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Mahmud N, Asrani SK, Kaplan DE, Ogola GO, Taddei TH, Kamath PS, Serper M. The Predictive Role of Model for End-Stage Liver Disease-Lactate and Lactate Clearance for In-Hospital Mortality Among a National Cirrhosis Cohort. Liver Transpl 2021; 27:177-189. [PMID: 37160007 PMCID: PMC7880877 DOI: 10.1002/lt.25913] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023]
Abstract
The burden of cirrhosis hospitalizations is increasing. The admission Model for End-Stage Liver Disease-lactate (MELD-lactate) was recently demonstrated to be a superior predictor of in-hospital mortality compared with MELD in limited cohorts. We identified specific classes of hospitalizations where MELD-lactate may be especially useful and evaluated the predictive role of lactate clearance. This was a retrospective cohort study of 1036 cirrhosis hospitalizations for gastrointestinal bleeding, infection, or other portal hypertension-related indications in the Veterans Health Administration where MELD-lactate was measured on admission. Performance characteristics for in-hospital mortality were compared between MELD-lactate and MELD/MELD-sodium (MELD-Na), with stratified analyses of MELD categories (≤15, >15 to <25, ≥25) and reason for admission. We also incorporated day 3 lactate levels into modeling and tested for an interaction between day 1 MELD-lactate and day 3 lactate clearance. MELD-lactate had superior discrimination for in-hospital mortality compared with MELD or MELD-Na (area under the curve [AUC] 0.789 versus 0.776 versus 0.760, respectively; P < 0.001) and superior calibration. MELD-lactate had higher discrimination among hospitalizations with MELD ≤15 (AUC 0.763 versus 0.608 for MELD, global P = 0.01) and hospitalizations for infection (AUC 0.791 versus 0.674 for MELD, global P < 0.001). We found a significant interaction between day 1 MELD-lactate and day 3 lactate clearance; heat maps were created as clinical tools to risk-stratify patients based on these clinical data. MELD-lactate had significantly superior performance in predicting in-hospital mortality among patients hospitalized for infection and/or with MELD ≤15 when compared with MELD or MELD-Na. Incorporating day 3 lactate clearance may further improve prognostication.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sumeet K. Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | | | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | | | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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Lee S, Doktorchik C, Martin EA, D'Souza AG, Eastwood C, Shaheen AA, Naugler C, Lee J, Quan H. Electronic Medical Record-Based Case Phenotyping for the Charlson Conditions: Scoping Review. JMIR Med Inform 2021; 9:e23934. [PMID: 33522976 PMCID: PMC7884219 DOI: 10.2196/23934] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/20/2020] [Accepted: 12/05/2020] [Indexed: 12/16/2022] Open
Abstract
Background Electronic medical records (EMRs) contain large amounts of rich clinical information. Developing EMR-based case definitions, also known as EMR phenotyping, is an active area of research that has implications for epidemiology, clinical care, and health services research. Objective This review aims to describe and assess the present landscape of EMR-based case phenotyping for the Charlson conditions. Methods A scoping review of EMR-based algorithms for defining the Charlson comorbidity index conditions was completed. This study covered articles published between January 2000 and April 2020, both inclusive. Embase (Excerpta Medica database) and MEDLINE (Medical Literature Analysis and Retrieval System Online) were searched using keywords developed in the following 3 domains: terms related to EMR, terms related to case finding, and disease-specific terms. The manuscript follows the Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews (PRISMA) guidelines. Results A total of 274 articles representing 299 algorithms were assessed and summarized. Most studies were undertaken in the United States (181/299, 60.5%), followed by the United Kingdom (42/299, 14.0%) and Canada (15/299, 5.0%). These algorithms were mostly developed either in primary care (103/299, 34.4%) or inpatient (168/299, 56.2%) settings. Diabetes, congestive heart failure, myocardial infarction, and rheumatology had the highest number of developed algorithms. Data-driven and clinical rule–based approaches have been identified. EMR-based phenotype and algorithm development reflect the data access allowed by respective health systems, and algorithms vary in their performance. Conclusions Recognizing similarities and differences in health systems, data collection strategies, extraction, data release protocols, and existing clinical pathways is critical to algorithm development strategies. Several strategies to assist with phenotype-based case definitions have been proposed.
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Affiliation(s)
- Seungwon Lee
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chelsea Doktorchik
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Elliot Asher Martin
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Adam Giles D'Souza
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Cathy Eastwood
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Abdel Aziz Shaheen
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Joon Lee
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hude Quan
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Serper M, Weinberg EM, Cohen JB, Reese PP, Taddei TH, Kaplan DE. Mortality and Hepatic Decompensation in Patients With Cirrhosis and Atrial Fibrillation Treated With Anticoagulation. Hepatology 2021; 73:219-232. [PMID: 32267547 PMCID: PMC7541418 DOI: 10.1002/hep.31264] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/10/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Outcomes with anticoagulation (AC) are understudied in advanced liver disease. We investigated effects of AC with warfarin and direct oral anticoagulants (DOACs) on all-cause mortality and hepatic decompensation as well as ischemic stroke, major adverse cardiovascular events, splanchnic vein thrombosis, and bleeding in a cohort with cirrhosis and atrial fibrillation (AF). APPROACH AND RESULTS This was a retrospective, longitudinal study using national data of U.S. veterans with cirrhosis at 128 medical centers, including patients with cirrhosis with incident AF, from January 1, 2012 to December 31, 2017 followed through December 31, 2018. To assess the effects of AC on outcomes, we applied propensity score (PS) matching and marginal structural models (MSMs) to account for confounding by indication and time-dependent confounding. The final cohort included 2,694 veterans with cirrhosis with AF (n = 1,694 and n = 704 in the warfarin and DOAC cohorts after PS matching, respectively) with a median of 4.6 years of follow-up. All-cause mortality was lower with warfarin versus no AC (PS matched: hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.55-0.76; MSM models: HR, 0.54; 95% CI, 0.40-0.73) and DOACs versus no AC (PS matched: HR, 0.68; 95% CI, 0.50-0.93; MSM models: HR, 0.50; 95% CI, 0.31-0.81). In MSM models, warfarin (HR, 0.29; 95% CI, 0.09-0.90) and DOACs (HR, 0.23; 95% CI, 0.07-0.79) were associated with reduced ischemic stroke. In secondary analyses, bleeding was lower with DOACs compared to warfarin (HR, 0.49; 95% CI, 0.26-0.94). CONCLUSIONS Warfarin and DOACs were associated with reduced all-cause mortality. Warfarin was associated with more bleeding compared to no AC. DOACs had a lower incidence of bleeding compared to warfarin in exploratory analyses. Future studies should prospectively investigate these observed associations.
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Affiliation(s)
- Marina Serper
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Ethan M. Weinberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Jordana B. Cohen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA,Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA,Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut CT,Division of Gastroenterology, Yale University School of Medicine, New Haven, CT
| | - David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
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Shah S, Goldberg DS, Kaplan DE, Sundaram V, Taddei TH, Mahmud N. Patient Frailty Is Independently Associated With the Risk of Hospitalization for Acute-on-Chronic Liver Failure. Liver Transpl 2021; 27:16-26. [PMID: 32946660 PMCID: PMC8249075 DOI: 10.1002/lt.25896] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 12/17/2022]
Abstract
There is significant interest in identifying risk factors associated with acute-on-chronic liver failure (ACLF). In transplant candidates, frailty predicts wait-list mortality and posttransplant outcomes. However, the impact of frailty on ACLF development and mortality is unknown. This was a retrospective study of US veterans with cirrhosis identified between 2008 and 2016. First hospitalizations were characterized as ACLF or non-ACLF admissions. Prehospitalization patient frailty was ascertained using a validated score based on administrative coding data. We used logistic regression to investigate the impact of an increasing frailty score on the odds of ACLF hospitalization and short-term ACLF mortality. Cox regression was used to analyze the association between frailty and longterm survival from hospitalization. We identified 16,561 cirrhosis hospitalizations over a median follow-up of 4.19 years (interquartile range, 2.47-6.34 years). In adjusted models, increasing frailty score was associated with significantly increased odds of ACLF hospitalization versus non-ACLF hospitalization (odds ratio, 1.03 per point; 95% CI 1.02-1.03; P < 0.001). By contrast, frailty score was not associated with ACLF 28- or 90-day mortality (P = 0.13 and P = 0.33, respectively). In an adjusted Cox analysis of all hospitalizations, increasing frailty scores were associated with poorer longterm survival from the time of hospitalization (hazard ratio, 1.02 per 5 points; 95% confidence interval, 1.01-1.03; P = 0.004). Frailty increases the likelihood of ACLF hospitalization among patients with cirrhosis, but it does not impact short-term ACLF mortality. These findings have implications for clinicians caring for frail outpatients with cirrhosis, including tailored follow-up, risk mitigation strategies, and possible expedited transplant evaluation.
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Affiliation(s)
- Shivani Shah
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Nadim Mahmud
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Mahmud N, Fricker Z, Hubbard RA, Ioannou GN, Lewis JD, Taddei TH, Rothstein KD, Serper M, Goldberg DS, Kaplan DE. Risk Prediction Models for Post-Operative Mortality in Patients With Cirrhosis. Hepatology 2021; 73:204-218. [PMID: 32939786 PMCID: PMC7902392 DOI: 10.1002/hep.31558] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are at increased risk of postoperative mortality. Currently available tools to predict postoperative risk are suboptimally calibrated and do not account for surgery type. Our objective was to use population-level data to derive and internally validate cirrhosis surgical risk models. APPROACH AND RESULTS We conducted a retrospective cohort study using data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) cohort, which contains granular data on patients with cirrhosis from 128 U.S. medical centers, merged with the Veterans Affairs Surgical Quality Improvement Program (VASQIP) to identify surgical procedures. We categorized surgeries as abdominal wall, vascular, abdominal, cardiac, chest, or orthopedic and used multivariable logistic regression to model 30-, 90-, and 180-day postoperative mortality (VOCAL-Penn models). We compared model discrimination and calibration of VOCAL-Penn to the Mayo Risk Score (MRS), Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease-Sodium MELD-Na, and Child-Turcotte-Pugh (CTP) scores. We identified 4,712 surgical procedures in 3,785 patients with cirrhosis. The VOCAL-Penn models were derived and internally validated with excellent discrimination (30-day postoperative mortality C-statistic = 0.859; 95% confidence interval [CI], 0.809-0.909). Predictors included age, preoperative albumin, platelet count, bilirubin, surgery category, emergency indication, fatty liver disease, American Society of Anesthesiologists classification, and obesity. Model performance was superior to MELD, MELD-Na, CTP, and MRS at all time points (e.g., 30-day postoperative mortality C-statistic for MRS = 0.766; 95% CI, 0.676-0.855) in terms of discrimination and calibration. CONCLUSIONS The VOCAL-Penn models substantially improve postoperative mortality predictions in patients with cirrhosis. These models may be applied in practice to improve preoperative risk stratification and optimize patient selection for surgical procedures (www.vocalpennscore.com).
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Rebecca A. Hubbard
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George N. Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - James D. Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Kenneth D. Rothstein
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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Hernaez R, Liu Y, Kramer JR, Rana A, El-Serag HB, Kanwal F. Model for end-stage liver disease-sodium underestimates 90-day mortality risk in patients with acute-on-chronic liver failure. J Hepatol 2020; 73:1425-1433. [PMID: 32531416 PMCID: PMC10424237 DOI: 10.1016/j.jhep.2020.06.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/18/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS It is unclear whether the model for end-stage liver disease-sodium (MELD-Na) score captures the clinical severity of acute-on-chronic liver failure (ACLF). We compared observed 90-day mortality in patients with ACLF with expected mortality based on the calculated MELD-Na and examined the consequences of underestimating clinical severity. METHODS We identified patients with ACLF during hospitalization for cirrhosis in 127 VA hospitals between 01/01/2004 and 12/31/2014. We examined MELD-Na scores by ACLF presence and grade. We used actual and observed 90-day mortality to estimate a standardized mortality ratio (SMR) by ACLF presence and grade. We used transplant center-specific median MELD-Na at transplantation (MMaT) to estimate the proportion likely to receive priority for liver transplantation (LT) based on MELD-Na alone. RESULTS Of 71,894 patients hospitalized for decompensated cirrhosis, 18,979 (26.4%) patients met the criteria for ACLF on admission. The median (P25-P75) MELD-Na on admission was 26 (22-30) for ACLF compared to 15 (12-20) for patients without ACLF; it was 24 (21-27), 27 (23-31), and 32 (26-37) for ACLF-1, 2 and 3, respectively. At 90 days, 40.0% of patients with ACLF died (30.8%, 41.6% and 68.8% with ACLF-1, 2 and 3, respectively) compared to 21.3% of patients without ACLF. Compared to the expected death rate based on MELD-Na, mortality risk was higher for patients with ACLF, SMR (95% CI): 1.52 (1.48-1.52), 1.46 (1.41-1.51), 1.50 (1.44-1.55), 1.66 (1.58-1.74) for overall ACLF, ACLF-1, -2 and -3, respectively. Only 9.1% of patients with ACLF reached the national median MELD-Na of 35 and between 17.3% to 35.1% exceeded the MMaT at any center. During index admission, 589 (0.8%) patients with ACLF were considered for LT evaluation and 16 (0.1%) were listed for LT. CONCLUSIONS In a US cohort of hospitalized patients with decompensated cirrhosis, MELD-Na did not capture 90-day mortality risk in patients with ACLF. Patients with ACLF are at a disadvantage in the current MELD-Na-based system. LAY SUMMARY Acute-on-chronic liver failure (ACLF) is a condition marked by multiple organ failures in patients with cirrhosis and is associated with a high risk of death. Liver transplantation may be the only curative treatment for these patients. A score called model for end-stage liver disease-sodium (MELD-Na) helps guide donor liver allocation for transplantation in the United States. The higher the MELD-Na score in a patient, the more likely that a patient receives a liver transplant. Our study data showed that MELD-Na score underestimates the risk of dying at 90 days in patients with ACLF. Thus, physicians need to start liver transplant evaluation early instead of waiting for a high MELD-Na number.
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Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, Texas, United States of America; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College.
| | - Yan Liu
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College
| | - Abbas Rana
- Section of Surgery, Baylor College of Medicine, Houston, Texas, United States of America
| | - Hashem B El-Serag
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, Texas, United States of America; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College
| | - Fasiha Kanwal
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, Texas, United States of America; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College
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The Use of Administrative Data to Investigate the Population Burden of Hepatic Encephalopathy. J Clin Med 2020; 9:jcm9113620. [PMID: 33182743 PMCID: PMC7696713 DOI: 10.3390/jcm9113620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Abstract
Hepatic encephalopathy (HE) is a devastating complication of cirrhosis with an increasing footprint in global public health. Although the condition is defined using a careful history and examination, we cannot accurately measure the true impact of HE relying on data collected exclusively from clinical studies. For this reason, administrative data sources are necessary to study the population burden of HE. Administrative data is generated with each health care encounter to account for health care resource utilization and is extracted into a dataset for the secondary purpose of research. In order to utilize such data for valid analysis, several pitfalls must be avoided—specifically, selecting the particular database capable of meeting the needs of the study’s aims, paying careful attention to the limits of each given database, and ensuring validity of case definition for HE specific to the dataset. In this review, we summarize the types of data available for and the results of administrative data studies of HE.
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Kanwal F, Taylor TJ, Kramer JR, Cao Y, Smith D, Gifford AL, El-Serag HB, Naik AD, Asch SM. Development, Validation, and Evaluation of a Simple Machine Learning Model to Predict Cirrhosis Mortality. JAMA Netw Open 2020; 3:e2023780. [PMID: 33141161 PMCID: PMC7610191 DOI: 10.1001/jamanetworkopen.2020.23780] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/01/2020] [Indexed: 12/12/2022] Open
Abstract
Importance Machine-learning algorithms offer better predictive accuracy than traditional prognostic models but are too complex and opaque for clinical use. Objective To compare different machine learning methods in predicting overall mortality in cirrhosis and to use machine learning to select easily scored clinical variables for a novel cirrhosis prognostic model. Design, Setting, and Participants This prognostic study used a retrospective cohort of adult patients with cirrhosis or its complications seen in 130 hospitals and affiliated ambulatory clinics in the integrated, national Veterans Affairs health care system from October 1, 2011, to September 30, 2015. Patients were followed up through December 31, 2018. Data were analyzed from October 1, 2017, to May 31, 2020. Exposures Potential predictors included demographic characteristics; liver disease etiology, severity, and complications; use of health care resources; comorbid conditions; and comprehensive laboratory and medication data. Patients were randomly selected for model development (66.7%) and validation (33.3%). Three different statistical and machine learning methods were evaluated: gradient descent boosting, logistic regression with least absolute shrinkage and selection operator (LASSO) regularization, and logistic regression with LASSO constrained to select no more than 10 predictors (partial pathway model). Predictor inclusion and model performance were evaluated in a 5-fold cross-validation. Last, the predictors identified in the most parsimonious (the partial path) model were refit using maximum-likelihood estimation (Cirrhosis Mortality Model [CiMM]), and its predictive performance was compared with that of the widely used Model for End Stage Liver Disease with sodium (MELD-Na) score. Main Outcomes and Measures All-cause mortality. Results Of the 107 939 patients with cirrhosis (mean [SD] age, 62.7 [9.6] years; 96.6% male; 66.3% white, 18.4% African American), the annual mortality rate ranged from 8.8% to 15.3%. In total, 32.7% of patients died within 3 years, and 46.2% died within 5 years after the index date. Models predicting 1-year mortality had good discrimination for the gradient descent boosting (area under the receiver operating characteristics curve [AUC], 0.81; 95% CI, 0.80-0.82), logistic regression with LASSO regularization (AUC, 0.78; 95% CI, 0.77-0.79), and the partial path logistic model (AUC, 0.78; 95% CI, 0.76-0.78). All models showed good calibration. The final CiMM model with machine learning-derived clinical variables offered significantly better discrimination than the MELD-Na score, with AUCs of 0.78 (95% CI, 0.77-0.79) vs 0.67 (95% CI, 0.66-0.68) for 1-year mortality, respectively (DeLong z = 17.00; P < .001). Conclusions and Relevance In this study, simple machine learning techniques performed as well as the more advanced ensemble gradient boosting. Using the clinical variables identified from simple machine learning in a cirrhosis mortality model produced a new score more transparent than machine learning and more predictive than the MELD-Na score.
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Affiliation(s)
- Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Thomas J. Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Jennifer R. Kramer
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Yumei Cao
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Donna Smith
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Allen L. Gifford
- Department of Medicine, VA Boston Healthcare System, Boston University, Boston, Massachusetts
- Department of Health Law, Policy, and Management, VA Boston Healthcare System, Boston University, Boston, Massachusetts
| | - Hashem B. El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Aanand D. Naik
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Steven M. Asch
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
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Mazumder NR, Celaj S, Atiemo K, Daud A, Jackson KL, Kho A, Levitsky J, Ladner DP. Liver-related mortality is similar among men and women with cirrhosis. J Hepatol 2020; 73:1072-1081. [PMID: 32344052 PMCID: PMC7572539 DOI: 10.1016/j.jhep.2020.04.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Sex-based differences are known to significantly contribute to outcomes in patients with chronic liver diseases; however, the role of patient sex in cirrhosis is unclear. We aimed to study the relationship between patient sex and cirrhosis. METHODS We analyzed a cohort of 20,045 patients with cirrhosis using a Chicago-wide electronic health record database that was linked with the United Network for Organ Sharing and cause of death data from the state death registry. Adjusted Cox survival analyses and competing risk analyses were performed to obtain subdistribution hazard ratios (HRs) for liver-related cause of death. RESULTS Female and male patients had similar age, racial distribution, insurance status, and comorbidity status by Elixhauser score. Females had higher rates of cholestatic liver disease (17.1% vs. 6.2%, p <0.001) and non-alcoholic steatohepatitis (29.8% vs. 21.2%, p <0.001) than males. They were less likely to have portal hypertensive complications and had lower peak MELD-Na scores during follow-up. Female sex was associated with a decreased hazard of all-cause mortality (adjusted HR 0.85; 95% CI 0.80-0.90). This effect was attenuated when liver-related mortality was examined (subdistribution HR 0.93; 95% CI 0.87-1.00). No significant difference was noted for women who were 'ever-listed' in competing risk analyses for either all-cause mortality (subdistribution HR 1.09; 95% CI 0.88-1.35) or liver-related death (subdistribution HR 1.12; 95% CI 0.87-1.43), despite lower rates of listing (7.5% vs. 9.8%; p <0.001) and transplant (3.5% vs. 5.2%; p <0.001). CONCLUSIONS In this longitudinal study of patients with cirrhosis, female sex was associated with a survival advantage likely driven by lower rates of non-liver-related death. Women were not at an increased risk of liver-related death despite lower rates of listing and transplantation. LAY SUMMARY Patient sex is an important contributor in many chronic diseases, including cirrhosis. Prior studies have suggested that female sex is associated with worse outcomes. We analyzed a cohort of 20,045 patients with cirrhosis using a Chicago-wide electronic health record database. Using multivariate competing risk analyses, we found that female sex in cirrhosis is actually associated with a lower risk of all-cause mortality and has no association with liver-related mortality. Our findings are novel because we show that women with cirrhosis have a similar risk of liver-related death as their male counterparts, despite lower rates of listing and transplantation.
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Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Stela Celaj
- Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kofi Atiemo
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Amna Daud
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kathryn L Jackson
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Chicago, IL
| | - Abel Kho
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Chicago, IL
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniela P Ladner
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL.
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Abstract
BACKGROUND In the United States, nearly 30% of liver transplants (LT) are performed for hepatocellular carcinoma (HCC). Although overall long-term survival is highest with LT, there are limited data on the incremental survival benefit of LT versus other curative options (resection or ablation) due to shunting of patients towards LT. METHODS We performed a retrospective cohort study of patients aged 50-69 with cirrhosis and HCC in the Veterans Health Administration (population enriched with 3 curative treatments) from 2008 to 2016. The cohort was restricted to patients who received LT, resection, or ablation and a calculated model for end-stage liver disease score <15 at HCC diagnosis. RESULTS Among 2129 veterans in the analytic cohort, 658 (26.7%) received LT, 244 (11.5%) underwent resection, and 1317 (61.59%) received ablation. In multivariable models, patients who underwent resection (hazard ratio: 5.42; 95% confidence interval: 4.15-7.08) or ablation (hazard ratio: 5.50; 95% confidence interval: 4.51-6.71) had significantly increased hazards of death. However, in absolute terms, the incremental survival benefit of LT over resection or ablation was small, between 0.02 and 0.03 years at 1 year, 0.32-0.42 years at 3 years, and 1.04-1.24 years at 5 years follow-up. These results were consistent in sensitivity analyses accounting for possible immortal time bias, as well as a cohort restricted to early/intermediate stage HCC. CONCLUSIONS Although LT is associated with significantly increased survival compared to resection and ablation, the absolute incremental survival benefit is small over a 5-year time horizon. Optimal selection of patients for LT is critical for maximizing utilization of a scarce resource.
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Abstract
Risk scoring for patients with cirrhosis has evolved greatly over the past several decades. However, patients with low Model for End-Stage Liver Disease-Sodium scores still suffer from liver-related morbidity and mortality. Unfortunately, it is not clear which of these low Model for End-Stage Liver Disease-Sodium score patients would benefit from earlier consideration of liver transplantation. This article reviews the literature of risk prediction in patients with cirrhosis, identifies which patients may benefit from earlier interventions, such as transplantation, and proposes directions for future research.
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Verna EC, Morelli G, Terrault NA, Lok AS, Lim JK, Di Bisceglie AM, Zeuzem S, Landis CS, Kwo P, Hassan M, Manns MP, Vainorius M, Akushevich L, Nelson DR, Fried MW, Reddy KR. DAA therapy and long-term hepatic function in advanced/decompensated cirrhosis: Real-world experience from HCV-TARGET cohort. J Hepatol 2020; 73:540-548. [PMID: 32243960 DOI: 10.1016/j.jhep.2020.03.031] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/27/2020] [Accepted: 03/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Direct-acting antiviral (DAA) therapy is used in patients with HCV-related decompensated cirrhosis with the expectation of improving hepatic function. However, little is known about the long-term hepatic benefit of successful antiviral treatment. METHODS Patients with advanced/decompensated cirrhosis (model for end-stage liver disease [MELD] ≥10), in whom NS5A-containing DAA therapy was initiated prior to September 2018, were included (from the HCV-TARGET cohort). Treatment outcomes and the impact of treatment on short-term and long-term hepatic function were examined. RESULTS A total of 642 patients were analyzed. The mean age was 60 years, 68% were male. The median baseline MELD was 12 (range 10-39) and 64% had prior decompensation. Among patients with available virologic outcomes, 90.5% achieved a sustained virologic response at 12 weeks (SVR12). Eighty (24%) patients achieved a clinically significant decrease in MELD by ≥3 points during short-term follow-up (9-26 weeks after the end of treatment). However, in long-term follow-up (median of 4 years after treatment), mean changes in MELD (-0.30 points), total bilirubin (+0.23 mg/dl) and albumin (+0.36 g/dl) were marginal. Fifty-one patients died and 22 underwent liver transplant. In long-term follow-up, a clinically meaningful decrease in MELD of ≥3 occurred in 29% and a final MELD score of <10 was achieved in 25%. CONCLUSION In a large real-world experience of patients with advanced/decompensated HCV-related cirrhosis treated with DAAs, there were only marginal improvements in MELD, total bilirubin, or albumin at long-term follow-up (after achieving SVR12). These patients may remain at high risk of decompensation and must continue to be closely monitored. CLINICALTRIALS.GOV: NCT01474811. LAY SUMMARY Hepatitis C virus infection can now be cured with medications, even in patients who have advanced scarring of the liver (cirrhosis). In this study, we evaluated whether liver function improves or deteriorates in the long-term, following successful treatment of hepatitis C in patients with cirrhosis. We found that overall liver function was relatively stable with only 29% of patients achieving a clinically meaningful improvement in liver function, and we therefore believe that these patients require ongoing monitoring.
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Affiliation(s)
| | - Giuseppe Morelli
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL
| | | | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Joseph K Lim
- Viral Hepatitis Program, Yale University School of Medicine, New Haven, CT
| | - Adrian M Di Bisceglie
- Chief of Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO
| | - Stefan Zeuzem
- Department of Medicine, Goethe University Hospital, Frankfurt, Germany
| | - Charles S Landis
- Department of Gastroenterology, University of Washington, Seattle, WA
| | - Paul Kwo
- Department of Hepatology, Stanford University, Stanford, CA
| | - Mohamed Hassan
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota, Minneapolis, MN
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Monika Vainorius
- Biometrics and Data Quality HCV-TARGET Data Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lucy Akushevich
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David R Nelson
- Department of Medicine, University of Florida, Gainesville, FL
| | - Michael W Fried
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - K Rajender Reddy
- Professor, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA.
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Mahmud N, Sundaram V, Kaplan DE, Taddei TH, Goldberg DS. Grade 1 Acute on Chronic Liver Failure Is a Predictor for Subsequent Grade 3 Failure. Hepatology 2020; 72:230-239. [PMID: 31677284 PMCID: PMC7195222 DOI: 10.1002/hep.31012] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Acute on chronic liver failure (ACLF) results in extremely high short-term mortality in patients with underlying cirrhosis. The European Association for the Study of the Liver criteria grade ACLF severity from 1 (least severe) to 3 (most severe) based on organ failures (OFs) that develop after an acute decompensation (AD). However, the implications of surviving low-grade ACLF in terms of risk of subsequent high-grade ACLF are unclear. APPROACH AND RESULTS We conducted a retrospective cohort study of patients with compensated cirrhosis in the Veterans Health Administration database from January 2008 to June 2016. Propensity matching for grade 1 (G1) ACLF, followed by Cox regression, was used to model risk of subsequent grade 3 (G3) ACLF. Stratified analyses of different ADs and OFs were also performed. We identified 4,878 patients with well-matched propensity scores. G1 ACLF events conferred a significantly increased risk of subsequent G3 ACLF relative no previous G1 ACLF (hazard ratio, 8.69; P < 0.001). When stratified by AD, patients with ascites or hepatic encephalopathy were significantly more likely to develop G3 ACLF relative to those with gastrointestinal bleed or infection as an AD (P < 0.001). Risk of G3 ACLF also varied significantly by type of OF characterizing previous G1 ACLF, with liver, coagulation, and circulatory failure posing the highest increased risk. CONCLUSIONS Patients who recover from G1 ACLF have substantially increased risk of later developing G3 ACLF as compared to those who never have G1 ACLF. Moreover, reversible decompensations for G1 ACLF have a lower risk of G3 ACLF, and liver-intrinsic OFs confer a much higher risk of G3 ACLF. These findings have implications for prognosis, future surveillance, and triaging early transplant evaluation.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - David S. Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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Xiao KY, Hubbard RA, Kaplan DE, Taddei TH, Goldberg DS, Mahmud N. Models for acute on chronic liver failure development and mortality in a veterans affairs cohort. Hepatol Int 2020; 14:587-596. [PMID: 32519219 DOI: 10.1007/s12072-020-10060-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE The diagnosis of acute on chronic liver failure (ACLF) carries a high short-term mortality, making early identification of at-risk patients crucial. To date, there are no models that predict which patients with compensated cirrhosis will develop ACLF, and limited models exist to predict ACLF mortality. We sought to create novel risk prediction models using a large North American cohort. METHODS We performed a retrospective study of 75,922 patients with compensated cirrhosis from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) dataset. Using 70% derivation/30% validation sets, we identified ACLF patients using the Asian Pacific Association of Liver (APASL) definition. Multivariable logistic regression was used to derive prediction models (called VOCAL-Penn) for developing ACLF at 3, 6, and 12 months. We then created prediction models for ACLF mortality at 28 and 90 days. RESULTS The VOCAL-Penn models for ACLF development had very good discrimination [concordance (C) statistics of 0.93, 0.92, and 0.89 at 3, 6, and 12 months, respectively] and calibration. The mortality models also had good discrimination at 28 and 90 days (C statistics 0.89 and 0.88, respectively), outperforming the Model for End-stage Liver Disease (MELD), MELD-sodium, and the APASL ACLF Research Consortium ACLF scores. CONCLUSION We have developed novel tools for predicting development of ACLF in compensated cirrhosis patients, as well as for ACLF mortality. These tools may be used to proactively guide patient follow-up, prognostication, escalation of care, and transplant evaluation. Receiver operating characteristic (ROC) curves for predicting development of APASL ACLF at 3 months (a), 6 months (b), and 1 year (c).
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Affiliation(s)
- Karen Y Xiao
- Department of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 100 Centrex, Philadelphia, PA, 19104, USA
| | - Rebecca A Hubbard
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 604 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - David E Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, PCAM 7S GI, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Tamar H Taddei
- Division of Digestive Diseases, Yale University School of Medicine, Digestive Diseases, 333 Cedar Street, PO Box 208019, New Haven, CT, 06520, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th St, Suite 1112 (D49), Miami, FL, 33136, USA
| | - Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, PCAM 7S GI, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA. .,Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Townsend L, Blais P, Huh A, Nayak L, Elwing JE, Sayuk GS. Survival benefit associated with early detection of spontaneous bacterial peritonitis in veteran inpatients with cirrhotic ascites. JGH Open 2020; 4:503-506. [PMID: 32514461 PMCID: PMC7273690 DOI: 10.1002/jgh3.12290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 12/01/2019] [Indexed: 01/23/2023]
Abstract
Background Spontaneous bacterial peritonitis (SBP) is common in hospitalized cirrhotic patients with ascites and carries high mortality. This study aimed to determine whether early diagnostic paracentesis (EDP) <12 h of hospitalization conveys an intermediate‐term (6‐month) survival benefit in cirrhotic patients diagnosed with SBP. Methods Consecutive US veterans with cirrhosis diagnosed with SBP over 13 years at a single VA medical center were reviewed retrospectively. Kaplan‐Meyer analyses assessed the effects of EDP on survival. Results A total of 79 cirrhotic patients were diagnosed with SBP (61.8 ± 8.8 years, n = 77 male, n = 52 [66.8%] Caucasian, n = 23 [29.1%] African‐American). Underlying liver diseases included hepatitis c viral infection (HCV) (17.5%), alcohol (28.6%), alcohol and HCV (30.1%), and cryptogenic/metabolic (15.9%). Median baseline model for end‐stage liver disease (MELD) was 12 (range 6–34), and median MELD at presentation was 18. Seven subjects had a history of hepatocellular carcinoma (11.1%), and 26 (41.3%) presented with sepsis. Thirty‐three (52.4%) subjects died within 6 months after the SBP admission. Of the subjects, 41 (65.1%) underwent EDP, of which 23 (56.0%) survived at least 6 months, compared to only 7 of the 22 patients (31.8%) undergoing paracentesis >12 h from presentation (P = 0.057). The maximal benefit of EDP on survival was observed beyond days 14 and 30; at these time points, no statistical difference in mortality was discernable (P = 0.55 and 0.71). In a multivariate model including age, MELD at admission, hepatocellular cancer, and sepsis criteria, EDP (p 0.034) positively impacted patient survival at 6 months. Conclusions EDP is associated with improved 6‐month mortality in cirrhotic patients with ascites. In this veteran cohort, EDP was as important as MELD as a predictor of intermediate‐term survival.
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Affiliation(s)
- Luke Townsend
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
| | - Pierre Blais
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
| | - Alex Huh
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
| | - Leela Nayak
- St. Louis Veterans Affairs Medical CenterJohn Cochran Division St. Louis Missouri USA
| | - Jill E Elwing
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
- St. Louis Veterans Affairs Medical CenterJohn Cochran Division St. Louis Missouri USA
| | - Gregory S Sayuk
- Division of GastroenterologyWashington University School of Medicine St. Louis Missouri USA
- St. Louis Veterans Affairs Medical CenterJohn Cochran Division St. Louis Missouri USA
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Mahmud N, Hubbard RA, Kaplan DE, Taddei TH, Goldberg DS. Risk prediction scores for acute on chronic liver failure development and mortality. Liver Int 2020; 40:1159-1167. [PMID: 31840390 PMCID: PMC7371261 DOI: 10.1111/liv.14328] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/25/2019] [Accepted: 12/06/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Acute on chronic liver failure (ACLF) causes high short-term mortality in patients with previously stable chronic liver disease. To date there are no models to predict which patients are likely to develop ACLF, and existing models to predict ACLF mortality are based on limited cohorts. We sought to create novel risk prediction scores using a large cohort of patients with cirrhosis. METHODS We performed a retrospective cohort study of 74 790 patients with incident cirrhosis in the Veterans Health Administration database using randomized 70% derivation/30% validation sets. ACLF events were identified per the European ACLF criteria. Multivariable logistic regression was used to derive prediction models for developing ACLF at 3, 6 and 12 months, and ACLF mortality at 28 and 90 days. Mortality models were compared to model for end-stage liver disease (MELD), MELD-sodium and the Chronic Liver Failure Consortium (CLIF-C) ACLF score. RESULTS Models for the developing ACLF had very good discrimination (concordance [C] statistics 0.83-0.87) at all timepoints. Models for ACLF mortality also had good discrimination at 28 and 90 days (C-statistics 0.79-0.82), and were superior to MELD, MELD-sodium and the CLIF-C ACLF score. The calibration of the novel models was excellent at all timepoints. CONCLUSION We have obtained highly-predictive models for developing ACLF, as well as for ACLF short-term mortality in a diverse United States cohort. These may be used to identify outpatients at significant risk of ACLF, which may prompt closer follow-up or early transplant referral, and facilitate decision making for patients with diagnosed ACLF, including escalation of care, expedited transplant evaluation or palliation.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Rebecca A. Hubbard
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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Naik AD, Arney J, Clark JA, Martin LA, Walling AM, Stevenson A, Smith D, Asch SM, Kanwal F. Integrated Model for Patient-Centered Advanced Liver Disease Care. Clin Gastroenterol Hepatol 2020; 18:1015-1024. [PMID: 31357029 PMCID: PMC9319576 DOI: 10.1016/j.cgh.2019.07.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/11/2019] [Accepted: 07/24/2019] [Indexed: 02/07/2023]
Abstract
Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.
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Affiliation(s)
- Aanand D. Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Jennifer Arney
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Sociology, University of Houston-Clear Lake, Houston, Texas
| | - Jack A. Clark
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Lindsey A. Martin
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Anne M. Walling
- Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Autumn Stevenson
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Donna Smith
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Steven M. Asch
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Medical Center, Palo Alto, California,Division of Primary Care and Population Health, Stanford University, Palo Alto, California
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
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Ability of the post-operative ALBI grade to predict the outcomes of hepatocellular carcinoma after curative surgery. Sci Rep 2020; 10:7290. [PMID: 32350365 PMCID: PMC7190718 DOI: 10.1038/s41598-020-64354-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 04/15/2020] [Indexed: 02/08/2023] Open
Abstract
The albumin-bilirubin (ALBI) grade has been validated as a significant predictor for hepatocellular carcinoma (HCC). However, there is little information about the impact of postoperative ALBI grade in patients with HCC who are undergoing liver resection. We enrolled 525 HCC patients who received primary resection from April 2001 to March 2017. The impact of the pre- and post-operative ALBI grades on overall survival (OS) and recurrence-free survival (RFS) were analyzed by multivariate analysis. During the follow-up period (mean, 65 months), 253 (48.1%) patients experienced recurrence, and 85 (16.2%) patients died. Multivariate analysis revealed that diabetes mellitus (DM) (p = 0.011), alpha-fetoprotein levels (AFP) (p < 0.001), low platelet count (p = 0.008), liver cirrhosis (p < 0.001), and the first year of ALBI grade after resection (p < 0.001) were independent predictors for RFS. Additionally, old age (p = 0.006), DM (p = 0.002), AFP (p = 0.027), and ALBI grade at the first year after resection (p < 0.001) were independent risk factors for poor liver-related survival. Patients with post-operative ALBI grades II/III had older age (p = 0.019), hypoalbuminemia (p = 0.038), DM (p = 0.043), and high stages of pTNM (p = 0.021). The post-operative ALBI grade is better for predicting the outcomes in HCC patients after curative hepatectomy than the pre-operative ALBI grade.
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Duan T, Jiang H, Xia C, Chen J, Cao L, Ye Z, Wei Y, Song B, Lee JM. Assessing Liver Function in Liver Tumors Patients: The Performance of T1 Mapping and Residual Liver Volume on Gd-EOBDTPA-Enhanced MRI. Front Med (Lausanne) 2020; 7:215. [PMID: 32549039 PMCID: PMC7270171 DOI: 10.3389/fmed.2020.00215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/29/2020] [Indexed: 02/05/2023] Open
Abstract
Purpose: To assess the performance of T1 mapping and residual liver volume (RLV) on Gd-EOBDTPA-enhanced MRI in pretreatment estimation of liver function in patients with liver tumors. Indocyanine green retention rate at 15 min (ICG R-15) was used as a reference standard. Methods: Ethical approval from the institutional review board and informed consent were obtained for this prospective study. We enrolled 155 patients with liver tumors who underwent pretreatment Gd-EOB-DTPA-enhanced MRI. T1 relaxation time before (T1-pre), 20 min after (T1-post) Gd-EOB-DTPA injection and RLV were measured. The absolute reduction (ΔT1) and reduction rate (ΔT1%) of T1 relaxation time, volume-assisted ΔT1 (ΔT1*RLV) and volume-assisted ΔT1% (ΔT1%*RLV) were calculated accordingly. The correlation of MR parameters with ICG R-15 was determined using Spearman's rank correlation analysis. Patients were classified into the normal liver function (NLF) group if their ICG R-15 levels were <10% or otherwise into the abnormal liver function (ALF) group. Receiver operating characteristic (ROC) analysis was conducted to evaluate the performances of the MR parameters in predicting ALF. Results: T1-post (r = 0.472, P < 0.001), ΔT1 (r = -0.355, P = 0.011), ΔT1% (r = -0.482, P < 0.001), RLV (r = -0.336, P < 0.001), volume-assisted ΔT1 (r = -0.458, P < 0.001) and volume-assisted ΔT1% (r = -0.522, P < 0.001) showed weak to moderate correlation with ICG R-15. The area under the ROC curves (AUROC) of volume-assisted ΔT1 in predicting ALF was 0.777, which was significantly higher than the other parameters (P < 0.05 for all). Conclusions: Combined T1 mapping and RLV on Gd-EOB-DTPA-enhanced MRI can help assess liver function with good diagnostic accuracy in patients with liver tumors before treatment.
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Affiliation(s)
- Ting Duan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hanyu Jiang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Chunchao Xia
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Chen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Likunn Cao
- Department of Radiology, Peking Union Medical University Hospital, Peking, China
| | - Zheng Ye
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Wei
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Song
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Bin Song
| | - Jeong Min Lee
- Department of Radiology, College of Medicine, Seoul National University, Seoul, South Korea
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Serper M, Kaplan DE, Shults J, Reese PP, Beste LA, Taddei TH, Werner RM. Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis. Hepatology 2019; 70:2062-2074. [PMID: 31107967 PMCID: PMC6864236 DOI: 10.1002/hep.30779] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/10/2019] [Indexed: 02/06/2023]
Abstract
Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.
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Affiliation(s)
- Marina Serper
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lauren A. Beste
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA
- VA Puget Sound Health Care System, General Medicine Service, Seattle, WA, USA
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut CT
- Division of Gastroenterology, Yale University School of Medicine, New Haven, CT
| | - Rachel M. Werner
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Wu B, Hu X, Jin H, Zhou L, Zhang D, Man Z, Wang Y, Yang S, Pang Q, Liu H, Cui P. Albumin-bilirubin and platelet-albumin-bilirubin grades for hepatitis B-associated hepatocellular carcinoma in Child-Pugh A patients treated with radical surgery: A retrospective observational study. Medicine (Baltimore) 2019; 98:e17394. [PMID: 31651841 PMCID: PMC6824664 DOI: 10.1097/md.0000000000017394] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Child-Pugh (CP) grade A patients with early stage hepatocellular carcinoma (HCC) are candidates for curative surgery, while some patients still have a poor outcome. The aim of this study was to investigate the prognostic values of 2 new evaluation models for liver function, named albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (PALBI) grades, in CP grade A patients with HCC.In this retrospective cohort study, we reviewed 134 cases of CP grade A patients with hepatitis B-associated HCC who underwent radical surgery. ALBI and PALBI grades were calculated based on preoperative serologic examinations. Overall survival (OS) and recurrence-free survival (RFS) were estimated by Kaplan-Meier curve and Cox regression. The prognostic performances of the models were estimated by using the concordance index (C-index).During a median follow-up time of 27 months, 27.6% (37/134) of patients died and 26.1% (35/134) experienced recurrence. Kaplan-Meier analyses showed that ALBI and PALBI grades were significantly associated with OS and RFS. Multivariate analyses further revealed that both ALBI and PALBI grades were independent predictors for survival. Furthermore, the prognostic values of the combination of tumor size with ALBI (C-index = 0.754, 95% confidence interval [CI]: 0.675-0.849) or with PALBI (C-index = 0.762, 95% CI: 0.664-0.844) may be comparable with both Barcelona Clinic Liver Cancer and Cancer of Liver Italian Program staging systems.The ALBI and PALBI grades, in particular the combination with tumor size, are effective models for discriminating survival in CP grade A patients with HCC.
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Mahmud N, Kaplan DE, Taddei TH, Goldberg DS. Incidence and Mortality of Acute-on-Chronic Liver Failure Using Two Definitions in Patients with Compensated Cirrhosis. Hepatology 2019; 69:2150-2163. [PMID: 30615211 PMCID: PMC6461492 DOI: 10.1002/hep.30494] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/20/2018] [Indexed: 12/12/2022]
Abstract
The term acute-on-chronic liver failure (ACLF) is intended to identify patients with chronic liver disease who develop rapid deterioration of liver function and high short-term mortality after an acute insult. The two prominent definitions (European Association for the Study of the Liver [EASL] and Asian Pacific Association for the Study of the Liver [APASL]) differ, and existing literature applies to narrow patient groups. We sought to compare ACLF incidence and mortality among a diverse cohort of patients with compensated cirrhosis, using both definitions. This was a retrospective cohort study of patients with incident compensated cirrhosis in the Veterans Health Administration from 2008 to 2016. First ACLF events were identified for each definition. Incidence rates were computed as events per 1,000 person-years, and mortality was calculated at 28 and 90 days. Among 80,383 patients with cirrhosis with 3.35 years median follow-up, 783 developed EASL and APASL ACLF, 4,296 developed EASL ACLF alone, and 574 developed APASL ACLF alone. The incidence rate of APASL ACLF was 5.7 per 1,000 person-years (95% confidence interval [CI]: 5.4-6.0), and the incidence rate of EASL ACLF was 20.1 (95% CI: 19.5-20.6). The 28-day and 90-day mortalities for APASL ACLF were 41.9% and 56.1%, respectively, and were 37.6% and 50.4% for EASL ACLF. The median bilirubin level at diagnosis of EASL-alone ACLF was 2.0 mg/dL (interquartile range: 1.1-4.0). Patients with hepatitis C or nonalcoholic fatty liver disease had among the lowest ACLF incidence rates but had the highest short-term mortality. Conclusion: There is significant discordance in ACLF events by EASL and APASL criteria. The majority of patients with EASL-alone ACLF have preserved liver function, suggesting the need for more liver-specific ACLF criteria.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - David S. Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Kaplan DE, Serper MA, Mehta R, Fox R, John B, Aytaman A, Baytarian M, Hunt K, Albrecht J, Njei B, Taddei TH. Effects of Hypercholesterolemia and Statin Exposure on Survival in a Large National Cohort of Patients With Cirrhosis. Gastroenterology 2019; 156:1693-1706.e12. [PMID: 30660733 DOI: 10.1053/j.gastro.2019.01.026] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 12/17/2018] [Accepted: 01/09/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Concerns related to hepatotoxicity frequently lead to discontinuation or non-initiation of 3-hydroxy-3-methylglutaryl-coenzyme A reductase therapy in patients with cirrhosis despite data supporting statin use. We investigated the independent effects of hyperlipidemia and statin exposure on mortality, hepatic decompensation, and hepatocellular carcinoma development in a large national cohort of patients with cirrhosis. METHODS We performed a retrospective cohort study of patients with newly diagnosed cirrhosis from January 1, 2008 through June 30, 2016 in the Veterans Health Administration. Subjects were divided into 2 cohorts: 21,921 patients with prior statin exposure (existing users) and 51,023 statin-naïve individuals, of whom 8794 subsequently initiated statin therapy (new initiators) and 44,269 did not (non-initiators). Multivariable Cox proportional hazard models with inverse probability weighting were constructed to assess the effects of time-updating lipid profiles and cumulative exposure to statins on survival and hepatic decompensation. Statin-naïve new initiators were propensity matched with non-initiators to simulate a randomized controlled trial of statin use in cirrhosis. RESULTS In statin-naïve subjects, every 10-mg/dL increase in baseline total cholesterol was associated with a 3.6% decrease in mortality. In existing users, each year of continued statin exposure was associated with a hazard ratio of 0.920 (95% confidence interval 0.0.897-0.943) for mortality. After risk-set matching, each year of statin exposure among new initiators was associated with a hazard ratio of 0.913 (95% confidence interval 0.890-0.937) for mortality. CONCLUSIONS In a retrospective cohort study of veterans with a new diagnosis of cirrhosis, we associated hypercholesterolemia with well-preserved hepatic function and decreased mortality. Nonetheless, each cumulative year of statin exposure was associated with an independent 8.0%-8.7% decrease of mortality of patients with cirrhosis of Child-Turcotte-Pugh classes A and B.
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Affiliation(s)
- David E Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Marina A Serper
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajni Mehta
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Rena Fox
- San Francisco VA Medical Center, San Francisco, California
| | - Binu John
- Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
| | - Ayse Aytaman
- VA New York Harbor Health Care System, Brooklyn, New York
| | | | - Kristel Hunt
- James J. Peters VA Medical Center, Bronx, New York
| | | | - Basile Njei
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut
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Hernaez R, Kramer JR, Liu Y, Tansel A, Natarajan Y, Hussain KB, Ginès P, Solà E, Moreau R, Gerbes A, El-Serag HB, Kanwal F. Prevalence and short-term mortality of acute-on-chronic liver failure: A national cohort study from the USA. J Hepatol 2019; 70:639-647. [PMID: 30590100 DOI: 10.1016/j.jhep.2018.12.018] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/21/2018] [Accepted: 12/11/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is characterised by the presence of organ failure in patients with decompensated cirrhosis and is associated with high short-term mortality. However, there are limited data on the prevalence and short-term outcomes of ACLF in patients with cirrhosis seen in the US. We aimed to study the prevalence and risk factors associated with the development and short term mortality in a large cohort of patients in the US. METHODS Using the US Department of Veterans Affairs (VA) Corporate Data Warehouse, we identified patients with ACLF during hospitalisation for decompensated cirrhosis at any of the 127 VA hospitals between January 1, 2004, and December 31, 2014. We examined the prevalence of ACLF and variables associated with 28- and 90-day mortality in ACLF, and trends in prevalence and survival over time. RESULTS Of 72,316 patients hospitalised for decompensated cirrhosis, 19,082 (26.4%) patients met the criteria of ACLF on admission. Of these, 12.8% had 1, 10.1% had 2, and 3.5% had 3 or more organ failures. Overall, 25.5% and 40.0% of ACLF patients died within 28 days and 90 days of admission, respectively. Older age, White race, liver cancer, higher model for end-stage liver disease sodium corrected score, and non-liver transplant centre were associated with increased risk of death in ACLF. Over the study period, the prevalence of ACLF decreased, and all grades but ACLF-3 had improvement in survival. CONCLUSIONS In a US cohort of hospitalised patients with decompensated cirrhosis, ACLF was common and associated with high short-term mortality. Over a decade, ACLF prevalence decreased but survival improvement of ACLF-3 was not seen. Early recognition and aggressive management including timely referral to transplant centres may lead to improved outcomes in ACLF. LAY SUMMARY Acute-on-chronic liver failure (ACLF) is a condition marked by multiple organ failures in patients with cirrhosis and associated with a high risk of death. In this study of US patients hospitalised with cirrhosis, 1 in 4 patients developed ACLF. In total, 25% of patients with ACLF died within 1 month and 40% died within 3 months. Thus, early recognition of ACLF is important for the initiation of aggressive management, which is required to save these patients' lives.
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Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Jennifer R Kramer
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yan Liu
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aylin Tansel
- Section of Gastroenterology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Yamini Natarajan
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Khozema B Hussain
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centros de Investigación Biomédica en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain; European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Elsa Solà
- Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centros de Investigación Biomédica en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain; European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain; Inserm, U1149, Centre de Recerche sur l'inflammation (CRI), Paris, France; Faculté de Médicine, Université Paris Diderot, Paris, France; Départment Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Alexander Gerbes
- Liver Centre Munich, Department of Medicine II, University Hospital, LMU Munich, Germany
| | - Hashem B El-Serag
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fasiha Kanwal
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Reply to Risk Stratification in Acute Variceal Bleeding: Child-Pugh Versus Model for End-stage Liver Disease. J Clin Gastroenterol 2019; 53:314-315. [PMID: 28375866 PMCID: PMC6035780 DOI: 10.1097/mcg.0000000000000830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Tan J, Chen Y, Wang L, Chan TC, Amer S, Xu X, Cai J, Li W, Zheng X, Zhou M, Qin S, Zhao N, Miao Z, Liu S. Acute sporadic hepatitis E in the Zhejiang coastal area of China: a 14-year hospital-based surveillance study. Virol J 2019; 16:16. [PMID: 30717759 PMCID: PMC6360671 DOI: 10.1186/s12985-019-1119-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To examine the epidemiological trends and changes of hepatitis E virus (HEV) infection and the potential risk factors for severe infection in the Zhejiang eastern coastal area of China. METHODS We analyzed statutory hepatitis E cases notifications and inpatient data held by the national surveillance and hospital information systems in Wenzhou, Taizhou, Ningbo, and Zhoushan cities of the Zhejiang eastern coastal area of China. RESULTS Nine thousand four hundred sixteen hepatitis E cases were reported from 2004 to 2017, with an average incidence of 2.94 per 100,000. The overall death rate was 0.06% (6/9416). A gradual decline of hepatitis E cases was found in the coastal areas since 2007, while a rise was identified in the non-coastal areas. Annual incidence in non-coastal cities was much higher than that in coastal cities (4.345 vs. 2.945 per 100,000, relative risk = 1.5, P value < 0.001). The mean age was 52 years old and 50.55 years with a male-to-female ratio of 2.32:1 and 2.21:1 in coastal and noncoastal areas respectively (all P > 0.05). Hepatitis E cases prevalence increased with age, highest among men in their 70s (9.02 vs. 11.33 per 100,000) and women in their 60s (3.94 vs. 4.66 per 100,000) groups for both coastal and noncoastal areas respectively. A clear seasonal pattern was observed, with a peak in March (0.4429 per 100,000) in coastal areas. 202 inpatients were documented, of which 50.50% (102/202) were severe cases. Male individuals with alcohol consumption, alcohol hepatic diseases, and superinfection were the three independent highest risks for severe infections (all with P value < 0.05). CONCLUSIONS This is to our knowledge the largest epidemiological study of hepatitis E cases in the eastern coastal area of Zhejiang province of China. The patterns of infection across the coastal areas were similar to those of the non-coastal areas, but the incidence was substantially lower and decreased gradually since 2007.
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Affiliation(s)
- Jun Tan
- Department of Hepatology, Ningbo No.2 Hospital, Ningbo, Zhejiang Province, China
| | - Yijuan Chen
- Department of Infectious Diseases, Zhejiang Provincial Center for Disease Control and Prevention, 3399 Binsheng Road, Binjiang District, Hangzhou, (310051), Zhejiang Province, China
| | - Lin Wang
- Department of Microbiology and Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Ta-Chien Chan
- Research Center for Humanities and Social Sciences, Academia Sinica, Taipei, Taiwan
| | - Said Amer
- Department of Zoology, Faculty of Science, Kafr El Sheikh University, Kafr El Sheikh, Egypt
| | - Xiaobin Xu
- School of Automation, Hangzhou Dianzi University, Hangzhou, China
| | - Jian Cai
- Department of Infectious Diseases, Zhejiang Provincial Center for Disease Control and Prevention, 3399 Binsheng Road, Binjiang District, Hangzhou, (310051), Zhejiang Province, China
| | - Wei Li
- Department of Hepatology, Ningbo No.2 Hospital, Ningbo, Zhejiang Province, China
| | - Xiaoqing Zheng
- Department of Hepatology, Ningbo No.2 Hospital, Ningbo, Zhejiang Province, China
| | - Mi Zhou
- The Medical School of Ningbo University, Ningbo, Zhejiang Province, China
| | - Shuwen Qin
- Department of Infectious Diseases, Zhejiang Provincial Center for Disease Control and Prevention, 3399 Binsheng Road, Binjiang District, Hangzhou, (310051), Zhejiang Province, China
| | - Na Zhao
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Ziping Miao
- Department of Infectious Diseases, Zhejiang Provincial Center for Disease Control and Prevention, 3399 Binsheng Road, Binjiang District, Hangzhou, (310051), Zhejiang Province, China.
| | - Shelan Liu
- Department of Infectious Diseases, Zhejiang Provincial Center for Disease Control and Prevention, 3399 Binsheng Road, Binjiang District, Hangzhou, (310051), Zhejiang Province, China.
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Brand M, Prodehl L, Ede CJ. Surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt for variceal haemorrhage in people with cirrhosis. Cochrane Database Syst Rev 2018; 10:CD001023. [PMID: 30378107 PMCID: PMC6516991 DOI: 10.1002/14651858.cd001023.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Variceal haemorrhage that is refractory or recurs after pharmacologic and endoscopic therapy requires a portal decompression shunt (either surgical shunts or radiologic shunt, transjugular intrahepatic portosystemic shunt (TIPS)). TIPS has become the shunt of choice; however, is it the preferred option? This review assesses evidence for the comparisons of surgical portosystemic shunts versus TIPS for variceal haemorrhage in people with cirrhotic portal hypertension. OBJECTIVES To assess the benefits and harms of surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt (TIPS) for treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science. We also searched on-line trial registries, reference lists of relevant articles, and proceedings of relevant associations for trials that met the inclusion criteria for this review (date of search 8 March 2018). SELECTION CRITERIA Randomised clinical trials comparing surgical portosystemic shunts versus TIPS for the treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials and extracted data using methodological standards expected by Cochrane. We assessed risk of bias according to domains and risk of random errors with Trial Sequential Analysis (TSA). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We found four randomised clinical trials including 496 adult participants diagnosed with variceal haemorrhage due to cirrhotic portal hypertension. The overall risk of bias in all the trials was judged at high risk. All the trials were conducted in the United States of America (USA). Two of the trials randomised participants to selective surgical shunts versus TIPS. The other two trials randomised participants to non-selective surgical shunts versus TIPS. The diagnosis of liver cirrhosis was by clinical and laboratory findings. We are uncertain whether there is a difference in all-cause mortality at 30 days between surgical portosystemic shunts compared with TIPS (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.44 to 1.99; participants = 496; studies = 4). We are uncertain whether there is a difference in encephalopathy between surgical shunts compared with TIPS (RR 0.56, 95% CI 0.27 to 1.16; participants = 496; studies = 4). We found evidence suggesting an increase in the occurrence of the following harms in the TIPS group compared with surgical shunts: all-cause mortality at five years (RR 0.61, 95% CI 0.42 to 0.90; participants = 496; studies = 4); variceal rebleeding (RR 0.18, 95% CI 0.07 to 0.49; participants = 496; studies = 4); reinterventions (RR 0.13, 95% CI 0.06 to 0.28; participants = 496; studies = 4); and shunt occlusion (RR 0.14, 95% CI 0.04 to 0.51; participants = 496; studies = 4). We could not perform an analysis of health-related quality of life but available evidence appear to suggest improved health-related quality of life in people who received surgical shunt compared with TIPS. We downgraded the certainty of the evidence for all-cause mortality at 30 days and five years, irreversible shunt occlusion, and encephalopathy to very low because of high risk of bias (due to lack of blinding); inconsistency (due to heterogeneity); imprecision (due to small sample sizes of the individual trials and few events); and publication bias (few trials reporting outcomes). We downgraded the certainty of the evidence for variceal rebleeding and reintervention to very low because of high risk of bias (due to lack of blinding); imprecision (due to small sample sizes of the individual trials and few events); and publication bias (few trials reporting outcomes). The small sample sizes and few events did not allow us to produce meaningful trial sequential monitoring boundaries, suggesting plausible random errors in our estimates. AUTHORS' CONCLUSIONS We found evidence suggesting that surgical portosystemic shunts may have benefit over TIPS for treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. Given the very low-certainty of the available evidence and risks of random errors in our analyses, we have very little confidence in our review findings.
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Affiliation(s)
- Martin Brand
- University of PretoriaDepartment of SurgeryPretoriaSouth Africa0001
| | - Leanne Prodehl
- University of the WitwatersrandDepartment of Surgery1 Jubilee RoadJohannesburgGautengSouth Africa2192
| | - Chikwendu J Ede
- University of the WitwatersrandDepartment of Surgery1 Jubilee RoadJohannesburgGautengSouth Africa2192
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Chi X, Pan J, Cai J, Luo G, Li S, Yuan D, Rui J, Chen W, Hei Z. Pharmacokinetic Analysis of Propofol Target-Controlled Infusion Models in Chinese Patients with Hepatic Insufficiency. Med Sci Monit 2018; 24:6925-6933. [PMID: 30269150 PMCID: PMC6180848 DOI: 10.12659/msm.910103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Effects of liver dysfunction on target-controlled infusion (TCI) with Marsh parameters of propofol remain poorly documented. The purpose of this study was to evaluate the performance of propofol TCI in a cohort of Chinese patients with severe hepatic insufficiency. Material/Methods We assigned 32 patients who underwent liver transplantation to 3 groups according to Child-Turcotte-Pugh (CTP) score. Anesthesia, preceding liver transplantation, was induced and maintained with TCI of 3 μg/mL propofol. Plasma propofol concentration was assessed. Propofol TCI system performance was analyzed in terms of error size, bias, and divergence. Data on plasma propofol concentrations were analyzed, and population pharmacokinetic parameters of propofol were fitted by NONMEM software. Results In the CTP C group, measured concentrations of propofol were much higher than those of predictive concentrations, with significantly higher overshoots compared to CTP A patients. Overall, TCI system performance was significantly lower in CTP C patients. Linear regression equations of Cm vs. Cp and a regression model of pharmacokinetics were obtained. Conclusions Propofol TCI device performance with Marsh parameters was clinically acceptable in CTP A patients but may not be suitable for patients with severe hepatic impairment.
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Affiliation(s)
- Xinjin Chi
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Department of Anesthesiology, Seventh Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Jingru Pan
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Jun Cai
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Gangjian Luo
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Shangrong Li
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Dongdong Yuan
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Jianzhong Rui
- Department of Pharmacology, Jinling Hospital, Nanjing, Jiangsu, China (mainland)
| | - Wenying Chen
- Department of Pharmacy, First Affiliated Hospital of Guangzhou Medical College, Guangzhou, Guangdong, China (mainland)
| | - Ziqing Hei
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
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Cacciola I, Filomia R, Alibrandi A, Franzè MS, Caccamo G, Maimone S, Saitta C, Saffioti F, Squadrito G, Raimondo G. Hypergammaglobulinemia is a strong predictor of disease progression, hepatocellular carcinoma, and death in patients with compensated cirrhosis. Liver Int 2018; 38:1220-1229. [PMID: 29194934 DOI: 10.1111/liv.13649] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 11/19/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The outcome of compensated cirrhosis may vary considerably and cannot be predicted by routinely performed tests at present. The aim of this study was to evaluate possible predictors of clinical evolution in patients with Child-Pugh (C-P) class A cirrhosis because of untreatable causes by analysing clinical/biochemical/instrumental parameters evaluated at the time of diagnosis and during the subsequent long-lasting follow-up. METHODS Two hundred and seventy-two consecutive C-P class A cirrhotic patients (155 males; median age 63 years, range 34-81) were analysed. All patients were followed up for a median time of 96 months (range 21-144) through periodically performed clinical/biochemical/ultrasonographic and esophagogastroduodenoscopic examinations. RESULTS During the follow-up, 97 individuals (36%) were clinically stable, 104 (38%) developed hepatocellular carcinoma (HCC) and 71 (26%) progressed towards C-P class B/C without developing cancer. One hundred and thirty-one patients (48%) died or underwent liver transplantation. Multivariate regression analysis showed that clinical stability was significantly associated with older age (P < .001), the absence of diabetes (P = .04) and of oesophageal varices (P < .001), serum albumin >3.5 gr/dL (P = .01) and gamma globulin <1.8 gr/dL (P = .01). HCC development was significantly associated with younger age (P = .01) and serum gamma globulin values ≥1.8 gr/dL (P < .001). C-P score progression was associated with oesophageal varices (P < .001), lower serum albumin (P = .03) and cholesterol (P = .01) values, and hypergammaglobulinemia (P = .02). Death was associated with younger age (P < .001) and hypergammaglobulinemia (P = .01). Multivariate Cox regression analysis and Kaplan-Meier's survival test confirmed that gammaglobulinemia ≥1.8 g/dL was a significant predictor of death (P < .02, and P < .01 respectively). CONCLUSIONS Hypergammaglobulinemia identifies C-P class A cirrhotic patients at higher risk of disease progression, HCC development and death.
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Affiliation(s)
- Irene Cacciola
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Filomia
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy
| | - Maria Stella Franzè
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gaia Caccamo
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Sergio Maimone
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Carlo Saitta
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Francesca Saffioti
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giovanni Squadrito
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy.,Department of Human Pathology, University of Messina, Messina, Italy
| | - Giovanni Raimondo
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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80
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Butt AA, Ren Y, Lo Re V, Taddei TH, Kaplan DE. Comparing Child-Pugh, MELD, and FIB-4 to Predict Clinical Outcomes in Hepatitis C Virus-Infected Persons: Results From ERCHIVES. Clin Infect Dis 2018; 65:64-72. [PMID: 28369305 DOI: 10.1093/cid/cix224] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/15/2017] [Indexed: 12/15/2022] Open
Abstract
Background Identifying hepatitis C virus (HCV)-positive persons at high risk of early complications can help prioritize treatment decisions. We conducted this study to compare Child-Turcotte-Pugh (CP), MELD, and FIB-4 scores for predicting clinical outcomes and to identify those at low risk of complications. Methods Within electronically retrieved cohort of HCV-infected veterans, we identified HCV-positive persons and excluded those with human immunodeficiency virus (HIV), hepatitis B surface antigen (HBsAg), prevalent hepatic decompensation (HD), hepatocellular carcinoma (HCC), and those treated for HCV. We calculated incidence rates for HD, HCC, and all-cause mortality at 1, 3, and 5 years after HCV diagnosis. Using receiver operating characteristic (ROC) curves, we determined the optimal cut-off values for each score for these outcomes. Results Among 21 116 persons evaluated, 89.7% were CP Class-A, 79.9% had MELD<9, and 43.4% had FIB-4<1.45. AUROC for HD at 1, 3, and 5 years was higher for FIB-4 (0.84-0.86) compared with MELD (0.70-0.76) (P < .001). AUROC for HCC at 1, 3, and 5 years was 0.81-0.82 for FIB-4 but 0.61-0.68 for CP and MELD scores. (P < .001) AUROC for all-cause mortality at 3 and 5 years was 0.65-0.68. The optimal cut-off scores to identify persons at low risk of complications were as follows: CP <5; MELD <8; FIB-4 <3 for HD and HCC, and <2 for all-cause mortality, below which <1.5% developed HD and HCC and ≤2.5% died at 3 years. Conclusions FIB-4 score is a better predictor of HD and HCC in HCV-positive persons. A score of <3 is associated with a low risk of HD and HCC 1 and 3 years after HCV diagnosis.
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Affiliation(s)
- Adeel A Butt
- VA Pittsburgh Healthcare System, Pennsylvania.,Weill Cornell Medical College, Doha, Qatar, and New York, New York.,Hamad Healthcare Quality Institute and Hamad Medical Corporation, Doha, Qatar
| | - Yanjie Ren
- VA Pittsburgh Healthcare System, Pennsylvania
| | - Vincent Lo Re
- University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven.,Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - David E Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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81
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Zou H, Wen Y, Yuan K, Miao XY, Xiong L, Liu KJ. Combining albumin-bilirubin score with future liver remnant predicts post-hepatectomy liver failure in HBV-associated HCC patients. Liver Int 2018; 38:494-502. [PMID: 28685924 DOI: 10.1111/liv.13514] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/03/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS Accurate assessment of liver functional reserve pre-operatively is vital for safe hepatic resection. The ALBI score is a new model for assessing liver function. This study aimed to evaluate the value of combining ALBI score with sFLR in predicting post-operative morbidity and PHLF in HCC patients who underwent hepatectomy. METHODS Patients undergoing three-dimensional CT reconstruction prior to hepatectomy for HCC between January 2015 and January 2017 were enrolled. The values of the CP score, ALBI score and sFLR in predicting post-operative outcomes were evaluated. RESULTS A total of 229 HCC patients were enrolled; 24 (10.5%) experienced major complications and 21 (9.2%) developed PHLF. The incidence of major complications and PHLF increased with increasing ALBI grade. The ALBI grade classified patients with CP grade A into two subgroups with different incidences of PHLF (P=.029). sFLR and ALBI scores were identified as independent predictors of PHLF. The AUC values for the CP score, ALBI score, sFLR and sFLR×ALBI for predicting major complications were 0.600, 0.756, 0.660 and 0.790 respectively. The AUC values of the CP score, ALBI score, sFLR and sFLR×ALBI for predicting PHLF were 0.646, 0.738, 0.758 and 0.884 respectively. CONCLUSIONS The ALBI score showed superior predictive value of post-operative outcomes over CP score, and the combination of sFLR and ALBI score was identified as a stronger predictor of post-operative outcomes than the sFLR or ALBI score alone.
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Affiliation(s)
- Heng Zou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yu Wen
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Kun Yuan
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiong-Ying Miao
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Li Xiong
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Kui-Jie Liu
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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82
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Zou H, Yang X, Li QL, Zhou QX, Xiong L, Wen Y. A Comparative Study of Albumin-Bilirubin Score with Child-Pugh Score, Model for End-Stage Liver Disease Score and Indocyanine Green R15 in Predicting Posthepatectomy Liver Failure for Hepatocellular Carcinoma Patients. Dig Dis 2018; 36:236-243. [PMID: 29495004 DOI: 10.1159/000486590] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/21/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The albumin-bilirubin (ALBI) grade is a newly proposed model for assessing the hepatic function. This study aimed to compare the value of the ALBI score with Child-Pugh score, model for end-stage liver disease (MELD) score and indocyanine green (ICG) R15 in predicting posthepatectomy liver failure (PHLF). METHODS Patients undergoing curative resection for hepatocellular carcinoma (HCC) between January 2014 and June 2017 were enrolled. The values of the Child-Pugh score, MELD score, ICG R15 and ALBI score in predicting PHLF were evaluated. RESULTS A total of 473 HCC patients were enrolled. The ALBI score was identified as an independent predictor of PHLF. The AUCs for the Child-Pugh score, MELD score, ICG R15 and ALBI score in predicting PHLF were 0.665, 0.649, 0.668, and 0.745 respectively. Multivariable analyses revealed that the ALBI score was an independent predictor of PHLF regardless of the hepatectomy subgroups, but the Child-Pugh score and MELD score were not significant predictors of PHLF both in major and minor hepatectomy subgroups, and ICG R15 was only a significant predictor of PHLF in minor hepatectomy subgroup. CONCLUSION The ALBI score showed superior predictive value of PHLF over Child-Pugh score, MELD score and ICG R15. We propose to use the ALBI score to evaluate surgical risk for HCC patients undergoing hepatic resection.
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Butt AA, Yan P, Simon TG, Abou-Samra AB. Effect of Paritaprevir/Ritonavir/Ombitasvir/Dasabuvir and Ledipasvir/Sofosbuvir Regimens on Survival Compared With Untreated Hepatitis C Virus-Infected Persons: Results From ERCHIVES. Clin Infect Dis 2018; 65:1006-1011. [PMID: 28903508 DOI: 10.1093/cid/cix364] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 07/15/2017] [Indexed: 12/17/2022] Open
Abstract
Background Interferon-based regimens are associated with a substantial survival benefit for persons infected with hepatitis C virus (HCV). Survival data with direct-acting antiviral agents are not available. We conducted this study to quantify the effect of paritaprevir/ritonavir, ombitasvir, dasabuvir (PrOD) and ledipasvir/sofosbuvir (LDV/SOF) regimens upon mortality. Methods In the Electronically Retrieved Cohort of HCV Infected Veterans (ERCHIVES), a well-established national cohort of HCV-infected Veterans, we identified HCV-infected persons initiated on PrOD or LDV/SOF, excluding those with human immunodeficiency virus, hepatitis B surface antigen positivity, hepatocellular carcinoma, or missing HCV RNA or FIB-4 scores. For each case, we identified a propensity score-matched control never initiated on treatment. Primary outcome was survival. Outcomes were assessed using frequency of events, Kaplan-Meier curves, and Cox proportional hazards regression analyses. Results We identified 1473 persons on PrOD, 5497 on LDV/SOF, and 6970 propensity score-matched untreated persons. Treated persons were more likely to be obese and have cirrhosis, but less likely to have stage 3-5 chronic kidney disease (CKD), alcohol or drug abuse or dependence diagnosis, and anemia. The proportion of persons who died was higher in the untreated group compared with either treatment group (PrOD, 0.3%; LDV/SOF, 1.4%; untreated controls, 2.5%; P < .001). A significantly larger percentage of treated patients survived to 18 months of follow-up, compared with untreated controls (P < .001). In multivariable Cox regression analysis, treatment with either regimen (hazard ratio [HR], 0.43; 95% confidence interval [CI], .33-.57) and attainment of sustained virologic response (SVR) were associated with significantly lower mortality (HR, 0.57; 95% CI, .33-.99). Conclusions Treatment with PrOD or LDV/SOF and SVR are associated with a significant mortality benefit, apparent within the first 18 months of treatment.
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Affiliation(s)
- Adeel Ajwad Butt
- Veterans Affairs Pittsburgh Healthcare System, Pennsylvania.,Weill Cornell Medical College, New York, New York and Doha, Qatar
| | - Peng Yan
- Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
| | - Tracey G Simon
- Massachusetts General Hospital and Harvard Medical School, Boston
| | - Abdul-Badi Abou-Samra
- Weill Cornell Medical College, New York, New York and Doha, Qatar.,Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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84
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Kaplan DE, Mehta R, D'Addeo K, Gade TP, Taddei TH. Transarterial Chemoembolization within First 3 Months of Sorafenib Initiation Improves Overall Survival in Hepatocellular Carcinoma: A Retrospective, Multi-Institutional Study with Propensity Matching. J Vasc Interv Radiol 2018; 29:540-549.e4. [PMID: 29477619 DOI: 10.1016/j.jvir.2017.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 11/14/2017] [Accepted: 11/14/2017] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The impact of transarterial chemoembolization after initiation of sorafenib (SOR) has not been prospectively compared with SOR alone in unresectable hepatocellular carcinoma (HCC). The objective of this study was to assess whether SOR + transarterial chemoembolization provides benefit over SOR alone in this setting. MATERIALS AND METHODS A retrospective cohort study with propensity matching using data from patients prescribed SOR for HCC at Veterans Health Administration hospitals from 2007 to 2015. The primary outcome was overall survival from the time of SOR prescription and stratified by receipt of transarterial chemoembolization within 90 days of SOR initiation. RESULTS A total of 4,896 patients received SOR for HCC, of whom 232 (4.7%) underwent transarterial chemoembolization within 90 days. Patients receiving transarterial chemoembolization + SOR were highly selected, being younger and with less significant hepatic dysfunction, earlier Barcelona Clinic Liver Cancer stage (P < .0001), and fewer tumors with lower rates of macrovascular invasion (MVI) and metastases (all P < .0001) than SOR-alone patients. In unadjusted analysis, SOR + transarterial chemoembolization was associated with reduced mortality (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.53-0.71; P < .0001). After propensity matching, SOR + transarterial chemoembolization continued to show significant associations with reduced mortality with HR 0.75 (95% CI 0.62-0.92; P = .0005). Subgroup analysis suggests that the addition of transarterial chemoembolization to SOR improves outcomes in most patients, particularly those with Model for End-Stage Liver Disease score <15, platelets >50,000/μL, and >3 tumors with or without macrovascular invasion, without local invasion or metastases. CONCLUSIONS Patients with unresectable HCC started on systemic therapy with SOR appear to benefit from adjuvant transarterial chemoembolization. Optimal application of multimodal therapy in this setting should be prospectively investigated.
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Affiliation(s)
- David E Kaplan
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Bldg 21, Room A422, Philadelphia, PA 19014.
| | - Rajni Mehta
- Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kathryn D'Addeo
- Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Terence P Gade
- Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Bldg 21, Room A422, Philadelphia, PA 19014; Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Tamar H Taddei
- Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
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85
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Crooks CJ, West J, Jepsen P. A validation study of the CirCom comorbidity score in an English cirrhosis population using the Clinical Practice Research Datalink. Clin Epidemiol 2018; 10:107-120. [PMID: 29391833 PMCID: PMC5774468 DOI: 10.2147/clep.s147535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose The CirCom score has been developed from Danish data as a specific measure of comorbidity for cirrhosis to predict all-cause mortality. We compared its performance with the Charlson Comorbidity Index (CCI) in an English cirrhosis population. Patients and methods We used comorbidity scores in a survival model to predict mortality in a cirrhosis cohort in the Clinical Practice Research Datalink. The discrimination of each score was compared by age, gender, socioeconomic status, cirrhosis etiology, cirrhosis stage, and year after cirrhosis diagnosis. We also measured their ability to predict liver-related versus non-liver-related death. Results There was a small improvement in the C statistic from the model using the CirCom score (C=0.63) compared to the CCI (C=0.62), and there was an overall improvement in the net reclassification index of 1.5%. The improvement was more notable in younger patients, those with an alcohol etiology, and those with compensated cirrhosis. Both scores performed better (C statistic >0.7) for non-liver-related deaths than liver-related deaths (C statistic <0.6), as comorbidity was only weakly predictive of liver-related death. Conclusion The CirCom score provided a small improvement in performance over the CCI in the prediction of all-cause and non-liver mortality, but not liver-related mortality. Therefore, it is important to include a measure of comorbidity in studies of cirrhosis survival, alongside a measure of cirrhosis severity.
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Affiliation(s)
- Colin J Crooks
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Joe West
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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86
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Kaplan DE, Chapko MK, Mehta R, Dai F, Skanderson M, Aytaman A, Baytarian M, D’Addeo K, Fox R, Hunt K, Pocha C, Valderrama A, Taddei TH. Healthcare Costs Related to Treatment of Hepatocellular Carcinoma Among Veterans With Cirrhosis in the United States. Clin Gastroenterol Hepatol 2018; 16:106-114.e5. [PMID: 28756056 PMCID: PMC5735018 DOI: 10.1016/j.cgh.2017.07.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/28/2017] [Accepted: 07/09/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS It is important to quantify medical costs associated with hepatocellular carcinoma (HCC), the incidence of which is rapidly increasing in the United States, for development of rational healthcare policies related to liver cancer surveillance and treatment of chronic liver disease. We aimed to comprehensively quantify healthcare costs for HCC among patients with cirrhosis in an integrated health system and develop a model for predicting costs that is based on clinically relevant variables. METHODS Three years subsequent to liver cancer diagnosis, costs accrued by patients included in the Veteran's Outcome and Cost Associated with Liver disease cohort were compiled by using the Department of Veterans Affairs Corporate Data Warehouse. The cohort includes all patients with HCC diagnosed in 2008-2010 within the VA with 100% chart confirmation as well as chart abstraction of tumor and clinical characteristics. Cancer cases were matched 1:4 with non-cancer cirrhosis controls on the basis of severity of liver disease, age, and comorbidities to estimate background cirrhosis-related costs. Univariable and multivariable generalized linear models were developed and used to predict cancer-related overall cost. RESULTS Our analysis included 3188 cases of HCC and 12,722 controls. The mean 3-year total cost of care in HCC patients was $154,688 (standard error, $150,953-$158,422) compared with $69,010 (standard error, $67,344-$70,675) in matched cirrhotic controls, yielding an incremental cost of $85,679; 64.9% of this value reflected increased inpatient costs. In univariable analyses, receipt of transplantation, Barcelona Clinic Liver Cancer (BCLC) stage, liver disease etiology, hospital academic affiliation, use of multidisciplinary tumor board, and identification through surveillance were associated with cancer-related costs. Multivariable generalized linear models incorporating transplantation status, BCLC stage, and multidisciplinary tumor board presentation accurately predicted liver cancer-related costs (Hosmer-Lemeshow goodness of fit; P value ≅ 1.0). CONCLUSIONS In a model developed to comprehensively quantify healthcare costs for HCC among patients with cirrhosis in an integrated health system, we associated receipt of liver transplantation, BCLC stage, and multidisciplinary tumor board with higher costs. Models that predict total costs on the basis of receipt of liver transplantation were constructed and can be used to model cost-effectiveness of therapies focused on HCC prevention.
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Affiliation(s)
- David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Michael K. Chapko
- Northwest Center for Outcomes Research in Older Adults, Health Services Research and Development Service, VA Puget Sound, Seattle, Washington
| | - Rajni Mehta
- Northwest Center for Outcomes Research in Older Adults, Health Services Research and Development Service, VA Puget Sound, Seattle, Washington
| | - Feng Dai
- VA Connecticut-Healthcare System, West Haven, Connecticut
| | | | - Ayse Aytaman
- VA New York Harbor Health Care System, Brooklyn, New York
| | | | - Kathryn D’Addeo
- Northwest Center for Outcomes Research in Older Adults, Health Services Research and Development Service, VA Puget Sound, Seattle, Washington
| | - Rena Fox
- San Francisco VA Medical Center, San Francisco, California
| | - Kristel Hunt
- James J. Peters VA Medical Center, Bronx, New York
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Kaplan DE, Mehta R, D’Addeo K, Valderrama A, Taddei TH. Sorafenib prescribed by gastroenterologists and hepatologists for hepatocellular carcinoma: A retrospective, multi-institutional cohort study. Medicine (Baltimore) 2018; 97:e9757. [PMID: 29369224 PMCID: PMC5794408 DOI: 10.1097/md.0000000000009757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Sorafenib is the only Food and Drug Administration (FDA)-approved first-line therapy shown to have survival benefit for patients with advanced hepatocellular carcinoma (HCC). Patients with advanced HCC are often but not exclusively transferred from non-oncologists to oncologists to initiate systemic therapy. The objective of this study was to assess whether sorafenib prescribing by non-oncologists has any impact on utilization, adverse effects, cost or outcome.This was a retrospective cohort study utilizing data from patients prescribed sorafenib for HCC within Veterans Health Administration hospitals with 100% chart abstraction to confirm HCC diagnosis, identify prescribing provider specialty (oncology versus gastroenterology/hepatology), and obtain data required for cancer staging by the Barcelona Clinic Liver Cancer (BCLC) system. The primary outcome was overall survival from the time of sorafenib prescription.A total of 4903 patients who prescribed sorafenib for HCC were identified, for whom 340 patients (6.9%) were prescribed drug by a non-oncologist (Onc). BCLC Stage, age, Child-Turcotte-Pugh score, and comorbidity indices were similar between patients prescribed sorafenib by oncologists and non-oncologists. Oncologists more often discontinued sorafenib due to progression, whereas non-oncologists were more likely to continue sorafenib until death resulting in greater pill utilization and cost. Overall survival in both unadjusted and multivariable models showed no significant impact of prescriber type on survival (222 vs 217 days, P = .96), confirmed with propensity-matched subcohorts.Similar survival outcomes were observed for patients with HCC prescribed sorafenib by non-oncologists and oncologists, suggesting that non-oncologists with expertise in the management of HCC can safely and effectively administer sorafenib.
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Affiliation(s)
- David E. Kaplan
- Department of Medicine, University of Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia PA
| | - Rajni Mehta
- Yale University School of Medicine
- VA Connecticut Healthcare System, West Haven, CT
| | - Kathryn D’Addeo
- Yale University School of Medicine
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Tamar H. Taddei
- Yale University School of Medicine
- VA Connecticut Healthcare System, West Haven, CT
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Reiss KA, Yu S, Mamtani R, Mehta R, D'Addeo K, Wileyto EP, Taddei TH, Kaplan DE. Starting Dose of Sorafenib for the Treatment of Hepatocellular Carcinoma: A Retrospective, Multi-Institutional Study. J Clin Oncol 2017; 35:3575-3581. [PMID: 28872925 DOI: 10.1200/jco.2017.73.8245] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose Sorafenib is currently the only Food and Drug Administration-approved first-line therapy for patients with advanced hepatocellular carcinoma. There are few data examining how sorafenib starting dose may influence patient outcomes and costs. Patients and Methods We retrospectively evaluated 4,903 patients from 128 Veterans Health Administration hospitals who were prescribed sorafenib for hepatocellular carcinoma between January 2006 and April 2015. After 1:1 propensity score matching to account for potential treatment bias, hazard ratios (HRs) were calculated using Cox regression and were tested against a noninferiority margin of HR = 1.1. A matched multivariate logistic regression was performed to adjust for potential confounders. The primary end point was overall survival (OS) of patients who were prescribed standard starting dosage sorafenib (800 mg/d per os) versus that of patients who were prescribed reduced starting dose sorafenib (< 800 mg/d per os). Results There were 3,094 standard dose sorafenib patients (63%) and 1,809 reduced starting dose sorafenib patients (37%). Reduced starting dose sorafenib patients had more Barcelona Clinic Liver Cancer stage D ( P < .001), higher Model for End-Stage Liver Disease Sodium scores ( P < .001), higher Child-Turcotte-Pugh scores ( P < .001), and higher Cirrhosis Comorbidity Index scores ( P = .01). Consequently, reduced starting dose sorafenib patients had lower OS (median, 200 v 233 days, HR = 1.10). After propensity score matching and adjusting for potential confounders, there was no longer a significant OS difference (adjusted hazard ratio [HRadj], 0.92; 95% CI, 0.83 to 1.01), and this fell significantly below the noninferiority margin ( P < .001). Reduced starting dose sorafenib patients experienced significantly lower total cumulative sorafenib cost and were less likely to discontinue sorafenib because of gastrointestinal adverse effects (8.7% v 10.8%; P = .047). Conclusion The initiation of sorafenib therapy at reduced dosages was associated with reduced pill burden, reduced treatment costs, and a trend toward a decreased rate of discontinuing sorafenib because of adverse events. Reduced dosing was not associated with inferior OS relative to standard dosing.
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Affiliation(s)
- Kim A Reiss
- Kim A. Reiss, Shun Yu, Ronac Mamtani, E. Paul Wileyto, and David E. Kaplan, University of Pennsylvania Perelman School of Medicine; David E. Kaplan, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA; Rajni Mehta, Kathryn D'Addeo, and Tamar H. Taddei, Yale University School of Medicine, New Haven; and Tamar H. Taddei, VA Connecticut Healthcare System, West Haven, CT
| | - Shun Yu
- Kim A. Reiss, Shun Yu, Ronac Mamtani, E. Paul Wileyto, and David E. Kaplan, University of Pennsylvania Perelman School of Medicine; David E. Kaplan, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA; Rajni Mehta, Kathryn D'Addeo, and Tamar H. Taddei, Yale University School of Medicine, New Haven; and Tamar H. Taddei, VA Connecticut Healthcare System, West Haven, CT
| | - Ronac Mamtani
- Kim A. Reiss, Shun Yu, Ronac Mamtani, E. Paul Wileyto, and David E. Kaplan, University of Pennsylvania Perelman School of Medicine; David E. Kaplan, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA; Rajni Mehta, Kathryn D'Addeo, and Tamar H. Taddei, Yale University School of Medicine, New Haven; and Tamar H. Taddei, VA Connecticut Healthcare System, West Haven, CT
| | - Rajni Mehta
- Kim A. Reiss, Shun Yu, Ronac Mamtani, E. Paul Wileyto, and David E. Kaplan, University of Pennsylvania Perelman School of Medicine; David E. Kaplan, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA; Rajni Mehta, Kathryn D'Addeo, and Tamar H. Taddei, Yale University School of Medicine, New Haven; and Tamar H. Taddei, VA Connecticut Healthcare System, West Haven, CT
| | - Kathryn D'Addeo
- Kim A. Reiss, Shun Yu, Ronac Mamtani, E. Paul Wileyto, and David E. Kaplan, University of Pennsylvania Perelman School of Medicine; David E. Kaplan, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA; Rajni Mehta, Kathryn D'Addeo, and Tamar H. Taddei, Yale University School of Medicine, New Haven; and Tamar H. Taddei, VA Connecticut Healthcare System, West Haven, CT
| | - E Paul Wileyto
- Kim A. Reiss, Shun Yu, Ronac Mamtani, E. Paul Wileyto, and David E. Kaplan, University of Pennsylvania Perelman School of Medicine; David E. Kaplan, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA; Rajni Mehta, Kathryn D'Addeo, and Tamar H. Taddei, Yale University School of Medicine, New Haven; and Tamar H. Taddei, VA Connecticut Healthcare System, West Haven, CT
| | - Tamar H Taddei
- Kim A. Reiss, Shun Yu, Ronac Mamtani, E. Paul Wileyto, and David E. Kaplan, University of Pennsylvania Perelman School of Medicine; David E. Kaplan, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA; Rajni Mehta, Kathryn D'Addeo, and Tamar H. Taddei, Yale University School of Medicine, New Haven; and Tamar H. Taddei, VA Connecticut Healthcare System, West Haven, CT
| | - David E Kaplan
- Kim A. Reiss, Shun Yu, Ronac Mamtani, E. Paul Wileyto, and David E. Kaplan, University of Pennsylvania Perelman School of Medicine; David E. Kaplan, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA; Rajni Mehta, Kathryn D'Addeo, and Tamar H. Taddei, Yale University School of Medicine, New Haven; and Tamar H. Taddei, VA Connecticut Healthcare System, West Haven, CT
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Zou H, Tao Y, Wang ZM. Integration of Child-Pugh score with future liver remnant yields improved prediction of liver dysfunction risk for HBV-related hepatocellular carcinoma following hepatic resection. Oncol Lett 2017; 13:3631-3637. [PMID: 28521464 PMCID: PMC5431318 DOI: 10.3892/ol.2017.5919] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 01/31/2017] [Indexed: 02/06/2023] Open
Abstract
Assessment of hepatic functional reserve is important to enable the selection of appropriate treatment methods and safe hepatic resection in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC). In the present study, an evaluation was made of the clinical value of combining the Child-Pugh score (CPS) with the standardized future liver remnant (sFLR) measurement to predict postoperative liver dysfunction (PLD). A total of 61 HBV-related HCC patients undergoing liver volumetry prior to hepatectomy were enrolled in the study. The sFLR was calculated as the ratio of FLR volume to standardized liver volume. PLD was defined as a prothrombin time of >18 sec or a peak serum bilirubin level of >51.3 µmol/l for 7 days after surgery. Univariate analysis and multivariate logistic regression analysis were performed to identify risk factors associated with PLD. The correlation between PLD and the combination of sFLR and CPS was analyzed. In total, 18 out of 61 patients developed PLD (29.5%), with a significantly higher PLD incidence for a CPS of 6 than a CPS of 5 (P<0.05). Multivariate logistic regression analysis revealed that a prothrombin time of <13.3 sec and an sFLR of <0.55 were independent risk factors for PLD. Receiver operating characteristic (ROC) curve analysis revealed that the cut-off values of sFLR and sFLR/CPS for predicting PLD were 54.5% and 0.0916, respectively, with areas under the ROC curve of 0.820 and 0.860, respectively. The combination of CPS and sFLR appears to yield improved prediction of the occurrence of PLD compared with either CPS or sFLR alone.
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Affiliation(s)
- Heng Zou
- Department of Hepatobiliary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Yiming Tao
- Department of Hepatobiliary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Zhi-Ming Wang
- Department of Hepatobiliary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
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Singal AG, Tiro JA, Marrero JA, McCallister K, Mejias C, Adamson B, Bishop WP, Santini NO, Halm EA. Mailed Outreach Program Increases Ultrasound Screening of Patients With Cirrhosis for Hepatocellular Carcinoma. Gastroenterology 2017; 152:608-615.e4. [PMID: 27825963 PMCID: PMC5285373 DOI: 10.1053/j.gastro.2016.10.042] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 10/25/2016] [Accepted: 10/28/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Surveillance of patients with cirrhosis increases early detection of hepatocellular carcinoma (HCC) and prolongs survival. However, its effectiveness is limited by underuse, particularly among racial/ethnic minorities and individuals of low socioeconomic status. We compared the effectiveness of mailed outreach strategies, with and without patient navigation, in increasing the numbers of patients with cirrhosis undergoing surveillance for HCC in a racially diverse and socioeconomically disadvantaged cohort. METHODS We performed a prospective study of patients with documented or suspected cirrhosis at a large safety-net health system from December 2014 through March 2016. Patients were assigned randomly (1:1:1) to groups that received mailed invitations for an ultrasound screening examination (n = 600), mailed invitations for an ultrasound screening examination and patient navigation (barrier assessment and motivational education for patients who declined screening; n = 600), or usual care (visit-based screening; n = 600). Patients who did not respond to outreach invitations within 2 weeks received up to 3 reminder telephone calls. The primary outcome was completion of abdominal imaging within 6 months of randomization. RESULTS Baseline characteristics were similar among groups. Cirrhosis was documented, based on International Classification of Diseases, 9th revision, codes, for 79.6% of patients, and suspected, based on noninvasive markers of fibrosis, for 20.4%. In an intent-to-treat analysis, significantly greater proportions of patients who received the mailed invitation and navigation (47.2%) or the mailed invitation alone (44.5%) underwent HCC screening than patients who received usual care (24.3%) (P < .001 for both comparisons). However, screening rates did not differ significantly between outreach the outreach groups (P = .25). The effects of the outreach program were consistent in all subgroups, including Caucasian vs non-Caucasian race, documented vs suspected cirrhosis, Child-Pugh A vs B cirrhosis, and receipt of gastroenterology care. CONCLUSIONS In a prospective study, we found outreach strategies to double the percentage of patients with cirrhosis who underwent ultrasound screening for HCC. However, adding patient navigation to telephone reminders provided no significant additional benefit. ClinicalTrials.gov no: NCT02312817.
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Affiliation(s)
- Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Jasmin A Tiro
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jorge A Marrero
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katharine McCallister
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Caroline Mejias
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brian Adamson
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Wendy Pechero Bishop
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
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Liu Q, Li XL, Liu JJ, Song XH, Jiang XY, Li W, Zhang H, Pan CQ. Efficacy and safety of endometrial ablation for treating abnormal uterine bleeding in pre- and postmenopausal women with liver cirrhosis. J Obstet Gynaecol Res 2016; 42:1753-1760. [PMID: 27647778 DOI: 10.1111/jog.13124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/15/2016] [Accepted: 07/06/2016] [Indexed: 12/15/2022]
Abstract
AIM Abnormal uterine bleeding (AUB) occurs in 10-30% of women of reproductive age and up to 61% of cirrhotic women. We evaluated the efficacy and safety of endometrial ablation (NovaSure therapy) for AUB in cirrhotic women. METHODS This prospective, two-arm, observational study enrolled patients for NovaSure treatment, and they were followed for 12 months. Primary measurements were the amenorrhea rate and changes of pictorial blood loss assessment chart (PBLAC) scores at 1-month post-therapy. Key secondary end-points included the longevity of amenorrhea at 12 months, safety profile, and progression of cirrhosis. RESULTS Among 88 women, 26 were cirrhotic and 62 were non-cirrhotic. At 1-month post-NovaSure treatment, a significant reduction of mean PBLAC scores was observed in cirrhotic patients compared to those at baseline (0.4 ± 1.3 vs 215.2 ± 410.9, P < 0.001), and the amenorrhea rate was 88.5%. The efficacy outcomes of the PBLAC scores and amenorrhea rate were maintained until the end of the 12-month follow-up. A significant improvement in quality of life scores was observed 1-month post-therapy compared to those at baseline (5.4 ± 3.1 vs 20.5 ± 5.5, P < 0.001). Patients' satisfaction rates were 100% and 92.31% at 6 and 12 months, respectively. The aforementioned outcomes were comparable with those in non-cirrhotic patients. No significant progression of cirrhosis or safety concern was reported. CONCLUSION Cirrhotic patients on NovaSure therapy had a high rate of amenorrhea 1-month post-treatment, which maintained longevity for 12 months. The safety profile was similar to that in non-cirrhotic patients.
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Affiliation(s)
- Qing Liu
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiu-Lan Li
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Ji-Juan Liu
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiao-Hong Song
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiao-Ying Jiang
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- Department of Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Hua Zhang
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Calvin Q Pan
- Center for Major Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Division of Gastroenterology and Hepatology, Department of Medicine, NYU Langone Medical Center, New York University School of Medicine, New York, USA
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Kaplan DE, Dai F, Skanderson M, Aytaman A, Baytarian M, D’Addeo K, Fox R, Hunt K, Knott A, Mehta R, Pedrosa M, Pocha C, Valderrama A, Taddei T. Recalibrating the Child-Turcotte-Pugh Score to Improve Prediction of Transplant-Free Survival in Patients with Cirrhosis. Dig Dis Sci 2016; 61:3309-3320. [PMID: 27405990 PMCID: PMC5067291 DOI: 10.1007/s10620-016-4239-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 06/21/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. However, the cutpoints for stratifying laboratory variables in CTP have never been validated. OBJECTIVE The objective of this study was to identify evidence-based cutpoints for the CTP laboratory subscores to improve its predictive capacity for transplant-free survival. DESIGN Retrospective observational study. DATA SOURCE Using a cohort of 30,897 cirrhotic US Veteran patients with at least 5 years of follow-up, we performed Cox proportional hazard survival model iterations varying the upper and lower cutpoints for INR, total bilirubin and albumin CTP subscores. Cutpoints yielding the highest Harrell's C-statistics for concordance with transplant-free survival were incorporated into a modified CTP (mCTP) score. Validation of the mCTP was performed at multiple time frames within the follow-up period of the cohort and within subsets defined by disease etiology. RESULTS Modification of CTP cutpoints increased the Harrell's C-statistic for age- and gender-adjusted Cox proportional hazard models from 0.701 ± 0.002 to 0.709 ± 0.002 and the risk ratio per unit change from 1.49 (1.48-1.50) to 1.53 (1.52-1.54). The modified cutpoints showed superiority in predicting 5-year transplant-free survival in various disease etiology subgroups. A mCTP substituting serum creatinine for INR performed superiorly for predicting 5-year transplant-free survival. CONCLUSION We propose an evidence-based recalibration of CTP score cutpoints that optimizes this model's capacity to predict transplant-free survival in patients with cirrhosis. The CTP score remains the best predictor of 5-year overall and transplant-free survival in patients with cirrhosis.
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Affiliation(s)
- David E. Kaplan
- Gastroenterology Section, Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Bldg. 21, Room A422, Philadelphia, PA 19104 USA
| | - Feng Dai
- VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT 06516 USA
| | - Melissa Skanderson
- VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT 06516 USA
| | - Ayse Aytaman
- VA New York Harbor Health Care System, 800 Poly Place, Brooklyn, NY 11209 USA
| | - Michelle Baytarian
- Boston VA Healthcare System, 150 S. Huntington Avenue, Boston, MA 02130 USA
| | - Kathryn D’Addeo
- VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT 06516 USA
| | - Rena Fox
- San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA 94121 USA
| | - Kristel Hunt
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468 USA
| | - Astrid Knott
- Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417 USA
| | - Rajni Mehta
- VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT 06516 USA
| | - Marcos Pedrosa
- Boston VA Healthcare System, 150 S. Huntington Avenue, Boston, MA 02130 USA
| | - Christine Pocha
- Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417 USA
| | - Adriana Valderrama
- Bayer HealthCare Pharmaceuticals, 100 Bayer Blvd, Whippany, NJ 07981 USA
| | - Tamar Taddei
- VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT 06516 USA
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