Indocyanine green retention is a potential prog-nostic indicator after splenectomy and pericar-dial devascularization for cirrhotic patients

BACKGROUND: Splenectomy and pericardial devasculariza-tion (SPD) is an effective treatment of upper gastrointestinal bleeding and hypersplenism in cirrhotic patients with portal hypertension. Indocyanine green retention at 15 minutes (ICGR15) was reported to offer better sensitivity and speciifc-ity than the Child-Pugh classiifcation in hepatectomy, but few reports describe ICGR15 in SPD. The present study was to evaluate the prognostic value of ICGR15 for cirrhotic patients with portal hypertension who underwent SPD.
METHODS: From January 2012 to January 2015, 43 patients with portal hypertension and hypersplenism caused by liver cirrhosis were admitted in our center and received SPD. The ICGR15, Child-Pugh classiifcation, model for end-stage liver disease (MELD) score, and perioperative characteristics were analyzed retrospectively.
RESULTS: Preoperative liver function assessment revealed that 34 patients were Child-Pugh class A with ICGR15 of 13.6%-43.0% and MELD score of 7-20; 8 patients were class B with ICGR15 of 22.8%-40.7% and MELD score of 7-17; 1 patient was class C with ICGR15 of 39.7% and MELD score of 22. The optimal ICGR15 threshold for liver function com-pensation was 31.2%, which offered a sensitivity of 68.4% and a speciifcity of 70.8%. Univariate analysis showed preopera-tive ICGR15, MELD score, surgical procedure, intraoperative blood loss, and autologous blood transfusion were signiifcant-ly different between postoperative liver function compensated and decompensated groups. Multivariate regression analysis revealed that ICGR15 was an independent risk factor of post-operative liver function recovery (P=0.020).
CONCLUSIONS: ICGR15 has outperformed the Child-Pugh classiifcation for assessing liver function in cirrhotic patients with portal hypertension. ICGR15 may be a suitable prognos-tic indicator for cirrhotic patients after SPD.     

MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study

BACKGROUND: Indices for predicting survival are essential for assessing prognosis and assigning priority for liver transplantation in patients with liver cirrhosis. The model for end stage liver disease (MELD) has been proposed as a tool to predict mortality risk in cirrhotic patients. However, this model has not been validated beyond its original setting. AIM: To evaluate the short and medium term survival prognosis of a European series of cirrhotic patients by means of MELD compared with the Child-Pugh score. We also assessed correlations between the MELD scoring system and the degree of impairment of liver function, as evaluated by the monoethylglycinexylidide (MEGX) test. PATIENTS AND METHODS: We retrospectively evaluated survival of a cohort of 129 cirrhotic patients with a follow up period of at least one year. The Child-Pugh score was calculated and the MELD score was computed according to the original formula for each patient. All patients had undergone a MEGX test. Multivariate analysis was performed on all variables to identify the parameters independently associated with one year and six month survival. MELD values were correlated with both Child-Pugh scores and MEGX test results. RESULTS: Thirty one patients died within the first year of follow up. Child-Pugh and MELD scores, and MEGX serum levels were significantly different among patients who survived and those who died. Serum creatinine, international normalised ratio, and MEGX(60) were independently associated with six month mortality while the same variables and the presence of ascites were associated with one year mortality. MELD scores showed significant correlations with both MEGX values and Child-Pugh scores. CONCLUSIONS: In a European series of cirrhotic patients the MELD score is an excellent predictor of both short and medium term survival, and performs at least as well as the Child-Pugh score. An increase in MELD score is associated with a decrease in residual liver function.     

Outcomes of pancreatoduodenectomy in the cirrhotic patient: risk stratification and meta-analysis

Background

Cirrhosis increases the risk of perioperative mortality in gastrointestinal surgery. Though cirrhosis is sometimes considered a contraindication to pancreatoduodenectomy (PD), few data are available in this patient population. The aim of the present study is to identify predictors of outcome in cirrhotic patients undergoing PD.

IRIS13C-美沙西汀呼气试验与Child-Pugh分级、MELD评分评估肝硬化患者肝功能的比较

目的通过比较肝硬化患者13C-美沙西汀呼气试验、Child-Pugh分级及MELD评分,结合腹部CT测量肝脾体积以探讨13C-美沙西汀呼气试验评价肝脏储备和代偿功能的临床应用价值。方法 139例肝硬化患者行13C-美沙西汀呼气试验、Child-Pugh分级及MELD评分,分析各组13C-美沙西汀呼气试验的呼气参数值之间的相互关系,比较乙型肝炎肝硬化患者肝脏、脾脏体积变化以进一步评估13C-美沙西汀呼气试验反映肝细胞储备和代偿功能的作用。结果13C-美沙西汀呼气试验肝脏功能分级与肝硬化患者传统的Child-Pugh分级判定肝功能状况具有良好一致性(κ=0.55,P<0.05),与MELD评分比较具有一致性(κ=0.41,P<0.05);肝脏病变程度越重,13C-美沙西汀呼气试验量化值越小,肝硬化患者呼气参数值显著下降(P<0.05),肝细胞储备和代偿功能越差;呼气试验参数与Child-Pugh分级计分、MELD评分、血清总胆红素、国际标准化比值(INR)呈明显负相关(P<0.01),与血清白蛋白、前白蛋白、凝血酶原活动度、胆碱酯酶呈正相关(P<0.01),与肝硬化患者脾脏体积呈负相关(P<0.05),与血肌酐、ALT、肝脏体积无显著相关性(P>0.05)。68例乙型肝炎肝硬化患者中Child-Pugh分级、MELD评分越高,肝脏体积越小;13C-美沙西汀呼气试验量化值与乙型肝炎肝硬化患者肝脏体积呈正相关(P<0.05)。结论 IRIS13C(红外线同位素13C)-美沙西汀呼气试验可准确反应肝硬化患者肝脏储备及代偿功能。     

Clinical value of increased serum creatinine concentration as predictor of short-term outcome in decompensated cirrhosis

BACKGROUND: The purpose of this study was to assess whether serum creatinine concentration alone or associated with other biological parameters was an independent predictor of short-term mortality in patients with decompensated cirrhosis. METHODS: A total of 212 consecutive episodes of decompensated cirrhosis in patients admitted to the hospital between January 1999 and December 2001 were reviewed retrospectively. Depending on a serum creatinine concentration equal to or greater than 1.5 mg/dL at the time of admission, patients were divided into decompensated cirrhosis with renal failure (101 episodes in 59 patients, aged 69.8 +/- 10 years) and without renal failure (111 episodes in 61 patients, aged 64.5 +/- 13 years). Outcome (alive, death) during the episode of decompensation of liver disease and outcome at 90 days after admission were assessed. RESULTS: Differences in the frequency of variables according to outcome in the overall episodes of decompensated cirrhosis with and without renal failure showed significant differences between patients who died and those who were alive both at hospital discharge and at 90 days in serum bilirubin, Child-Pugh score, MELD (model for end-stage liver disease) score, and serum creatinine levels. In the multivariate analysis, serum creatinine was not an independent predictor of outcome. The prediction accuracy according to the area under the ROC (receiver operating characteristic) curve was greater for the MELD scale than for serum creatinine. CONCLUSIONS: Serum creatinine concentration is a parameter that should be included in the prognostic assessment of patients with decompensated cirrhosis, but should be combined with other specific parameters of liver function, such as bilirubin, albumin, and the international normalized ratio (INR) for prothrombin time.     

The impact of diabetes mellitus in mortality of patients with compensated liver cirrhosis-a prospective study

Background. It has been suggested that DM may reduce survival of patients with liver cirrhosis (LC). Nevertheless only few prospective studies assessing the impact of DM on mortality of cirrhotic patients have been published, none in compensated LC.Aims. (i) to study the impact of DM on mortality and (ii) to identify predictors of death.Methods. Patients with compensated LC with and without DM were studied. Survival was analyzed by the Kaplan-Meier Method. Univariate and multivariate analysis was performed to determine independent predictors of mortality.Results. 110 patients were included: 60 without DM and 50 with DM. Diabetic patients had significantly higher frequency of cryptogenic cirrhosis, anemia, hypoalbuminemia, and hypercreatininemia. They also had significantly higher BMI and Child-Pugh score. The 2.5-years cumulative survival was significantly lower in patients with DM (48 vs. 69%, p < 0.05). By univariate analysis: DM, female gender, serum creatinine > 1.5 mg/dL, Child-Pugh score class C and cryptogenic cirrhosis were significant. However, only serum creatinine > 1.5 mg/dL and Child-Pugh score class C were independent predictors of death.Conclusion: DM was associated with a significant increase in mortality in patients with compensated liver cirrhosis. Serum creatinine > 1.5 mg/dL and Child-Pugh score class C were independent predictors of death.     

Cardiac surgery in patients with liver cirrhosis: Risk factors for predicting mortality

AIM: To evaluate the results of cardiac surgery in cirrhotic patients and to find the predictors of early and late mortality.METHODS: We included 55 consecutive cirrhotic patients undergoing cardiac surgery between 1993 and 2012. Child-Turcotte-Pugh (Child) classification and Model for End-Stage Liver Disease (MELD) score were used to assess the severity of liver cirrhosis. The online EuroSCORE II calculator was used to calculate the logistic EuroSCORE in each patient. Stepwise logistic regression analysis was used to identify the risk factors for mortality at different times after surgery. Multivariate Cox proportional hazard models were applied to estimate the hazard ratios (HR) of predictors for mortality. The Kaplan-Meier method was used to generate survival curves, and the survival rates between groups were compared using the log-rank test.RESULTS: There were 30 patients in Child class A, 20 in Child B, and five in Child C. The hospital mortality rate was 16.4%. The actuarial survival rates were 70%, 64%, 56%, and 44% at 1, 2, 3, and 5 years after surgery, respectively. There were no significant differences in major postoperative complications, and early and late mortality between patients with mild and advanced cirrhosis. Multivariate logistic regression showed preoperative serum bilirubin, the EuroSCORE and coronary artery bypass grafting (CABG) were associated with early and late mortality; however, Child class and MELD score were not. Cox regression analysis identified male gender (HR = 0.319; P = 0.009), preoperative serum bilirubin (HR = 1.244; P = 0.044), the EuroSCORE (HR = 1.415; P = 0.001), and CABG (HR = 3.344; P = 0.01) as independent risk factors for overall mortality.CONCLUSION: Advanced liver cirrhosis should not preclude patients from cardiac surgery. Preoperative serum bilirubin, the EuroSCORE, and CABG are major predictors of early and late mortality.     

MELD评分联合血清胆红素水平预测肝硬化预后

目的比较child-pugh评分、MELD评分体系及MELD联合血清胆红素对肝硬化失代偿期患者的短期、中期死亡危险的预测价值.方法入选59例肝硬化失代偿期患者,分别根据随访6月及12月的存活情况分组,观察存活组与死亡组中血清胆红素水平、血清肌酐水平、INR值、child-pugh评分、MELD评分.结果随访至6月,8例死亡,存活组与死亡组血清总胆红素水平、INR值、child-pugh评分、MELD评分均有统计学差异.随访至12月,18例死亡,存活组与死亡组上述各项观察指标均有统计学差异.而年龄、血清肌酐水平均无统计学差异.存活组与死亡组中不同child-pugh分级所占比例有统计学差异.MELD评分与child-puSh评分密切相关,r=0.936,P＜0.001.在预测死亡的危险性方面,MELD评分联合血清胆红素水平预测6月死亡的敏感性为100%,特异性86.8%.结论MELD评分系统对判断肝硬化肝功能失代偿期患者的预后具有良好的价值和准确性.MELD评分联合血清胆红素与单独MELD评分、Child-Pugh评分系统相比,在预测肝硬化肝功能失代偿期患者短、中期死亡率方面也具有更好的作用.     

Assessment of prognosis of cirrhosis

Once patients with cirrhosis experience decompensation, early mortality risk increases sharply. Liver transplantation has transformed the prognosis of decompensated cirrhosis. Child-Pugh score has been the reference for many years for assessing the prognosis of cirrhosis. However, Child-Pugh score has important limitations among which is subjective interpretation of some of its variables, making it difficult to categorize patients according to their own disease severity. The model for end-stage liver disease (MELD) score, which was originally designed for assessing the prognosis of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS), is a continuous score relying on three objective variables. Along with TIPS, MELD score proved to be a robust marker of early mortality across a wide spectrum of causes of cirrhosis, even though 10 to 20% of patients are still misclassified. MELD is especially useful for prioritizing candidates for transplantation according to a "sickest first" policy. However, MELD is not a universal prognostic marker of cirrhosis and several MELD exceptions require more specific approaches.     

Predicting outcome after cardiac surgery in patients with cirrhosis: a comparison of Child-Pugh and MELD scores.

BACKGROUND & AIMS: This study aims to quantify the risk of cardiac surgery in patients with cirrhosis. METHODS: Records of all adult patients with cirrhosis undergoing cardiac surgery using cardiopulmonary bypass at the Cleveland Clinic (Cleveland, OH) from January 1992 to June 2002 were analyzed for any relationship of Child-Pugh class and/or score and Model for End-Stage Liver Disease (MELD) score with outcome measures of hepatic decompensation and death during the first 3 months after surgery. RESULTS: Forty-four patients underwent coronary artery bypass grafting (16 patients), valve surgery (16 patients), a combination of the 2 procedures (10 patients), or pericardiectomy (2 patients). Twelve patients (27%) developed hepatic decompensation, and 7 patients (16%) died. Proportions of hepatic decompensation were 3 of 31, 8 of 12, and 1 of 1 patients, and death, 1 of 31, 5 of 12, and 1 of 1 patients in Child-Pugh classes A, B, and C, respectively. The association of hepatic decompensation and mortality with Child-Pugh class, Child-Pugh score, and MELD score was significant (P < 0.005). Areas under the receiver operating characteristic curves for mortality were similar for Child-Pugh (0.84 +/- 0.09) and MELD scores (0.87 +/- 0.09). A cutoff Child-Pugh score >7 was found to have a sensitivity and specificity of 86% and 92% for mortality, with a negative predictive value of 97% (95% confidence interval [CI], 83-99) and positive predictive value of 67% (95% CI, 31-91), respectively. However, a similar cutoff value for MELD score could not be established. CONCLUSIONS: Child-Pugh score and/or class and MELD score are significantly associated with hepatic decompensation and mortality after cardiac surgery using cardiopulmonary bypass in patients with cirrhosis. Such surgery can be conducted safely in patients with a Child-Pugh score /=8 have a significant risk for mortality.     

肝移植术后早期急性肺水肿14例临床相关因素分析

目的 探讨肝移植术后早期急性肺水肿的临床相关因素,为临床合理处理提供线索。方法观察我院行肝移植术后急性肺水肿14例患者的术前终末期肝病模型（MELD）评分、手术前后肾功能（尿量、血肌酐）的变化情况;记录移植术中及术后前3d总入量、总出量和液体平衡量。结果肝移植术后急性肺水肿患者（14例）术前MELD评分较非肺水肿组（127例）显著增高（P〈0．01）,且术后死亡率明显上升（P〈0．01）;急性肺水肿患者术前存在肾功能不全,术后血肌酐、尿量延迟恢复;术中、术后液体正平衡显著增加,与非肺水肿组差异均有统计学意义（P〈0．01）。结论肝移植术后早期急性肺水肿与术前高MELD分值、术前肾功能障碍、术后肾功能延迟恢复及术中大量输液、术后限液不足密切相关,术中、术后严格控制出入量平衡,尽快恢复患者肾功能及相关重要脏器支持是防止肝移植早期急性肺水肿的有效措施。     

Gallstones in patients with liver cirrhosis: Incidence,etiology, clinical and therapeutical aspects

Gallstones occur in about one third of the patients having liver cirrhosis. Pigment gallstones are the most frequent type, while cholesterol stones represent about 15% of all stones in cirrhotics. Increased secretion of unconjugated bilirubin, increased hydrolysis of conjugated bilirubin in the bile, reduced secretion of bile acids and phospholipds in bile favor pigment lithogenesis in cirrhotics. Gallbladder hypomotility also contributes to lithogenesis. The most recent data regarding risk factors for gallstones are presented. Gallstone prevalence increases with age, with a ratio male/female higher than in the general population. Chronic alcoholism, viral C cirrhosis, and non-alcoholic fatty liver disease are the underlying liver diseases most often associated with gallstones. Gallstones are often asymptomatic, and discovered incidentally. If asymptomatic, expectant management is recommended, as for asymptomatic gallstones in the general population. However, a closer follow-up of these patients is necessary in order to earlier treat symptoms or complications. For symptomatic stones, laparoscopic cholecystectomy has become the therapy of choice. Child-Pugh class and MELD score are the best predictors of outcome after cholecystectomy. Patients with severe liver disease are at highest surgical risk, therefore gallstone complications should be treated using noninvasive or minimally invasive procedures, until stabilization of the patient condition.     

MELD vs Child-Pugh and creatinine-modified Child-Pugh score for predicting survival in patients with decompensated cirrhosis

AIM：Model of End-stage Liver Disease (MELD) score has recently gained wide acceptance over the old Child-Pugh score in predicting survival in patients with decompensated cirrhosis, although it is more sophisticated. We compared the predictive values of MELD, Child-Pugh and creatininemodified Child-Pugh scores in decompensated cirrhosis.METHODS: A cohort of 102 patients with decompensated cirrhosis followed-up for a median of 6 mo was studied.Two types of modified Child-Pugh scores estimated by adding 0-4 points to the original score using creatinine levels as a sixth categorical variable were evaluated.RESULTS: The areas under the receiver operating characteristic curves did not differ significantly among the four scores, but none had excellent diagnostic accuracy (areas:0.71-0.79). Child-Pugh score appeared to be the worst, while the accuracy of MELD was almost identical with that of modified Child-Pugh in predicting short-term and slightly better in predi~ng medium-term survival. In Cox regression analysis, all four scores were significantly associated with survival, while MELD and creatinine-modified Child-Pugh scores had better predictive values (c-statistics: 0.73 and 0.69-0.70) than Child-Pugh score (c-statistics: 0.65).Adjustment for gamma-glutamate transpeptidase levels increased the predictive values of all systems (c-statistics:0.77-0.81). Analysis of the expected and observed survival curves in patients subgroups according to their prognosis showed that all models fit the data reasonably well with MELD probably discriminating better the subgroups withworse prognosis.CONCLUSION: MELD compared to the old Child-Pugh and particularly to creatinine-modified Child-Pugh scores does not appear to offer a clear advantage in predicting survival in patients with decompensated cirrhosis in daily clinical practice.     

MELD vs Child-Pugh and creatinine-modified Child-Pugh score for Dredicting survival in patients with decompensated cirrhosis

AIM: Model of End-stage Liver Disease (MELD) score has recently gained wide acceptance over the old Child-Pugh score in predicting survival in patients with decompensated cirrhosis, although it is more sophisticated. We compared the predictive values of MELD, Child-Pugh and creatinine-modified Child-Pugh scores in decompensated cirrhosis. METHODS: A cohort of 102 patients with decompensated cirrhosis followed-up for a median of 6 mo was studied. Two types of modified Child-Pugh scores estimated by adding 0-4 points to the original score using creatinine levels as a sixth categorical variable were evaluated. RESULTS: The areas under the receiver operating characteristic curves did not differ significantly among the four scores, but none had excellent diagnostic accuracy (areas: 0.71-0.79). Child-Pugh score appeared to be the worst, while the accuracy of MELD was almost identical with that of modified Child-Pugh in predicting short-term and slightly better in predicting medium-term survival. In Cox regression analysis, all four scores were significantly associated with survival, while MELD and creatinine-modified Child-Pugh scores had better predictive values (c-statistics: 0.73 and 0.69-0.70) than Child-Pugh score (c-statistics: 0.65). Adjustment for gamma-glutamate transpeptidase levels increased the predictive values of all systems (c-statistics: 0.77-0.81). Analysis of the expected and observed survival curves in patients subgroups according to their prognosis showed that all models fit the data reasonably well with MELD probably discriminating better the subgroups with worse prognosis. CONCLUSION: MELD compared to the old Child-Pugh and particularly to creatinine-modified Child-Pugh scores does not appear to offer a clear advantage in predicting survival in patients with decompensated cirrhosis in daily clinical practice.     

Model for end-stage liver disease score to serum sodium ratio index as a prognostic predictor and its correlation with portal pressure in patients with liver cirrhosis.

BACKGROUND: The models for end-stage liver disease (MELD) and serum sodium (SNa) are important prognostic markers in cirrhosis. A novel index, MELD to SNa ratio (MESO), was developed to amplify the opposing effect of MELD and SNa on outcome prediction. METHODS: A total of 213 cirrhotic patients undergoing hepatic venous pressure gradient (HVPG) measurement were retrospectively analyzed. RESULTS: The MESO index correlated with HVPG (r=0.258, P<0.001) and Child-Pugh score (rho=0.749, P<0.001). Using mortality as the end point, the area under receiver operating characteristic curve (AUC) was 0.860 for SNa, 0.795 for the MESO index and 0.789 for MELD (P values all >0.3) at 3 months. Among patients with Child-Pugh class A or B, the MESO index had a significantly higher AUC compared with MELD (0.80 vs. 0.766, P<0.001). A MESO index <1.6 identified 97% of patients who survived at 3 months and the predicted survival rate was 96.5%. In survival analysis, MESO index >1.6 independently predicted a higher mortality rate (relative risk: 3.32, P<0001) using the Cox model. CONCLUSIONS: The MESO index, which takes into account the predictive power of both MELD and SNa, is a useful prognostic predictor for both short- and long-term survival in cirrhotic patients.     

Extrahepatic digestive surgery in cirrhotic patients: mortality, morbidity and preoperative prognostic factors

The purpose of this work was to study postoperative mortality and morbidity with respect to preoperative prognostic factors in 67 patients with alcoholic or posthepatitis cirrhosis. Surgical procedures involved the biliary tract (n = 20), stomach (n = 16), colon or rectum (n = 12), and hernia (n = 7). Thirteen preoperative clinical and biological variables were subjected to mono- and multivariate statistical analysis. The mortality rate was 23 p. 100. There was no statistical difference between the three main surgical procedures. No patients died after herniorrhaphy. The rate of morbidity was 37 p. 100. The most common complications were sepsis, organ failure, and ascites. Three preoperative variables were found to be different between survivors and non survivors: ascites, prothrombin time and the Child-Pugh score. Multidimensional analysis demonstrated that the only variable to have an independent unfavorable prognostic value was albuminemia. These results suggest that postoperative mortality following extrahepatic abdominal surgery in cirrhotic patients is: 1) especially high after digestive procedures, 2) increased by ascites, low prothrombin time and high Child-Pugh score. Only hypoalbuminemia had a significant independent explanatory value regarding prognosis.     

终末期肝病模型及Child-Pugh分级对肝硬化患者的短期预后分析

评价终末期肝病模型(MELD)评分、Child-Pugh(CTP)及包含血肌酐值的CTP(CrCTP)分级对肝硬化患者的短期预后的意义.分别计算104例肝硬化患者的MELD、CTP及CrCTP分值,运用ROC曲线及曲线下面积(AUC)比较MELD评分、CTP及CrCTP分级判断肝硬化患者3个月生存率的准确性.在判断患者3个月生存率的ROC曲线AUC比较中,MELD评分＞CrCTP分级＞CTP分级(P＜0.05).提示在CTP中引入血肌酐值可以提高CTP分级对肝硬化患者短期预后的判断准确性;MELD评分在判断肝硬化患者的短期预后方面优于CTP及CrCTP.     

Is an estimated glomerular filtration rate better than creatinine to be incorporated into the end-stage liver disease score?

AIM: To incorporate estimated glomerular filtrationrate (eGFR) into the model for end-stage liver disease(MELD) score to evaluate the predictive value.METHODS: From January 2004 to October 2008,the records of 4127 admitted cirrhotic patients were reviewed. Patients who survived and were followed up as outpatients were defined as survivors and theirmost recent available laboratory data were collected.Patients whose records indicated death at any time during the hospital stay were defined as non-survivors(in-hospital mortality). Patients with incomplete dataor with cirrhosis due to a congenital abnormality suchas primary biliary cirrhosis were excluded; thus, a totalof 3857 patients were enrolled in the present study.The eGFR, which was calculated by using either the modification of diet in renal disease (MDRD) equationor the chronic kidney disease epidemiology collaboration (CKD-EPI) equation, was incorporated into the MELD score after adjustment with the original MELDequation by logistic regression analysis [bilirubin and international normalized ratio (INR) were set at 1.0 forvalues less than 1.0].RESULTS: Patients defined as survivors were significantly younger, had a lower incidence of hepatoma,lower Child-Pugh and MELD scores, and better renalfunction. The underlying causes of cirrhosis werevery different from those in Western countries. In Tai-wan, most cirrhotic patients were associated with thehepatitis virus, especially hepatitis B. There were 16parameters included in univariate logistic regressionanalysis to predict in-hospital mortality and those with significant predicting values were included in furthermultivariate analysis. Both 4-variable MDRD eGFR and6-variable MDRD eGFR, rather than creatinine, weresignificant predictors of in-hospital mortality. Threenew equations were constructed (MELD-MDRD-4,MELD-MDRD-6, MELD-CKD-EPI). As expected, originalMELD score was a significant predictor of in-hospitalmortality (odds ratio = 1.25, P 0.001). MELD-MDRD-4 excluded serum creatinine, with the coeffi-cients refit among the remaining 3 variables, i.e., totalbilirubin, INR and 4-variable MDRD eGFR. This model represented an exacerbated outcome over MELD score,as suggested by a decrease in chi-square (2161.45 vs2198.32) and an increase in -2 log (likelihood) (2810.77vs 2773.90). MELD-MDRD-6 included 6-variable MDRDeGFR as one of the variables and showed an improvement over MELD score, as suggested by an increasein chi-square (2293.82 vs 2198.32) and a decrease in-2 log (likelihood) (2810.77 vs 2664.79). Finally, whenserum creatinine was replaced by CKD-EPI eGFR, itshowed a slight improvement compared to the originalMELD score (chisquare: 2199.16, -2 log (likelihood): 2773.07). In the receiver-operating characteristic curve, the MELD-MDRD-6 score showed a marginal improvement in area under the curve (0.909 vs 0.902), sensitivity (0.854 vs 0.819) and specificity (0.818 vs 0.839) compared to the original MELD equation. In patients with a different eGFR, the MELD-MDRD-6 equation showed a better predictive value in patients with eGFR ≥ 90, 60-89, 30-59 and 15-29.CONCLUSION: Incorporating eGFR obtained by the 6-variable MDRD equation into the MELD score showed an equal predictive performance in in-hospital mortality compared to a creatinine-based MELD score.     

Elevated nitric oxide and 3′,5′ cyclic guanosine monophosphate levels in patients with alcoholic cirrhosis

AIM： To evaluate whether serum levels of nitric oxide （NO^.） and plasma levels of cyclic guanosine monophosphate （cGMP） and total glutathione （GSH） are altered in patients with alcoholic cirrhosis and to examine their correlation with the severity of liver disease.
METHODS： Twenty-six patients with alcoholic liver cirrhosis were studied. Serum levels of NO^. and plasma levels of cGMP and GSH were measured in 7 patients with compensated alcoholic cirrhosis （Child-Pugh A） and 19 patients with advanced cirrhosis （Child-Pugh B and C）. The model for end-stage liver disease （MELD） score was evaluated. Sixteen healthy volunteers served as controls. Liver enzymes and creatinine levels were also tested.
RESULTS： NO^. and cGMP levels were higher in patients with Child-Pugh B and C cirrhosis than in Child-Pugh A cirrhosis or controls （NO^.： 21.70 ± 8.07 vs 11.70 ± 2.74; 21.70± 8.07 vs 7.26 ± 2.47 μmol/L, respectively; P 〈 0.001） and （cGMP： 20.12 ± 6.62 vs 10.14 ± 2.78; 20.12 ± 6.62 vs 4.95 ± 1.21 pmol/L, respectively; P 〈 0.001）. Total glutathione levels were lower in patients with Child-Pugh B and C cirrhosis than in patients with Child-Pugh A cirrhosis or controls （16.04 ± 6.06 vs 23.01 ± 4.38 or 16.04 ± 6.06 vs 66.57 ±26.23 μmol/L, respectively; P 〈 0.001）. There was a significant correlation between NO^. and cGMP levels in all patients with alcoholic cirrhosis. A significant negative correlation between reduced glutathione/glutathione disulfide and the MELD score was found in all cirrhotic patients.
CONCLUSION： Our results suggest a role for oxidative stress in alcoholic liver cirrhosis, which is more significant in decompensated patients with higher levels of NO^. and cGMP and lower GSH levels than in compensated and control patients. Altered mediator levels in decompensated patients may influence the hemodynamic changes in and progression of liver disease.     

Pre-hepatectomy type Ⅳ collagen 7S predicts post-hepatectomy liver failure and recovery

BACKGROUND Liver resection is an effective treatment for benign and malignant liver tumors.However,a method for preoperative evaluation of hepatic reserve has not yet been established.Previously reported assessments of preoperative hepatic reserve focused only on liver failure in the early postoperative period and did not consider the long-term recovery of hepatic reserve.When determining eligibility for hepatectomy,the underlying pathophysiology needs to be considered to determine if the functional hepatic reserve can withstand both surgery and any postoperative therapy.AIM To identify pre-hepatectomy factors associated with both early postoperative liver failure and long-term postoperative liver function recovery.METHODS This study was a retrospective cohort study.We retrospectively investigated 215 patients who underwent hepatectomy at our hospital between May 2013 and December 2016.Early post-hepatectomy liver failure(PHLF)was defined using the International Study Group of Liver Surgery’s definition of PHLF.Long-term postoperative recovery of liver function was defined as the time taken for serum total bilirubin and albumin levels to return to levels of<2 mg/dL and>2.8 g/dL,respectively,and the time taken for Child-Pugh score to return to Child-Pugh class A.RESULTS Preoperative type IV collagen 7S was identified as a significant independent factor associated with both PHLF and postoperative long-term recovery of liver function.Further analysis revealed that the time taken for the recovery of Child-Pugh scores and serum total bilirubin and albumin levels was significantly shorter in patients with type IV collagen 7S≤6 ng/mL than in those with type IV collagen 7S>6 ng/mL.In additional analyses,similar results were observed in patients without chronic viral hepatitis associated with fibrosis.CONCLUSION Preoperative type IV collagen 7S is a preoperative predictor of PHLF and longterm postoperative liver function recovery.It can also be used in patients without chronic hepatitis virus.