to interlaboratory variations and may need unifying standardizations. Patients with refractory complications of cirrhosis may need a priority MELD score to prioritize them on the waiting list. Appropriate modifications and the fine‐tuning of the MELD based on well‐designed prospective studies are necessary in solving the current controversial issues.     

Region 11 MELD Na exception prospective study

Introduction. Hyponatremia complicates cirrhosis and predicts short term mortality, including adverse outcomes before and after liver transplantation.Material and methods. From April 1, 2008, through April 2, 2010, all adult candidates for primary liver transplantation with cirrhosis, listed in Region 11 with hyponatremia, were eligible for sodium (Na) exception.Results. Patients with serum sodium (SNa) less than 130 mg/dL, measured two weeks apart and within 30 days of Model for End Stage Liver Disease (MELD) exception request, were given preapproved Na exception. MELD Na was calculated [MELD + 1.59 (135-SNa/30 days)]. MELD Na was capped at 22, and subject to standard adult recertification schedule. On data end of follow-up, December 28, 2010, 15,285 potential U.S. liver recipients met the inclusion criteria of true MELD between 6 and 22. In Region 11, 1,198 of total eligible liver recipients were listed. Sixty-two (5.2%) patients were eligible for Na exception (MELD Na); 823 patients (68.7%) were listed with standard MELD (SMELD); and 313 patients (26.1%) received HCC MELD exception. Ninety percent of MELD Na patients and 97% of HCC MELD patients were transplanted at end of follow up, compared to 49% of Region 11 standard MELD and 40% of U.S.A. standard MELD (USA MELD) patients (p < 0.001); with comparable dropout rates (6.5, 1.6, 6.9, 9% respectively; p = 0.2). MELD Na, HCC MELD, Region 11 SMELD, and USA MELD post-transplant six-month actual patient survivals were similar (92.9, 92.8, 92.2, and 93.9 %, respectively).Conclusion. The Region 11 MELD Na exception prospective trial improved hyponatremic cirrhotic patient access to transplant equitably, and without compromising transplant efficacy.     

Classification and regression tree analysis of acute‐on‐chronic hepatitis B liver failure: Seeing the forest for the trees

At present, there is no ideal model for predicting the short‐term outcome of patients with acute‐on‐chronic hepatitis B liver failure (ACHBLF). This study aimed to establish and validate a prognostic model by using the classification and regression tree (CART) analysis. A total of 1047 patients from two separate medical centres with suspected ACHBLF were screened in the study, which were recognized as derivation cohort and validation cohort, respectively. CART analysis was applied to predict the 3‐month mortality of patients with ACHBLF. The accuracy of the CART model was tested using the area under the receiver operating characteristic curve, which was compared with the model for end‐stage liver disease (MELD) score and a new logistic regression model. CART analysis identified four variables as prognostic factors of ACHBLF: total bilirubin, age, serum sodium and INR, and three distinct risk groups: low risk (4.2%), intermediate risk (30.2%‐53.2%) and high risk (81.4%‐96.9%). The new logistic regression model was constructed with four independent factors, including age, total bilirubin, serum sodium and prothrombin activity by multivariate logistic regression analysis. The performances of the CART model (0.896), similar to the logistic regression model (0.914, P=.382), exceeded that of MELD score (0.667, P<.001). The results were confirmed in the validation cohort. We have developed and validated a novel CART model superior to MELD for predicting three‐month mortality of patients with ACHBLF. Thus, the CART model could facilitate medical decision‐making and provide clinicians with a validated practical bedside tool for ACHBLF risk stratification.     

Survival outcomes in liver transplant recipients with Model for End‐stage Liver Disease scores of 40 or higher: a decade‐long experience

BackgroundThe Model for End‐stage Liver Disease (MELD) has been used as a prognostic tool since 2002 to predict pre‐transplant mortality. Increasing proportions of transplant candidates with higher MELD scores, combined with improvements in transplant outcomes, mandate the need to study surgical outcomes in patients with MELD scores of ≥40.MethodsA retrospective longitudinal analysis of United Network for Organ Sharing (UNOS) data on all liver transplantations performed between February 2002 and June 2011 (n= 33 398) stratified by MELD score (<30, 30–39, ≥40) was conducted. The primary outcomes of interest were short‐ and longterm graft and patient survival. A Kaplan–Meier product limit method and Cox regression were used. A subanalysis using a futile population was performed to determine futility predictors.ResultsOf the 33 398 transplant recipients analysed, 74% scored <30, 18% scored 30–39, and 8% scored ≥40 at transplantation. Recipients with MELD scores of ≥40 were more likely to be younger (P < 0.001), non‐White and to have shorter waitlist times (P< 0.001). Overall patient survival correlated inversely with increasing MELD score; this trend was consistent for both short‐term (30 days and 90 days) and longterm (1, 3 and 5 years) graft and patient survival. In multivariate analysis, increasing age, African‐American ethnicity, donor obesity and diabetes were negative predictors of survival. Futility predictors included patient age of >60 years, obesity, peri‐transplantation intensive care unit hospitalization with ventilation, and multiple comorbidities.ConclusionsLiver transplantation in recipients with MELD scores of ≥40 offers acceptable longterm survival outcomes. Futility predictors indicate the need for prospective follow‐up studies to define the population to gain the highest benefit from this precious resource.     

Outcome predictors of cirrhotic patients with spontaneous bacterial empyema

Background: Spontaneous bacterial empyema (SBE) is a complication of cirrhotic patients in which a pre‐existing pleural effusion becomes infected. This retrospective study was designed to investigate the bacteriology and outcome predictors of SBE in cirrhotic patients. Methods: Medical records of cirrhotic patients treated in a tertiary care university hospital from December 2004 to December 2008 were retrospectively reviewed. Results: Of 3390 cirrhotic patients seen during the study period, 81 cases of SBE were diagnosed. The incidence of SBE was 2.4% (81/3390) in cirrhotic patients and 16% (81/508) in patients with cirrhosis with hydrothorax. There were 46 monomicrobial infections found in 46 SBE patients. Aerobic Gram‐negative organisms were the predominant pathogens (n=29, 63%), and Escherichia coli (n=9, 20%) was the most frequently isolated sole pathogen. The mortality rate of SBE was 38% (31/81). Univariate analysis showed that Child–Pugh score, model for end‐stage liver disease (MELD)–Na score, concomitant bacteraemia, concomitant spontaneous bacterial peritonitis, initial intensive care unit (ICU) admission and initial antibiotic treatment failure were predictors of poor outcomes. Multivariate regression analysis demonstrated that the independent factors related to a poor outcome were initial ICU admission [odds ratio (OR): 4.318; 95% confidence interval 1CI) 1.09–17.03; P=0.037], MELD–Na score (OR: 1.267; 95% CI 1.08–1.49; P=0.004) and initial antibiotic treatment failure (OR: 13.10; 95% CI 2.60–66.03). Conclusion: Spontaneous bacterial empyema in cirrhotic patients is a high mortality complication. The independent factors related to poor outcome are high MELD–Na score, initial ICU admission and initial antibiotic treatment failure. High MELD–Na score may be a useful mortality predictor of SBE in cirrhotic patients.     

The model for end-stage liver disease score is useful for predicting economic outcomes in adult cases of living donor liver transplantation

Background The model for end-stage liver disease (MELD) is useful for assessing the recipients of liver transplants, namely, deceased-donor transplantation. The application of MELD for living donor liver transplantation (LDLT) is under investigation. Thus, the aim of this study was to analyze the impact of the MELD score in LDLT in Japan. Methods Seventeen adult cases of LDLT during 2001 to 2005 were enrolled. Indications for LDLT were primary biliary cirrhosis, seven; liver cirrhosis, two; hepatocellular carcinoma (HCC), three; metabolic liver disease, one; primary sclerosing cholangitis, two; Caroli's disease, one; and biliary atresia, one. Total medical charges during the operative periods were retrospectively evaluated. The united network of organ sharing (UNOS) modified was obtained using preoperative clinical data. Results The average medical expense of the 17 cases was approximately $97 901. The UNOS-modified MELD score was 22.1. A statistically significant positive correlation was found between the MELD score and medical expense (P = 0.0086, ρ = 0.657), and between the MELD score and the length of stay in the intensive care unit (ICU) (P = 0.0396, ρ = 0.515). The cause of the liver disease leading to transplantation was not related to MELD score, medical expense, or length of ICU stay. Conclusions Although not originally designed for the application to LDLT, the MELD score is useful for predicting medical expenses in LDLT. Similar to those of deceased-donor liver transplantation, the disadvantage of high medical expenses associated with a high MELD score allow consideration of an earlier elective operation in suitable cases.     

MELD联合多项血清学指标对失代偿期肝硬化患者食管静脉曲张短期再出血的预测

食管静脉曲张破裂出血（EVB）是失代偿期肝硬化患者的常见并发症,预测EVB的危险性对合理选择药物或手术方式、改善疗效和判断预后极为重要。目的：评估MELD评分联合多项血清学指标对失代偿期肝硬化患者首次EVB后短期内再出血的预测价值。方法：收集失代偿期肝硬化的EVB患者168例,其中随访3个月后再出血者51例。检测白细胞、血红蛋白、血小板（PLT）、白蛋白、胆红素、肌酐、ALT、AST、凝血酶原时间国际标准化比值、D．二聚体、血清钠指标,计算MELD评分。应用单因素和Logistic多因素回归分析筛选再出血的独立危险因素,建立回归方程并拟合ROC曲线,比较回归方程和单独MELD评分的曲线下面积（AUC）。结果：D-二聚体（OR=1．2714）、MELD（OR=2．3340）、Na（OR=0．8136）、PLT（OR=0．9431）是引起食管静脉曲张再出血的独立预测因子,回归模型为LogisticP=0．1073＋0．3013×D-二聚体＋1．1132XMELD-0．0688×Na-0．0396×PLT,其AUC明显高于单独MELD评分（0．873对0．738,P=0．0028）,敏感性为66．7％,特异性96．1％。结论：MELD评分联合D-二聚体、血清钠、PLT对失代偿期肝硬化患者首次EVB后短期内再出血有较好的预测能力。     

Effect of hyponatraemia on outcomes following orthotopic liver transplantation

Background: Hyponatraemia increases risk of adverse outcomes following orthotopic liver transplantation (OLT), but it is unclear whether improvement of pretransplant hyponatraemia ameliorates post‐transplant complications. Aims: To assess impact of pretransplant hyponatraemia on post‐transplant outcomes. Methods: We performed a retrospective analysis of 213 patients with cirrhosis who underwent liver transplantation. Patients with serum sodium ≤130 mEq/L immediately before transplantation (‘hyponatraemia at OLT’; n=34) were compared with those who had experienced hyponatraemia but subsequently improved to a serum sodium >130 mEq/L at transplantation (‘resolved hyponatraemia’; n=56) and to those without history of hyponatraemia before transplantation (‘never hyponatraemic’; n=123). Primary endpoint was survival at 180 days post‐OLT. Secondary outcomes included time until discharge alive, complications during hospitalization, length of time ventilated and length of post‐transplant intensive care unit stay. Results: There was no survival difference at 180 days post‐OLT between groups. After transplantation, patients with either hyponatraemia at OLT or resolved hyponatraemia had longer time until discharge alive and had higher rates of delirium, acute renal failure, acute cellular rejection and infection than those who were never hyponatraemic. As compared with patients with hyponatraemia at OLT, those with resolved hyponatraemia were more likely to be discharged alive within 3 weeks, but other outcomes, including survival, did not differ significantly. Conclusions: We conclude that hyponatraemia at any time before liver transplantation is associated with adverse post‐transplant outcome, even when hyponatraemia has resolved.     

Trends and outcomes of infective endocarditis in patients on dialysis

Dialysis patients are at high risk for infective endocarditis (IE ); however, no large contemporary data exist on this issue. We examined outcomes of 44 816 patients with IE on dialysis and 202 547 patients with IE not on dialysis from the Nationwide Inpatient Sample database from 2006 thorough 2011. Dialysis patients were younger (59 ± 15 years vs 62 ± 18 years) and more likely to be female (47% vs 40%) and African‐American (47% vs 40%; all P < 0.001). Hospitalizations for IE in the dialysis group increased from 175 to 222 per 10 000 patients (P _trend = 0.04). Staphylococcus aureus was the most common microorganism isolated in both dialysis (61%) and nondialysis (45%) groups. IE due to S aureus (adjusted odds ratio [aOR ]: 1.79, 95% confidence interval [CI ]: 1.73‐1.84), non‐aureus staphylococcus (aOR : 1.72, 95% CI : 1.64‐1.80), and fungi (aOR : 1.4, 95% CI : 1.12‐1.78) were more likely in the dialysis group, whereas infection due to gram‐negative bacteria (aOR : 0.85, 95% CI : 0.81‐0.89), streptococci (aOR : 0.38, 95% CI : 0.36‐0.39), and enterococci (aOR : 0.78, 95% CI : 0.74‐0.82) were less likely (all P < 0.001). Dialysis patients had higher in‐hospital mortality (aOR : 2.13, 95% CI : 2.04‐2.21), lower likelihood of valve‐replacement surgery (aOR : 0.82, 95% CI : 0.76‐0.86), and higher incidence of stroke (aOR : 1.08, 95% CI : 1.03‐1.12; all P < 0.001). We demonstrate rising incidence of IE ‐related hospitalizations in dialysis patients, highlight significant differences in baseline comorbidities and microbiology of IE compared with the general population, and validate the association of long‐term dialysis with worse in‐hospital outcomes.     

血清钠对肝硬化并发症及预后的影响

目的 探讨血清钠水平与失代偿期肝硬化患者并发症及预后的关系.方法 225例失代偿期肝硬化患者,根据其入院时血清钠水平分低钠血症轻、中、重度组和血清钠正常组,分析患者血清钠水平与终末期肝病模型(MELD)、Child-Pugh分级、并发症发生率及预后的关系.结果 在235例患者中,低钠血症发生率为54.04％.血清钠水平越低,患者MELD、Child-Pugh分级越高;除消化道出血外,其它并发症如肝性脑病、自发性腹膜炎、低钾血症、肝肾综合征发生率越高;患者腹水程度越严重.血钠正常组、低钠血症轻、中、重度组病死率分别为7.09％、12.77％、28.95％、60.87％,中、重度组病死率明显高于血钠正常组.重度组病死率也高于中、轻度组(P＜0.01).结论 低钠血症与失代偿期肝硬化患者MELD、Child-Pugh分级、并发症及预后密切相关,监测血清钠水平可作为判断肝硬化患者预后的指标之一.     

Outcomes in partial liver transplantation: deceased donor split-liver vs. live donor liver transplantation

BackgroundOrgan shortage has resulted in greater emphasis on partial liver transplantation (PLT) as an alternative to whole-organ liver transplantation.MethodsThis study was conducted to assess outcomes in PLT and to compare outcomes of deceased donor split-liver transplantation (DD-SLT) and live donor liver transplantation (LDLT) in adults transplanted in the USA using data reported to the United Network for Organ Sharing in the era of Model for End-stage Liver Disease (MELD) scores.ResultsBetween 2002 and 2009, 2272 PLTs were performed in the USA; these represented 5.3% of all liver transplants carried out in the country and included 557 (24.5%) DD-SLT and 1715 LDLT (75.5%) procedures. The most significant differences between the DD-SLT and LDLT groups related to mean MELD scores, which were lower in LDLT recipients (14.5 vs. 20.9; P < 0.001), mean recipient age, which was lower in the LDLT group (50.7 years vs. 52.8 years; P < 0.001), and mean donor age, which was lower in the DD-SLT group (23.0 years vs. 37.3 years; P < 0.001). Allograft survival was comparable between the two groups (P= 0.438), but patient survival after LDLT was better (P= 0.04). In Cox regression analysis, LDLT was associated with better allograft (hazards ratio [HR]= 0.7, 95% confidence interval [CI] 0.630–0.791; P < 0.0001) and patient (HR = 0.6, 95% CI 0.558–0.644; P < 0.0001) survival than DD-SLT.ConclusionsPartial liver transplantation represents a potentially underutilized resource in the USA. Despite the differences in donor and recipient characteristics, LDLT is associated with better allograft and patient survival than DD-SLT. A different allocation system for DD-SLT allografts that takes into consideration cold ischaemia time and recipient MELD score should be considered.     

Liver transplant recipient survival benefit with living donation in the model for endstage liver disease allocation era

Receipt of a living donor liver transplant (LDLT) has been associated with improved survival compared with waiting for a deceased donor liver transplant (DDLT). However, the survival benefit of liver transplant has been questioned for candidates with Model for Endstage Liver Disease (MELD) scores <15, and the survival advantage of LDLT has not been demonstrated during the MELD allocation era, especially for low MELD patients. Transplant candidates enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study after February 28, 2002 were followed for a median of 4.6 years. Starting at the time of presentation of the first potential living donor, mortality for LDLT recipients was compared to mortality for patients who remained on the waiting list or received DDLT (no LDLT group) according to categories of MELD score (<15 or ≥ 15) and diagnosis of hepatocellular carcinoma (HCC). Of 868 potential LDLT recipients (453 with MELD <15; 415 with MELD ≥ 15 at entry), 712 underwent transplantation (406 LDLT; 306 DDLT), 83 died without transplant, and 73 were alive without transplant at last follow-up. Overall, LDLT recipients had 56% lower mortality (hazard ratio [HR] = 0.44, 95% confidence interval [CI] 0.32-0.60; P < 0.0001). Among candidates without HCC, mortality benefit was seen both with MELD <15 (HR = 0.39; P = 0.0003) and MELD ≥ 15 (HR = 0.42; P = 0.0006). Among candidates with HCC, a benefit of LDLT was not seen for MELD <15 (HR = 0.82, P = 0.65) but was seen for MELD ≥ 15 (HR = 0.29, P = 0.043). CONCLUSION: Across the range of MELD scores, patients without HCC derived a significant survival benefit when undergoing LDLT rather than waiting for DDLT in the MELD liver allocation era. Low MELD candidates with HCC may not benefit from LDLT.