Diabetes is associated with an increased risk of in-hospital mortality in liver cirrhosis with acute upper gastrointestinal bleeding

Hepatogenous diabetes: Knowledge, evidence, and skepticism

The diabetogenic potential of liver cirrhosis (LC) has been known for a long time, and the name "hepatogenous diabetes" (HD) was coined in 1906 to define the condition. Diabetes mellitus (DM) that develops as a consequence of LC is referred to as HD. In patients with LC, the prevalence rates of HD have been reported to vary from 21% to 57%. The pathophysiological basis of HD seems to involve insulin resistance (IR) and pancreatic β-cell dysfunction. The neurohormonal changes, endotoxemia, and chronic inflammation of LC initially create IR; however, the toxic effects eventually lead to β-cell dysfunction, which marks the transition from impaired glucose tolerance to HD. In addition, a number of factors, including sarcopenia, sarcopenic obesity, gut dysbiosis, and hyperammonemia, have recently been linked to impaired glucose metabolism in LC. DM is associated with complications and poor outcomes in patients with LC, although the individual impact of each type 2 DM and HD is unknown due to a lack of categorization of diabetes in most published research. In fact, there is much skepticism within scientific organizations over the recognition of HD as a separate disease and a consequence of LC. Currently, T2DM and HD are being treated in a similar manner although no standardized guidelines are available. The different pathophysiological basis of HD may have an impact on treatment options. This review article discusses the existence of HD as a distinct entity with high prevalence rates, a strong pathophysiological basis, clinical and therapeutic implications, as well as widespread skepticism and knowledge gaps.

Der hepatogene Diabetes – aktueller Stand der Diagnostik und Therapie

Hintergrund

Patienten mit Leberzirrhose entwickeln häufig Störungen des Glukosemetabolismus wie Glukoseintoleranz oder einen hepatogenen Diabetes, welche neben der hepatozellulären Funktionseinschränkung durch die ausgeprägte Insulinresistenz als Folge der chronischen Lebererkrankung verursacht sind.

Diskussion

Empfehlungen mit Leitliniencharakter zur Diagnostik und Therapie des hepatogenen Diabetes fehlen bislang. Im Hinblick auf basistherapeutische Maßnahmen sollte eine ausreichende Deckung des Energie- und Proteinstoffwechsels gewährleistet sein, da ein Großteil der Zirrhosepatienten mangelernährt ist. Bei der medikamentösen Behandlung des hepatogenen Diabetes muss auf die erhöhte Hypoglykämiegefährdung geachtet werden. Aufgrund der Nebenwirkungen sind Biguanide sowie PPAR-gamma-Liganden bei Leberzirrhose kontraindiziert. Geeignete orale Antidiabetika sind insbesondere Sulfonylharnstoffanaloga und kurz wirksame Sulfonylharnstoffe. Wenn eine suffiziente Diabeteseinstellung mit oralen Antidiabetika nicht gelingt, sollte eine prandiale Insulintherapie mit Insulinen von kurzer Wirkdauer oder kurz wirksamen Insulinanaloga eingesetzt werden.

Schlussfolgerung

Die Optimierung einer diabetischen Stoffwechsellage hat neben der Vermeidung typischer diabetischer Spätkomplikationen eine wichtige Bedeutung für die Vermeidung und Reduzierung von Zirrhose-assoziierten Komplikationen wie z. B. gastrointestinalen Blutungsereignissen, hepatischer Enzephalopathie oder dem Auftreten eines hepatozellulären Karzinoms.

Clinical implications of diabetes in chronic liver disease: Diagnosis, outcomes and management, current and future perspectives

Diabetes mellitus (DM) is common in liver cirrhosis (LC). The pathophysiological association is bidirectional. DM is a risk factor of LC and LC is a diabetogenic condition. In the recent years, research on different aspects of the association DM and LC has been intensified. Nevertheless, it has been insufficient and still exist many gaps. The aims of this review are: (1) To discuss the latest understandings of the association of DM and LC in order to identify the strategies of early diagnosis; (2) To evaluate the impact of DM on outcomes of LC patients; and (3) To select the most adequate management benefiting the two conditions. Literature searches were conducted using PubMed, Ovid and Scopus engines for DM and LC, diagnosis, outcomes and management. The authors also provided insight from their own published experience. Based on the published studies, two types of DM associated with LC have emerged: Type 2 DM (T2DM) and hepatogenous diabetes (HD). High-quality evidences have determined that T2DM or HD significantly increase complications and death pre and post-liver transplantation. HD has been poorly studied and has not been recognized as a complication of LC. The management of DM in LC patients continues to be difficult and should be based on drug pharmacokinetics and the degree of liver failure. In conclusion, the clinical impact of DM in outcomes of LC patients has been the most studied item recently. Nevertheless many gaps still exist particularly in the management. These most important gaps were highlighted in order to propose future lines for research.

Effects of diabetes on the rebleeding rate following endoscopic treatment in patients with liver cirrhosis

In the present study, the effects of diabetes on rebleeding following endoscopic treatment were assessed in patients with liver cirrhosis. A retrospective analysis of patients who underwent endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) at the First Affiliated Hospital of Anhui Medical University (Hefei, China) between June 2015 and March 2018 was performed. The patients were divided into the EVL and the EIS groups and each group was subdivided into diabetic and non-diabetic groups. The post-operative rebleeding rate was compared between the EVL and the EIS groups and between the diabetic and non-diabetic patients. The differences in the post-operative rebleeding rate of diabetic patients with hepatogenic and non-hepatogenic diabetes and in patients with different liver function grades were also determined. In the total patient cohort, the rebleeding rate in the EVL subgroup (11.3, 16.5 and 23.5%) was not significantly different compared with that in the EIS subgroup (9.8, 17.4 and 29.3%) at 1, 3 and 6 months following surgery, respectively (P=0.724, 0.868 and 0.339). In the total diabetic group, the rebleeding rate in the EVL subgroup (25.0, 36.1 and 44.4%) was not significantly different compared with that in the EIS subgroup (20.6, 32.4 and 47.1%) at 1, 3 and 6 months following surgery (P=0.660, 0.741 and 0.826, respectively). In the EVL group, the rebleeding rate in the diabetic subgroup (25.0, 36.1 and 44.4%) was higher than that in the non-diabetic subgroup (5.1, 7.6 and 13.9%) at 1, 3, and 6 months following surgery and the differences were significant (P=0.005, <0.001 and <0.001, respectively). In the EIS group, the rebleeding rate in the diabetic subgroup (20.6, 32.4 and 47.1%) was significantly higher than that in the non-diabetic subgroup (3.4, 8.6 and 19.0%) at 1, 3 and 6 months following surgery (P=0.021, 0.004 and 0.004, respectively). Adjustment for age and liver function grade in the EVL and EIS groups was performed using binary logistic regression and the parameter diabetes was indicated to be a risk factor for post-operative rebleeding (P<0.05). No significant difference was noted in the rate of rebleeding between patients with hepatogenic diabetes and non-hepatogenic diabetes at 1, 3 and 6 months following surgery (P=0.634, 0.726 and 0.446, respectively). In the total diabetic group, the rebleeding rate in the Child-Pugh grade A subgroup (14.3, 17.9 and 25.0%) was lower than that in the Child-Pugh grade B/C subgroup (28.6, 45.2 and 59.5%) at 1, 3 and 6 months following surgery, respectively. No significant difference was noted between the two groups at 1 month following surgery (P=0.163). However, the differences were significant at 3 and 6 months following surgery (P=0.018 and 0.005, respectively). The results suggested that diabetes is a risk factor for post-operative rebleeding in patients with cirrhosis. Diabetic patients with poor liver function were more likely to bleed following surgery and the post-operative bleeding rate was not significantly different between patients with hepatogenic and non-hepatogenic diabetes. The study was registered in the Chinese Clinical Trial Registry (no. ChiCTR1800017772).

Development and Validation of CAGIB Score for Evaluating the Prognosis of Cirrhosis with Acute Gastrointestinal Bleeding: A Retrospective Multicenter Study

INTRODUCTION

Acute gastrointestinal bleeding (GIB) is a major cause of death in liver cirrhosis. This multicenter study aims to develop and validate a novel and easy-to-access model for predicting the prognosis of patients with cirrhosis and acute GIB.

METHODS

Patients with cirrhosis and acute GIB were enrolled and randomly divided into the training (n = 865) and validation (n = 817) cohorts. In the training cohort, the independent predictors for in-hospital death were identified by logistic regression analyses, and then a new prognostic model (i.e., CAGIB score) was established. Area under curve (AUC) of CAGIB score was calculated by receiver operating characteristic curve analysis and compared with Child-Pugh, model for end-stage liver disease (MELD), MELD-Na, and neutrophil-lymphocyte ratio (NLR) scores.

RESULTS

In the training cohort, hepatocellular carcinoma (HCC), diabetes, total bilirubin (TBIL), albumin (ALB), alanine aminotransferase (ALT), and serum creatinine (Scr) were independent predictors of in-hospital death. CAGIB score = diabetes (yes = 1, no = 0) × 1.040 + HCC (yes = 1, no = 0) × 0.974 + TBIL (μmol/L) × 0.005 - ALB (g/L) × 0.091 + ALT (U/L) × 0.001 + Scr (μmol/L) × 0.012 - 3.964. In the training cohort, the AUC of CAGIB score for predicting in-hospital death was 0.829 (95% CI 0.801-0.854, P < 0.0001), which was higher than that of Child-Pugh (0.762, 95% CI 0.732-0.791), MELD (0.778, 95% CI 0.748-0.806), MELD-Na (0.765, 95% CI 0.735-0.793), and NLR (0.587, 95% CI 0.553-0.620) scores. In the validation cohort, the AUC of CAGIB score (0.714, 95% CI 0.682-0.746, P = 0.0006) remained higher than that of Child-Pugh (0.693, 95% CI 0.659-0.725), MELD (0.662, 95% CI 0.627-0.695), MELD-Na (0.660, 95% CI 0.626-0.694), and NLR (0.538, 95% CI 0.503-0.574) scores.

CONCLUSION

CAGIB score has a good predictive performance for prognosis of patients with cirrhosis and acute GIB.

Relationship Between Diabetes Mellitus and Cirrhosis Risk in Chronic Hepatitis B Patients in Wuhan, China

Background

The objective of our research was to assess the possible link between diabetes mellitus (DM) and liver cirrhosis in chronic hepatitis B (CHB) patients in Wuhan, China.

Material/Methods

Individuals with a diagnosis of both liver cirrhosis and chronic HBV infection (n=257), and CHB-only patients (n=514) were matched 1: 2 by age and sex. Demographic, lifestyle, laboratory, and clinical characteristics were reviewed. Univariate and the multiple logistic regression analysis were conducted to investigate the association between DM and HBV-related liver cirrhosis.

Results

The prevalence of DM was higher among CHB patients with liver cirrhosis than in those without liver cirrhosis (22.2% vs. 12.8%, P=0.001), yielding an adjusted odds ratio (AOR) of 2.317 and a 95% confidence interval (CI) of 1.528–3.513. Among them, 87.7% of liver cirrhosis patients were diagnosed with DM before liver cirrhosis diagnosis, yielding an AOR (95% CI) of 2.386 (1.533–3.714). In comparison to patients with a DM duration of 2–5 years, the AOR (95% CI) for those with a DM duration >5 years was 2.073 (0.701–6.132). In DM treatment, the AOR (95% CI) for those treated with insulin was 4.746 (1.329–16.949).

Conclusions

DM was associated with cirrhosis risk in CHB patients in Wuhan, China.

Liver-to-abdominal area ratio for predicting the in-hospital mortality in advanced liver cirrhosis

OBJECTIVES

To identify the value of liver-to-abdominal area ratio (LAAR) score for predicting the in-hospital mortality in advanced cirrhotic patients.

METHODS

All cirrhotic patients with Child-Pugh class B or C who were admitted between July 2012 and June 2014 and underwent abdominopelvic CT scans were considered in this retrospective observational study. The association of LAAR with in-hospital death was calculated. Receiver operating characteristic curve analysis was performed. The area under curve (AUC) was calculated.

RESULTS

In the overall analysis of 128 cirrhotic patients with Child-Pugh class B or C, LAAR score was significantly associated with the risk of in-hospital death (p = 0.012). The AUC of LAAR score for predicting the in-hospital mortality was 0.764 (p < 0.0001). The best cut-off value was 0.29 with a sensitivity of 75% and a specificity of 73.33%. In the subgroup analysis of 37 patients with Child-Pugh class C, LAAR score was significantly associated with the risk of in-hospital death (p = 0.008). The AUC of LAAR score was 0.821. The best cut-off value was 0.29 with a sensitivity of 85.71% and a specificity of 80%. In the subgroup analysis of 80 patients with moderate-severe ascites, LAAR score was not significantly associated with the risk of in-hospital death (p = 0.072). The AUC of LAAR score was 0.684 (p = 0.0158). The best cut-off value was 0.29 with a sensitivity of 75% and a specificity of 63.89%.

CONCLUSION

LAAR score might be effective for predicting the in-hospital death of advanced cirrhosis.

Pro-Brain Natriuretic Peptide and Troponin T-Hypersensitivity Levels Correlate With the Severity of Liver Dysfunction in Liver Cirrhosis

BACKGROUND

Increased pro-brain natriuretic peptide (pro-BNP) or troponin T-hypersensitivity (TnT-HSST) levels are common in liver cirrhosis. We conducted a retrospective observational study aimed to evaluate the correlation of pro-BNP and TnT-HSST levels with the clinical characteristics, laboratory data and in-hospital outcomes of patients with liver cirrhosis.

MATERIALS AND METHODS

We selected cirrhotic patients admitted to our hospital between January 2011 and June 2014. All eligible patients had pro-BNP or TnT-HSST data, or both. The pro-BNP and TnT-HSST data were further divided according to the presence of cardiac diseases.

RESULTS

The prevalence of pro-BNP level >900pg/mL was 41.72% (63 of 151 patients). The prevalence of TnT-HSST level >0.05ng/mL was 11.22% (45 of 401 patients). In the overall analysis, pro-BNP level significantly correlated with red blood cell (RBC), platelet, ascites, blood urea nitrogen (BUN), creatinine (Cr), Child-Pugh score, model for end-stage liver disease (MELD) score and in-hospital death; TnT-HSST level significantly correlated with white blood cell, ascites, albumin (ALB), BUN, Cr, Child-Pugh score, MELD score and in-hospital death. In patients with cardiac diseases, pro-BNP level significantly correlated with RBC, ascites, BUN, Cr, Child-Pugh score and MELD score; TnT-HSST level significantly correlated with sex, ascites, white blood cell, ALB, BUN, Cr, Child-Pugh score, MELD score and in-hospital death. In patients without cardiac diseases, pro-BNP level significantly correlated with ascites, RBC, platelet, BUN, Cr, MELD score and in-hospital death; TnT-HSST level significantly correlated with age, ascites, RBC, ALB, BUN, Cr, Child-Pugh score, MELD score and in-hospital death.

CONCLUSIONS

Pro-BNP and TnT-HSST levels significantly correlated with the severity of liver dysfunction and in-hospital mortality in cirrhosis.

Association Between Hepatocellular Carcinoma and Type 2 Diabetes Mellitus in Chinese Hepatitis B Virus Cirrhosis Patients: A Case-Control Study

BACKGROUND Whether the presence of type 2 diabetes mellitus (T2DM) increases the risk of hepatocellular carcinoma (HCC) in hepatitis B virus (HBV) cirrhosis patients is controversial. We conducted a retrospective case-control study to evaluate this issue. MATERIAL AND METHODS We considered all patients diagnosed with HBV-related liver cirrhosis at our hospital from July 2011 to June 2014. The case (n=91) and control (n=91) groups were HBV cirrhosis patients with and without T2DM, respectively. They were matched at a ratio of 1: 1 according to the individual age (±2 years) and same sex and Child-Pugh score. RESULTS None of the baseline data were significantly different between the 2 groups. The percentage of HCC was similar between the 2 groups (case versus control group: 34.1% versus 46.2%, P=0.13). In the case group, sex (P=0.002), alkaline phosphatase (P<0.001), g-glutamine transferase (P=0.001), and sodium (P=0.003) were associated with the risk of HCC. In the control group, platelet (P=0.041), alanine aminotransferase (P=0.034), aspartate aminotransferase (P=0.026), alkaline phosphatase (P<0.001), and γ-glutamine transferase (P<0.001) were associated with the risk of HCC. CONCLUSIONS T2DM may not be a risk factor for the presence of HCC in HBV cirrhosis.

Hepatogenous diabetes: Is it time to separate it from type 2 diabetes?

By definition, hepatogenous diabetes is directly caused by loss of liver function, implying that it develops after cirrhosis onset. Therefore, it should be distinguished from type 2 diabetes developing before cirrhosis onset, in which specific causes of liver disease play a major role, in addition to traditional risk factors. Currently, although hepatogenous diabetes shows distinct pathophysiological and clinical features, it is not considered as an autonomous entity. Recent evidence suggests that the failing liver exerts an independent "toxic" effect on pancreatic islets resulting in β-cell dysfunction. Moreover, patients with hepatogenous diabetes usually present with normal fasting glucose and haemoglobin A_1c levels and abnormal response to an oral glucose tolerance test, which is therefore required for diagnosis. This article discusses the need to separate hepatogenous diabetes from type 2 diabetes occurring in subjects with chronic liver disease and to identify individuals suffering from this condition for prognostic and therapeutic purposes.

Diagnostic accuracy of contrast-enhanced computed tomography for esophageal varices in liver cirrhosis: a retrospective observational study

BACKGROUND AND AIM

Esophageal variceal bleeding is a life-threatening complication of liver cirrhosis. Upper gastrointestinal endoscopy was the gold standard for the diagnosis of esophageal varices (EVs). The study aimed to evaluate the accuracy of contrast-enhanced computed tomography (CT) in the diagnosis of EVs and moderate-severe EVs in patients with liver cirrhosis.

METHODS

Medical records in cirrhotic patients who were admitted to our hospital between June 2012 and June 2014 were retrospectively reviewed. Two observers reviewed the contrast-enhanced CT scans to evaluate the presence and diameter of EVs. Area under curve (AUC), sensitivity, and specificity were calculated.

RESULTS

A total of 52 cirrhotic patients were included in our study. According to the endoscopic results, 13.5% of these patients did not have any EVs, 11.5% had mild EVs, and 75% had moderate-severe EVs. The AUC of contrast-enhanced CT scans for the diagnosis of EVs was 0.835. The sensitivity and specificity were 95.56% and 71.43%, respectively. The AUC of contrast-enhanced T scans for the diagnosis of moderate-severe EVs was 0.821. When the cut-off value for the diameter of EVs on contrast-enhanced CT scans was 3.9 mm, the sensitivity and specificity were 89.74% and 69.23%, respectively.

CONCLUSIONS

Contrast-enhanced CT scans had a moderate diagnostic accuracy for EVs in liver cirrhosis. It might be useful to decrease the use of upper gastrointestinal endoscopy in clinical practice.

D-dimer level for predicting the in-hospital mortality in liver cirrhosis: A retrospective study

The present study aimed to examine the correlation of D-dimer levels with the Child-Pugh and MELD scores, as well as to determine the predictive ability of D-dimer level for the in-hospital mortality of liver cirrhosis patients. All cirrhotic patients who were consecutively admitted to our hospital between January 2011 and June 2014, and underwent D-dimer tests on admission were retrospectively analyzed. Pearson's χ2 tests were employed to evaluate the correlations of D-dimer levels with Child-Pugh and MELD scores. In addition, receiver operating curve (ROC) analysis was employed to evaluate the specificity and sensitivity of D-dimer levels for predicting the in-hospital mortality. In total, 703 cirrhotic patients were included in the study, with an in-hospital mortality of 5.4% (38/703). The D-dimer levels were correlated with Child-Pugh (correlation coefficient, 0.219; P<0.001) and MELD scores (correlation coefficient, 0.207; P<0.001). The highest D-dimer level was observed in the Child-Pugh class C patients, followed by the class B and A patients. Furthermore, D-dimer was significantly higher in the MELD score >15 group compared with the MELD score <15 group. The area under the ROC of D-dimer levels for predicting the in-hospital mortality of liver cirrhosis was 0.729 (P<0.0001), while the best cut-off D-dimer value was 0.28 µg/ml with a sensitivity of 86.84% and a specificity of 49.17%. In conclusion, the D-dimer level is significantly associated with the degree of liver dysfunction. Therefore, D-dimer testing could be employed for the prognostic stratification of liver cirrhosis.

Association of conventional haemostasis and coagulation tests with the risk of acute upper gastrointestinal bleeding in liver cirrhosis: a retrospective study

OBJECTIVE

A retrospective study was performed to compare the difference in platelet count (PLT), prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), between cirrhotic patients with and without acute upper gastrointestinal bleeding (AUGIB) or acute oesophageal variceal bleeding (AEVB).

METHODS

Between January 2012 and June 2014, a total of 1734 cirrhotic patients were enrolled and were classified into 'AUGIB' (n = 497) and 'no AUGIB' (n = 1237) groups according to their disease history. They were further divided into 'AEVB' (n = 297) and 'no AEVB' (n = 1259) groups according to the endoscopic findings. Additionally, 178 patients with AUGIB were not assigned to either the 'AEVB' or 'no AEVB' groups due to the absence of any endoscopic findings.

RESULTS

Compared with the 'no AUGIB' group, the 'AUGIB' group had similar PLT (99.99 ± 89.90 vs.101.47 ± 83.03; P = 0.734) and APTT (42.96 ± 15.20 vs.43.77 ± 11.01; P = 0.219), but significantly higher PT (17.30 ± 5.62 vs.16.03 ± 4.68; P < 0.001) and INR (1.45 ± 0.69 vs.1.31 ± 0.59; P < 0.001). A lower PT was independently associated with the absence of AUGIB (OR = 0.968; 95% CI: 0.942-0.994). Compared with the 'no AEVB' group, the 'AEVB' group had significantly lower PLT (86.87 ± 62.14 vs.101.74 ± 83.62; P = 0.004) and APTT (40.98 ± 7.9 vs.43.72 ± 10.97; P < 0.001), but similar PT (16.53 ± 3.71 vs.16.04 ± 4.68; P = 0.088) and INR (1.35 ± 0.41 vs.1.31 ± 0.59; P = 0.225). A higher PLT was independently associated with the absence of AEVB (OR = 1.004; 95% CI: 1.002-1.006; P = 0.001).

CONCLUSIONS

PLT was associated with the occurrence of portal hypertension-related bleeding in liver cirrhosis.

Prevalence, Risk Factors and In-hospital Outcomes of QTc Interval Prolongation in Liver Cirrhosis

BACKGROUND

QTc interval prolongation is an electrocardiographic abnormality in liver cirrhosis. The objective of this study was to evaluate the prevalence, risk factors and in-hospital outcomes of QTc interval prolongation in Chinese patients with liver cirrhosis.

METHODS

This was a retrospective analysis of a total of 1,268 patients with liver cirrhosis who were consecutively admitted to our hospital between January 2011 and June 2014. QTc interval data were collected from the medical records. QTc interval prolongation was defined as QTc interval > 440 milliseconds.

RESULTS

The prevalence of QTc interval prolongation was 38.2% (485 of 1268). In the entire cohort, the risk factors for QTc interval prolongation included an older age, a higher proportion of alcohol abuse and ascites, higher bilirubin, blood urea nitrogen, creatinine, prothrombin time, international normalized ratio, Child-Pugh score and model for end-stage liver diseases score, and lower red blood cell (RBC), hemoglobin (Hb), albumin (ALB), alanine aminotransferase and calcium. The in-hospital mortality was not significantly different between patients with and without QTc interval prolongation (2.1% versus 1.3%, P = 0.276). In the subgroup analyses of patients with hepatitis B virus or alcohol alone-related liver cirrhosis, the risk factors included higher bilirubin, creatinine, prothrombin time, international normalized ratio, Child-Pugh score and model for end-stage liver diseases score, and lower RBC, Hb and ALB. In the subgroups analyses of patients with acute upper gastrointestinal bleeding or ascites, the risk factors included lower RBC, Hb and ALB.

CONCLUSIONS

QTc interval prolongation was frequent in liver cirrhosis. Although QTc interval prolongation was positively associated with alcohol-related liver cirrhosis and more severe liver dysfunction, it did not significantly influence the in-hospital mortality.

Splenectomy Causes 10-Fold Increased Risk of Portal Venous System Thrombosis in Liver Cirrhosis Patients

BACKGROUND Portal venous system thrombosis (PVST) is a life-threatening complication of liver cirrhosis. We conducted a retrospective study to comprehensively analyze the prevalence and risk factors of PVST in liver cirrhosis. MATERIAL AND METHODS All cirrhotic patients without malignancy admitted between June 2012 and December 2013 were eligible if they underwent contrast-enhanced CT or MRI scans. Independent predictors of PVST in liver cirrhosis were calculated in multivariate analyses. Subgroup analyses were performed according to the severity of PVST (any PVST, main portal vein [MPV] thrombosis >50%, and clinically significant PVST) and splenectomy. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. RESULTS Overall, 113 cirrhotic patients were enrolled. The prevalence of PVST was 16.8% (19/113). Splenectomy (any PVST: OR=11.494, 95%CI=2.152-61.395; MPV thrombosis >50%: OR=29.987, 95%CI=3.247-276.949; clinically significant PVST: OR=40.415, 95%CI=3.895-419.295) and higher hemoglobin (any PVST: OR=0.974, 95%CI=0.953-0.996; MPV thrombosis >50%: OR=0.936, 95%CI=0.895-0.980; clinically significant PVST: OR=0.935, 95%CI=0.891-0.982) were the independent predictors of PVST. The prevalence of PVST was 13.3% (14/105) after excluding splenectomy. Higher hemoglobin was the only independent predictor of MPV thrombosis >50% (OR=0.952, 95%CI=0.909-0.997). No independent predictors of any PVST or clinically significant PVST were identified in multivariate analyses. Additionally, PVST patients who underwent splenectomy had a significantly higher proportion of clinically significant PVST but lower MELD score than those who did not undergo splenectomy. In all analyses, the in-hospital mortality was not significantly different between cirrhotic patient with and without PVST. CONCLUSIONS Splenectomy may increase by at least 10-fold the risk of PVST in liver cirrhosis independent of severity of liver dysfunction.

Epidemiology, Risk Factors, and In-Hospital Mortality of Venous Thromboembolism in Liver Cirrhosis: A Single-Center Retrospective Observational Study

BACKGROUND

Risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), may be increased in liver cirrhosis. We conducted a single-center study to explore the epidemiology, risk factors, and in-hospital mortality of VTE in Chinese patients with liver cirrhosis.

MATERIAL/METHODS

All patients with liver cirrhosis who were consecutively admitted to our hospital between January 2011 and December 2013 were retrospectively included.

RESULTS

Of 2006 patients with liver cirrhosis included, 9 patients were diagnosed with or developed VTE during hospitalization, including 5 patients with a previous history of DVT, 1 patient with either a previous history of DVT or new onset of PE, and 3 patients with new onset of VTE (PE, n=1; DVT, n=2). Risk factors for VTE included a significantly higher proportion of hypertension and significantly higher red blood cells, hemoglobin, alanine aminotransferase, aspartate aminotransferase, prothrombin time (PT), international normalized ratio (INR), D-dimer, and Child-Pugh scores. The in-hospital mortality was significantly higher in patients with VTE than those without VTE (33.3% [3/9] versus 3.4% [67/1997], P<0.001).

CONCLUSIONS

VTE was observed in 0.4% of patients with liver cirrhosis during hospitalization and it significantly increased the in-hospital mortality. Elevated PT/INR aggravated the risk of VTE.

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, and King Scores for Diagnosis of Esophageal Varices in Liver Cirrhosis: A Retrospective Study

BACKGROUND Aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, fibrosis index (FI), and King scores might be alternatives to the use of upper gastrointestinal endoscopy for the diagnosis of esophageal varices (EVs) in liver cirrhosis. This study aimed to evaluate their diagnostic accuracy in predicting the presence and severity of EVs in liver cirrhosis. MATERIAL AND METHODS All patients who were consecutively admitted to our hospital and underwent upper gastrointestinal endoscopy between January 2012 and June 2014 were eligible for this retrospective study. Areas under curve (AUCs) were calculated. Subgroup analyses were performed according to the history of upper gastrointestinal bleeding (UGIB) and splenectomy. RESULTS A total of 650 patients with liver cirrhosis were included, and 81.4% of them had moderate-severe EVs. In the overall analysis, the AUCs of these non-invasive scores for predicting moderate-severe EVs and presence of any EVs were 0.506-0.6 and 0.539-0.612, respectively. In the subgroup analysis of patients without UGIB, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.601-0.664 and 0.596-0.662, respectively. In the subgroup analysis of patients without UGIB or splenectomy, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.627-0.69 and 0.607-0.692, respectively. CONCLUSIONS APRI, AAR, FIB-4, FI, and King scores had modest diagnostic accuracy of EVs in liver cirrhosis. They might not be able to replace the utility of upper gastrointestinal endoscopy for the diagnosis of EVs in liver cirrhosis.