Association of serum albumin level with incidence and mortality of overt hepatic encephalopathy in cirrhosis during hospitalization

BACKGROUND

Hepatic encephalopathy (HE) is a serious complication of cirrhosis. Decreased serum albumin (ALB) level may facilitate the development of HE and accelerate the death of cirrhotic patients with HE. Recent evidence also suggests that human albumin infusion may reduce the incidence of HE and improve the outcomes of cirrhotic patients. This study aimed to explore the association of serum ALB level with the development of overt HE and HE-associated mortality during hospitalization.

METHODS

Cirrhotic patients admitted to our hospital between January 2010 and February 2019 were screened. Independent predictors for HE were identified by logistic regression analyses. Odds ratio (OR) with 95% confidence interval (95% CI) was calculated. Area under curve (AUC) was calculated by receiver operator characteristic curve analyses.

RESULTS

Of the 2376 included patients with cirrhosis but without HE at admission, 113 (4.8%) developed overt HE during hospitalizations. ALB level (OR = 0.878, 95% CI = 0.834-0.924) was an independent risk factor for development of overt HE. AUC of ALB level for predicting the development of overt HE was 0.770 (95% CI = 0.752-0.787, p < 0.0001), and the best cut-off value was ⩽31.6 g/l. Of the 183 included patients with cirrhosis and overt HE at admission, 20 (10.9%) died during hospitalizations. ALB level (OR = 0.864, 95% CI = 0.771-0.967) was an independent risk factor for death from overt HE. The AUC of ALB level for predicting death from overt HE was 0.737 (95% CI = 0.667-0.799, p = 0.0001), and the best cut-off value was ⩽22.8 g/l.

CONCLUSIONS

Decreased serum ALB level may be associated with higher risk of overt HE and HE-associated mortality during hospitalizations in cirrhosis.

Prevalence of CALR mutations in splanchnic vein thrombosis: A systematic review and meta-analysis

BACKGROUND

The prevalence of calreticulin (CALR) mutations in splanchnic vein thrombosis (SVT) varies among studies. The role of routine screening for CALR mutations in SVT patients remains a debate.

AIM

To synthesize the prevalence of CALR mutations according to the different types (i.e., Budd-Chiari syndrome [BCS] and portal vein thrombosis [PVT]) and characteristics (i.e., with and without myeloproliferative neoplasms [MPNs] and JAK2V617F mutation) of SVT patients.

METHODS

Eligible studies were searched by the PubMed and Embase databases. The study quality was assessed according to the STROBE checklist. The proportion of CALR mutations was pooled by using a random-effects model. The heterogeneity and publication bias were calculated.

RESULTS

Eleven papers were included. The study quality was moderate to high. The pooled proportion of CALR mutations was 1.21%, 1.41%, and 1.59% in SVT, BCS, and PVT patients, respectively; 1.52%, 1.03%, and 1.82% in these patients without JAK2V617F mutation, respectively; 3.71%, 2.79%, and 7.87% in these patients with MPN, respectively; and 15.16%, 17.22%, and 31.44% in these patients with MPN but without JAK2V617F mutation, respectively. Only the meta-analysis examining the prevalence of CLAR mutations in BCS patients with MPN but without the JAK2V617F mutation showed statistically significant heterogeneity. Statistically significant publication bias was seen only in the meta-analysis examining the prevalence of CALR mutations in SVT patients without the JAK2V617F mutation.

CONCLUSION

Screening for CALR mutations may have a role in SVT patients with a high probability of MPN in whom the JAK2V617F mutation has been excluded.

Clinical outcomes of the transplantation of stem cells from various human tissue sources in the management of liver cirrhosis: a systematic review and meta-analysis

AIMS

A systematic review and meta-analysis were performed to explore the clinical outcome of the transplantation of stem cells from various human tissue sources in cirrhotic patients.

METHODS

The relevant papers were searched via PubMed, EMBASE, and Cochrane Library databases. Changes in liver function before and after stem cell therapy were evaluated (self-control data). Difference in liver function and incidence of procedure-related complications, hepatocellular carcinoma (HCC), and death between patients undergoing stem cell therapy and conventional treatment were evaluated (case-control data).

RESULTS

Of 786 papers initially identified, 31 were included. The sources of stem cell included bone marrow (n=26), umbilical cord (n=3), peripheral blood (n=1), and human fetal liver (n=1). No severe procedure-related complications were reported. According to the meta- analyses of self-control data, model for end-stage liver diseases (MELD) score was significantly reduced at the 3rd-4th and 6th months after stem cell therapy, but this reduction was not statistically significant at the 1st-2nd or 12th postoperative months. Child-Pugh score was also reduced after stem cell therapy, but the reduction was not statistically significant at all follow-up time points. According to the meta-analyses of case-control data, MELD and Child-Pugh scores were not significantly different between treatment and control groups at all follow-up time points. The incidence of HCC was not significantly different between treatment and control groups (odds ratio [OR] to=0.41, P=0.53). The mortality was not significantly different between the two groups (OR=0.48, P=0.20).

CONCLUSION

Stem cell therapy could improve the liver function without any severe procedure-related complications. However, compared with conventional treatment, the benefit of stem cell therapy appeared to be not significant in improving the liver function and survival.

Outcomes of early versus delayed endoscopy in cirrhotic patients with acute variceal bleeding: a systematic review with meta-analysis

OBJECTIVES

Endoscopy is the mainstay treatment option for acute variceal bleeding (AVB) in liver cirrhosis. However, the optimal timing of endoscopy in such patients remains unclear.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched. We compared the mortality, incidence of rebleeding, length of stay, endoscopic hemostasis, need for salvage and units of transfusion between cirrhotic patients with AVB who underwent early and delayed endoscopy. Meta-analyses were performed by using a random-effect model. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Subgroup analysis was performed in studies where early endoscopy was defined as <12 h.

RESULTS

Nine retrospective studies involving 2824 patients were included. The early endoscopy group had a significantly lower overall mortality than the delayed endoscopy group in overall analysis (OR = 0.56, 95% CI, 0.33-0.95, P = 0.03), but the difference between them was NS in subgroup analysis (OR = 0.72, 95% CI, 0.38-1.38, P = 0.33). In-hospital (OR = 0.77, 95% CI, 0.26-2.32, P = 0.65) and 6-week (OR = 0.78, 95% CI, 0.42-1.47, P = 0.45) mortality were not significantly different between them. Overall rebleeding was not significantly different between early and delayed endoscopy groups in both overall (OR = 0.88, 95% CI, 0.51-1.51, P = 0.63) and subgroup (OR = 1.04, 95% CI, 0.55-1.95, P = 0.90) analyses. In-hospital (OR = 1.41, 95% CI, 0.67-2.96, P = 0.37) and 6-week (OR = 0.93, 95% CI, 0.40-2.17, P = 0.86) rebleeding remained not significantly different between them. Additionally, the length of stay, endoscopic hemostasis, need for salvage and units of transfusion were not significantly different between them.

CONCLUSIONS

Early endoscopy may improve the survival of cirrhotic patients with AVB, but has no remarkable benefit on the prevention of rebleeding. These findings should be further validated by high-quality studies.

Gastrointestinal Bleeding due to Pancreatic Disease-Related Portal Hypertension

BACKGROUND AND AIMS

Left-sided portal hypertension (LSPH) is a rare type of portal hypertension, which occurs due to obstruction, stenosis, or thrombosis within the splenic vein. Pancreatic diseases are the most common etiology of LSPH. This study is aimed at reporting our experiences and discussing the presentation, management, and prognosis of LSPH secondary to pancreatic diseases. Patients and Methods. We retrospectively reviewed five patients who were diagnosed with LSPH secondary to pancreatic diseases at our department. We collected the demographic information, history, comorbidities, clinical presentations, laboratory tests, esophagogastroduodenoscopy (EGD), images, and outcome data.

RESULTS

Three elderly patients (>60 years old) were diagnosed with pancreatic cancer, of whom one underwent laparoscopic radical distal pancreatectomy and splenectomy, one received chemotherapy, and another one chose conservative management due to multiple systemic metastases. Two younger patients (<40 years old) were diagnosed with acute recurrent pancreatitis and chronic pancreatitis. Four of these five included patients presented with hematemesis and/or melena at our admission. All patients had gastric varices, and one of them also had esophageal varices. One elderly patient with metastatic pancreatic cancer underwent endoscopic variceal treatment as a rescue therapy but finally died of refractory gastrointestinal (GI) bleeding; another younger patient with chronic pancreatitis died of massive GI bleeding; and the remaining three patients survived at their last follow-up.

CONCLUSIONS

LSPH should be seriously taken into consideration in patients with pancreatic diseases who develop upper GI bleeding. Clinicians should individualize the treatment strategy of LSPH according to the patients' clinical conditions and nature of pancreatic diseases.

Percutaneous Transhepatic Biliary Stent Implantation for Obstructive Jaundice of Perihilar Cholangiocarcinoma: A Prospective Study on Predictors of Stent Patency and Survival in 92 Patients

PURPOSE

To evaluate prognostic factors for stent patency and survival in patients with perihilar cholangiocarcinoma (pCCA) who underwent percutaneous biliary stent placement.

MATERIALS AND METHODS

This prospective study followed 92 consecutive patients with pCCA who underwent metal stent placement between January 2013 and July 2014. Of the total number of patients, 11 had ascites, and 36 had biliary obstruction for > 1 month at the time of stent placement. Cumulative patency and survival rates were assessed with Kaplan-Meier curves, and independent predictors were calculated with Cox regression. A new formula was developed to predict patient survival.

RESULTS

Tumor size was significantly associated with stent patency (hazard ratio = 2.425; 95% confidence interval, 1.134-5.168). Independent predictors of survival included lymph node metastasis, intrahepatic mass lesion, cancer antigen 19-9 (CA19-9), ascites, and duration of jaundice. A new equation was developed to assess risk: R = 7 × (duration of biliary obstruction-0 if < 30 d, 1 if > 30 d) + 7 × (CA19-9-0 if < 500, 1 if > 500) + 7 × (ascites-0 if none present, 1 if ascites present) + 10 × (lymph node metastasis-0 if no metastasis, 1 if metastasis present) + 9 (intrahepatic mass lesion-0 if absent, 1 if present). Among patients who developed stent occlusion, patients who underwent recanalization of the occluded stent had longer survival compared with patients who did not undergo recanalization (109 d vs 29 d, P = .001).

CONCLUSIONS

Prognostic factors for survival after percutaneous stent placement in patients with pCCA were tumor stage, duration of jaundice, CA19-9, and ascites. Tumor size affected stent patency. Prognosis for patients with reintervention after occlusion of the stent improved.

Serum Liver Fibrosis Markers for Predicting the Presence of Gastroesophageal Varices in Liver Cirrhosis: A Retrospective Cross-Sectional Study

Background and Aims. A retrospective cross-sectional study was conducted to evaluate the role of hyaluronic acid (HA), laminin (LN), amino-terminal propeptide of type III procollagen (PIIINP), and collagen IV (CIV) in predicting the presence of gastroesophageal varices (GEVs) in patients with liver cirrhosis. Methods. We enrolled 118 patients with liver cirrhosis who underwent the tests for the four serum liver fibrosis markers and upper gastrointestinal endoscopy at the same admissions. The predictive values of the four serum liver fibrosis markers were evaluated by the areas under the receiving operator characteristics curves (AUROCs) with 95% confidence intervals (CIs). Results. The prevalence of GEVs was 88% (104/118). The AUROCs for HA, LN, PIIINP, and CIV levels in predicting the presence of GEVs were 0.553 (95% CI: 0.458 to 0.644, P = 0.5668), 0.490 (95% CI: 0.397 to 0.584, P = 0.9065), 0.622 (95% CI: 0.528 to 0.710, P = 0.1099), and 0.560 (95% CI: 0.466 to 0.652, P = 0.4909). The PIIINP level at a cut-off value of 31.25 had a sensitivity of 73.1% and a specificity of 57.1%. Conclusions. The present study did not recommend HA, LN, PIIINP, and CIV levels to evaluate the presence of GEVs in liver cirrhosis.

Synergistic Effect of Biejia-Ruangan on Fibrosis Regression in Patients With Chronic Hepatitis B Treated With Entecavir: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Long-term nucleos(t)ide analogue (NA) treatment can reverse liver fibrosis in chronic hepatitis B (CHB), but its effect on fibrosis regression remains limited. Biejia-Ruangan (BR) has been approved in China as an antifibrotic traditional Chinese medicine drug in patients with chronic liver diseases. A multicenter randomized controlled trial aims to evaluate the effect of BR on fibrosis regression in CHB patients treated with NAs.

METHODS

CHB patients with histologically confirmed advanced fibrosis or cirrhosis were randomly assigned to receive entecavir (ETV) (0.5 mg per day) plus BR (2 g 3 times a day) or placebo for 72 weeks. Liver fibrosis regression was defined as a reduction of ≥ 1 point by the Ishak fibrosis stage (IFS).

RESULTS

Overall, 500 patients were enrolled in each group as the intention-to-treat population. The rate of fibrosis regression after 72 weeks of treatment was significantly higher in the ETV + BR group (40% vs 31.8%; P = .0069). Among 388 patients with cirrhosis (ie, IFS ≥ 5) at baseline, the rate of cirrhosis reversal (ie, IFS ≤ 4) was significantly higher in the ETV + BR group (41.5% vs 30.7%; P = .0103).

CONCLUSIONS

Addition of BR to the current standard treatment with NAs in CHB patients with advanced fibrosis or cirrhosis can improve liver fibrosis regression.

CLINICAL TRIALS REGISTRATION

NCT01965418.

Risk factors for mortality of coronavirus disease 2019 (COVID-19) patients during the early outbreak of COVID-19: a systematic review and meta-analysis

BACKGROUND

Identification of risk factors for poor prognosis of patients with coronavirus disease 2019 (COVID-19) is necessary to enable the risk stratification and modify the patient's management. Thus, we performed a systematic review and meta-analysis to evaluate the in-hospital mortality and risk factors of death in COVID-19 patients.

METHODS

All studies were searched via the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang databases. The in-hospital mortality of COVID-19 patients was pooled. Odds ratios (ORs) or mean difference (MD) with 95% confidence intervals (CIs) were calculated for evaluation of risk factors.

RESULTS

A total of 80 studies were included with a pooled in-hospital mortality of 14% (95% CI: 12.2-15.9%). Older age (MD =13.32, 95% CI: 10.87-15.77; P<0.00001), male (OR =1.66, 95% CI: 1.37-2.01; P<0.00001), hypertension (OR =2.67, 95% CI: 2.08-3.43; P<0.00001), diabetes (OR =2.14, 95% CI: 1.76-2.6; P<0.00001), chronic respiratory disease (OR =3.55, 95% CI: 2.65-4.76; P<0.00001), chronic heart disease/cardiovascular disease (OR =3.15, 95% CI: 2.43-4.09; P<0.00001), elevated levels of high-sensitive cardiac troponin I (MD =66.65, 95% CI: 16.94-116.36; P=0.009), D-dimer (MD =4.33, 95% CI: 2.97-5.68; P<0.00001), C-reactive protein (MD =48.03, 95% CI: 27.79-68.27; P<0.00001), and a decreased level of albumin at admission (MD =-3.98, 95% CI: -5.75 to -2.22; P<0.0001) are associated with higher risk of death. Patients who developed acute respiratory distress syndrome (OR =62.85, 95% CI: 29.45-134.15; P<0.00001), acute cardiac injury (OR =25.16, 95% CI: 6.56-96.44; P<0.00001), acute kidney injury (OR =22.86, 95% CI: 4.60-113.66; P=0.0001), and septic shock (OR =24.09, 95% CI: 4.26-136.35; P=0.0003) might have a higher in-hospital mortality.

CONCLUSIONS

Advanced age, male, comorbidities, increased levels of acute inflammation or organ damage indicators, and complications are associated with the risk of mortality in COVID-19 patients, and should be integrated into the risk stratification system.

Anthropometric measures associated with sarcopenia in outpatients with liver cirrhosis

AIM

The present study aimed to identify variables associated with sarcopenia in cirrhotic outpatients using clinical data, anthropometric measures and lab tests. In a single centre prospective study, 261 cirrhotic outpatients were followed on average for 2 years. The diagnostic criteria of sarcopenia were applied according to the current guidelines, combining muscle strength and appendicular muscle mass index.

METHODS

Age, sex, liver disease aetiology and the Model of End-Stage Liver Disease score were included as independent variables, as well as mid-arm circumference (MAC), body mass index and triceps skinfold. Multiple logistic regression was applied including all independent variables (maximum model). Then, the analysis was performed only with the variables that were significant in the first analysis (parsimonious model). Once the variable most related to sarcopenia was determined by the two models, the area under the receiver operator characteristic curve was calculated. Mortality rates were described for patients with and without sarcopenia.

RESULTS

Sarcopenia was diagnosed in 14 subjects (5.36%), and the variable best associated with sarcopenia was MAC (P < 0.01). The 1-year mortality rate of 35.71% found among subjects with sarcopenia was not significantly higher (P = 0.07) than the 15.38% observed among those without this condition.

CONCLUSIONS

Before examinations requiring ionising radiation, patients with cirrhosis can be submitted to simple screening tools to identify those who have a high risk of sarcopenia, thus promoting a cost-effective assessment.

Esophageal Stent for Refractory Variceal Bleeding: A Systemic Review and Meta-Analysis

Background. Preliminary studies suggest that covered self-expandable metal stents may be helpful in controlling esophageal variceal bleeding. Aims. To evaluate the effectiveness and safety of esophageal stent in refractory variceal bleeding in a systematic review and meta-analysis. Methods. A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 1970 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using I (2) test. Results. Five studies involving 80 patients were included in the analysis. The age of patients ranged from 18 to 91 years. The mean duration of follow-up was 46.8 d (range, 30-60 d). The success rate of stent deployment was 96.7% (95% CI: 91.6%-99.5%) and complete response to esophageal stenting was in 93.9% (95% CI: 82.2%-99.6%). The incidence of rebleeding was 13.2% (95% CI: 1.8%-32.8%) and the overall mortality was 34.5% (95% CI: 24.8%-44.8%). Most of patients (87.4%) died from hepatic or multiple organ failure, and only 12.6% of patients died from uncontrolled bleeding. There was no stent-related complication reported and the incidence of stent migration was 21.6% (95% CI: 4.7%-46.1%). Conclusion. Esophageal stent may be considered in patients with variceal bleeding refractory to conventional therapy.

Association of proton pump inhibitors with the risk of hepatic encephalopathy during hospitalization for liver cirrhosis

BACKGROUND

Hepatic encephalopathy is associated with altered gut microbiota. Proton pump inhibitors increase the risk of small bowel bacterial overgrowth.

OBJECTIVES

This was a case-control study aimed at exploring the relationship of proton pump inhibitor use with the risk of hepatic encephalopathy during hospitalization in liver cirrhosis.

METHODS

Case and control groups were defined as cirrhotic patients who developed hepatic encephalopathy during hospitalization and those without hepatic encephalopathy at admission or during hospitalization, respectively. Age, gender, and Child-Pugh score were matched between the groups. Odds ratios with 95% confidence intervals were calculated to express the association of proton pump inhibitors with the risk of hepatic encephalopathy. Four subgroup analyses were performed after excluding patients with acute upper gastrointestinal bleeding, infections, and in-hospital death, and after matching model for end-stage liver disease score.

RESULTS

In the overall analysis, 128 patients were included in each group of cases and controls. The proportion of proton pump inhibitor use was significantly higher in the case group than the control group (79.7% vs 43%, p < 0.001). Proton pump inhibitor use (odds ratio = 3.481, 95% confidence interval: 1.651-7.340, p = 0.001) was independently associated with the development of hepatic encephalopathy in the multivariate analysis. In the four subgroup analyses, proton pump inhibitor use remained independently associated with the risk of hepatic encephalopathy.

CONCLUSION

Proton pump inhibitor use might increase the risk of hepatic encephalopathy during hospitalization.

Effect of Body Mass Index on the Prognosis of Liver Cirrhosis

Objective: At present, the association of body mass index (BMI) with the prognosis of liver cirrhosis is controversial. Our retrospective study aimed to evaluate the impact of BMI on the outcome of liver cirrhosis. Methods: In the first part, long-term death was evaluated in 436 patients with cirrhosis and without malignancy from our prospectively established single-center database. In the second part, in-hospital death was evaluated in 379 patients with cirrhosis and with acute gastrointestinal bleeding (AGIB) from our retrospective multicenter study. BMI was calculated and categorized as underweight (BMI <18.5 kg/m2), normal weight (18.5 ≤ BMI < 23.0 kg/m2), and overweight/obese (BMI ≥ 23.0 kg/m2). Results: In the first part, Kaplan-Meier curve analyses demonstrated a significantly higher cumulative survival rate in the overweight/obese group than the normal weight group (p = 0.047). Cox regression analyses demonstrated that overweight/obesity was significantly associated with decreased long-term mortality compared with the normal weight group [hazard ratio (HR) = 0.635; 95% CI: 0.405-0.998; p = 0.049] but not an independent predictor after adjusting for age, gender, and Child-Pugh score (HR = 0.758; 95%CI: 0.479-1.199; p = 0.236). In the second part, Kaplan-Meier curve analyses demonstrated no significant difference in the cumulative survival rate between the overweight/obese and the normal weight groups (p = 0.094). Cox regression analyses also demonstrated that overweight/obesity was not significantly associated with in-hospital mortality compared with normal weight group (HR = 0.349; 95%CI: 0.096-1.269; p = 0.110). In both of the two parts, the Kaplan-Meier curve analyses demonstrated no significant difference in the cumulative survival rate between underweight and normal weight groups. Conclusion: Overweight/obesity is modestly associated with long-term survival in patients with cirrhosis but not an independent prognostic predictor. There is little effect of overweight/obesity on the short-term survival of patients with cirrhosis and with AGIB.

Impact of spontaneous splenorenal shunt on liver volume and long-term survival of liver cirrhosis

BACKGROUND AND AIM

Spontaneous splenorenal shunt (SSRS) is one of the manifestations of portal hypertension in liver cirrhosis. However, the impact of SSRS on long-term survival of cirrhotic patients remains unclear. We hypothesize that SSRS may worsen liver dysfunction and deteriorate prognosis in liver cirrhosis by decreasing hepatic perfusion.

METHODS

Patients with liver cirrhosis who were admitted to our department between December 2014 and August 2019 and underwent contrast-enhanced computed tomography or magnetic resonance imaging scans were prospectively collected. The maximum diameters of SSRS and portal vein system vessels were retrospectively measured. Liver-to-abdominal area ratio, Child-Pugh, and model for end-stage liver disease scores were calculated.

RESULTS

Overall, 122 cirrhotic patients were included. The prevalence of SSRS was 30.3% (37/122). Median diameter of SSRS was 13.5 mm. Patients with SSRS had significantly thinner diameters of right portal vein (9 mm vs 11.2 mm, P = 0.001) and main portal vein (15.3 mm vs 16.8 mm, P = 0.017) than those without SSRS. Patients with SSRS had significantly lower liver-to-abdominal area ratio score (25.39 vs 31.58, P < 0.001) and higher Child-Pugh (7 vs 6, P = 0.046) and model for end-stage liver disease (12.17 vs 9.79, P < 0.006) scores than those without SSRS. Patients with SSRS had a significantly lower cumulative survival rate than those without SSRS (P = 0.014). Cox regression analysis also showed that SSRS was a risk factor of death of cirrhotic patients (hazard ratio = 4.161, 95% confidence interval = 1.215-14.255, P = 0.023).

CONCLUSIONS

Spontaneous splenorenal shunt may narrow portal vein diameter and shrink liver volume, thereby worsening liver function and increasing mortality in liver cirrhosis.

Splanchnic Vein Thrombosis in Liver Cirrhosis After Splenectomy or Splenic Artery Embolization: A Systematic Review and Meta-Analysis

INTRODUCTION

Splenectomy and splenic artery embolization are major treatment options for hypersplenism and portal hypertension in liver cirrhosis, but may lead to splanchnic vein thrombosis (SVT), which is potentially lethal. We conducted a systematic review and meta-analysis to explore the incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization and the risk factors for SVT.

METHODS

All relevant studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization was pooled. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Sixty-six studies with 5632 patients with cirrhosis were included. The pooled incidence of SVT after splenectomy and splenic artery embolization was 24.6% (95% CI 20.2-29.3%) and 11.7% (95% CI 7.1-17.3%), respectively. A meta-analysis of three comparative studies demonstrated that the incidence of SVT after splenectomy was statistically similar to that after splenic artery embolization (OR 3.15, P = 0.290). Platelet count, mean platelet volume, preoperative splenic or portal vein diameter, preoperative or postoperative portal blood velocity, splenic volume and weight, and periesophagogastric devascularization were significant risk factors for SVT after splenectomy. Postoperative use of preventive antithrombotic therapy was a significant protective factor against SVT after splenectomy.

CONCLUSIONS

SVT is common in liver cirrhosis after splenectomy and splenic artery embolization. Coagulation and hemostasis factors, anatomical factors, and surgery-related factors have been widely identified for the assessment of high risk of SVT after splenectomy. Prophylactic strategy after splenectomy, such as antithrombotic therapy, might be considered in such high-risk patients.

STUDY REGISTRATION

This study was registered in PROSPERO with a registration number of CRD42019129673.

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.

Use of albumin infusion for cirrhosis-related complications: An international position statement

BACKGROUND & AIMS

Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy.

METHODS

Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications.

RESULTS

Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion.

CONCLUSIONS

Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated.

IMPACT AND IMPLICATIONS

Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion.

Thrombosis of the Portal Venous System in Cirrhotic vs. Non-Cirrhotic Patients

INTRODUCTION AND AIM

Thrombosis is a vascular disorder of the liver often associated with significant morbidity and mortality. Cirrhosis is a predisposing factor for portal venous system thrombosis. The aim of this study is to determine differences between cirrhotics and non-cirrhotics that develop thrombosis in portal venous system and to evaluate if cirrhosis severity is related to the development of portal venous system thrombosis.

MATERIAL AND METHODS

We studied patients diagnosed with portal venous system thrombosis using contrast-enhanced computed tomography scan and doppler ultrasound at Medica Sur Hospital from 2012 to 2017. They were categorized into two groups; cirrhotics and non-cirrhotics. We assessed the hepatic function by Child-Pugh score and model for end-stage liver disease.

RESULTS

67 patients with portal venous system thrombosis (25 with non-cirrhotic liver and 42 with cirrhosis) were included. The mean age (± SD) was 65 ± 9.5 years in cirrhotic group and 57 ± 13.2 years (p = 0.009) in non-cirrhotic group. Comparing non-cirrhotics and cirrhotics, 8 non-cirrhotic patients showed evidence of extra-hepatic inflammatory conditions, while in the cirrhotic group no inflammatory conditions were found (p < 0.001). 27 (64.29%) cirrhotic patients had thrombosis in the portal vein, while only 9 cases (36%) were found in non-cirrhotics (p = 0.02).

CONCLUSIONS

In cirrhotic patients, hepatocellular carcinoma and cirrhosis were the strongest risk factors to develop portal venous system thrombosis. In contrast, extrahepatic inflammatory conditions were main risk factors associated in non-cirrhotics. Moreover, the portal vein was the most frequent site of thrombosis in both groups.

Supersonic shear imaging for the diagnosis of liver fibrosis and portal hypertension in liver diseases: a meta-analysis

BACKGROUND AND AIMS

The meta-analysis aimed to summarize the technical success rate of supersonic shear imaging (SSI) and to evaluate the diagnostic performance of liver and spleen stiffness measurement (LSM and SSM) with SSI for the detection of liver fibrosis, portal hypertension, and gastroesophageal varices in liver diseases.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched. Technical success rate of SSI was pooled. Area under curve (AUC), sensitivity, and specificity with corresponding 95% confidence interval (CI) were calculated.

RESULTS

Included studies regarding the diagnostic performance of SSI for liver fibrosis, portal hypertension, and esophageal varices numbered 28, 4, and 4 respectively. The pooled technical success rates of LSM and SSM were 95.3% and 75.5%, respectively. The AUC, sensitivity, and specificity of LSM/SSM for different stages of liver fibrosis were 0.85-0.94, 0.7-0.89, and 0.82-0.92, respectively. The AUC, sensitivity, and specificity of LSM were 0.84 (95%CI = 0.8-0.86), 0.79 (95%CI = 0.7-0.85), and 0.82 (95%CI = 0.72-0.88) for clinically significant portal hypertension, 0.85 (95%CI = 0.82-0.88), 0.8 (95%CI = 0.68-0.88), and 0.8 (95%CI = 0.6-0.92) for any varices, and 0.86 (95%CI = 0.83-0.89), 0.86 (95%CI = 0.76-0.92), and 0.61 (95%CI = 0.35-0.83) for high-risk varices, respectively.

CONCLUSIONS

LSM with SSI had a high diagnostic accuracy for liver fibrosis, but a moderate diagnostic accuracy for portal hypertension and esophageal varices.

Clinical significance of neutrophil extracellular traps biomarkers in thrombosis

Neutrophil extracellular traps (NETs) may be associated with the development of thrombosis. Experimental studies have confirmed the presence of NETs in thrombi specimens and potential role of NETs in the mechanisms of thrombosis. Clinical studies also have demonstrated significant changes in the levels of serum or plasma NETs biomarkers, such as citrullinated histones, myeloperoxidase, neutrophil elastase, nucleosomes, DNA, and their complexes in patients with thrombosis. This paper aims to comprehensively review the currently available evidence regarding the change in the levels of NETs biomarkers in patients with thrombosis, summarize the role of NETs and its biomarkers in the development and prognostic assessment of venous thromboembolism, coronary artery diseases, ischemic stroke, cancer-associated thromboembolism, and coronavirus disease 2019-associated thromboembolism, explore the potential therapeutic implications of NETs, and further discuss the shortcomings of existing NETs biomarkers in serum and plasma and their detection methods.

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.

Metabolic dysfunction: The silenced connection with fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) represents a global public health burden. Despite the increase in its prevalence, the disease has not received sufficient attention compared to the associated diseases such as diabetes mellitus and obesity. In 2020 it was proposed to rename NAFLD to metabolic dysfunction-associated fatty liver disease (MAFLD) in order to recognize the metabolic risk factors and the complex pathophysiological mechanisms associated with its development. Furthermore, along with the implementation of the proposed diagnostic criteria, the aim is to address the whole clinical spectrum of the disease, regardless of BMI and the presence of other hepatic comorbidities. As would it be expected with such a paradigm shift, differing viewpoints have emerged regarding the benefits and disadvantages of renaming fatty liver disease. The following review aims to describe the way to the MAFLD from a historical, pathophysiological and clinical perspective in order to highlight why MAFLD is the approach to follow.