Liver cirrhosis

Spleen stiffness: a predictive factor of dismal prognosis in liver cirrhosis

Portal hypertension (PH) is a major complication of liver cirrhosis, as it predisposes to the development of serious clinical manifestations such as ascites, hepatic encephalopathy and variceal bleeding, aggravating the prognosis of patients. Hepatic vein pressure gradient (HVPG) is considered the reference method for the estimation of the presence and severity of PH, but this procedure is available only in specialized centers. Alternatively, many non-invasive methods have been proposed in order to substitute HVPG. Among them, liver stiffness measurement (LSM) has been widely used, as it has been shown to correlate well with HVPG, though this relationship seems to weaken in values of HVPG higher than 12 mmHg, the threshold of serious complications development. Several studies supported the use of spleen stiffness measurement (SSM) instead of LSM, anticipating to a more adequate assessment of this advanced stage of PH. The aim of this paper is to critically appraise and summarize the literature about the role of SSM as a predictive tool of liver decompensation and prognosis, highlighting the strengths and the potential limitations of the studies published so far. EXPERT'S OPINION: The utility of SSM in ruling out high risk for bleeding varices in cirrhotic patients has been demonstrated, driving the Baveno VII consensus to encompass SSM in its last recommendations, though its use in patients with non-viral cirrhosis remains to be validated. We believe that in the near future, SSM alone or combined with other tests, will being used not only for sparing upper endoscopies, but also for predicting decompensation and prognosis in advanced compensated cirrhotic patients, regardless of liver disease's etiology. Herein, we present the data that support this consideration, pointing out these issues that should further be investigated in order to elucidate and intensify the value of SSM in the management of patients with liver cirrhosis.

Inadequate social support decreases survival in decompensated liver cirrhosis patients

INTRODUCTION

Inadequate social support is associated with higher mortality both in the general population and in patients with chronic diseases. There are no studies that have described social support in liver cirrhosis and its impact on prognosis.

OBJECTIVES

To analyze the impact social support has in the survival of patients with decompensated cirrhosis.

METHODS

Prospective multicentric cohort study (2016-2019). Patients with decompensated liver cirrhosis were included. Epidemiological, clinical and social variables were collected, using the validated Medical Outcomes Study Social Support Survey, with a 12-month follow-up.

RESULTS

A total of 127 patients were included, of which 79.5% were men. The most common etiology of cirrhosis was alcohol (74.8%), mean age was 60 years (SD 10.29), mean MELD was 15.6 (SD 6.3) and most of the patients had a Child-Pugh B (53.5%) or C (35.4%). In the assessment of social support, we observed that most of the patients (92.2%) had adequate global support. At the end of the follow-up (median 314 days), 70.1% of the patients survived. The 1-year survival rate in patients with inadequate global social support was 30%, compared to 73.5% in the presence of social support. In multivariate Cox regression analysis, inadequate social support predicted survival with an adjusted HR of 5.5 (95% CI 2,3-13,4) independently of MELD (HR 1.1, 95% CI 1-1.2), age (HR 1, 95% CI 1-1.1) and hepatocarcinoma (HR 10.6, 95% CI 4.1-27.4).

CONCLUSION

Adequate social support improves survival in liver cirrhosis, independently of clinical variables. Social intervention strategies should be considered for their management.

Differential metabolites in cirrhotic patients with hepatitis B and muscle mass loss

Background

Sarcopenia leads to complications (infections, hepatic encephalopathy and ascites) and poor overall survival in patients with cirrhosis, in which the phenotypic presentation is loss of muscle mass. This study aimed to reveal the metabolic profile and identify potential biomarkers in cirrhotic patients with hepatitis B virus and muscle mass loss.

Method

Twenty decompensated cirrhotic patients with HBV and muscle mass loss were designated Group S; 20 decompensated cirrhotic patients with HBV and normal muscle mass were designated Group NS; and 20 healthy people were designated Group H. Muscle mass loss was defined as the skeletal muscle mass index less than 46.96 cm²/m² for males and less than 32.46 cm²/m² for females. Gas chromatography-mass spectrometry was used to explore the distinct metabolites and pathways in the three groups.

Results

Thirty-seven metabolic products and 25 associated metabolic pathways were significantly different in the Group S patients from Group NS patients. Strong predictive value of 11 metabolites (inosine-5'-monophosphate, phosphoglycolic acid, D-fructose-6-phosphate, N-acetylglutamate, pyrophosphate, trehalose-6-phosphate, fumaric acid, citrulline, creatinine, (r)-3-hydroxybutyric acid, and 2-ketobutyric acid) were selected as potential biomarkers in Group S patients compared with Group NS patients. Two pathways may be associated with loss of muscle mass in patients with liver cirrhosis: amino acid metabolism and central carbon metabolism in cancer.

Conclusion

Seventy differential metabolites were identified in patients who have liver cirrhosis and loss of muscle mass compared with patients who have cirrhosis and normal muscle mass. Certain biomarkers might distinguish between muscle mass loss and normal muscle mass in HBV-related cirrhosis patients.

Gamma Delta T Cells: Role in Immunotherapy of Hepatocellular Carcinoma

The most typical type of liver cancer or hepatocellular carcinoma (HCC) develops from hepatocyte loss. Non-alcoholic fatty liver disease (NAFLD), viral hepatitis C and cirrhosis are the leading causes of HCC. With the Hepatitis B vaccine and medicines, there are several treatments for HCC, including liver resection, ablation, transplantation, immunotherapy, gene therapy, radiation embolization, and targeted therapy. Currently, a wide range of studies are carried out on gene therapy to identify biomarkers and pathways, which help us identify the exact stage of the disorder and reduce its effects. γδT cells have recently received much interest as a potential cancer treatment method in adaptive immunotherapy. γδT cells can quickly form connections between receptor and ligand activation. They can clonally expand and are a significant source of cytokines and chemokines. The present review provides a comprehensive understanding on the function of γδT cells in immunotherapies and how they are used to treat HCC.

Single-cell RNA transcriptomics reveals differences in the immune status of alcoholic and hepatitis B virus-related liver cirrhosis

BACKGROUND

Alcoholic and hepatitis B virus (HBV)-related liver cirrhosis has placed a tremendous burden on the healthcare system with limited treatment options. This study explored the differences in the immune status of alcoholic and HBV-related liver cirrhosis.

METHODS

A total of 15 human liver samples from the Third Xiangya Hospital of Central South University, including five healthy controls (HC group), five alcoholic cirrhosis patients (ALC group), and five HBV-related cirrhosis patients (HBV group) were used. Of these, eight samples, including 3 HC group, 2 ALC group and 3 HBV group, were randomly collected to do single-cell RNA sequencing (scRNA-seq). The degree of steatosis was assessed by H&E staining and the presence of intrahepatic immune cells was evaluated by immunochemistry (IHC).

RESULTS

The immune status of alcoholic and HBV-related liver cirrhosis differed significantly. ScRNA-seq analysis identified a higher ratio of intrahepatic monocyte/macrophages and an obvious decreased ratio of T cells and B cells in the ALC group than in the HBV group. IHC staining of intrahepatic monocyte/macrophages, T and B cell exhibited similar results with scRNA-seq analysis. CD5L⁺ Kupffer cells, a cell type involved in lipid metabolism, were the major monocyte/macrophage subset in ALC liver tissue. H&E staining indicated that the level of steatosis was more severe in the ALC than in the HBV group. Ligand/receptor analysis showed that the T cell exhaustion observed in the ALC liver may be related to the expression of Galectin-9 on Kupffer cells. Fewer B cells were also found in the ALC group and most had higher lipid metabolism, reduced ribosomal activity, and a dysregulated mitochondrial oxidative phosphorylation system. Moreover, scRNA-seq showed a significantly lower ratio of plasma B cells, indicating that the humoral immune response in the ALC liver was similarly dysfunctional. Ligand/receptor analysis also discovered that Galectin-9 expressed on Kupffer cells may inhibit humoral immunity.

CONCLUSION

Patients with ALC have different immune characteristics than those with HBV-induced cirrhosis, including an increased ratio of intrahepatic monocyte/macrophages and a dysfunctional adaptive immune response in the liver. Galectin-9 could serve as a potential therapeutic target for ALC treatment.

Differentiation between alcohol-associated cirrhosis and hepatitis B-associated cirrhosis based on hepatic complications and psychological symptoms

Background

The prognosis of and occurrence of complications in patients with different clinical features of cirrhosis differ, and cirrhosis with different etiologies has varying clinical characteristics. The aim of this study was to describe the liver function markers, hepatic complications, and psychological features differentiating patients with hepatitis B virus (HBV) infection-related and alcohol-related cirrhosis.

Materials and Methods

This was a retrospective and observational study that analyzed the medical data of inpatients with alcohol-related or HBV infection-related cirrhosis from May 2014 to May 2020. Markers of liver function, portal hypertension, and psychological symptoms were compared between the two groups.

Results

Patients with alcohol-related cirrhosis showed higher Self-Rating Anxiety Scale scores and prevalence of hypoproteinemia, fatty liver, and depression than those with HBV infection-related cirrhosis (all P < 0.05). After adjustment for potential confounders, patients with alcohol-related cirrhosis also showed higher risks of increased total cholesterol (odds ratio [OR] =2.671, 95% confidence interval [CI]: 1.160-6.151, P = 0.021), increased high-density lipoprotein-cholesterol (OR = 2.714, 95% CI: 1.009-7.299, P = 0.048), and fatty liver (OR = 2.713, 95% CI: 1.002-7.215, P = 0.048); however, splenomegaly and splenectomy were significantly associated with HBV infection-related cirrhosis (OR = 2.320, 95% CI: 1.066-5.050, P = 0.034).

Conclusion

Patients with alcohol-related cirrhosis were more likely to develop hyperlipidemia, fatty liver, and psychological symptoms, whereas those with HBV-related cirrhosis had a higher risk of splenomegaly.

Global, regional, and national burden and quality of care index of liver cirrhosis by cause from global burden of disease 1990-2019

BACKGROUND AND AIM

Cirrhosis and other chronic liver diseases are complex disorders with a known burden. Currently health systems have different approaches to dealing with this issue. The objective of this study is to describe the burden attributed to and quality of care for cirrhosis and other chronic liver diseases.

METHODS

Data of cirrhosis and other chronic liver diseases extracted from Global-Burden-of-Diseases 2019. Four indicators, including mortality to incidence ratio, prevalence to incidence ratio, disability-adjusted-life-years (DALYs) to prevalence ratio, and years-of-life-lost (YLLs) to years-lived-with-disability (YLDs) ratio, were defined and combined by the principal-components-analysis to construct the Quality-of-Care-Index (QCI).

RESULTS

The global QCI of cirrhosis increased from 71.0 in 1990 to 79.3 in 2019. The QCI showed a favorable situation in higher SDI countries compared with lower SDI countries, with a QCI of 86.8 in high SDI countries and 60.1 in low SDI countries. The highest QCI was found in Western Pacific Region (90.2), and the lowest was for African Region (60.4). Highest QCI belonged to the 50-54 age group (99.5), and the lowest was for the 30.34 age group (70.9). Among underlying causes of cirrhosis, the highest QCI belonged to alcohol use, followed by hepatitis C and NAFLD with QCIs of 86.1, 85.3, and 81.1.

CONCLUSIONS

There was a considerable variation in the QCI of cirrhosis and other chronic liver diseases. Countries with low QCI, mainly located in developing regions, need organized action to control the burden of cirrhosis and its underlying causes and improve their quality of care.

Sex is a major effect modifier between body composition and mortality in patients with cirrhosis assessed for liver transplantation

BACKGROUND AND AIMS

Body composition predicts mortality in patients with cirrhosis. The impact of sex on this association is unknown. We investigated the impact of sex on this association in patients with cirrhosis assessed for liver transplantation.

METHODS

This single-centre retrospective cohort study included adults assessed for liver transplantation. Nutritional status was assessed using the Royal Free Hospital-Global Assessment (RFH-GA). Body composition at the third lumbar vertebrae was determined. SarcopeniaSMI was defined as Skeletal Muscle Index <50 cm2 /m2 in males and <39 cm2 /m2 in females. SarcopeniaPMI was defined as the sex-specific 25th percentile of the Psoas Muscle Index. Patients were assessed for the occurrence of liver transplantation and death. Analyses were stratified by sex.

RESULTS

The cohort comprised 628 patients, including 199 females and 429 males. Both groups were similar in terms of baseline liver disease severity by Model for End-stage Liver Disease (MELD) (p = .98) and nutritional status (p = .24). SarcopeniaSMI was present in 41% of males compared to 27% of females (p < .001). In the male cohort, when adjusted for age and MELD, sarcopeniaPMI (aHR 1.74, 95% CI 1.08-2.80) and RFH-GA (aHR 1.40, 95% CI 1.03-1.90) remained independent predictors of mortality. Adipose tissue had no impact on outcomes in males. In female patients, adipose tissue (TATI or VATI depending on the multivariable model) was independently associated with mortality, whereas sarcopenia and malnutrition were not.

CONCLUSIONS

This study demonstrates that male patients were susceptible to low muscle mass, whereas female patients were not. Future research in this patient population should minimize sex-related bias and present data for both groups separately.

A Novel Neutrophil-to-Lymphocyte Ratio and Sarcopenia Based TACE-Predict Model of Hepatocellular Carcinoma Patients

Purpose

Transarterial chemoembolization (TACE) was commonly applied in hepatocellular carcinoma (HCC) patients across BCLC A-C stages with heterogeneous outcomes in real-world practice. We aimed to develop a neutrophil-to-lymphocyte ratio (NLR) and sarcopenia-based prognostic nomogram to estimate the prognosis of HCC patients after TACE treatment.

Patients and Methods

Between June 2013 and December 2019, a total of 364 HCC patients who underwent TACE were included and randomly assigned to the training (n=255) and the validation cohort (n=109). Sarcopenia was diagnosed based on the third lumbar vertebra skeletal muscle mass index (L3-SMI). The multivariate Cox proportional risk model was used to generate a nomogram.

Results

NLR ≥4.0, sarcopenia, alpha-fetoprotein (AFP) ≥200 ng/mL, albumin-bilirubin (ALBI) grade 2 or 3, number of lesions (≥2), and maximum size of the lesion (≥5 cm) were independent predictors for overall survival (OS) (P < 0.05). The calibration curve shows that the predicted results agree well with the observed results. The time-dependent areas under the receiver-operating characteristic curves for OS at 1, 2, and 3 years predicted by the nomogram were 0.818/0.827, 0.742/0.823, and 0.748/0.836 in both training and validation cohorts. Nomogram can divide patients into low-, medium- and high-risk groups based on predictor factors. The C-indexes of the nomogram for OS were 0.782/0.728 in the training and validation cohorts, outperforming other currently available models.

Conclusion

A novel nomogram based on NLR and sarcopenia may be useful to predict the prognosis of HCC patients who underwent TACE across BCLC A-C stage patients.

Updates on Quantitative MRI of Diffuse Liver Disease: A Narrative Review

Diffuse liver diseases are highly prevalent conditions around the world, including pathological liver changes that occur when hepatocytes are damaged and liver function declines, often leading to a chronic condition. In the last years, Magnetic Resonance Imaging (MRI) is reaching an important role in the study of diffuse liver diseases moving from qualitative to quantitative assessment of liver parenchyma. In fact, this can allow noninvasive accurate and standardized assessment of diffuse liver diseases and can represent a concrete alternative to biopsy which represents the current reference standard. MRI approach already tested for other pathologies include diffusion-weighted imaging (DWI) and radiomics, able to quantify different aspects of diffuse liver disease. New emerging MRI quantitative methods include MR elastography (MRE) for the quantification of the hepatic stiffness in cirrhotic patients, dedicated gradient multiecho sequences for the assessment of hepatic fat storage, and iron overload. Thus, the aim of this review is to give an overview of the technical principles and clinical application of new quantitative MRI techniques for the evaluation of diffuse liver disease.

Liver-related long-term outcomes of alpha-glucosidase inhibitors in patients with diabetes and liver cirrhosis

Background: Adequate management of diabetes in patients with liver cirrhosis can be challenging. We conducted this study to investigate the liver-related long term outcomes of alpha-glucosidase inhibitors (AGIs) in patients with diabetes and cirrhosis. Methods: From National Health Insurance Research Database (NHIRD) in Taiwan, we recruited propensity-score matched alpha-glucosidase inhibitor users and non-users from a cohort of type 2 diabetes mellitus (T2DM) with compensated liver cirrhosis between 1 January 2000, and 31 December 2017, and followed them until 31 December 2018. Cox proportional hazards models with robust sandwich standard error estimates were used to assess the risk of main outcomes for alpha-glucosidase inhibitor users versus non-users. Results: The incidence rates of mortality during follow-up were 65.56 vs. 96.06 per 1,000 patient-years for alpha-glucosidase inhibitor users and non-users, respectively. The multivariable-adjusted model shows that alpha-glucosidase inhibitor users had significantly lower risks of all-cause mortality (aHR 0.63, 95% CI 0.56-0.71), hepatocellular carcinoma (aHR 0.55, 95% CI 0.46-0.67), decompensated cirrhosis (aHR 0.74 95% CI 0.63-0.87), hepatic encephalopathy (aHR 0.72, 95% CI 0.60-0.87), and hepatic failure (aHR 0.74, 95% CI 0.62-0.88) than alpha-glucosidase inhibitor non-users. Patients who received alpha-glucosidase inhibitors for a cumulative duration of more than 364 days had significantly lower risks of these outcomes than non-users. Conclusion: Alpha-glucosidase inhibitor use was associated with a lower risk of mortality, hepatocellular carcinoma, decompensated cirrhosis, and hepatic failure in patients with diabetes and compensated cirrhosis. alpha-glucosidase inhibitors may be useful for the management of diabetes in patients with compensated liver cirrhosis. Large-scale prospective studies are required to verify our results.

Coumaric acid from M. polymorphum extracts reverses the activated state of hepatic stellate cells (GRX) and inhibits their proliferation by decreasing the p53/p21 pathway

Coumaric acid is a phenolic compound found in medicinal plants. Its use has been reported in the treatment of inflammatory diseases, prevention of alterations induced by oxidative stress, as well as acetaminophen-induced hepatotoxicity. Thus, this study evaluated coumaric acid as a potential treatment for liver fibrosis. Cell proliferation was assessed by the trypan blue exclusion technique and the cytotoxicity of coumaric acid was performed using an LDH assay. Mechanisms of cell apoptosis were evaluated by flow cytometry. The expression of genes associated with apoptosis, cell cycle control, and fibrosis was assessed by qPCR. The production of lipid droplets was quantified by oil red staining. The experiments performed showed that the treatment with coumaric acid was able to reduce cell proliferation without causing cell cytotoxicity or apoptosis. Coumaric acid was able to inhibit the expression of cyclin D1 and CDK's (CDK2, CDK4, and CDK6), increasing p53 and p21, which could lead to cell cycle arrest. Treatment with coumaric acid was also able to revert the activated phenotype of GRX cells to their quiescent state. Thus, our results suggest that coumaric acid has a potential therapeutic effect against liver fibrosis.

Contrast-enhanced ultrasonography for the management of portal hypertension in cirrhosis

Portal hypertension is a major pathophysiological condition in patients with cirrhosis. This accounts for the occurrence and severity of the various manifestations. The degree is determined by the portal pressure or hepatic venous pressure gradients, both of which are obtained by invasive interventional radiological procedures. Ultrasound (US) is a simple and minimally invasive imaging modality for the diagnosis of liver diseases. Owing to the availability of microbubble-based contrast agents and the development of imaging modes corresponding to contrast effects, contrast-enhanced US (CEUS) has become popular worldwide for the detailed evaluation of hepatic hemodynamics, diffuse liver disease, and focal hepatic lesions. Recent advancements in digital technology have enabled contrast-based demonstrations with improved resolution, leading to a wider range of applications. This review article describes the current role, benefits, and limitations of CEUS in the management of portal hypertension.

Correlation between serum liver fibrosis markers and early gastroesophageal varices among patients with compensated liver cirrhosis: a cross-sectional analysis

BACKGROUND AND AIM

Portal hypertension is a common complication of chronic liver diseases responsible for most liver cirrhosis consequences. In patients with portal hypertension, oesophagogastric variceal bleeding is a leading cause of death. Most research has focused on high-risk gastroesophageal varices and bleeding, with only a few studies on early varices. However, early intervention of gastroesophageal varices was found to better improve the prognosis and reduce mortality, but there is still no relevant research. Ultrasonic endoscopy is a combination of endoscopy and ultrasonic imaging. It can gastroscopically detect varices around the oesophagus and stomach and detect oesophageal collateral veins and perforating veins earlier, which is helpful for the early diagnosis of varices. Therefore, this study aimed to explore the correlation between serum fibrosis markers and early gastroesophageal varices in compensated cirrhosis patients.

METHODS

This study included 791 patients with compensated cirrhosis. The selected patients were categorized into three groups. The early gastroesophageal varices group included patients with gastroesophageal varices found by endoscopic ultrasonography but not by gastroscopy. The no gastroesophageal varices group underwent endoscopic ultrasonography and gastroscopy without varices. In addition, gastroesophageal varices can be detected with both techniques. Multiple logistic regression analysis explored the association of serum fibrosis markers with early gastroesophageal varices.

RESULTS

Among the 791 compensated liver cirrhosis patients, 198 patients were without gastroesophageal varices, 279 patients had early gastroesophageal varices, 314 patients had gastroesophageal varices, and both techniques could detect varices. There was a positive correlation between serum fibrosis markers and early gastroesophageal varices. In univariate logistic regression analysis, the patients with early gastroesophageal varices had lower platelet counts (P = 0.034) and higher aspartate aminotransferase (P = 0.046), total bilirubin (P = 0.041), hyaluronic acid (P < 0.001), laminin (P < 0.001), type III procollagen (P = 0.005), type IV collagen (P = 0.002), liver stiffness measurement (P = 0.001), APRI (P = 0.019) and FIB-4 (P = 0.002). Multivariate analysis showed that laminin (OR 1.011; 95% CI 1.004-1.017, P = 0.001) was an independent risk factor for predicting early gastroesophageal varices in compensated cirrhosis patients.

CONCLUSION

Higher laminin was independently associated with early gastroesophageal varices in compensated cirrhosis patients.

Prognosis prediction performs better in patients with non-cirrhosis hepatitis B virus-related acute-on-chronic liver failure than those with cirrhosis

Background

The accurate prediction of the outcome of hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is impeded by population heterogeneity. The study aimed to assess the impact of underlying cirrhosis on the performance of clinical prediction models (CPMs).

Methods

Using data from two multicenter, prospective cohorts of patients with HBV-ACLF, the discrimination, calibration, and clinical benefit were assessed for CPMs predicting 28-day and 90-day outcomes in patients with cirrhosis and those without, respectively.

Results

A total of 919 patients with HBV-ACLF were identified by Chinese Group on the Study of Severe Hepatitis B (COSSH) criteria, including 675 with cirrhosis and 244 without. COSSH-ACLF IIs, COSSH-ACLFs, Chronic Liver Failure-Consortium Acute-on-Chronic Liver Failure score (CLIF-C ACLFs), Tongji Prognostic Predictor Model score (TPPMs), Model for End-Stage Liver Disease score (MELDs), and MELD-Sodium score (MELD-Nas) were all strong predictors of short-term mortality in patients with HBV-ACLF. In contrast to a high model discriminative capacity in ACLF without cirrhosis, each prognostic model represents a marked decline of C-index, net reclassification index (NRI), and integrated discrimination improvement (IDI) in predicting either 28-day or 90-day prognosis of patients with cirrhosis. The hazard analysis identified largely overlapping risk factors of poor outcomes in both subgroups, while serum bilirubin was specifically associated with short-term mortality in patients with cirrhosis and blood urea nitrogen in patients without cirrhosis. A subgroup analysis in patients with cirrhosis showed a decline of discrimination of CPMS in those with ascites or infections compared to that in those without.

Conclusion

Predicting the short-term outcome of HBV-ACLF by CPMs is optimal in patients without cirrhosis but limited in those with cirrhosis, at least partially due to the complicated ascites or infections.

The 50% and 95% effective doses of remimazolam tosilate with adjuvant sufentanil for sedation in patients with liver cirrhosis undergoing oesophagogastric varices screening endoscopy

WHAT IS ALREADY KNOWN AND OBJECTIVE

Sedation is routinely provided for patients undergoing gastrointestinal endoscopy. Remimazolam tosilate is a novel and short-acting sedative agent that has been used for sedation during endoscopic procedures. The optimal dose of remimazolam in gastrointestinal endoscopy for patients with liver cirrhosis has not been elucidated.

BACKGROUND

To determine the effective dose of remimazolam tosilate with adjuvant sufentanil for sedation in patients with liver cirrhosis undergoing oesophagogastric varices screening endoscopy.

MATERIAL AND METHODS

Patients aged 18-65 years with liver cirrhosis undergoing screening endoscopy for oesophagogastric varices were recruited. Sufentanil 0.15 μg/kg was given intravenously at 2 min before administration of remimazolam tosilate. The initial dose of remimazolam was 0.1 mg/kg and adjusted by 0.025 mg/kg as a step size, based on the Dixon and Massay up-and-down sequential method. Inclusion of patients was stopped after eight crossovers and the calculated median effective dose (ED₅₀ ) of remimazolam for successful endoscopy was obtained by calculating the mean of midpoint of all crossovers. Furthermore, a probit regression was applied to establish the dose-response curve of remimazolam and further assess the 95% effective dose (ED₉₅ ) of remimazolam.

RESULTS

The calculated ED₅₀ of remimazolam for successful endoscopy using the mean of midpoint of all crossovers was 0.097 mg/kg (95% CI, 0.004-0.099 mg/kg). Using the probit regression analysis, the ED₅₀ and ED₉₅ of remimazolam for successful endoscopy was 0.097 mg/kg (95% CI, 0.004-0.099 mg/kg) and 0.107 mg/kg (95% CI, 0.103-0.336 mg/kg), respectively. No adverse events were observed throughout the study period.

CONCLUSIONS

This pilot study suggests that the ED₅₀ and ED₉₅ of remimazolam tosilate with adjuvant sufentanil for sedation in liver cirrhosis patients undergoing oesophagogastric varices screening endoscopy was 0.097 and 0.107 mg/kg, respectively.

Global cirrhosis prevalence trends and attributable risk factors-an ecological study using data from 1990-2019

BACKGROUND AND AIMS

Cirrhosis is a major public health issue worldwide with significant morbidity and mortality. We aimed to explore the time series associations between varying levels of risk factors and cirrhosis prevalence and predict the cirrhosis prevalence under alternative scenarios to consolidate evidence for further intervention plans.

METHODS

We collected data of cirrhosis and its risk factors from 1990 to 2019 across 178 countries and used a generalized linear mixed model to explore the time series associations between cirrhosis and risk factors. We simulated scenarios with varying levels of risk factors and investigated benefits gained from the control of risk factors compared with the status quo.

RESULTS

The global cirrhosis prevalence varied geographically, with the highest observed in East and Southeast Asia, mainly due to high hepatitis prevalence. Our study revealed that each 1% increase in prevalence of hepatitis B and C, cirrhosis prevalence would correspondingly increase 0.028% and 0.288%. There would be approximately 392.15 million fewer cirrhosis patients if the goals of a 65% reduction in prevalence of hepatitis and a 10% reduction in alcohol consumption were achieved.

CONCLUSIONS

Given that cirrhosis prevalence has different risk factors depending on geography, it is important to identify an appropriate set of interventions for cirrhosis that are adapted to the epidemiological situation in a specific country. Interventions targeting hepatitis may have a significant impact on global cirrhosis prevalence, therefore, the adoption of specific interventions for hepatitis in high-burden regions and high-risk groups is warranted to lower the global burden of cirrhosis.

FSTL1 promotes liver fibrosis by reprogramming macrophage function through modulating the intracellular function of PKM2

OBJECTIVE

Follistatin-like protein 1 (FSTL1) is widely recognised as a secreted glycoprotein, but its role in modulating macrophage-related inflammation during liver fibrosis has not been documented. Herein, we aimed to characterise the roles of macrophage FSTL1 in the development of liver fibrosis.

DESIGN

Expression analysis was conducted with human liver samples obtained from 33 patients with liver fibrosis and 18 individuals without fibrosis serving as controls. Myeloid-specific FSTL1-knockout (FSTL1^M-KO) mice were constructed to explore the function and mechanism of macrophage FSTL1 in 3 murine models of liver fibrosis induced by carbon tetrachloride injection, bile duct ligation or a methionine-deficient and choline-deficient diet.

RESULTS

FSTL1 expression was significantly elevated in macrophages from fibrotic livers of both humans and mice. Myeloid-specific FSTL1 deficiency effectively attenuated the progression of liver fibrosis. In FSTL1^M-KO mice, the microenvironment that developed during liver fibrosis showed relatively less inflammation, as demonstrated by attenuated infiltration of monocytes/macrophages and neutrophils and decreased expression of proinflammatory factors. FSTL1^M-KO macrophages exhibited suppressed proinflammatory M1 polarisation and nuclear factor kappa B pathway activation in vivo and in vitro. Furthermore, this study showed that, through its FK domain, FSTL1 bound directly to the pyruvate kinase M2 (PKM2). Interestingly, FSTL1 promoted PKM2 phosphorylation and nuclear translocation, reduced PKM2 ubiquitination to enhance PKM2-dependent glycolysis and increased M1 polarisation. Pharmacological activation of PKM2 (DASA-58) partially countered FSTL1-mediated glycolysis and inflammation.

CONCLUSION

Macrophage FSTL1 promotes the progression of liver fibrosis by inducing M1 polarisation and inflammation based on the intracellular PKM2 reprogramming function of macrophages.

Event dependent overall survival in the population-based LIFE-Adult-Study

BACKROUND

Information about the direct comparability of big data of epidemiological cohort studies and the general population still is lacking, especially regarding all-cause mortality rates. The aim of this study was to investigate the overall survival and the influence of several diagnoses in the medical history on survival time, adjusted to common risk factors in a populations-based cohort.

METHODS

From 10,000 subjects of the population-based cohort LIFE-Adult-Study (Leipzig Research Centre for Civilization Diseases), the medical history and typical risk factors such as age, smoking status and body-mass-index (BMI) were assessed. The survival status was identified from the saxonian population register. Univariate and multivariate analyses were used to determine the influence of the medical history and risk factors on overall survival. To develope an optimal model, the method by Collet [1] was used.

RESULTS

The mortality rate of the participants is approximately half the mortality rate expected for the german population. The selection bias in epidemiological studies needs to be considered whenever interpreting results of epidemiological cohort studies. Nevertheless we have shown that several diagnoses proved to have a negative influence on overall survival time even in this relatively healthy cohort. This study showed the significantly increased mortality risk if the following diseases are reported in medical history of the participants in a large population-based cohort study including adults aged 18 and over: diabetes mellitus (HR 1.533, p = 0.002), hypertension (HR 1.447, p = 0.005), liver cirrhosis (HR 4.251, p < 0.001), osteoporosis (HR 2.165, p = 0.011), chronic bronchitis (HR 2.179, p < 0.001), peptic ulcer disease (HR 1.531, p = 0.024) and cancer (HR 1.797, p < 0.001). Surprisingly, asthma has the opposite effect on survival time (HR 0.574, p = 0.024), but we believe this may be due to an overrepresentation of mild to moderate asthma and its management, which includes educating patients about a healthy lifestyle.

CONCLUSION

In the LIFE-Adult-Study, common risk factors and several diseases had relevant effect on overall survival. However, selection bias in epidemiological studies needs to be considered whenever interpreting results of epidemiological cohort studies. Nevertheless it was shown that the general cause-and-effect principles also apply in this relatively healthy cohort.

Transjugular Intrahepatic Portosystemic Shunt Outcomes in the Elderly Population: A Systematic Review and Meta-Analysis

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure typically utilized to treat refractory ascites and variceal bleeding. However, TIPS can lead to significant complications, most commonly hepatic encephalopathy (HE). Advanced age has been described as a risk factor for HE, as the elderly population tends to have decreased cognitive reserve and increased sarcopenia. We conducted a systematic review and meta-analysis of the available literature to summarize the association between advanced age and risk of adverse events after undergoing TIPS.

Methods

A comprehensive search strategy to identify reports of specific outcomes (HE, 30-day and 90-day mortality, and 30-day readmission due to HE) in elderly patients after undergoing TIPS was developed in Embase (Embase.com, Elsevier). We compared outcomes and performed separate data analyses for patients aged < 70 vs. > 70 years and patients aged < 65 vs. > 65 years.

Results

Six studies with a total of 1,591 patients met our inclusion criteria and were included in the final meta-analysis. Three studies divided patients by age < 65 vs. > 65 years, with a total of 816 patients who were 54% male. The remaining three studies divided patients by age < 70 vs. > 70 years, with a total of 775 patients who were 63% male. Results demonstrated a significantly lower risk of post-TIPS HE (risk ratio (RR): 0.42, confidence interval (CI): 0.185 - 0.953, P = 0.03, I2 = 49%), 30-day mortality (RR: 0.37, CI: 0.188 - 0.74, P = 0.005, I2 = 0%), and 90-day mortality (RR: 0.35, CI: 0.24 - 0.49, P = 0.001, I2 = 0%) in patients aged > 70 vs. < 70 years, as well as a trend towards lower risk of 30-day readmission due to HE. There was no significant difference in post-TIPS HE, 30-day or 90-day mortality, or 30-day readmission due to HE between patients aged < 65 vs. > 65 years.

Conclusion

Age > 70 years is associated with significantly higher rates of HE and 30-day and 90-day mortality rates in patients after undergoing TIPS, as well as a trend towards higher 30-day readmission due to HE.

A potential novel inflammation biomarker for predicting the prognosis of decompensated liver cirrhosis

OBJECTIVE

This study aimed to explore the prognostic value of the lymphocyte (LYM)-to-white blood cell (WBC) ratio (LWR) in patients with decompensated liver cirrhosis (DLC).

METHODS

This study was conducted by recruiting 214 patients with DLC with different aetiologies (development cohort). Receiver operating characteristic (ROC) curve analyses were used to assess the predictive accuracy of the LWR, and Youden's index was used to determine the optimal cut-off values of the LWR based on the ROC curve. Next, patients were divided into high- and low-LWR groups according to the cut-off values. Multivariate logistic analyses were performed to determine the independent predictors for the 1-, 3- and 6-month mortality. Restricted cubic spline (RCS) was used to determine and visualize the association between LWR and the risk of death. We verified the predictive ability of LWR in the validation cohort of 139 patients.

RESULTS

In the development cohort, there were 16 (7.5%), 22 (10.3%) and 30 patients (14.0%) who died at 1, 3 and 6 months, respectively. The LWR was significantly lower in non-survivors than in survivors and was an independent predictor of poor outcomes. The ROC analyses with the Delong test showed that the LWR had comparable predictive power with the Model for End-Stage Liver Disease (MELD) score, neutrophil-to-LYM ratio (NLR) and Chronic Liver Failure consortium score for acute decompensated (CLIF-C ADs). RCS showed a non-linear relationship between the LWR and the risk of death at 1 and 3 months, whereas a linear relationship was observed between the LWR and the risk of death at 6 months. We verified that the decreased LWR was an independent predictor of adverse outcomes at 3-, and 6-month follow-up endpoints in the validation cohort.

CONCLUSIONS

Our findings indicate that a lower LWR is an independent factor for unfavourable outcomes and may serve as a potential novel prognostic predictor in patients with DLC.KEY MESSAGESThis study is the first report on the prognostic value of the lymphocyte (LYM)-to-white blood cell (WBC) ratio (LWR) in patients with decompensated liver cirrhosis (DLC).Decreased LWR is an independent factor for adverse outcomes in patients with DLC.

Gastrointestinal System: COVID-19 and Potential Mechanisms Associated with Coagulopathy

SARS-CoV-2 is a novel coronavirus that expanded worldwide, generating a pandemic of acute respiratory syndrome called "coronavirus disease 2019" (COVID-19), which resulted in a global health crisis. The spectrum of COVID-19 manifestations ranges from none or mild symptoms to severe respiratory failure associated with systemic manifestations, mostly gastrointestinal symptoms. Hypercoagulability is an important feature of COVID-19 disease, which can potentially influence patients' prognosis. Therefore, gastroenterologists should focus on subjects with concomitant hypercoagulable gastrointestinal disorders as they may display a higher risk of thrombotic complications during SARS-CoV-2 infection. The aim of this review is to summarize the available evidence regarding the interplay of the prothrombotic pathogenetic mechanisms of both COVID-19 and hypercoagulable digestive diseases and the possible clinical implications. We summarized the potential interplay of prothrombotic mechanisms of both COVID-19 and hypercoagulable digestive diseases in the graphical abstract.

Elevated calprotectin levels are associated with mortality in patients with acute decompensation of liver cirrhosis

BACKGROUND

Acute decompensation (AD) of cirrhosis is related to systemic inflammation and elevated circulating cytokines. In this context, biomarkers of inflammation, such as calprotectin, may be of prognostic value.

AIM

To evaluate serum calprotectin levels in patients hospitalized for complications of cirrhosis.

METHODS

This is a prospective cohort study that included 200 subjects hospitalized for complications of cirrhosis, 20 outpatients with stable cirrhosis, and 20 healthy controls. Serum calprotectin was measured by enzyme-linked immunosorbant assay.

RESULTS

Calprotectin levels were higher among groups with cirrhosis when compared to healthy controls. Higher median calprotectin was related to Child-Pugh C, ascites, and hepatic encephalopathy. Higher calprotectin was related to acute-on-chronic liver failure (ACLF) and infection in the bivariate, but not in multivariate analysis. Calprotectin was not associated with survival among patients with ACLF; however, in patients with AD without ACLF, higher calprotectin was associated with a lower 30-d survival, even after adjustment for chronic liver failure-consortium (CLIF-C) AD score. A high-risk group (CLIF-C AD score ≥ 60 and calprotectin ≥ 580 ng/mL) was identified, which had a 30-d survival (27.3%) similar to that of patients with grade 3 ACLF (23.3%).

CONCLUSION

Serum calprotectin is associated with prognosis in patients with AD without ACLF and may be useful in clinical practice to early identify patients with a very low short-term survival.

In Vitro Models for the Study of Liver Biology and Diseases: Advances and Limitations

In vitro models of liver (patho)physiology, new technologies, and experimental approaches are progressing rapidly. Based on cell lines, induced pluripotent stem cells or primary cells derived from mouse or human liver as well as whole tissue (slices), such in vitro single- and multicellular models, including complex microfluidic organ-on-a-chip systems, provide tools to functionally understand mechanisms of liver health and disease. The International Society of Hepatic Sinusoidal Research (ISHSR) commissioned this working group to review the currently available in vitro liver models and describe the advantages and disadvantages of each in the context of evaluating their use for the study of liver functionality, disease modeling, therapeutic discovery, and clinical applicability.

Microbe-bridged disease-metabolite associations identification by heterogeneous graph fusion

MOTIVATION

Metabolomics has developed rapidly in recent years, and metabolism-related databases are also gradually constructed. Nowadays, more and more studies are being carried out on diverse microbes, metabolites and diseases. However, the logics of various associations among microbes, metabolites and diseases are limited understanding in the biomedicine of gut microbial system. The collection and analysis of relevant microbial bioinformation play an important role in the revelation of microbe-metabolite-disease associations. Therefore, the dataset that integrates multiple relationships and the method based on complex heterogeneous graphs need to be developed.

RESULTS

In this study, we integrated some databases and extracted a variety of associations data among microbes, metabolites and diseases. After obtaining the three interconnected bilateral association data (microbe-metabolite, metabolite-disease and disease-microbe), we considered building a heterogeneous graph to describe the association data. In our model, microbes were used as a bridge between diseases and metabolites. In order to fuse the information of disease-microbe-metabolite graph, we used the bipartite graph attention network on the disease-microbe and metabolite-microbe bipartite graph. The experimental results show that our model has good performance in the prediction of various disease-metabolite associations. Through the case study of type 2 diabetes mellitus, Parkinson's disease, inflammatory bowel disease and liver cirrhosis, it is noted that our proposed methodology are valuable for the mining of other associations and the prediction of biomarkers for different human diseases.Availability and implementation: https://github.com/Selenefreeze/DiMiMe.git.

MiRNA/mRNA network topology in hepatitis virus B-related liver cirrhosis reveals miR-20a-5p/340-5p as hubs initiating fibrosis

Background

The pathophysiology of hepatitis B-related liver cirrhosis (HBV-LC) remains unclear. This study aimed to explore the disease mechanisms using topological analysis of the miRNA/mRNA network.

Methods

Paired miRNA/mRNA sequencing was performed with thirty-three peripheral blood mononuclear cell samples (LC, n = 9; chronic hepatitis B, n = 12; normal controls, n = 12) collected from a prospective cohort to identify the miRNA/mRNA network. Topological features and functional implications of the network were analyzed to capture pathophysiologically important miRNAs/mRNAs, whose expression patterns were confirmed in the validation group (LC, n = 15; chronic hepatitis B, n = 15; normal controls, n = 10), and functional potentials initiating fibrogenesis were demonstrated in vitro.

Results

The miRNA/mRNA network contained 3121 interactions between 158 differentially expressed (DE) miRNAs and 442 DE-mRNAs. The topological analysis identified a core module containing 99 miRNA/mRNA interactions and two hub nodes (miR-20a-5p/miR-340-5p), which connected to 75 DE-mRNAs. The expression pattern along the disease progression of the core module was found associated with a continuous increase in wound healing, inflammation, and leukocyte migration but an inflection of immune response and lipid metabolic regulation, consistent with the pathophysiology of HBV-LC. MiR-20a-5p/miR-340-5p were found involved in macrophage polarization and hepatic stellate cell (HSC) activation in vitro (THP-1, LX-2 cell lines), and their expression levels were confirmed in the validation group independently.

Conclusion

Topological analysis of the miRNA/mRNA network in HBV-LC revealed the association between fibrosis and miR-20a-5p/miR-340-5p involving initiating activations of macrophage and HSC. Further validations should be performed to confirm the HSC/macrophage activations and the interactions between miR-20a-5p/miR-340-5p and their potential targets, which may help to develop non-invasive prognostic markers or intervention targets for HBV-LC.

Computed tomography perfusion in liver and spleen for hepatitis B virus-related portal hypertension: A correlation study with hepatic venous pressure gradient

BACKGROUND

Hepatic venous pressure gradient (HVPG) is the gold standard for diagnosis of portal hypertension (PH). However, its use can be limited because it is an invasive procedure. Therefore, it is necessary to explore a non-invasive method to assess PH.

AIM

To investigate the correlation of computed tomography (CT) perfusion of the liver with HVPG and Child-Pugh score in hepatitis B virus (HBV)-related PH.

METHODS

Twenty-eight patients (4 female, 24 male) with gastroesophageal variceal bleeding induced by HBV-related PH were recruited in our study. All patients received CT perfusion of the liver before transjugular intrahepatic portosystemic stent-shunt (TIPS) therapy. Quantitative parameters of CT perfusion of the liver, including liver blood flow (LBF), liver blood volume (LBV), hepatic artery fraction, splenic blood flow and splenic blood volume were measured. HVPG was recorded during TIPS therapy. Correlation of liver perfusion with Child-Pugh score and HVPG were analyzed, and the receiver operating characteristic curve was analyzed. Based on HVPG (> 12 mmHg vs ≤ 12 mmHg), patients were divided into moderate and severe groups, and all parameters were compared.

RESULTS

Based on HVPG, 18 patients were classified into the moderate group and 10 patients were classified into the severe group. The Child-Pugh score, HVPG, LBF and LBV were significantly higher in the moderate group compared to the severe group (all P < 0.05). LBF and LBV were negatively associated with HVPG (r = -0.473, P < 0.05 and r = -0.503, P < 0.01, respectively), whereas splenic blood flow was positively associated with hepatic artery fraction (r = 0.434, P < 0.05). LBV was negatively correlated with Child-Pugh score. Child-Pugh score was not related to HVPG. Using a cutoff value of 17.85 mL/min/100 g for LBV, the sensitivity and specificity of HVPG ≥ 12 mmHg for diagnosis were 80% and 89%, respectively.

CONCLUSION

LBV and LBF were negatively correlated with HVPG and Child-Pugh scores. CT perfusion imaging is a potential non-invasive quantitative predictor for PH in HBV-related liver cirrhosis.

Deep learning-based quantification of NAFLD/NASH progression in human liver biopsies

Non-alcoholic fatty liver disease (NAFLD) affects about 24% of the world's population. Progression of early stages of NAFLD can lead to the more advanced form non-alcoholic steatohepatitis (NASH), and ultimately to cirrhosis or liver cancer. The current gold standard for diagnosis and assessment of NAFLD/NASH is liver biopsy followed by microscopic analysis by a pathologist. The Kleiner score is frequently used for a semi-quantitative assessment of disease progression. In this scoring system the features of active injury (steatosis, inflammation, and ballooning) and a separated fibrosis score are quantified. The procedure is time consuming for pathologists, scores have limited resolution and are subject to variation. We developed an automated deep learning method that provides full reproducibility and higher resolution. The system was established with 296 human liver biopsies and tested on 171 human liver biopsies with pathologist ground truth scores. The method is inspired by the way pathologist's analyze liver biopsies. First, the biopsies are analyzed microscopically for the relevant histopathological features. Subsequently, histopathological features are aggregated to a per-biopsy score. Scores are in the identical numeric range as the pathologist's ballooning, inflammation, steatosis, and fibrosis scores, but on a continuous scale. Resulting scores followed a pathologist's ground truth (quadratic weighted Cohen's κ on the test set: for steatosis 0.66, for inflammation 0.24, for ballooning 0.43, for fibrosis 0.62, and for the NAFLD activity score (NAS) 0.52. Mean absolute errors on a test set: for steatosis 0.29, for inflammation 0.53, for ballooning 0.61, for fibrosis 0.78, and for the NAS 0.77).

Covered transjugular intrahepatic portosystemic stent-shunt vs large volume paracentesis in patients with cirrhosis: A real-world propensity score-matched study

BACKGROUND

Refractory ascites has a 1-year survival rate of 50%. In selected patients, treatment options include liver transplantation (LT) or transjugular intrahepatic portosystemic stent shunt (TIPSS).

AIM

To assess the outcomes of patients who underwent a TIPSS compared to large volume paracentesis (LVP).

METHODS

Retrospective study of patients who underwent a covered TIPSS or LVP for refractory or recurrent ascites over 7 years. Primary outcome was transplant-free survival (TFS). Further analysis was done with propensity score matching (PSM).

RESULTS

There were 150 patients [TIPSS group (n = 75), LVP group (n = 75)]. Seven patients in the TIPSS group underwent LT vs 22 patients in the LVP group. Overall median follow up, 20 (0.47-179.53) mo. In the whole cohort, there was no difference in TFS [hazard ratio (HR): 0.80, 95% confidence interval (CI): 0.54-1.21]; but lower de novo hepatic encephalopathy with LVP (HR: 95%CI: 0.20-0.96). These findings were confirmed following PSM analysis. On multivariate analysis albumin and hepatocellular carcinoma at baseline were associated with TFS.

CONCLUSION

Covered TIPSS results in similar TFS compared to LVP in cirrhotic patients with advanced liver failure. Liver transplant assessment should be considered in all potential candidates for TIPSS. Further controlled studies are recommended to select appropriate patients for TIPSS.

Reprogramming the spleen into a functioning 'liver' in vivo

OBJECTIVE

Liver regeneration remains one of the biggest clinical challenges. Here, we aim to transform the spleen into a liver-like organ via directly reprogramming the splenic fibroblasts into hepatocytes in vivo.

DESIGN

In the mouse spleen, the number of fibroblasts was through silica particles (SiO₂) stimulation, the expanded fibroblasts were converted to hepatocytes (iHeps) by lentiviral transfection of three key transcriptional factors (Foxa3, Gata4 and Hnf1a), and the iHeps were further expanded with tumour necrosis factor-α (TNF-α) and lentivirus-mediated expression of epidermal growth factor (EGF) and hepatocyte growth factor (HGF).

RESULTS

SiO₂ stimulation tripled the number of activated fibroblasts. Foxa3, Gata4 and Hnf1a converted SiO₂-remodelled spleen fibroblasts into 2×10⁶ functional iHeps in one spleen. TNF-α protein and lentivirus-mediated expression of EGF and HGF further enabled the total hepatocytes to expand to 8×10⁶ per spleen. iHeps possessed hepatic functions-such as glycogen storage, lipid accumulation and drug metabolism-and performed fundamental liver functions to improve the survival rate of mice with 90% hepatectomy.

CONCLUSION

Direct conversion of the spleen into a liver-like organ, without cell or tissue transplantation, establishes fundamental hepatic functions in mice, suggesting its potential value for the treatment of end-stage liver diseases.

Pathogenesis of Alcohol-Associated Liver Disease

Excessive alcohol consumption is a global healthcare problem with enormous social, economic, and clinical consequences. While chronic, heavy alcohol consumption causes structural damage and/or disrupts normal organ function in virtually every tissue of the body, the liver sustains the greatest damage. This is primarily because the liver is the first to see alcohol absorbed from the gastrointestinal tract via the portal circulation and second, because the liver is the principal site of ethanol metabolism. Alcohol-induced damage remains one of the most prevalent disorders of the liver and a leading cause of death or transplantation from liver disease. Despite extensive research on the pathophysiology of this disease, there are still no targeted therapies available. Given the multifactorial mechanisms for alcohol-associated liver disease pathogenesis, it is conceivable that a multitherapeutic regimen is needed to treat different stages in the spectrum of this disease.

Real-life experience of ledipasvir and sofosbuvir for HCV infected Korean patients: a multicenter cohort study

BACKGROUND/AIMS

To evaluate the efficacy and safety of ledipasvir/sofosbuvir (LDV/SOF) therapy in hepatitis C virus (HCV)-infected Korean patients in a real clinical setting.

METHODS

A total of 273 patients who received LDV/SOF therapy between May 2016 and February 2021 were consecutively enrolled and analyzed. A per-protocol analysis was performed to evaluate the virologic response.

RESULTS

Seventy-five percent were infected with genotype 1, and 25% were infected with genotype 2. A hundred eightyone (66.3%) patients had chronic hepatitis, 74 (27.1%) had compensated cirrhosis, eight (2.9%) had decompensated cirrhosis, and 10 (3.7%) had undergone liver transplantation. Undetectable HCV RNA at week 4 was achieved in 90.2% (231/256) of patients, 99.2% (250/252) achieved the end of treatment response, and 98.1% (202/206) achieved sustained virologic response at 12 weeks post-treatment (SVR12). According to liver function, the SVR12 rates were 99.3% (135/136) in chronic hepatitis, 96.4% (53/55) in compensated cirrhosis, and 100% (6/6) in decompensated cirrhosis. The SVR12 rates according to the genotype were 98.2% (167/170) for genotype 1 and 97.2% (35/36) for genotype 2. An 8-week LDV/SOF treatment in treatment-naïve chronic hepatitis patients with HCV RNA &lt; 6,000,000 IU/mL at baseline resulted in 100% (23/23) SVR12 rates. Overall, LDV/SOF was tolerated well, with a 0.7% (2/273) discontinuation rate due to adverse events that were unrelated to LDV/SOF.

CONCLUSION

LDV/SOF is effective and safe for treating HCV-infected Korean patients with high SVR12 rates.

SRF/MRTF-A and liver cirrhosis: Pathologic associations

Liver cirrhosis results from prolonged and extensive liver fibrosis in which fibrotic tissues replace functional hepatic cells. Chronic liver disease due to various viral, chemical, or metabolic factors initiates hepatic fibrogenesis. Cirrhosis is associated with multiple clinical complications and a poor patient prognosis; therefore, developing novel antifibrotic therapies to prevent cirrhosis is of high priority. Mounting evidence points to the key role of serum response factor (SRF) and myocardin-related transcription factor (MRTF)-A in the pathogenesis of liver fibrosis. SRF is a transcription factor and MRTF-A is a co-activator of SRF and normally resides in the cytoplasm. Upon the induction of fibrotic pathways, MRTF-A translocates into the nucleus and forms the active SRF/MRTF-A complex, leading to the expression of a multitude of fibrotic proteins and components of extracellular matrix. Silencing or inhibiting MRTF-A impedes hepatic stellate cell transdifferentiation into myofibroblasts and slows down the deposition of extracellular matrix in the liver, making it a potential therapeutic target. Here, we review the recent findings regarding the role of the SRF/MRTF-A complex in liver fibrosis and its therapeutic potential for the management of cirrhosis.

Liver Stiffness is Reduced to Normal After Successful Renal Transplantation: A Prospective Cohort Study

Background

Liver stiffness (LS) may be falsely elevated in patients on maintenance hemodialysis (MHD) due to fluid overload. We measured LS change by transient elastography (TE) in MHD patients before and after successful renal transplantation.

Method

Adults on ≥2 years of MHD, without additional risk factors for liver fibrosis or fluid overload, and planned for renal transplantation were prospectively recruited. LS was measured on two occasions, i.e., within two weeks before transplantation (pre-Tx LS) and after ≥ 3 months after successful transplantation (post-Tx LS). The participants with pre-Tx LS ≤ 7.0 KPa and >7.0 KPa were classified as "Group I" and "Group II," respectively. Categorical and numerical data are expressed as ratio/proportions and mean (SD), respectively.

Results

Paired data from 43 participants (males 42 [97.7%]; age 32 [11] years) were analyzed. The pre-Tx and post-Tx LS of the entire cohort, measured at 307 (198) days of interval, were 8.5 (7.3) KPa and 6.7 (3.1) KPa, respectively. Before transplantation, 21 (49%) participants belonged to Group II and 22 (51%) to Group I. Among the Group II participants, 12 (57%) showed LS normalization after 312 (182) days of transplantation. Of the 22 participants in Group I, three (13.6%) showed LS elevation to >7.0 KPa after 303 (217) days of transplantation. The mean LS changes among the overall cohort, Group II, and Group I were -1.8 KPa, -4.1 KPa, and +0.2 KPa, respectively.

Conclusion

LS in people on MHD may be falsely elevated, which is likely to normalize after successful renal transplantation.

Sarcopenia-related gut microbial changes are associated with the risk of complications in people with cirrhosis

Background & Aims

Sarcopenia and gut dysbiosis are common in individuals with cirrhosis. However, the association between sarcopenia and microbial alterations, and the subsequent impact on cirrhotic outcomes are poorly understood. This study aimed to identify muscle-dependent microbial changes and related risks of cirrhotic complications.

Methods

From September 2018 to December 2020, 89 individuals with cirrhosis and 16 healthy volunteers were prospectively enrolled. Muscle and nutritional status, serum amino acids, and fecal microbiota were analyzed. The association between microbial signatures of sarcopenia and cirrhotic complications was investigated.

Results

A decline in muscle mass and strength were associated with gut microbial alterations in individuals with cirrhosis. The greatest microbial dissimilarity was observed between those with sarcopenia (both decline in muscle mass and strength) and those with normal-muscle status (p = 0.035). Individuals with sarcopenia had lower serum levels of alanine, valine, leucine, isoleucine, proline, tryptophan and ornithine. Besides, gut microbial functions associated with amino acid biosynthesis were significantly reduced in individuals with sarcopenia and cirrhosis. Depletion of Dialister, Ruminococcus 2, and Anaerostipes were associated with cirrhotic sarcopenia, and significantly correlated with the serum levels of amino acids. Individuals with coexistent depletion of Ruminococcus 2 and Anaerostipes developed more infectious (44.4% vs. 3.0%) and non-infectious (74.1% vs. 3.0%) complications, and more hospitalizations (54 vs. 3) than those with cirrhosis with good microbial signatures (all p <0.001). In contrast, fecal enrichment of Ruminococcus 2 and Anaerostipes independently decreased the risk of 1-year complications.

Conclusions

Sarcopenia-related fecal microbial alterations are associated with cirrhotic complications. These findings may facilitate measures to improve the outcomes of individuals with cirrhosis and sarcopenia by modifying gut microbiota.

Impact and implications

The composition and biosynthetic functions of gut microbiota are significantly changed in individuals with sarcopenic cirrhosis. Those with a sarcopenia-related poor microbial signature, in which Ruminococcus 2 and Anaerostipes were both depleted, had significantly more infectious and non-infectious complications, as well as more hospitalizations. These findings highlight the therapeutic potential of modifying the gut microbiota of individuals with sarcopenic cirrhosis to improve their clinical outcomes.

A Prognostic Nomogram for Hepatocellular Carcinoma Based on Wound Healing and Immune Checkpoint Genes

BACKGROUND AND AIMS

Wound healing and tumor progression share some common biological features; however, how variations in wound healing patterns affect hepatocellular carcinoma (HCC) prognosis remains unclear.

METHODS

We analyzed the wound healing patterns of 594 HCC samples from The Cancer Genome Atlas (TCGA) and the International Cancer Genome Consortium (ICGC) and correlated them with immune infiltration and the expression levels of immune checkpoint genes. A risk score, which we named the "heal.immune" score, was established via stepwise Cox estimation. We constructed a nomogram based on age, sex, TNM stage, and heal.immune score and explored its predictive value for HCC prognosis. Seventy-four clinical patients were enrolled in this study, and all were from Huashan Hospital of Fudan University between 2015 and 2017 to serve as an independent validation group.

RESULTS

We identified two distinct wound healing patterns in HCC. The biological processes of healing cluster 1 (C1) are related to metabolism, while those of healing cluster 2 (C2) are related to the inflammatory response and immune cell accumulation. A total of 565 wound healing-related genes (based on Gene Ontology) and 25 immune checkpoint genes were considered. By analyzing differentially expressed genes and implementing a stepwise Cox estimation analysis, six genes with p values less than 0.02 in a multivariate Cox estimation were chosen as the "heal.immune" gene set (FCER1G, PLAT, ITGA5, CCNB1, CD86 and CD40). The "heal.immune" gene set, as an OS risk factor, was further validated in Fudan cohort. We constructed a nomogram to predict the 1-, 3- and 5-year overall survival (OS) in the TCGA cohort. The area under curve vales of the receiver characteristic operator curves were 0.82, 0.76 and 0.73 in the training group and 0.84, 0.76 and 0.72 in the test group.

CONCLUSIONS

We established a prognostic nomogram based on the heal.immune gene signature, which includes six wound healing- and immunity-related genes. This nomogram accurately predicts the OS of HCC patients.

Branched-chain amino acids supplementation has beneficial effects on the progression of liver cirrhosis: A meta-analysis

BACKGROUND

Liver cirrhosis (LC) is currently the 11^th most common cause of death and 15^th cause of morbidity globally. The treatment of LC is mainly aimed at etiological intervention, lifestyle intervention, prevention and treatment of complications and nutritional treatment. Nutritional treatment of LC mainly includes increasing dietary intake, food intake time and branched-chain amino acids (BCAAs). Despite the recommendation of BCAAs in some guidelines, adverse effects have been reported in studies so the efficacy and safety of BCAAs remain controversial. Currently, BCAAs have been widely used in chronic liver disease, while the summary of the effect of BCAAs on long-term prognosis is rare.

AIM

To determine the effects of BCAAs in patients with LC.

METHODS

The PubMed, Cochrane Library, Embase and Web of Science databases were searched. The retrieval deadline was 1 October 2021 and there were no language restrictions set in the retrieval. The study was performed in strict accordance with the inclusion and exclusion criteria. Nine studies were finally included. The primary outcome was complications of LC. The secondary outcomes were nutritional status and liver function. This meta-analysis used the Review Manager, version 5 statistical package (Cochrane Collaboration, Oxford, England) for analysis.

RESULTS

The analysis included nine studies that consisted of 1080 patients (554 in the BCAA groups and 526 in the control groups). The nine studies were randomized control trials (RCTs). The quality of the studies was assessed using the risk of bias method recommended by the Cochrane Collaboration. BCAAs reduced the rate of complications in LC patients [Risk ratio: 0.70, 95% confidence interval (CI): 0.56-0.88, P = 0.002] and improved patients’ albumin levels [std mean difference SMD: 0.26, 95%CI: 0.12-0.40, P = 0.0002]. Meanwhile, BCAAs significantly ameliorated the levels of alanine transaminase (SMD: -2.03, 95%CI: -2.52 to -1.53, P < 0.00001) and aspartate aminotransferase (SMD: -1.8, 95%CI: -2.14 to -1.46, P < 0.00001). Meanwhile, glucose in the LC was significantly increased in BCAA-treated patients (MD: 13.04, 95%CI: 6.81-19.89, P = 0.0002).

CONCLUSION

BCAAs reduce the incidence of complications in patients with LC and ameliorate nutritional status.

Impact of metabolic syndrome on the long-term prognosis of patients with hepatitis B virus-related hepatocellular carcinoma after hepatectomy

Background & aims

The long-term prognosis of patients with metabolic syndrome (MS) and hepatitis B virus-related hepatocellular carcinoma (HBV-HCC) after radical hepatectomy remains unclear. The purpose of this study was to elucidate the effect of MS on long-term survival for patients with HBV-related HCC after hepatectomy.

Methods

Patients with HBV-HCC after hepatectomy were included. Patients were stratified into MS-HBV-HCC and HBV-HCC groups. Clinical features and surgical outcomes were compared between the two groups, and COX regression analysis was used to determine independent risk factors associated with overall survival (OS) and recurrence-free survival (RFS).

Result

389 patients (MS-HBV-HCC group: n=50, HBV-HCC group: n=339) were enrolled for further analysis. Baseline characteristics showed that patients with MS-HBV-HCC were associated with a high rate of elderly patients, ASA score, and co-morbid illness, but a lower rate of anatomy hepatectomy. There were no significant differences in perioperative complications. After excluding patients who relapsed or died within 90 days after surgery, multivariate Cox regression analysis showed MS was an independent risk factor of OS (HR 1.68, 95% CI 1.05-2.70, P = 0.032) and RFS (HR 1.78, 95% CI 1.24-2.57, P = 0.002).

Conclusion

MS is an independent risk factor for poor OS and RFS in HBV-infected HCC patients after radical hepatectomy. This suggests that we need to strengthen postoperative follow-up of the relevant population and encourage patients to develop a healthy lifestyle.

Hepatic perfusion as a new predictor of prognosis and mortality in critical care patients with acute-on-chronic liver failure

Background and aims

Liver diseases are frequent causes of morbidity and mortality worldwide. Liver diseases can lead to cirrhosis, with the risk of acute-on-chronic liver failure (ACLF). For the detection of changes in hepatic hemodynamics, Doppler ultrasonography is a well-established method. We investigated hepatic hemodynamics via serial Doppler ultrasonography to determine the predictive value of changes in hepatic perfusion for the outcome in patients with severe liver diseases compared to established prognostic models such as the MELD (Model for End-Stage Liver Disease) or CLIF-C (Chronic Liver Failure-Consortium) ACLF score.

Methods

In this prospective cohort study, hepatic perfusion was quantified at baseline before the initiation of treatment and every third day by means of serial measurements of the hepatic artery resistance index (HARI) and the maximum portal vein velocity (PVv) using Doppler ultrasonography in 50 consecutive patients with severe liver diseases admitted to a medical intensive care unit (MICU). The recorded hemodynamic parameters were compared to the MELD score, and the CLIF-C ACLF score to analyze their utility for the prediction of the outcome of patients with severe liver diseases, liver cirrhosis, and ACLF.

Results

The changes (delta) obtained by serial measurements of the MELD score, HARI, and PVv were analyzed through scatter plots. Bivariate correlation analysis yielded a new positive linear correlation between the delta-HARI and the delta-MELD score (r = 0.469; p < 0.001). In addition, our data revealed a new negative linear correlation between delta-PVv and the delta-MELD score (r = -0.279, p = 0.001). The leading cause of MICU mortality was acute-on-chronic liver failure (ACLF). A subgroup analysis of patients with liver cirrhosis revealed a positive linear correlation between the delta-HARI and the delta-CLIF-C-ACLF score (r = 0.252, p = 0.005). Of clinical relevance, non-survivors of ACLF exhibited a significantly higher mean value for the delta-HARI (0.010 vs. -0.005; p = 0.015) and a lower mean value for the delta-PVv (-0.7 vs. 1.9 cm/s; p = 0.037) in comparison to survivors of ACLF.

Conclusion

This study shows the prognostic value of the assessment of hepatic perfusion in critical care patients with severe liver diseases by bedside Doppler ultrasound examination and its utility as an accurate predictor of the outcome in patients with ACLF. Increasing HARI and a decreasing PVv are predictors of an adverse outcome. Delta-HARI and delta-PVv are new biomarkers of prognosis and ACLF-related mortality in patients with liver diseases. Delta-HARI and delta-PVv may be helpful in guiding clinical decision-making, especially in catecholamine and fluid management.

Liver Function-How to Screen and to Diagnose: Insights from Personal Experiences, Controlled Clinical Studies and Future Perspectives

Acute and chronic liver disease is a relevant problem worldwide. Liver function plays a crucial role in the course of liver diseases not only in estimating prognosis but also with regard to therapeutic interventions. Within this review, we discuss and evaluate different tools from screening to diagnosis and give insights from personal experiences, controlled clinical studies and future perspectives. Finally, we offer our novel diagnostic algorithm to screen patients with presumptive acute or chronic liver disease in the daily clinical routine.

Clinical effects of cluster technology optimization and innovations on laparoscopic splenectomy and azygoportal disconnection: a single-center retrospective study with 500 consecutive cases

BACKGROUND

In Asia, laparoscopic splenectomy and azygoportal disconnection (LSD) has been widely regarded as a preferential treatment modality for cirrhotic portal hypertension (PH). However, LSD involves high surgical risk, technical challenges, and many potential postoperative complications. Technology optimization and innovation in LSD aiming to solve to these difficulties has scarcely been reported. In this retrospective study, we aimed to evaluate the clinical therapeutic effect of our cluster technology optimization and innovation on LSD for PH.

METHODS

From February 2012 to January 2020, 500 patients with cirrhosis who had esophagogastric variceal bleeding and hypersplenism underwent LSD in our department. According to different operation periods, patients were divided into the early-, intermediate-, and late-period groups. We collected information regarding clinical characteristics of all patients as well as their preoperative and postoperative follow-up data.

RESULTS

Compared with the early-period group, operation time and postoperative hospital stay were all significantly different and gradually declined from the intermediate- and late-period groups, respectively (all P &lt; 0.05). Intraoperative blood loss of these three groups was gradually decreased, with significant differences (P &lt; 0.05). The incidences of delayed gastric emptying and diarrhea in the late-period group were all significantly lower than those in the early- and intermediate-period groups, respectively (all P &lt; 0.05). Compared with the early-period group, the incidence of variceal re-bleeding was significantly lower in the intermediate- and late-period groups (all P &lt; 0.05).

CONCLUSION

Our cluster technology optimization and innovation of LSD not only contributed to faster recovery and fewer complications but also enhanced surgical safety for patients. It is worth promoting this approach among patients with EVB and hypersplenism secondary to cirrhotic PH.

The role of microRNAs on the pathogenesis, diagnosis and management of portal hypertension in patients with chronic liver disease

INTRODUCTION

Portal hypertension (PH) is the elevated pressure in the portal vein, which results in poor functioning of the liver and is influenced by various factors like liver cirrhosis, nonalcoholic fatty liver disease, schistosomiasis, thrombosis, and angiogenesis. Though the diagnosis and treatment have been advanced, early diagnosis of the disease remains a challenge, and the diagnosis methods are often invasive. Hence, the clear understanding of the molecular mechanisms of PH can give rise to the development of novel biomarkers which can pave way for early diagnosis in noninvasive methods, and also the identification of target genes can elucidate an efficient therapeutic target.

AREAS COVERED

PubMed and Embase database was used to search articles with search terms 'Portal Hypertension' or 'pathophysiology' and 'diagnosis' and 'treatment' or "role of miRNAs in portal hypertension.

EXPERT OPINION

Interestingly, biomarkers like microRNAs (miRNAs) have been studied for their potential role in various diseases including hypertension. In recent years, miRNAs have been proved to be an efficient biomarker and therapeutic target and few studies have assessed the roles of miRNAs in PH. The present paper highlights the potential roles of miRNAs in PH.

Development and validation of a nomogram for esophagogastric variceal bleeding in liver cirrhosis: A cohort study in 1099 cases

OBJECTIVES

Esophagogastric variceal bleeding (EVB) is a catastrophic complication of decompensated liver cirrhosis. We aimed to establish a nomogram based on noninvasive clinical and imaging variables to predict the risk of EVB.

METHODS

The cut-off value of each variable was determined through univariate regression analysis. The least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses were used to determine the risk factors and establish predictive models. The nomogram was established and validated using the calibration discrimination across different groups.

RESULTS

Six indicators, including platelet count, hemoglobin, albumin to globulin ratio, fasting blood glucose, serum chloride, and computed tomography portal vein diameter (CTPD), were found to be related to the risk of EVB. Two models, with or without CTPD, were established and compared. Model 1 with CTPD had better discrimination than model 2 with C-index of 0.893 (95% confidence interval [CI] 0.872-0.915) and 0.862 (95% CI 0.837-0.887) in the primary cohort, respectively (Z = 2.027, P = 0.043). While the C-index of the two models in the validation cohort was 0.878 (95% CI 0.838-0.919) and 0.810 (95% CI 0.757-0.863). Moreover, the clinical decision analysis curve and clinical impact curve showed that these models might confer a significant net benefit on patients and provide a reference threshold for clinicians.

CONCLUSION

A nomogram using routine clinical indicators was established to predict the risk of EVB in patients with liver cirrhosis, which was verified in an independent cohort and demonstrated a great consistency.

Carvedilol reduces the risk of decompensation and mortality in patients with compensated cirrhosis in a competing-risk meta-analysis

BACKGROUND & AIMS

Whether non-selective β-blockers can prevent decompensation of cirrhosis warrants clarification. Carvedilol might be particularly effective since its intrinsic vasodilatory activity may ameliorate hepatic vascular resistance, a major mechanism of portal hypertension in early cirrhosis. We assessed whether carvedilol may prevent decompensation and improve survival in patients with compensated cirrhosis and clinically significant portal hypertension (CSPH).

METHODS

By systematic review we identified randomized-controlled trials (RCTs) comparing carvedilol vs. control therapy (no-active treatment or endoscopic variceal ligation [EVL]) in patients with cirrhosis and CSPH without previous bleeding. We performed a competing-risk time-to-event meta-analysis using individual patient data (IPD) obtained from principal investigators of RCTs. Only compensated patients were included. Primary outcomes were prevention of decompensation (liver transplantation and death were competing events) and death (liver transplantation was a competing event). Models were adjusted using propensity scores for baseline covariates with the inverse probability of treatment weighting (IPTW) approach.

RESULTS

Among 125 full-text studies evaluated, 4 RCTs were eligible. The 4 provided IPD and were included, comprising 352 patients with compensated cirrhosis, 181 treated with carvedilol and 171 controls (79 received EVL and 92 placebo). Baseline characteristics were similar between groups. Standardized differences were <10% by IPTW. The risk of developing decompensation of cirrhosis was lower with carvedilol than in controls (subdistribution hazard ratio [SHR] 0.506; 95% CI 0.289-0.887; p = 0.017; I2 = 0.0%, Q-statistic-p = 0.880), mainly due to a reduced risk of ascites (SHR 0.491; 95% CI 0.247-0.974; p = 0.042; I2 = 0.0%, Q-statistic-p = 0.384). The risk of death was also lower with carvedilol (SHR 0.417; 95% CI 0.194-0.896; p = 0.025; I2 = 0.0%, Q-statistic-p = 0.989).

CONCLUSIONS

Long-term carvedilol therapy reduced decompensation of cirrhosis and significantly improved survival in compensated patients with CSPH. This suggests that screening patients with compensated cirrhosis for CSPH to enable the prompt initiation of carvedilol could improve outcomes.

PROSPERO REGISTRATION NUMBER

CRD42019144786.

LAY SUMMARY

The transition from compensated cirrhosis to decompensated cirrhosis is associated with markedly reduced life expectancy. Therefore, preventing decompensation in patients with compensated cirrhosis would be associated with greatly improved patient outcomes. There has been controversy regarding the use of non-selective β-blockers (portal pressure-lowering medications) in patients with cirrhosis and elevated portal blood pressure (portal hypertension). Herein, using a competing-risk meta-analysis to optimize sample size and properly investigate cirrhosis as a multistate disease and outcomes as time-dependent events, we show that carvedilol (a non-selective β-blocker) is associated with a reduced risk of decompensating events and improved survival in patients with cirrhosis and portal hypertension.

A deep learning approach for detecting liver cirrhosis from volatolomic analysis of exhaled breath

Liver disease such as cirrhosis is known to cause changes in the composition of volatile organic compounds (VOC) present in patient breath samples. Previous studies have demonstrated the diagnosis of liver cirrhosis from these breath samples, but studies are limited to a handful of discrete, well-characterized compounds. We utilized VOC profiles from breath samples from 46 individuals, 35 with cirrhosis and 11 healthy controls. A deep-neural network was optimized to discriminate between healthy controls and individuals with cirrhosis. A 1D convolutional neural network (CNN) was accurate in predicting which patients had cirrhosis with an AUC of 0.90 (95% CI: 0.75, 0.99). Shapley Additive Explanations characterized the presence of discrete, observable peaks which were implicated in prediction, and the top peaks (based on the average SHAP profiles on the test dataset) were noted. CNNs demonstrate the ability to predict the presence of cirrhosis based on a full volatolomics profile of patient breath samples. SHAP values indicate the presence of discrete, detectable peaks in the VOC signal.

VariScreen secures the screening of high-risk varices in patients with hepatitis B virus-related cirrhosis beyond Baveno VI criteria

We aimed to validate the performance of the ratio of the platelet count (PLT) to liver stiffness measurement (LSM) in excluding high-risk varices (HRVs) in patients with hepatitis B virus (HBV)-related compensated cirrhosis beyond Baveno VI criteria. A total of 310 patients were assessed. The performances of the PLT:LSM ratio (PLER), PLER adjusted for the international normalized ratio, etiology, age, and sex (PLEASE), and the sequential algorithm for HRV screening (VariScreen) in excluding HRVs were evaluated and compared with those of expanded Baveno VI criteria (LSM &lt;25 kPa and PLT &gt;110×109/L, EB6C); PLT &gt;150×109/L and model for end-stage liver disease score = 6 (P150M6 criterion); PLT &gt;120×109/L and albumin &gt;36 g/L (P120A36 criterion); and albumin-bilirubin (ALBI) grade and PLT score (ALBI-PLT score). Among the enrolled patients, 43 (13.9%) had HRVs. The area under the receiver operating characteristic curve of PLER for predicting HRVs (0.771, 95% confidence interval, 0.720–0.817) was significantly higher than that for PLT and LSM (p &lt; 0.01). PLER was an independent risk factor for HRVs. VariScreen, PLEASE, and PLER could spare 20 (6.5%), 91 (29.4%), and 60 (19.4%) endoscopies, with 0, 3 (3.3%), and 1 (1.7%) HRVs missed, respectively. The EB6C and P120A36 criteria could spare 45 (14.5%) and 36 (11.6%) endoscopies, with 1 (2.2%) and 1 (2.8%) HRVs missed, respectively. The P150M6 criterion and ALBI-PLT score missed 6.8% and 10.3% of HRVs, respectively. We found that PLER performed better than other non-invasive tests. VariScreen secured the screening of HRVs in patients with HBV-related cirrhosis beyond Baveno VI criteria.

Flow Resistance Analysis of Clinically Significant Portal Hypertension in Patients with Liver Cirrhosis

Cirrhosis-induced clinically significant portal hypertension (CSPH) is a fatal disease. Early detection of CSPH is vitally important to reduce the patients' mortality rate. In this study, combined with three-dimensional image construction technology and computational fluid dynamics (CFD), an image-based flow resistance analysis was proposed. The flow resistance analysis was performed for nine cirrhosis patients with CSPH and ten participants without liver diseases, respectively. The results showed that the flow resistance coefficient of the portal vein system in CSPH patients was significantly lower than that in the control group (0.97 ± 0.11 Pa/(mL/s) for CSPH patients; 1.80 ± 0.40 Pa/(mL/s) for the control group; P = 0.028). In contrast, although main portal vein dilation was found in CSPH patients, the cross-sectional area enlargement was not statistically significant (186.01 ± 57.48 mm² for CSPH patients; 166.26 ± 33.74 mm² for the control group; P = 0.39). The research outcomes indicated that the flow resistance analysis was more sensitive than the commonly used vessel size measurement in the detection of CSPH. In summary, we suggest using flow resistance analysis as a supplementary noninvasive method to detect cirrhosis patients with CSPH.