Predictors of morbidity and mortality after the first episode of upper gastrointestinal bleeding in liver cirrhosis

A combination of models for end-stage liver disease and cirrhosis-related complications to predict the prognosis of liver cirrhosis

BACKGROUND

The Child-Pugh score, the model for end-stage liver disease (MELD) score, and the occurrence of cirrhosis-related complications are independent prognostic predictors used in the assessment of chronic liver diseases.

OBJECTIVES

The objectives of this study were to determine the best prognostic scoring system, and to create a combined method to predict the prognosis of liver cirrhosis more accurately.

METHODS

We retrospectively reviewed 435 cirrhotic patients from January 2009 to June 2010 and evaluated their short- and medium-term survival. Child-Pugh, MELD and its advanced scoring systems were computed for each patient. The sensitivity and specificity of these scoring systems were analyzed and their validity was assessed using concordance (c)-statistics in predicting the prognosis of cirrhotic patients.

RESULTS

Overall, 107 patients died within 6 months and 150 patients died within 1 year. The clinical and biochemical characteristics, cirrhosis-related complications, and the scores were significantly different among the survivors and patients who died. The largest area under the receiver operating characteristic curve was 0.741 for the integrated MELD (iMELD) at 6 months and 0.713 for iMELD at 12 months, indicating that iMELD was the best scoring system tested. Given this result, we created a new scoring system that combined iMELD and an index of cirrhosis-related complications, called iMELD-C. This novel system had c indexes of 0.758 for the 6-month survival and 0.746 for the 1-year survival.

CONCLUSIONS

The iMELD-C score is a better predictor of both short- and medium-term survival in patients with cirrhosis.

Intrasplenic transplantation of bioencapsulated mesenchymal stem cells improves the recovery rates of 90% partial hepatectomized rats

Mesenchymal stem cells (MSCs) derived from bone marrow can secrete cytokines and growth factors and can transdifferentiate into liver cells. We transplanted polymeric membrane bioencapsulated MSCs into the spleens of 90% partial hepatectomized rats. This resulted in 91.6% recovery rates. This is compared to a recovery rate of 21.4% in the 90% hepatectomized rats and 25% in the 90% hepatectomized rats receiving intrasplenic transplantation of free MSCs. After 14 days, the remnant livers in the bioencapsulated MSCs group are not significantly different in weight when compared to the sham control group. From day 1 to day 3 after surgery, in the bioencapsulated MSCs group, the plasma HGF and IL-6 were significantly higher than those in the free MSCs group and control group (P < 0.01); plasma TNF-α was significantly lower (P < 0.001). We concluded that the intrasplenic transplantation of bioencapsulated MSCs significantly increases the recovery rates of 90% hepatectomized rats. It is likely that the initial effect is from proliver regeneration factors followed later by the transdifferentiated hepatocyte-like cells. However, histopathological analysis and hepatocyte proliferation study will be needed to better understand the regenerative mechanisms of this result. This study has implications in improving the survival and recovery of patients with very severe liver failure due to hepatitis, trauma, or extensive surgical resection.

Regulation of the g1/s transition in hepatocytes: involvement of the cyclin-dependent kinase cdk1 in the DNA replication

A singular feature of adult differentiated hepatocytes is their capacity to proliferate allowing liver regeneration. This review emphasizes the literature published over the last 20 years that established the most important pathways regulating the hepatocyte cell cycle. Our article also aimed at illustrating that many discoveries in this field benefited from the combined use of in vivo models of liver regeneration and in vitro models of primary cultures of human and rodent hepatocytes. Using these models, our laboratory has contributed to decipher the different steps of the progression into the G1 phase and the commitment to S phase of proliferating hepatocytes. We identified the mitogen dependent restriction point located at the two-thirds of the G1 phase and the concomitant expression and activation of both Cdk1 and Cdk2 at the G1/S transition. Furthermore, we demonstrated that these two Cdks contribute to the DNA replication. Finally, we provided strong evidences that Cdk1 expression and activation is correlated to extracellular matrix degradation upon stimulation by the pro-inflammatory cytokine TNFα leading to the identification of a new signaling pathway regulating Cdk1 expression at the G1/S transition. It also further confirms the well-orchestrated regulation of liver regeneration via multiple extracellular signals and pathways.

Vitamin K for upper gastrointestinal bleeding in patients with acute or chronic liver diseases

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Several treatments are used for upper gastrointestinal bleeding in patients with liver diseases. One of them is vitamin K administration, but it is not known whether it benefits or harms patients with acute or chronic liver disease and upper gastrointestinal bleeding.

OBJECTIVES

To assess the beneficial and harmful effects of vitamin K for patients with acute or chronic liver disease and upper gastrointestinal bleeding.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (12 June 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 5 of 12, 2012), MEDLINE (Ovid SP) (1946 to 12 June 2012), EMBASE (Ovid SP) (1974 to 12 June 2012), Science Citation Index EXPANDED (1900 to 12 June 2012), and LILACS (1982 to 19 June 2012). Additional randomised trials were sought from two registries of clinical trials: the Clinical Trials Search Portal of the WHO, and the Metaregister of Controlled Trials. We looked through the reference lists of the retrieved publications and review articles.

SELECTION CRITERIA

Randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. Observational studies were considered for assessment of harms only.

DATA COLLECTION AND ANALYSIS

Data from randomised clinical trials were to be summarised by standard Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised trials on vitamin K for upper gastrointestinal bleeding in patients with liver diseases in which we could assess benefits and harms. We could not identify quasi-randomised studies, historically controlled or observational studies in which we could assess harms.

AUTHORS' CONCLUSIONS

This updated review found no randomised clinical trials on the benefits and harms of vitamin K for upper gastrointestinal bleeding in patients with liver diseases. The effects of vitamin K need to be tested in randomised clinical trials. Until randomised clinical trials are conducted to assess the trade off between benefits and harms, we cannot recommend nor refute vitamin K for upper gastrointestinal bleeding in patients with liver diseases.

Renal failure after upper-gastrointestinal bleeding among cirrhotic patients in Upper Egypt

BACKGROUND AND STUDY AIMS

Renal dysfunction is a common and serious problem in patients with advanced liver disease. The study aims to assess the incidence, risk factors and short-term prognosis of renal failure after upper-gastrointestinal bleeding among cirrhotic patients in Upper Egypt.

METHODS

We recruited 159 cirrhotic patients with 168 episodes of upper-gastrointestinal bleeding from Tropical Medicine and Gastroenterology Department, Assiut University Hospital. For all participants, the following were conducted: clinical evaluation, abdominal ultrasonography (US) examination, laboratory investigations and upper endoscopy. Risk factors of renal failure were identified using univariate, then multivariate analysis.

RESULTS

The incidence of renal failure among bleeding episodes was 28%. Higher risk of renal failure among cirrhotic patients with upper-gastrointestinal bleeding was observed with shock (odds ratio (OR) 0.171, 95% confidence interval (CI) 0.047:0.624), bacterial infection (OR 0.310, 95% CI 107:897), Child-Pugh class C (OR 2.79, 95% CI 1.018:7.62), higher serum bilirubin (OR 0.122, 95% CI 0.000:0.002), lower serum albumin (OR -0.188, 95% CI -0.288:-0.056) and raised baseline blood urea (OR 0.181, 95% CI 0.003:0.017) and serum creatinine (OR 0.533, 95% CI 0.002:0.004). Mortality among patients with renal failure was 31.9%.

CONCLUSION

Renal failure is a frequent event among cirrhotic patients with upper-gastrointestinal bleeding and there are many contributing factors for its development. Mortality is relatively high among patients with renal failure in cirrhotics with upper-gastrointestinal bleeding.

Endoscopic management of esophageal varices

The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis

Non-steroidal anti-inflammatory drugs use and risk of upper gastrointestinal adverse events in cirrhotic patients

BACKGROUND/AIMS

The upper gastrointestinal (GI) toxicity associated with non-steroidal anti-inflammatory drugs (NSAID) use among cirrhotic patients remains unclear. The objective of this study was to evaluate the risk of upper GI adverse events associated with celecoxib and oral and parenteral non-selective NSAIDs in cirrhotic patients.

METHODS

All the patients aged ≥ 20 years with a diagnosis of cirrhosis hospitalized for variceal bleeding and non-variceal upper GI adverse events (oesophageal, gastric, duodenal ulcer, bleeding; gastritis and duodenitis) in 2006 were identified using ICD-9-CM diagnosis codes from inpatient claims from the Taiwan National Health Insurance Database. In the case-crossover study design, the case period was defined as 1-30 days and the control period as 31-60 days before the date of hospitalization. The information for individual NSAID use was obtained from the outpatient pharmacy prescription database. Adjusted self-matched odds ratios (OR) and their 95% confidence intervals (CI) were estimated with a conditional logistic regression model.

RESULTS

A total of 4876 cirrhotic patients were included. The adjusted OR (95% CI) was 1.44 (0.89-2.31) for celecoxib, 1.87 (1.66-2.11) for oral non-selective NSAIDs and 1.90 (1.55-2.32) for parenteral NSAIDs overall. Risks were similar for variceal and non-variceal events. Concomitant use of proton pump inhibitors and histamine-2 receptor antagonists tended to decrease the upper GI toxicity associated with non-selective NSAIDs and celecoxib.

CONCLUSION

The use of nsNSAIDs but not celecoxib was associated with a two-fold increased risk of variceal and non-variceal upper GI events among cirrhotic patients.

Systematic review of noncancer presentations with a median survival of 6 months or less

PURPOSE

We report on clinical indicators of 6-month mortality in advanced noncancer illnesses and the effect of treatment on survival.

METHODS

The MEDLINE database was searched comprehensively to find studies evaluating survival for common advanced noncancer illnesses. We retrieved and evaluated studies that reported a median survival of ≤1 year and evaluated prognostic factors or effect of treatment on survival. We extracted data on presentations with median survivals of ≤6 months for heart failure, chronic obstructive pulmonary disease, dementia, geriatric failure to thrive, cirrhosis, and end-stage renal failure. Independent risk factors for survival were combined and included if their combination was associated with a 6-month mortality of ≥50%.

RESULTS

The search identified 1000 potentially relevant studies, of which 475 were retrieved and evaluated, and 74 were included. We report the common clinical presentations that are consistently associated with a 6-month median survival. Even though advanced noncancer syndromes differ clinically, a universal set of prognostic factors signals progression to terminal disease, including poor performance status, advanced age, malnutrition, comorbid illness, organ dysfunction, and hospitalization for acute decompensation. Generally, a 6-month median survival is associated with the presence of 2-4 of these factors. With few exceptions, these terminal presentations are quite refractory to treatment.

CONCLUSION

This systematic review summarizes prognostic factors common to advanced noncancer illness. There is little evidence at present that treatment prolongs survival at these terminal stages.

Risk factors for in-hospital mortality in cirrhotic patients with oesophageal variceal bleeding

INTRODUCTION

Oesophageal variceal bleeding (OVB) is a high mortality rate complication in patients with cirrhosis. The aim of this study was to assess the risk factors for in-hospital mortality (IHM) in cirrhotic patients with OVB.

PATIENTS AND METHODS

The study cohort included 102 patients (average age, 55.4 ± 12.6 years, 71.6% men) consecutively admitted to our hospital with OVB. All the patients underwent upper endoscopy within 12 h and octeotride or terlipressin therapy was started at admission and continued for 5 days. To calculate Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh scores, laboratory test data from blood samples taken within 6 h of admission were used.

RESULTS

The IHM was 18.6% [19 patients; confidence interval (95% CI): 11.1-26.2%]. In the univariate analysis, transfusion with 2 or more units of packed red blood cells [PRBC; P=0.038; odds ratio (OR)=7.8; 95% CI: 1.2-61.3], platelets of 100/ml or less (P=0.014; OR=3.6; 95% CI: 1.2-10.3), Child-Turcotte-Pugh score of 10 or more (P=0.002; OR=4.0; 95% CI: 1.2-13.2) and MELD of 18 or more (P=0.044; OR=2.8; 95% CI: 1.1-8.1) were associated with IHM. In the multivariate analysis, transfusion with 2 or more units of PRBC (P=0.076; OR=6.7; 95% CI: 0.82-54.8), platelets of 100/ml or less (P=0.031; OR=3.4; 95% CI: 1.1-10.6) and MELD of 18 or more (P=0.048; OR=3.2; 95% CI: 1.02-10.1) remained independently associated with IHM. Applying a receiver operating characteristic analysis, the area under the curve derived from the multivariate analysis model was 0.76 (95% CI: 0.64-0.88) for IHM.

CONCLUSION

Cirrhotic patients with OVB and MELD of 18 or more, platelets of 100/ml or less and requiring transfusion of 2 or more units of PRBC were at an increased risk of IHM. Overall, the logistic regression model correctly predicts 82.2% of IHM patients.

Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases

BACKGROUND

Mortality from upper gastrointestinal bleeding in patients with liver disease is high. Recombinant human activated factor VII (rHuFVIIa) has been suggested for patients with liver disease and upper gastrointestinal bleeding.

OBJECTIVES

To assess the beneficial and harmful effects of rHuFVIIa in patients with liver disease and upper gastrointestinal bleeding.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2011), MEDLINE (1948 to December 2011), EMBASE (1980 to December 2011), Science Citation Index Expanded (1900 to December 2011), and LILACS (December 2011). We sought additional randomised trials from the reference lists of the trials and reviews identified through the electronic searches.

SELECTION CRITERIA

Randomised clinical trials.

DATA COLLECTION AND ANALYSIS

Outcome data from randomised clinical trials were extracted and were presented using random-effects model meta-analyses. Data on the risk of bias in the included trials were also extracted.

MAIN RESULTS

We included two trials with 493 randomised participants with various Child-Pugh scores. The trials had a low risk of bias. The rHuFVIIa administration did not reduce the risk of mortality within five days (21/288 (7.3%) versus 15/205 (7.3%); risk ratio (RR) 0.88, 95% confidence interval (CI) 0.48 to 1.64, I(2) = 49%) and within 42 days (5/286 (1.7%) versus 36/205 (17.6%); RR 1.01, 95% CI 0.55 to 1.87, I(2) = 55%) when compared with placebo. Trial sequential analysis demonstrated that there is sufficient evidence to exclude that rHuFVIIa decreases mortality by 80%, but there is insufficient evidence to exclude smaller effects. The rHuFVIIa did not increase the risk of adverse events by number of patients (218/297 (74%) and 164/210 (78%); RR 0.94, 95% CI 0.84 to 1.04, I(2) = 1%), serious adverse events by adverse events reported (164/590 (28%) versus 123/443 (28%); RR 0.91, 95% CI 0.75 to 1.11, I(2) = 0%), and thromboembolic adverse events (16/297 (5.4%) versus 14/210 (6.7%); RR 0.80, 95% CI 0.40 to 1.60, I(2) = 0%) when compared with placebo.

AUTHORS' CONCLUSIONS

We found no evidence to support or reject the administration of rHuFVIIa for patients with liver disease and upper gastrointestinal bleeding. Further adequately powered randomised clinical trials are needed in order to evaluate the proper role of rHuFVIIa for treating upper gastrointestinal bleeding in patients with liver disease. Although the results are based on trials with low risk of bias, the heterogeneity and the small sample size result in rather large confidence intervals that cannot exclude the possibility that the intervention has some beneficial or harmful effect. Further trials with alow risk of bias are required to make more confident conclusions about the effects of the intervention.

The MAPK MEK1/2-ERK1/2 Pathway and Its Implication in Hepatocyte Cell Cycle Control

Primary cultures of hepatocytes are powerful models in studying the sequence of events that are necessary for cell progression from a G0-like state to S phase. The models mimic the physiological process of hepatic regeneration after liver injury or partial hepatectomy. Many reports suggest that the mitogen-activated protein kinase (MAPK) ERK1/2 can support hepatocyte proliferation in vitro and in vivo and the MEK/ERK cascade acts as an essential element in hepatocyte responses induced by the EGF. Moreover, its disregulation has been associated with the promotion of tumor cell growth of a variety of tumors, including hepatocellular carcinoma. Whereas the strict specificity of action of ERK1 and ERK2 is still debated, the MAPKs may have specific biological functions under certain contexts and according to the differentiation status of the cells, notably hepatocytes. In this paper, we will focus on MEK1/2-ERK1/2 activations and roles in normal rodent hepatocytes in vitro and in vivo after partial hepatectomy and in human hepatocarcinoma cells. The possible specificity of ERK1 and ERK2 in normal and transformed hepatocyte will be discussed in regard to other differentiated and undifferentiated cellular models.

Combined Stimulation with the Tumor Necrosis Factor α and the Epidermal Growth Factor Promotes the Proliferation of Hepatocytes in Rat Liver Cultured Slices

The culture liver slices are mainly used to investigate drug metabolism and xenobiotic-mediated liver injuries while apoptosis and proliferation remain unexplored in this culture model. Here, we show a transient increase in LDH release and caspase activities indicating an ischemic injury during the slicing procedure. Then, caspase activities decrease and remain low in cultured slices demonstrating a low level of apoptosis. The slicing procedure is also associated with the G0/G1 transition of hepatocytes demonstrated by the activation of stress and proliferation signalling pathways including the ERK1/2 and JNK1/2/3 MAPKinases and the transient upregulation of c-fos. The cells further progress up to mid-G1 phase as indicated by the sequential induction of c-myc and p53 mRNA levels after the slicing procedure and at 24 h of culture, respectively. The stimulation by epidermal growth factor induces the ERK1/2 phosphorylation but fails to activate expression of late G1 and S phase markers such as cyclin D1 and Cdk1 indicating that hepatocytes are arrested in mid-G1 phase of the cell cycle. However, we found that combined stimulation by the proinflammatory cytokine tumor necrosis factor α and the epidermal growth factor promotes the commitment to DNA replication as observed in vivo during the liver regeneration.

Functional Relationships between Lipid Metabolism and Liver Regeneration

The regenerative capacity of the liver is well known, and the mechanisms that regulate this process have been extensively studied using experimental model systems including surgical resection and hepatotoxin exposure. The response to primary mitogens has also been used to investigate the regulation of hepatocellular proliferation. Such analyses have identified many specific cytokines and growth factors, intracellular signaling events, and transcription factors that are regulated during and necessary for normal liver regeneration. Nevertheless, the nature and identities of the most proximal events that initiate hepatic regeneration as well as those distal signals that terminate this process remain unknown. Here, we review the data implicating acute alterations in lipid metabolism as important determinants of experimental liver regeneration and propose a novel metabolic model of regeneration based on these data. We also discuss the association between chronic hepatic steatosis and impaired regeneration in animal models and humans and consider important areas for future research.

Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality

Despite major advances in diagnosis, prevention, and treatment, nonvariceal upper gastrointestinal bleeding still is a serious problem in clinical practice. Current evidence indicates that most peptic ulcer bleeding-linked deaths are not a direct sequela of the bleeding ulcer itself. Instead, mortality derives from multiorgan failure, cardiopulmonary conditions, or terminal malignancy, suggesting that improving further current treatments for the bleeding ulcer may have a limited impact on mortality unless supportive therapies are developed for the global management of these patients.

RIFLE criteria accurately identifies renal dysfunction and renal failure in elderly patients with upper gastrointestinal hemorrhage: a pilot study

BACKGROUND

The incidence of acute kidney injury (AKI) as a complication of acute upper gastrointestinal bleeding (AUGIB) is not known. Recently, RIFLE criteria were used widely in the medical research to identify patients with different degrees of renal insufficiency.

OBJECTIVES

Our purpose is to determine the incidence, clinical presentations, endoscopic findings and outcomes of AKI in the elderly presenting with AUGIB using RIFLE criteria. The study was conducted in a community hospital in Washington State. This was a retrospective pilot study of elderly patients (≥60 years old) presenting with AUGIB. Categorical variables were analyzed using the Chi-square test. The Student t-test was used to compare continuous variables. A total of 113 patients were included (52 males and 61 females) in the study. The patients were classified into those with AKI based on RIFLE criteria and those without. The two groups were compared in regard to clinical presentations, laboratory and endoscopic findings, complications, length and cost of hospitalization.

RESULTS

Fifty five patients (48.7%) met RIFLE criteria for AKI, while 58 patients did not develop any renal dysfunction. Patients with AUGIB complicated with AKI tend to be residents at nursing homes (38% vs. 14%, P < 0.004), present with weakness (49% vs 29%., P < 0.04) and altered mental status (25% vs. 55%, P < 0.003), have higher serum creatinine at presentation (1.8 mg/dL vs. 1.2 mg/dL, P < 0.002), have less incidence of gastritis/gastric ulcers (67% vs. 42%, P < 0.007), have nondiagnostic upper endoscopic examination (29% vs. 14%, P < 0.05), higher incidences of cardiac complications including myocardial infarction (9% and 0%, P < 0.02), longer lengths of stay (5.0 days vs. 2.37 days, P < 0.005) and higher hospitalization costs ($20,230 vs. $11,779, P < 0.02).

CONCLUSION

The incidence of developing AKI as a consequence of AUGIB in the elderly is very common. Those with AKI tend to have a more complicated clinical course in the hospital.

NF-κB, JNK, and TLR Signaling Pathways in Hepatocarcinogenesis

Hepatocellular carcinoma (HCC) is the third largest cause of cancer deaths worldwide. The role of molecular changes in HCC have been used to identify prognostic markers and chemopreventive or therapeutic targets. It seems that toll-like receptors (TLRs) as well as the nuclear factor (NF)-κB, and JNK pathways are critical regulators for the production of the cytokines associated with tumor promotion. The cross-talk between an inflammatory cell and a neoplastic cell, which is instigated by the activation of NF-κB and JNKs, is critical for tumor organization. JNKs also regulate cell proliferation and act as oncogenes, making them the main tumor-promoting protein kinases. TLRs play roles in cytokine and hepatomitogen expression mainly in myeloid cells and may promote liver tumorigenesis. A better understanding of these signaling pathways in the liver will help us understand the mechanism of hepatocarcinogenesis and provide a new therapeutic target for HCC.

High doses of beta-blockers and alcohol abstinence improve long-term rebleeding and mortality in cirrhotic patients after an acute variceal bleeding

BACKGROUND & AIM

We analysed prognostic indicators of long-term outcome in cirrhotic patients surviving the critical 6-week period after an episode of acute variceal bleeding.

METHODS

All patients with oesophageal variceal bleeding from 2001-2007 were prospectively registered. Follow-up extended from day 42 after index bleeding to last visit, death or liver transplantation (LT). Multivariate Cox regression analysis was performed.

RESULTS

Two hundred and fifty variceal bleeding episodes were registered. Fifty-four patients (26%) died before day 42, and 123 patients were finally included. Median follow-up was 23.5 months. Nadolol+/-nitrates alone or combined with variceal ligation were used as prophylaxis in 93% of patients. During follow-up, 43 patients (35%) experienced rebleeding, 34 (27.5%) died and 10 (8%) were transplanted. Follow-up beta-blocker dose (HR 0.993, 95% CI 0.987-0.998, P=0.027) and alcohol abstinence (HR 0.324, 95% CI 0.152-0.691, P=0.004) were independent rebleeding predictors. The Cox analysis disclosed the Child-Pugh score (HR 1.24, 95% CI 1.08-1.43, P=0.002), creatinine (HR 1.82, 95% CI 1.17-2.82, P=0.008), beta-blocker dose (HR 0.992, 95% CI 0.987-0.997, P=0.003), viral cirrhosis (HR 2.72, 95% CI 1.31-5.67, P=0.008), hepatocellular carcinoma (HR 9.44, 95% CI 3.54-25.20, P<0.001) and alcohol abstinence (HR 0.29, 95% CI 0.13-0.62, P=0.002) to be independent prognostic markers for mortality/LT.

CONCLUSION

High doses of beta-blockers and alcohol abstinence decrease rebleeding and mortality in cirrhotic patients surviving the 6-week period after acute variceal bleeding.

Predicting early mortality after acute variceal hemorrhage based on classification and regression tree analysis

BACKGROUND & AIMS

Available prognostic models for mortality after an acute variceal hemorrhage have limitations that restrict their clinical value. We assessed the performance of a novel prognostic approach based on classification and regression tree (CART) analysis.

METHODS

Logistic regression (LR) and CART analyses were performed to identify prognostic models for mortality at 6 weeks in a single-center cohort of 267 consecutive patients with acute variceal bleeding. Receiver operating characteristic (ROC) curves were constructed to assess the performance of the models. Prognostic models were fitted and validated by split-sample technique (training set, 164 patients, 2001-2005; test set, 103 patients, 2006-2008).

RESULTS

After 6 weeks, 21% of patients experienced rebleeding and 24% died. The best LR model was based on Child-Pugh score, creatinine level, bacterial infection, and hepatocellular carcinoma. CART analysis provided a simple algorithm based on the combined use of just 3 variables (Child-Pugh score, creatinine level, and bacterial infection), allowing accurate early discrimination of 3 distinct prognostic subgroups with 8% (low risk), 17% (intermediate), and 50% to 73% (high) mortality. Its accuracy was similar to the LR model (area under the ROC curves, 0.81 vs 0.84; P = .17) and better than that of Child-Pugh (0.75; P = .05) and model for end-stage liver disease (0.74; P = .05). The prognostic accuracy of both LR and CART models was validated in the test set (area under the ROC curve values, 0.81 and 0.83, respectively).

CONCLUSIONS

A simple CART algorithm based on Child-Pugh score, creatinine level, and infection allowed an accurate predictive assessment of 6-week mortality after acute variceal bleeding.

Vapreotide: a somatostatin analog for the treatment of acute variceal bleeding

BACKGROUND

Portal hypertension is a clinically important consequence of cirrhosis that can lead to morbidities such as variceal bleeding, hepatic encephalopathy and ascites. All of these outcomes carry high mortality rates. There have been several drugs created to assist with endoscopic therapy for the treatment of acute variceal bleeding. Recently, vapreotide has been studied in patients to evaluate its efficacy as treatment for acute variceal hemorrhage. Although no comparisons have been made between vapreotide and other somatostatin analogues, this drug has been shown to have efficacy in the control of acute variceal bleeding as well as reducing the risk of recurrent bleeding and death, especially when started prior to endoscopy.

OBJECTIVE

This paper reviews the literature regarding the basic science and clinical efficacy of vapreotide in acute variceal bleeding.

METHODS

We used a PubMed/Medline search in order to review the literature regarding the drug, vapreotide.

RESULTS/CONCLUSIONS

Vapreotide appears to have benefit in the control of acute variceal bleeding. It is easy to administer and has few side effects, which are minor. These findings endorse the need for future trials to evaluate vapreotide and its use in acute variceal hemorrhage, a morbidity among patients with cirrhosis.

Emerging drugs for hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy (HE) is a severe complication of cirrhosis, seriously affecting the patients' quality of life. The classical approach aimed at reducing the production of gut-derived toxins, such as ammonia, is under debate as, at the moment, the information obtained from the clinical trials does not support any specific treatment for HE.

OBJECTIVES

i) To discuss present therapeutic strategies and possible future developments; ii) to identify areas of medical needs and iii) to suggest the ideal design and methodology for randomized controlled trials (RCTs) in HE.

METHODS

Current approaches were obtained from already available RCTs or from experimental animal studies. Those approaches developed from studies on HE pathophysiology were considered as working hypotheses for future therapies.

RESULTS/CONCLUSION

Our competence in testing old and new treatment modalities by RCTs with appropriate clinically relevant end points should urgently be improved. The patients at risk of HE are identifiable, and studies specifically aimed at establishing whether HE may be prevented or not are needed. As far as new treatment modalities are concerned, RCTs on the modulators of the intestinal bacterial flora and on the molecular adsorbent recirculating system are already available, but further studies are needed to confirm these promising approaches.

Influence of portosystemic shunt on liver regeneration after hepatic resection in pigs

Objective. The minimal amount of liver mass necessary for regeneration is still a matter of debate. The aim of the study was to analyze liver regeneration factors after extended resection with or without portosystemic shunt. Methods. An extended left hemihepatectomy was performed in 25 domestic pigs, in 15 cases after a portosystemic H-shunt. The expression of Ki-67, VEGF, TGF-α, FGF, and CK-7 was analyzed in paraffin-embedded tissue sections. Results. The volume of the remnant liver increased about 2.5-fold at the end of the first week after resection. With 19 cells/10 Glisson fields versus 4/10, Ki-67-expression was significantly higher in the H-shunt group. VEGF- and CK-7-expressions were significantly higher in the control group. No significant change was found in FGF-expression. The expression of TGF-α was higher, but not significantly, in the control group. Conclusions. The expression of Ki-67, and therefore hepatocyte regeneration, was increased in the shunt group. The expression of CK-7 on biliary epithelium and the expression of VEGF, however, were stronger in the control group.

Metallothionein as an anti-inflammatory mediator

The integration of knowledge concerning the regulation of MT, a highly conserved, low molecular weight, cystein-rich metalloprotein, on its proposed functions is necessary to clarify how MT affects cellular processes. MT expression is induced/enhanced in various tissues by a number of physiological mediators. The cellular accumulation of MT depends on the availability of cellular zinc derived from the diet. MT modulates the binding and exchange/transport of heavy metals such as zinc, cadmium, or copper under physiological conditions and cytoprotection from their toxicities, and the release of gaseous mediators such as hydroxyl radicals or nitric oxide. In addition, MT reportedly affects a number of cellular processes, such as gene expression, apoptosis, proliferation, and differentiation. Given the genetic approach, the apparently healthy status of MT-deficient mice argues against an essential biological role for MT; however, this molecule may be critical in cells/tissues/organs in times of stress, since MT expression is also evoked/enhanced by various stresses. In particular, because metallothionein (MT) is induced by inflammatory stress, its roles in inflammation are implied. Also, MT expression in various organs/tissues can be enhanced by inflammatory stimuli, implicating in inflammatory diseases. In this paper, we review the role of MT of various inflammatory conditions.

Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding

AIM: To identify clinical parameters, and develop an Upper Gastrointesinal Bleeding (UGIB) Etiology Score for predicting the types of UGIB and validate the score.

METHODS: Patients with UGIB who underwent endoscopy within 72 h were enrolled. Clinical and basic laboratory parameters were prospectively collected. Predictive factors for the types of UGIB were identified by univariate and multivariate analyses and were used to generate the UGIB Etiology Score. The best cutoff of the score was defined from the receiver operating curve and prospectively validated in another set of patients with UGIB.

RESULTS: Among 261 patients with UGIB, 47 (18%) had variceal and 214 (82%) had non-variceal bleeding. Univariate analysis identified 27 distinct parameters significantly associated with the types of UGIB. Logistic regression analysis identified only 3 independent factors for predicting variceal bleeding; previous diagnosis of cirrhosis or signs of chronic liver disease (OR 22.4, 95% CI 8.3-60.4, P < 0.001), red vomitus (OR 4.6, 95% CI 1.8-11.9, P = 0.02), and red nasogastric (NG) aspirate (OR 3.3, 95% CI 1.3-8.3, P = 0.011). The UGIB Etiology Score was calculated from (3.1 × previous diagnosis of cirrhosis or signs of chronic liver disease) + (1.5 × red vomitus) + (1.2 × red NG aspirate), when 1 and 0 are used for the presence and absence of each factor, respectively. Using a cutoff ≥ 3.1, the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) in predicting variceal bleeding were 85%, 81%, 82%, 50%, and 96%, respectively. The score was prospectively validated in another set of 195 UGIB cases (46 variceal and 149 non-variceal bleeding). The PPV and NPV of a score ≥ 3.1 for variceal bleeding were 79% and 97%, respectively.

CONCLUSION: The UGIB Etiology Score, composed of 3 parameters, using a cutoff ≥ 3.1 accurately predicted variceal bleeding and may help to guide the choice of initial therapy for UGIB before endoscopy.

Model for end-stage liver disease, model for end-stage liver disease-sodium and Child-Turcotte-Pugh scores over time for the prediction of complications of liver cirrhosis

BACKGROUND/AIMS

There has been no report concerning the predictive capability of each scoring system in determining the development of complications of liver cirrhosis such as variceal bleeding and/or hepatic encephalopathy.

METHODS

We retrospectively studied 128 patients with liver cirrhosis [92 males; mean (standard deviation) 54.2 (11.2) years] admitted to our institution from March 2004 to April 2006. Seventy-three patients (57.0%, group 1) were admitted because of complications of cirrhosis and 55 patients (43.0%, group 2) were admitted for causes unrelated to complications of cirrhosis. We calculated values for model for end-stage liver disease (MELD), MELD-sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) scores on admission and at 3 and 6 months before admission. Each delta score was defined as the difference in the scores of 3 and 6 months before admission.

RESULTS

The relative risk for complications in the patients with DeltaMELD/3 months >/=1.35, DeltaMELD-Na/3 months >/=1.35 and DeltaCTP/3 months >/=1 was 2.05 [95% confidence intervals (CI) 1.47-2.85, P<0.01], 2.04 (95% CI 1.45-2.88, P<0.01) and 1.98 (95% CI 1.39-2.81, P<0.01) respectively. The area under the receiver-operating characteristic curves of DeltaMELD/3 months, DeltaMELD-Na/3 months and DeltaCTP/3 months for the occurrence of cirrhotic complications were 0.691, 0.694 and 0.722 respectively. A higher DeltaMELD/3 months (>/=1.35), DeltaMELD-Na/3 months (>/=1.35) and DeltaCTP/3 months (>/=1) was associated with decreased survival.

CONCLUSIONS

Delta model for end-stage liver disease/3 months, DeltaMELD-Na/3 months and DeltaCTP/3 months were clinically useful parameters for predicting the occurrence of cirrhotic complications.

High-D-dimer plasma levels predict poor outcome in esophageal variceal bleeding

BACKGROUND AND AIM

Variceal bleeding carries a high-mortality rate in patients with liver cirrhosis. Since coagulation and fibrinolysis are abnormal in these patients we evaluated whether or not abnormalities of these haemostasis systems were independently related to mortality.

METHODS

Global coagulation, coagulation activation and fibrinolysis measurements were performed in 43 cirrhotics bleeding from esophageal varices at baseline and during follow-up and in 43 non-bleeding cirrhotic patients at baseline only.

RESULTS

Baseline measurements of coagulation activation and fibrinolysis were more impaired in bleeders. In bleeders, prothrombin time, tissue type plasminogen activator antigen and D-dimer plasma levels were persistently more abnormal in patients who died. High-D-dimer, infection, Child-Pugh C class and MELD score >or=17 were the significant predictors of death at univariate analysis. Two different multivariate analyses to assess the independent prognostic value of these variables, one including the Child-Pugh class, the other including MELD, were performed. Independent predictors of death were high-D-dimer and infection, but not Child-Pugh class, in the former; MELD and infection, but not D-dimer, in the latter.

CONCLUSIONS

Beside infection, high-D-dimer is a stronger predictor of death as compared to Child-Pugh C class, but not to a MELD score >or=17.

Long-term prognosis of cirrhotics with an upper gastrointestinal bleeding episode: does infection play a role?

BACKGROUND AND AIM

We evaluated the effect of infection on the short- and long-term outcome of cirrhotic patients with upper gastrointestinal bleeding (UGIB), in a series of patients not submitted to antibiotic prophylaxis.

METHODS

The cirrhotic patients hospitalized for UGIB were prospectively followed up until the last visit, death, or transplantation. A standard screening protocol was used for bacterial infection at admission.

RESULTS

In total, 205 patients were included in the study. Antibiotics were administered in 79 (38.5%) patients and an infection was documented in 64 (31.4%) patients. In total, 130 (63.4%) patients died after a mean (SD) follow up of 23.8 (30.9) months. Six-week mortality was higher in the infected patients (P < 0.0001). The mortality of patients who were alive 6 weeks after admission was not different between the infected and non-infected patients. Antibiotic use or bacterial infection, the Child-Pugh score, hepatocellular carcinoma, and creatinine were the independent predictors of 6-week mortality. Age and the Child-Pugh score were the only predictors of mortality of the patients who had survived for more than 6 weeks after acute bleeding. In total, 51 (24.9%) patients rebled, 37 (18.1%) within 5 days of admission. Rebleeding was more frequent (41.8% vs 14.3%, P < 0.0001) in infected patients, mostly due to differences in early rebleeding (31.6% vs 9.5%, P = 0.0001).

CONCLUSION

Bacterial infection is associated with failure to control UGIB and early mortality in cirrhotic patients, but does not seem to affect the outcome of patients who overcome the bleeding episode.

Vitamin K for upper gastrointestinal bleeding in patients with liver diseases

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Several treatments are used for upper gastrointestinal bleeding in patients with liver diseases. One of them is vitamin K administration, but it is unknown whether it benefits or harms patients with liver disease and upper gastrointestinal bleeding.

OBJECTIVES

To assess the beneficial and harmful effects of vitamin K for patients with liver disease and upper gastrointestinal bleeding.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (September 2007), which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2007), MEDLINE (1950 to September 2007), EMBASE (1980 to September 2007), Science Citation Index Expanded (1945 to September 2007), and LILACS (1982 to November 2007). Additional randomised trials were sought from two registries of clinical trials, ClinicalTrials.gov and Sistema de Información Esencial en Terapéutica y Salud, the reference lists of the trials found, and reviews identified by the electronic searches.

SELECTION CRITERIA

Randomised clinical trials.

DATA COLLECTION AND ANALYSIS

Data from randomised clinical trials were to be summarised by standard Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised trials on vitamin K for upper gastrointestinal bleeding in patients with liver diseases.

AUTHORS' CONCLUSIONS

This updated review found no randomised clinical trials on the safety and efficacy of vitamin K for upper gastrointestinal bleeding in patients with liver diseases. The effects of vitamin K need to be tested in randomised clinical trials. Unless randomised clinical trials provide evidence of a treatment effect and the trade off between potential benefits and harms are established, policy-makers, clinicians, and academics should not use vitamin K for upper gastrointestinal bleeding in patients with liver diseases.

The management of portal hypertension: rational basis, available treatments and future options

Variceal bleeding is the last step in a chain of events initiated by an increase in portal pressure, followed by the development and progressive dilation of varices until these finally rupture and bleed. This sequence of events might be prevented - and reversed - by achieving a sufficient decrease in portal pressure. A different approach is the use of local endoscopic treatments at the varices. This article reviews the rationale for the management of patients with cirrhosis and portal hypertension, the current recommendations for the prevention and treatment of variceal bleeding, and outlines the unsolved issues and the perspectives for the future opened by new research developments.

Vapreotide acetate for the treatment of esophageal variceal bleeding

Variceal bleeding is a life-threatening complication of portal hypertension. The recommended treatment includes the early administration of a vasoactive drug. Vapreotide is a somatostatin analogue with a different receptor affinity to octreotide. It decreases portal pressure and blood flow of collateral circulation in rats with cirrhosis. The pivotal study of early administration of vapreotide in patients with cirrhosis and variceal bleeding has shown a significant improvement in bleeding control and, in the subset of patients with significant bleeding, a significant reduction in mortality. In addition, a meta-analysis of four randomized studies has shown a significant improvement in bleeding control. Vapreotide administrated via the intravenous route is simple to use, with practically no contraindications and few, usually minor, side effects.

Epidemiology of acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding is an important emergency situation. Population-based epidemiology data are important to get insight in the actual healthcare problem. There are only few recent epidemiological surveys regarding acute upper gastrointestinal bleeding. Several surveys focusing on peptic ulcer disease showed a significant decrease in admission and mortality of peptic ulcer disease. Several more recent epidemiological surveys show a decrease in incidence of all cause upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding remained stable. Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, responsible for about 50% of all cases, followed by oesophagitis and erosive disease. Variceal bleeding is the cause of bleeding in cirrhotic patients in 50-60%. Rebleeding in upper gastrointestinal bleeding occurs in 7-16%, despite endoscopic therapy. Rebleeding is especially high in variceal bleeding and peptic ulcer bleeding. Mortality ranges between 3 and 14% and did not change in the past 10 years. Mortality is increasing with increasing age and is significantly higher in patients who are already admitted in hospital for co-morbidity. Risk factors for peptic ulcer bleeding are NSAIDs use and H. pylori infection. In patients at risk for gastrointestinal bleeding and using NSAIDs, a protective drug was only used in 10%. COX-2 selective inhibitors do cause less gastroduodenal ulcers compared to non-selective NSAIDs, however, more cardiovascular adverse events are reported. H. pylori infection is found in about 50% of peptic ulcer bleeding patients. H. pylori should be tested for in all ulcer patients and eradication should be given.

Upper gastrointestinal bleeding from duodenal vascular ectasia in a patient with cirrhosis

We report a cirrhotic patient with duodenal vascular ectasia and spontaneous bleeding. The bleeding was successfully controlled with argon plasma coagulation. Duodenal vascular ectasia may be a cause of upper gastrointestinal bleeding in patients with cirrhosis, and argon plasma coagulation may be effective and safe to achieve hemostasis of this lesion.

The model for end-stage liver disease (MELD)

The Model for End-stage Liver Disease (MELD) was initially created to predict survival in patients with complications of portal hypertension undergoing elective placement of transjugular intrahepatic portosystemic shunts. The MELD which uses only objective variables was validated subsequently as an accurate predictor of survival among different populations of patients with advanced liver disease. The major use of the MELD score has been in allocation of organs for liver transplantation. However, the MELD score has also been shown to predict survival in patients with cirrhosis who have infections, variceal bleeding, as well as in patients with fulminant hepatic failure and alcoholic hepatitis. MELD may be used in selection of patients for surgery other than liver transplantation and in determining optimal treatment for patients with hepatocellular carcinoma who are not candidates for liver transplantation. Despite the many advantages of the MELD score, there are approximately 15%-20% of patients whose survival cannot be accurately predicted by the MELD score. It is possible that the addition of variables that are better determinants of liver and renal function may improve the predictive accuracy of the model. Efforts at further refinement and validation of the MELD score will continue.

Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases

BACKGROUND

Mortality from upper gastrointestinal bleeding in patients with liver disease is high. The human recombinant activated factor VII is one of the suggested treatments for upper gastrointestinal bleeding in these patients.

OBJECTIVES

To assess the beneficial and harmful effects of human recombinant factor VIIa in patients with liver disease and upper gastrointestinal bleeding.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, ISI Web of Knowledge, and LILACS. The search strategies used are given in Table 01. We sought additional randomised trials from the reference lists of the trials and reviews identified through the electronic searches.

SELECTION CRITERIA

All randomised clinical trials irrespective of design, publication status, and language comparing human recombinant activated factor VII versus placebo, or any other control intervention for patients with liver disease and upper gastrointestinal bleeding, irrespectively of aetiology.

DATA COLLECTION AND ANALYSIS

We estimated relative risks (RR) for dichotomous outcomes and mean differences for continuous data. Since only one trial was identified, meta-analysis was not possible.

MAIN RESULTS

We included one trial with 242 adult patients. In this study, human recombinant activated factor VII administration did not reduce the risk of death (mortality within five days (RR 1.75, 95% confidence interval (CI) 0.53 to 5.82), and mortality within 42 days (RR 1.45, 95% CI 0.70 to 3.00)).

AUTHORS' CONCLUSIONS

We found no evidence that human recombinant activated factor VII reduces the risk of death in patients with liver disease and upper gastrointestinal bleeding. However, we made our conclusion on a single randomised clinical trial. More randomised clinical trials having low risk of bias are necessary in order to determine the role of human recombinant factor VIIa in clinical practice.

Endoscopic therapy for bleeding esophageal varices improves the outcome of Child C cirrhotic patients

BACKGROUND AND AIM

Bleeding from esophageal varices is one of the frequent severe complications arising in patients with liver cirrhosis. The management of esophageal varices is therefore important for patient survival. The purpose of this study was to clarify the predictive factors for mortality in patients with Child C cirrhosis presenting with variceal bleeding.

METHODS

A retrospective analysis of 77 Child C cirrhotic patients with bleeding from esophageal varices was conducted. All patients received endoscopic therapy. Twenty-nine patients received endoscopic variceal ligation, and 48 patients received endoscopic injection sclerotherapy or endoscopic injection sclerotherapy with ligation. Univariate and multivariate analyses of clinical data were performed to identify the prognostic factors for survival for these 77 patients.

RESULTS

Fifty-seven of 77 patients received endoscopic therapy within 24 h after variceal bleeding, and bleeding was controlled in 55 (96.5%). The remaining 20 patients received endoscopic therapy more than 24 h after bleeding. Higher bilirubin level and rebleeding were the predictive parameters for 6-week survival in the 77 patients, according to univariate and multivariate analysis. Higher bilirubin level, refractory ascites, and the presence of hepatocellular carcinoma were the predictive parameters for mortality in 77 patients as determined by multivariate analysis.

CONCLUSIONS

Endoscopic therapy was effective in controlling acute variceal bleeding of Child C cirrhotic patients. The prognosis of Child C stage patients presenting with variceal bleeding depended on the severity of liver damage and the presence of hepatocellular carcinoma.

Limitation of the model for end-stage liver disease for outcome prediction in patients with cirrhosis-related complications

The model for end-stage liver disease (MELD) has been used to prioritize cirrhotic patients awaiting liver transplantation. Bleeding esophageal varices, spontaneous bacterial peritonitis and hepatic encephalopathy are major complications of cirrhosis and traditional indications for liver transplantation evaluation. However, these complications are not included in the MELD and it is not clear if these complications correlate with MELD score in terms of outcome prediction. This study aimed to investigate the feasibility of cirrhosis-related complication as a prognostic predictor in 290 cirrhotic patients. The MELD score and outcome were compared between patients with and without cirrhosis-related complications. There was no significant difference of the MELD score between patients with (n = 67) and without (n = 223) complications (11.6 +/- 2.9 vs. 12.2 +/- 3.2, p = 0.184). The area under the receiver operating characteristic curve was 0.687 for MELD vs. 0.604 for complications (p = 0.174) at six months, and the area was 0.641 for MELD vs. 0.611 for complications (p = 0.522) at 12 months. A high MELD score and presence of complications had a similar profile of predictive accuracy and both were significant predictors of mortality at six and 12 months in multivariate logistic regression analysis. Patients with cirrhosis-related complications at presentation had a decreased survival compared with those without complications (p < 0.0001). In conclusion, the occurrence of cirrhosis-related complications is a predictor of poor prognosis. While early transplantation referral is recommended, these patients do not necessarily have a higher MELD score and could be down-staged in the MELD era.

Nutritional status and prognosis in cirrhotic patients

BACKGROUND AND AIM

The potential prognostic value for survival of nutritional status in cirrhotics after adjusting Child-Pugh classification and Model for End-Stage Liver Disease has not been evaluated.

METHODS

We used Kaplan-Meier and Cox proportional hazards regression models to identify factors associated with mortality in a cohort of 222 cirrhotics [M/F:145/77 median age 52 (18-68) years] with prospectively collected nutritional parameters as well as modified subjective global nutritional assessment, Royal Free Hospital-Subjective Global Assessment index. Follow-up was censored at the time of transplantation. Other variables were ones in Child-Pugh and Model for End-Stage Liver Disease scores, age, aetiology of cirrhosis and renal function.

RESULTS

Pretransplant mortality (Kaplan-Meier) was 21% by 2 years (135 patients were transplanted). Among the nutritional parameters, only Royal Free Hospital-Subjective Global Assessment remained significantly associated with mortality in multivariable models (P = 0.0006). The final model included the following variables: urea (P = 0.0001), Royal Free Hospital-Subjective Global Assessment (P = 0.003), age (P = 0.0001), Child-Pugh grade (P = 0.009) and prothrombin time (P = 0.003). The results were similar when the Child-Pugh grade was replaced by the Model for End-Stage Liver Disease score in the model, and whether a competing risks model was used.

CONCLUSIONS

Nutritional indices add significantly to both Child-Pugh grade and Model for End-Stage Liver Disease scores when assessing the patient prognosis.

The vital threat of an upper gastrointestinal bleeding: Risk factor analysis of 121 consecutive patients

AIM: To analyze the importance in predicting patients risk of mortality due to upper gastrointestinal (UGI) bleeding under today's therapeutic regimen.

METHODS: From 1998 to 2001, 121 patients with the diagnosis of UGI bleeding were treated in our hospital. Based on the patients’ data, a retrospective multivariate data analysis with initially more than 270 single factors was performed. Subsequently, the following potential risk factors underwent a logistic regression analysis: age, gender, initial hemoglobin, coumarines, liver cirrhosis, prothrombin time (PT), gastric ulcer (small curvature), duodenal ulcer (bulbus back wall), Forrest classification, vascular stump, variceal bleeding, Mallory-Weiss syndrome, RBC substitution, recurrent bleeding, conservative and surgical therapy.

RESULTS: Seventy male (58%) and 51 female (42%) patients with a median age of 70 (range: 21-96) years were treated. Their in-hospital mortality was 14%. While 12% (11/91) of the patients died after conservative therapy, 20% (6/30) died after undergoing surgical therapy. UGI bleeding occurred due to duodenal ulcer (n = 36; 30%), gastric ulcer (n = 35; 29%), esophageal varicosis (n = 12; 10%), Mallory-Weiss syndrome (n = 8; 7%), erosive lesions of the mucosa (n = 20; 17%), cancer (n = 5; 4%), coagulopathy (n = 4; 3%), lymphoma (n = 2; 2%), benign tumor (n = 2; 2%) and unknown reason (n = 1; 1%). A logistic regression analysis of all aforementioned factors revealed that liver cirrhosis and duodenal ulcer (bulbus back wall) were associated risk factors for a fatal course after UGI bleeding. Prior to endoscopy, only liver cirrhosis was an assessable risk factor. Thereafter, liver cirrhosis, the location of a bleeding ulcer (bulbus back wall) and patients’ gender (male) were of prognostic importance for the clinical outcome (mortality) of patients with a bleeding ulcer.

CONCLUSION: Most prognostic parameters used in clinical routine today are not reliable enough in predicting a patient’s vital threat posed by an UGI bleeding. Liver cirrhosis, on the other hand, is significantly more frequently associated with an increased risk to die after bleeding of an ulcer located at the posterior duodenal wall.

Recombinant factor VIIa in patients with coagulopathy secondary to anticoagulant therapy, cirrhosis, or severe traumatic injury: review of safety profile

BACKGROUND

In recent years, the hemostatic agent recombinant factor VIIa (rFVIIa) has emerged as a potentially new therapeutic agent for management of coagulopathy in patients with cirrhosis or following severe traumatic injury, a complex problem for clinicians in which standard treatment strategies are not always effective. As with other hemostatic agents, a primary safety concern of rFVIIa therapy is the theoretical possibility that systemic administration could confer an increased risk of thrombotic complications. So far, clinical experience indicates rFVIIa to be a safe treatment for currently approved indications within hemophilia. Little information is available, however, for patient populations outside this clinical setting.

STUDY DESIGN AND METHODS

This article reviews critical safety data obtained from 13 Novo Nordisk-sponsored clinical trials of rFVIIa in patients with coagulopathy secondary to anticoagulant therapy, cirrhosis, or severe traumatic injury.

RESULTS

Thrombotic adverse events were reported for 5.3 percent (23/430) of placebo-treated patients and 6.0 percent (45/748) of patients on active treatment. No significant difference was found between placebo-treated and rFVIIa-treated patients with respect to the incidence of thrombotic AEs, either on an individual trial basis or for these trial populations combined (p=0.57).

CONCLUSION

An important determinant for the safety profile reported here is likely to be the specific mechanism of action of rFVIIa, shown in experimental studies to be localized to the site of vascular injury where tissue factor is exposed.

A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation

Progression of gastric variceal hemorrhage (GVH) is poorer than esophageal variceal bleeding. However, data on its optimal treatment are limited. We designed a prospective study to compare the efficacy of endoscopic band ligation (GVL) and endoscopic N-butyl-2-cyanoacrylate injection (GVO). Liver patients with cirrhosis with or without concomitant hepatocellular carcinoma (HCC) and patients presenting with acute GVH were randomized into two treatment groups. Forty-eight patients received GVL, and another 49 patients received GVO. Both treatments were equally successful in controlling active bleeding (14/15 vs. 14/15, P = 1.000). More of the patients who underwent GVL had GV rebleeding (GVL vs. GVO, 21/48 vs. 11/49; P = .044). The 2-year and 3-year cumulative rate of GV rebleeding were 63.1% and 72.3% for GVL, and 26.8% for both periods with GVO; P = .0143, log-rank test. The rebleeding risk of GVL was sustained throughout the entire follow-up period. Multivariate Cox regression indicated that concomitance with HCC (relative hazard: 2.453, 95% CI: 1.036-5.806, P = .041) and the treatment method (GVL vs. GVO, relative hazard: 2.660, 95% CI: 1.167-6.061, P = .020) were independent factors predictive of GV rebleeding. There was no difference in survival between the two groups. Severe complications attributable to these two treatments were rare. In conclusion, the efficacy of GVL to control active GVH appears not different to GVO, but GVO is associated with a lower GV rebleeding rate.

Occurrence of cirrhosis-related complications is a time-dependent prognostic predictor independent of baseline model for end-stage liver disease score

BACKGROUND

The model for end-stage liver disease (MELD) is used to prioritize cirrhotic patients awaiting liver transplantation. Many cirrhosis-related complications are indications for transplantation but are not included in MELD. This study investigated the impact of these complications on survival and association with MELD.

METHODS

The mortality risk of cirrhosis-related complications, including bleeding esophageal varices, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome and hepatic decompensation, was analyzed using a time-dependent Cox regression model in 227 cirrhotic patients.

RESULTS

A total of 281 episodes of complications occurred in 142 (63%) patients. Patients who died had a significantly higher baseline MELD score compared with those who survived (14.5 +/- 4.5 vs 12.8 +/- 3.9, P = 0.004). There was no significant difference in the MELD score between patients with and without the occurrence of complications (13.6 +/- 4.3 vs 12.9 +/- 4.0, P = 0.093). Patients with a higher baseline MELD score tended to develop early complications (rho = -0.598, P< 0.001). Using the Cox regression model, the risk ratio of mortality was 4.9 (95% confidence interval: 3.9-6.3, P< 0.0001) for each additional episode of complication.

CONCLUSIONS

The mortality risk increases as the number of complication episodes increases. While patients with repeated complications have a poor outcome, they do not necessarily have a higher baseline MELD score and could be down-staged in the MELD era.

Vitamin K for upper gastrointestinal bleeding in patients with liver diseases

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Several treatments are used for upper gastrointestinal bleeding in patients with liver diseases. However, supplementary interventions are often used as well. One of them is vitamin K administration, but it is unknown whether it benefits or harms patients with liver disease and upper gastrointestinal bleeding.

OBJECTIVES

To assess the beneficial and harmful effects of vitamin K for patients with liver disease and upper gastrointestinal bleeding.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (February 2004), which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to March 2004), EMBASE (1988 to March 2004), and LILACS (1982 to March 2004). Additional randomised trials were sought from the reference lists of the trials found and reviews identified by the electronic searches.

SELECTION CRITERIA

We intended to include randomised clinical trials.

DATA COLLECTION AND ANALYSIS

We intended to summarise data by standard Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised trials on vitamin K for upper gastrointestinal bleeding in patients with liver diseases.

AUTHORS' CONCLUSIONS

We were unable to identify randomised trials on the safety and efficacy of vitamin K for upper gastrointestinal bleeding in patients with liver diseases. The effects of vitamin K need to be tested in randomised clinical trials.

Evaluation of the increase in model for end-stage liver disease (DeltaMELD) score over time as a prognostic predictor in patients with advanced cirrhosis: risk factor analysis and comparison with initial MELD and Child-Turcotte-Pugh score

BACKGROUND/AIMS

The model for end-stage liver disease (MELD) has been used to prioritize cirrhotic patients awaiting liver transplantation. The change in MELD score over time (DeltaMELD) may have additional prognostic value. We investigated the ability of DeltaMELD to predict the outcome of advanced cirrhosis and prospectively assessed the factors associated with increasing DeltaMELD.

METHODS

Risk factors were determined in 58 prospectively followed-up patients. The predictive power of DeltaMELD, initial MELD and Child-Turcotte-Pugh (CTP) score was compared by using c-statistic in 351 patients.

RESULTS

Ascites (P=0.020) and hepatic encephalopathy (P=0.023) were significantly associated with increasing MELD score at 3 months. The area under receiver operating characteristic (ROC) curve for DeltaMELD/month was 0.779 compared with 0.718 for MELD (P=0.130) and 0.528 for CTP score (P<0.001) at 6 months; the area was 0.822, 0.744 and 0.528, respectively (P=0.018 and <0.001, respectively) at 12 months. DeltaMELD/month >2.5 was the only significant prognostic predictor at 6 (odds ratio: 9.8, P<0.001) and 12 months (odds ratio: 16.3, P<0.001) in multivariate logistic analysis.

CONCLUSIONS

Increasing MELD score is associated with the onset of ascites and encephalopathy. DeltaMELD is superior to initial MELD and CTP scores to predict intermediate term outcome in patients with advanced cirrhosis.

MELD score and hepatocellular carcinoma identify patients at different risk of short-term mortality among cirrhotics bleeding from esophageal varices

BACKGROUND/AIMS

The role of model for end stage liver disease (MELD) and the presence of hepatocellular carcinoma (HCC) as risk factors of short-term mortality in patients bleeding from oesophageal varices were evaluated.

METHODS

From February 2002 to August 2003, 172 cirrhotic patients admitted for the first episode of bleeding from oesophageal varices received vasoactive and endoscopic therapy. Patients' survival was evaluated at 6 weeks and 3 months. The role of MELD and HCC as independent risk factors of mortality was evaluated.

RESULTS

In the 172 patients, the overall mortality was 21.5% at 6 weeks and 30.2% at 3 months. MELD score resulted a good predictor of mortality either at 6 weeks or 3 months. Fifty-four patients (31.3%) had HCC. The presence of advanced HCC was an independent risk factor of mortality at 3 months. Patients with MELD score>15 and advanced HCC had a significantly worse survival than patients with MELD<or=15 and without HCC or with early HCC either at 6 weeks or 3 months

CONCLUSIONS

MELD score and the presence of HCC allow to identify patients at different risk of short-term mortality among cirrhotic patients at first episode of bleeding from oesophageal varices.

Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study

GOALS

To assess epidemiologic features and predictive factors of mortality of acute upper gastrointestinal bleeding (UGIB).

STUDY

During a 6-month period, a prospective population-based study including all the UGIB occurring in a geographic area of 3 million people was conducted. Data from cirrhotic patients were compared with those of noncirrhotic patients.

RESULTS

A total of 2,133 UGIB were recorded, 21.9% in cirrhotic patients (n = 468). Endoscopic hemostasis was performed in 46.5% and 8.3% in cirrhotic and noncirrhotic patients, respectively (P < 0.001). Mortality during hospitalization was 23.5% in cirrhotic patients and 11.2% in noncirrhotic patients (P < 0.001). Six independent predictive factors of mortality were observed in both patient groups: a prothrombin level less than 40%, an UGIB occurring in inpatients, a concomitant digestive carcinoma, a hematemesis revealing the UGIB, a recent use of steroid drugs, and age over 60 years. Four other predictive factors of mortality were also identified in noncirrhotic patients.

CONCLUSIONS

Although epidemiologic features, clinical course, management, and prognosis of UGIB were quite different in cirrhotic and noncirrhotic patients, the majority of predictive factors of mortality were the same in both patient groups. These data underline the major role of debilitated status and hepatic failure in the prognosis of UGIB in cirrhotic patients.