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Dongelmans E, Erler N, Adam R, Nadalin S, Karam V, Yilmaz S, Kelly C, Pirenne J, Acarli K, Allison M, Hakeem A, Dhakshinamoorthy V, Fedaruk D, Rummo O, Kilic M, Nordin A, Fischer L, Parente A, Mirza D, Bennet W, Tokat Y, Faitot F, Antonelli BB, Berlakovich G, Patch D, Berrevoet F, Ribnikar M, Gerster T, Savier E, Gruttadauria S, Ericzon BG, Valdivieso A, Cuervas-Mons V, Perez Saborido B, Croner RS, De Carlis L, Magini G, Rossi R, Popescu I, Razvan L, Schneeberger S, Blokzijl H, Llado L, Gomez Bravo MA, Duvoux C, Mezjlík V, Oniscu GC, Pearson K, Dayangac M, Lucidi V, Detry O, Rotellar F, den Hoed C, Polak WG, Darwish Murad S. Recent outcomes of liver transplantation for Budd-Chiari syndrome: A study of the European Liver Transplant Registry (ELTR) and affiliated centers. Hepatology 2024; 80:136-151. [PMID: 38358658 DOI: 10.1097/hep.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/06/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND AIMS Management of Budd-Chiari syndrome (BCS) has improved over the last decades. The main aim was to evaluate the contemporary post-liver transplant (post-LT) outcomes in Europe. APPROACH AND RESULTS Data from all patients who underwent transplantation from 1976 to 2020 was obtained from the European Liver Transplant Registry (ELTR). Patients < 16 years, with secondary BCS or HCC were excluded. Patient survival (PS) and graft survival (GS) before and after 2000 were compared. Multivariate Cox regression analysis identified predictors of PS and GS after 2000. Supplemental data was requested from all ELTR-affiliated centers and received from 44. In all, 808 patients underwent transplantation between 2000 and 2020. One-, 5- and 10-year PS was 84%, 77%, and 68%, and GS was 79%, 70%, and 62%, respectively. Both significantly improved compared to outcomes before 2000 ( p < 0.001). Median follow-up was 50 months and retransplantation rate was 12%. Recipient age (aHR:1.04,95%CI:1.02-1.06) and MELD score (aHR:1.04,95%CI:1.01-1.06), especially above 30, were associated with worse PS, while male sex had better outcomes (aHR:0.63,95%CI:0.41-0.96). Donor age was associated with worse PS (aHR:1.01,95%CI:1.00-1.03) and GS (aHR:1.02,95%CI:1.01-1.03). In 353 patients (44%) with supplemental data, 33% had myeloproliferative neoplasm, 20% underwent TIPS pre-LT, and 85% used anticoagulation post-LT. Post-LT anticoagulation was associated with improved PS (aHR:0.29,95%CI:0.16-0.54) and GS (aHR:0.48,95%CI:0.29-0.81). Hepatic artery thrombosis and portal vein thrombosis (PVT) occurred in 9% and 7%, while recurrent BCS was rare (3%). CONCLUSIONS LT for BCS results in excellent patient- and graft-survival. Older recipient or donor age and higher MELD are associated with poorer outcomes, while long-term anticoagulation improves both patient and graft outcomes.
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Affiliation(s)
- Edo Dongelmans
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nicole Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rene Adam
- Department of Hepato-Biliary Surgery, Cancer and Transplantation Unit, Hospital Paul Brousse, Villejuif, France
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, Universitätsklinik Tübingen, Tubingen, Germany
| | - Vincent Karam
- Department of Hepato-Biliary Surgery, Cancer and Transplantation Unit, Hospital Paul Brousse, Villejuif, France
| | - Sezai Yilmaz
- Department of Surgery, Liver Transplant Institute, Turgut Özal Medical Center, Malatya, Turkey
| | - Claire Kelly
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, Universitaire Ziekenhuizen Leuven, Belgium
| | - Koray Acarli
- Department of Liver and Biliary Tract Surgery, Memorial Hospital, Istanbul, Turkey
| | - Michael Allison
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge NIHR Biomedical Research Center, Cambridge, UK
| | - Abdul Hakeem
- Department of HPB Surgery and Liver Transplantation, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Dzmitry Fedaruk
- Department of Transplantation, Minsk Scientific and Practical Center for Surgery, Transplantology and Hepatology, Minsk, Belarus
| | - Oleg Rummo
- Department of Transplantation, Minsk Scientific and Practical Center for Surgery, Transplantology and Hepatology, Minsk, Belarus
| | - Murat Kilic
- Department of Surgery, Kent Hospital, Izmir, Turkey
| | - Arno Nordin
- Transplantation and Liver Surgery Unit, Helsinki University Hospital, Helsinki, Finland
| | - Lutz Fischer
- Department of Surgery, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Darius Mirza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - William Bennet
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Yaman Tokat
- Department of General Surgery, International Liver Center and Acibadem Health Care Hospitals, Istanbul, Turkey
| | - Francois Faitot
- Department of HPB Surgery and Transplantation, C.H.R.U. de Strasbourg, Strasbourg, France
| | - Barbara B Antonelli
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriela Berlakovich
- Department of Transplantation Surgery, Medical University of Vienna, Wien, Austria
| | - David Patch
- Department of Hepatology and Liver Transplantation, Royal Free Hospital, London, UK
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, University Hospital Gent, Ghent, Belgium
| | - Marija Ribnikar
- Department of Gastroenterology, University Medical Center Lubljana, Ljubljana, Slovenia
| | - Theophile Gerster
- Department of Gastroenterology and Hepatology, C.H.U. de Grenoble, Grenoble, France
| | - Eric Savier
- Department of Digestive Surgery and Liver Transplantation, Pitie Salpetriere university hospital, Sorbonne University, Paris, France
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
- Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - Bo-Göran Ericzon
- Department of Transplantation Surgery, Karolinska University Hospital, Huddinge, Sweden
| | - Andrés Valdivieso
- Department of HBP Surgery and Liver Transplantation, Cruces University hospital, Bilbao, Spain
| | | | - Baltasar Perez Saborido
- Department of General and Digestive Surgery, Hospital Universitario "Rio Hortega", Valladolid, Spain
| | - Roland S Croner
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, Germany
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, University of Milano-Bicocca, Milan, Italy
| | - Giulia Magini
- Department of Surgery, Hôpital Universitaire de Genève, Geneve, Switzerland
| | - Roberta Rossi
- Department of Gastroenterology and Transplantation, Università Politecnica delle Marche, Ancona, Italy
| | - Irinel Popescu
- Department of Surgery, University of Medicine "Carol Davila", Bucharest, Romania
| | - Laze Razvan
- Department of Surgery, University of Medicine "Carol Davila", Bucharest, Romania
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, University Hospital, Innsbruck, Austria
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Laura Llado
- Department of Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Christophe Duvoux
- Department of Medical Liver Transplant Unit and Liver, Hôpital Henri Mondor, Creteil, France
| | - Vladimír Mezjlík
- Department of Transplantation, Center of cardiovascular surgery and transplantations, Brno, Czech Republic
| | - Gabriel C Oniscu
- Edinburgh Transplant Center, Royal Infirmary of Edinburgh, Edinburg, UK
| | - Kelsey Pearson
- Edinburgh Transplant Center, Royal Infirmary of Edinburgh, Edinburg, UK
| | - Murat Dayangac
- Center for Organ Transplantation, Medipol University Hospital, Istanbul, Turkey
| | - Valerio Lucidi
- Department of abdominal surgery, Unit of Hepato-biliary surgery and Liver Transplantation, Hôpital Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, Liege, Belgium
| | - Fernando Rotellar
- Department of General and Digestive Surgery, Clinica Universitaria de Navarra, Pamplona, Spain
| | - Caroline den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Lupasco I, Dumbrava VT. Diagnosis and therapy of Budd Chiari syndrome. Med Pharm Rep 2021; 94:S68-S71. [PMID: 34527916 DOI: 10.15386/mpr-2235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Budd-Chiari syndrome is described as a disorder characterized by the obstruction of hepatic venous outflow. The first description of the syndrome was done by George Budd in 1846. The etiology of the disease is multifactorial and requires differential diagnosing. The prognostic evaluation of patients with liver outflow obstruction differentiates special groups for further treatment procedures. The stepwise approach of Budd-Chiari syndrome allows the finding of the right technique on an individual basis for every patient.
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Affiliation(s)
- Iulianna Lupasco
- Research Laboratory of Gastroenetrology, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
| | - Vlada-Tatiana Dumbrava
- Research Laboratory of Gastroenetrology, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
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A Scoring Model to Predict In-Hospital Mortality in Patients With Budd-Chiari Syndrome. Am J Gastroenterol 2021; 116:1905-1912. [PMID: 33900212 DOI: 10.14309/ajg.0000000000001273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/18/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION A model that can predict short-term mortality in patients with the Budd-Chiari syndrome (BCS) with a high degree of accuracy is currently lacking. The primary objective of our study was to develop an easy-to-use in-hospital mortality prediction model in patients with BCS using easily available clinical variables. METHODS Data were extracted from the National Inpatient Sample to identify all adult patients with a listed diagnosis of BCS from 2008 to 2017 using ICD-9 or ICD-10 codes. After identifying independent risk factors of in-hospital mortality, we developed a prediction model using logistic regression analysis. The model was built and validated in a training and a validation data set, respectively. Using the model, we risk stratified patients into low-, intermediate-, and high-risk groups. RESULTS Between 2008 and 2017, we identified a total of 5,306 (weighted sample size 26,110) discharge diagnosis of patients with BCS, with an overall in-hospital mortality of 7.14%. The independent risk factors that predicted mortality were age of 50 years or older, ascites, sepsis, acute respiratory failure, acute liver failure, hepatorenal syndrome, and cancers. The mortality prediction model that incorporated these risk factors had an area under the receiver operating characteristic curve of 0.87 (95% CI 0.85-0.95) for the training data and 0.89 (95% CI 0.86-0.92) for the validation data. Patients with low-, intermediate-, and high-risk scores had a predicted in-patient mortality of 4%, 30%, and 66%, respectively. DISCUSSION Using a national administrative database, we developed a reliable in-patient mortality prediction model with an excellent accuracy. The model was able to risk stratify patients into low-, intermediate-, and high-risk groups.
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Shukla A, Shreshtha A, Mukund A, Bihari C, Eapen CE, Han G, Deshmukh H, Cua IHY, Lesmana CRA, Al Meshtab M, Kage M, Chaiteeraki R, Treeprasertsuk S, Giri S, Punamiya S, Paradis V, Qi X, Sugawara Y, Abbas Z, Sarin SK. Budd-Chiari syndrome: consensus guidance of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 2021; 15:531-567. [PMID: 34240318 DOI: 10.1007/s12072-021-10189-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/11/2021] [Indexed: 02/07/2023]
Abstract
Budd Chiari syndrome (BCS) is a diverse disease with regard to the site of obstruction, the predisposing thrombophilic disorders and clinical presentation across the Asia-Pacific region. The hepatic vein ostial stenosis and short segment thrombosis are common in some parts of Asia-Pacific region, while membranous obstruction of the vena cava is common in some and complete thrombosis of hepatic veins in others. Prevalence of myeloproliferative neoplasms and other thrombophilic disorders in BCS varies from region to region and with different sites of obstruction. This heterogeneity also raises several issues and dilemmas in evaluation and approach to management of a patient with BCS. The opportunity to recanalize hepatic vein in patients with hepatic vein ostial stenosis or inferior vena cava stenting or pasty among those membranous obstruction of the vena cava is a unique opportunity in the Asia-Pacific region to restore hepatic outflow closely mimicking physiology. In order to address these issues arising out of the diversity as well as the unique features in the region, the Asia Pacific Association for Study of Liver has formulated these guidelines for clinicians.
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Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India.
| | | | - Amar Mukund
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - C E Eapen
- Christian Medical College, Vellore, India
| | - Guohong Han
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Hemant Deshmukh
- Dean and Head of Radiology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Ian Homer Y Cua
- Institute of Digestive and Liver Diseases, St Lukes Medical Center, Global City, Philippines
| | - Cosmas Rinaldi Adithya Lesmana
- Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
| | - Mamun Al Meshtab
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
- Center for Innovative Cancer Therapy, Kurume University Research, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Masayoshi Kage
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Roongruedee Chaiteeraki
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sombat Treeprasertsuk
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suprabhat Giri
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Sundeep Punamiya
- Vascular and Interventional Radiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valerie Paradis
- Dpt dAnatomie Pathologique, Hôpital Beaujon, 100 bd du Gal Leclerc, Clichy, 92110, France
| | - Xingshun Qi
- General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, China
| | - Yasuhiko Sugawara
- Department of Transplantation and Pediatric Surgery, Kumamoto University, Kumamoto, Japan
| | - Zaigham Abbas
- Department of Hepatogastroenterology, Dr. Ziauddin University Hospital Clifton, Karachi, Pakistan
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Thrombocytopenia and Hemostatic Changes in Acute and Chronic Liver Disease: Pathophysiology, Clinical and Laboratory Features, and Management. J Clin Med 2021; 10:jcm10071530. [PMID: 33917431 PMCID: PMC8038677 DOI: 10.3390/jcm10071530] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
Thrombocytopenia, defined as a platelet count <150,000/μL, is the most common complication of advanced liver disease or cirrhosis with an incidence of up to 75%. A decrease in platelet count can be the first presenting sign and tends to be proportionally related to the severity of hepatic failure. The pathophysiology of thrombocytopenia in liver disease is multifactorial, including (i) splenomegaly and subsequently increased splenic sequestration of circulating platelets, (ii) reduced hepatic synthesis of thrombopoietin with missing stimulation both of megakaryocytopoiesis and thrombocytopoiesis, resulting in diminished platelet production and release from the bone marrow, and (iii) increased platelet destruction or consumption. Among these pathologies, the decrease in thrombopoietin synthesis has been identified as a central mechanism. Two newly licensed oral thrombopoietin mimetics/receptor agonists, avatrombopag and lusutrombopag, are now available for targeted treatment of thrombocytopenia in patients with advanced liver disease, who are undergoing invasive procedures. This review summarizes recent advances in the understanding of defective but at low level rebalanced hemostasis in stable cirrhosis, discusses clinical consequences and persistent controversial issues related to the inherent bleeding risk, and is focused on a risk-adapted management of thrombocytopenia in patients with chronic liver disease, including a restrictive transfusion regimen.
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Thuluvath PJ, Alukal JJ, Zhang T. Acute liver failure in Budd-Chiari syndrome and a model to predict mortality. Hepatol Int 2021; 15:146-154. [PMID: 33387301 DOI: 10.1007/s12072-020-10115-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Acute liver failure (ALF) occurs in approximately 1-2% of patients with Budd-Chiari syndrome (BCS). The primary objective of our study was to study the outcome of patients with BCS-ALF using the National Inpatient Sample (NIS) database and develop a mortality prediction model. DESIGN We identified all adult patients with BCS, with and without ALF, using ICD-9 or ICD-10. Using clinical variables, we identified risk factors for in-hospital mortality and developed a prediction model using logistic regression analysis. The model was built and validated in a training and validation datasets. RESULTS Between 2008 and 2017, of the estimated total of 5,306 (weighted sample size 26,110) BCS discharges, 325 (6.1%) patients (weighted sample size 1,598) presented with ALF. Of 325 BCS-ALF patients, 114 (34.7%, weighted n = 554) died and in contrast only 267 of 4,981 (5%, weighted n = 1310) without ALF died during the hospitalization. The independent risk factors that predicted mortality were age 50 years or older, acute respiratory failure, spontaneous bacterial peritonitis, sepsis and cancers. The prediction model that incorporated these risk factors had an area under the receiver operating characteristic curve (AUROC) of 0.85 (95% CI 0.80-0.90) for training data and 0.80 (95% CI 0.71-0.89) for validation data. The predicted mortality risk with low (score < 6), intermediate (score 6-16), and high risk (score ≥ 17) scores were 8%, 37% and 71%, respectively. CONCLUSION ALF due to BCS is associated with a very high in-hospital mortality that could be predicted with reasonable accuracy.
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Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD, USA. .,Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Joseph J Alukal
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD, USA
| | - Talan Zhang
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD, USA
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Abstract
Budd-Chiari syndrome (BCS), or hepatic venous outflow obstruction, is a rare cause of liver disease that should not be missed. Variable clinical presentation among patients with BCS necessitates a high index of suspicion to avoid missing this life-threatening diagnosis. BCS is characterized as primary or secondary, depending on etiology of venous obstruction. Most patients with primary BCS have several contributing risk factors leading to a prothrombotic state. A multidisciplinary stepwise approach is integral in treating BCS. Lifelong anticoagulation is recommended. Long-term monitoring of patients for development of cirrhosis, complications of portal hypertension, hepatocellular carcinoma, and progression of underlying diseases is important.
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Hernández-Gea V, De Gottardi A, Leebeek FWG, Rautou PE, Salem R, Garcia-Pagan JC. Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis. J Hepatol 2019; 71:175-199. [PMID: 30822449 DOI: 10.1016/j.jhep.2019.02.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.
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Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain
| | - Andrea De Gottardi
- Hepatology, University Clinic of Visceral Medicine and Surgery, Inselspital, and Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France; Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain.
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Abstract
AIM Outcomes of endovascular intervention in Budd-Chiari syndrome (BCS) have been reported with varied results. Clinical outcomes of endovascular interventions in BCS and role of various prognostic scores were critically evaluated in this study. METHODS This study retrospectively analyzed consecutive patients of BCS who underwent endovascular intervention between January 2007 and May 2016 at our center. Technical, clinical successes and complications were documented. The role of the prognostic scores such as Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), Rotterdam index, and original Clichy score in predicting mortality, clinical success, and need for re-interventions were also assessed. RESULTS A total of 88 patients were analyzed. The median follow up was 12 months (range 1-96 months). Thirteen (14.8%) patients had combined inferior vena cava (IVC) and hepatic vein (HV) obstruction; HV obstruction in 33 (37.5%) and inferior vena cava IVC obstruction in 42 (47.7%) patients. The following interventions were done: IVC angioplasty alone (n = 11), IVC angioplasty with stenting (n = 36), HV angioplasty with stenting (n = 26), combined HV and IVC stent (n = 2), and direct intrahepatic porto-systemic shunt (DIPS) (n = 13). Overall technical success was 87/88 (98.86%), and clinical success was 76/88 (86.36%). Immediate complications were noted in 8 patients (10%). The 1-, 2-, 3-, and 4-year stent patency rates were 90.91%, 81.08%, 74.59%, and 70.45%, respectively. Re-interventions were required in 15 (17%). Overall mortality was 6 (6.8%). Apart from MELD >14, none of the other prognostic score could predict mortality, clinical success, and need for re-interventions. CONCLUSION Endovascular interventions play an important role in the management of BCS, in properly selected patients, even if prognostic score is unfavorable.
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Shalimar, Kumar A, Kedia S, Sharma H, Gamanagatti SR, Gulati GS, Nayak B, Thakur B, Acharya SK. Hepatic venous outflow tract obstruction: treatment outcomes and development of a new prognostic score. Aliment Pharmacol Ther 2016; 43:1154-67. [PMID: 27060876 DOI: 10.1111/apt.13604] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 01/29/2016] [Accepted: 03/10/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Results of endovascular interventions in hepatic venous outflow tract obstruction (HVOTO) have been reported from limited studies. Treatment outcomes and prognostic scores need further validation. AIM To evaluate treatment outcomes and prognostic scores for hepatic venous outflow tract obstruction in an Indian population. METHODS Consecutive patients with hepatic venous outflow tract obstruction diagnosed at a tertiary centre were included. Technical success and clinical response after endovascular interventional therapy were documented. Predictors of survival were assessed with Cox-proportional model. A new score was derived from the factors significant on multivariate analysis and compared with Child-Turcotte-Pugh, model for end-stage liver disease (MELD), Rotterdam prognostic index (PI) and Budd-Chiari syndrome-transjugular intrahepatic portosystemic shunt ( BCS-TIPSS) PI. RESULTS Three hundred and thirty-four patients (56.6% males), median age 24 (3-62) years were included. Hepatic vein was the commonest site of block-isolated hepatic vonous block in 48%, combined hepatic venous-inferior vena cava block in 46%. Endovascular interventional therapy was performed in 233/334 (70%) with 90% technical success. Clinical response was complete in 166 (71.2%), partial in 58 (24.9%) and no response in nine (3.9%). Majority of cases with HV block did not require TIPSS and could be treated with angioplasty (with/without stenting). On Cox-proportional multivariate analysis, Child class C and response to intervention were independent predictors of outcome and used to derive the All India Institute of Medical Sciences (AIIMS) hepatic venous outflow tract obstruction score. The 5-year survival was 92% (95% CI, 81-97%) for score ≤3, 79% (95%CI, 63-88%) for score >3 and ≤4, and 39% (95% CI, 21-57%) for score >4. The performance of AIIMS hepatic venous outflow obstruction score was superior to other prognostic indices. CONCLUSIONS Advanced Child class and no response to intervention are associated with poor outcomes. The All India Institute of Medical Sciences hepatic venous outflow tract obstruction score predicts survival better than other prognostic scores.
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Affiliation(s)
- Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - A Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - S Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - H Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - S R Gamanagatti
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - G S Gulati
- Department of Cardiovascular and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - B Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - B Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - S K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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11
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Mansfield AS, Rudek MA, Vulih D, Smith GL, Harris PJ, Ivy SP. The Effect of Hepatic Impairment on Outcomes in Phase I Clinical Trials in Cancer Subjects. Clin Cancer Res 2016; 22:5472-5479. [PMID: 27189163 DOI: 10.1158/1078-0432.ccr-16-0449] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE The NCI Cancer Therapy Evaluation Program sponsors hepatic dysfunction phase I clinical trials (HDCT) and phase 1 clinical trials (P1CT) to determine safe doses and schedules of antineoplastic therapeutics. We sought to compare clinical outcomes between these trial types while stratifying by hepatotoxic agents. EXPERIMENTAL DESIGN Individual subject data were extracted from the records of 51 NCI-sponsored HDCT and P1CT. The NCI's Organ Dysfunction Working Group's hepatic impairment categorization and two drug-induced liver injury (DILI) scales (FDA R ratio and Hy's law) were used to classify subjects. The number of cycles administered and treatment discontinuation reason were also evaluated and compared between groups. RESULTS There were 513 and 1,328 subjects treated on HDCT (n = 9) and P1CT (n = 42), respectively. There were differing patterns of DILI with significant worsening of total bilirubin in subjects on HDCT, and worsening of alanine aminotransferase (ALT) in subjects on P1CT. Cholestatic peak patterns of liver impairment (predominant increases in alkaline phosphatase rather than transaminases) were more frequent in HDCT. Criteria for Hy's law were met by 11 subjects on P1CT, but not by any subjects on HDCT. Disease progression was the most common reason for treatment discontinuation, followed by adverse events at similar frequencies in both HDCT and P1CT. CONCLUSIONS The differential effects on hepatotoxicity suggest that underlying hepatic function may affect susceptibility to and patterns of DILI. The incorporation of additional measures of hepatic function may help identify those at highest risk of hepatotoxicity in future trials because baseline liver tests did not. Clin Cancer Res; 22(22); 5472-9. ©2016 AACR.
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Affiliation(s)
| | - Michelle A Rudek
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Gary L Smith
- Clinical Trials Monitoring Branch, Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - Pamela Jo Harris
- Investigational Drug Branch, Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - S Percy Ivy
- Investigational Drug Branch, Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
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Abstract
Budd-Chiari syndrome (BCS) is a rare and potentially life-threatening disorder characterized by obstruction of the hepatic outflow tract at any level between the junction of the inferior vena cava with the right atrium and the small hepatic veins. In the West, BCS is a rare hepatic manifestation of one or more underlying prothrombotic risk factors. The most common underlying prothrombotic risk factor is a myeloproliferative disorder, although it is now recognized that almost half of patients have multiple underlying prothrombotic risk factors. Clinical manifestations can be diverse, making BCS a possible differential diagnosis of many acute and chronic liver diseases. The index of suspicion should be very low if there is a known underlying prothrombotic risk factor and new onset of liver disease. Doppler ultrasound is sufficient for confirming the diagnosis, although tomographic imaging (computed tomography (CT) or magnetic resonance imaging (MRI)) is often necessary for further treatment and discussion with a multidisciplinary team. Anticoagulation is the cornerstone of the treatment. Despite the use of anticoagulation, the majority of patients need additional (more invasive) treatment strategies. Algorithms consisting of local angioplasty, TIPS and liver transplantation have been proposed, with treatment choice dictated by a lack of response to a less-invasive treatment regimen. The application of these treatment strategies allows for a five-year survival rate of 90%. In the long term the disease course of BCS can sometimes be complicated by recurrence, progression of the underlying myeloproliferative disorder, or development of post-transplant lymphoma in transplant patients.
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Affiliation(s)
| | - Frederik Nevens
- Department of Liver and Biliopancreatic Disorders, University Hospital Gasthuisberg KU Leuven, Leuven, Belgium
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13
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Qi X, Ren W, Wang Y, Guo X, Fan D. Survival and prognostic indicators of Budd-Chiari syndrome: a systematic review of 79 studies. Expert Rev Gastroenterol Hepatol 2015; 9:865-75. [PMID: 25754880 DOI: 10.1586/17474124.2015.1024224] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This paper aimed to systematically review the survival of Budd-Chiari syndrome and to identify the most robust prognostic predictors. Overall, 79 studies were included. According to the treatment modalities, the median 1-, 5- and 10-year survival rate was 93, 83 and 73% after interventional radiological treatment; 81, 75 and 72.5% after surgery other than liver transplantation; 82.5, 70.2 and 66.5% after liver transplantation and 68.1, 44.4% and unavailable after medical therapy alone. According to the publication years, the median 1-, 5- and 10-year survival rate was 68.6, 44.4% and unavailable before 1990; 75.1, 69.5 and 57% during the year 1991-1995; 77, 69.6 and 65.6% during the year 1996-2000; 86.5, 74 and 63.5% during the year 2001-2005 and 90, 82.5 and 72% after 2006. Bilirubin, creatinine and ascites were more frequently identified as significant prognostic factors in univariate analyses. But their statistical significance was less frequently achieved in multivariate analyses.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, 110840, China
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14
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Jalan R, Pavesi M, Saliba F, Amorós A, Fernandez J, Holland-Fischer P, Sawhney R, Mookerjee R, Caraceni P, Moreau R, Ginès P, Durand F, Angeli P, Alessandria C, Laleman W, Trebicka J, Samuel D, Zeuzem S, Gustot T, Gerbes AL, Wendon J, Bernardi M, Arroyo V. The CLIF Consortium Acute Decompensation score (CLIF-C ADs) for prognosis of hospitalised cirrhotic patients without acute-on-chronic liver failure. J Hepatol 2015; 62:831-40. [PMID: 25463539 DOI: 10.1016/j.jhep.2014.11.012] [Citation(s) in RCA: 233] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 10/28/2014] [Accepted: 11/04/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Cirrhotic patients with acute decompensation frequently develop acute-on-chronic liver failure (ACLF), which is associated with high mortality rates. Recently, a specific score for these patients has been developed using the CANONIC study database. The aims of this study were to develop and validate the CLIF-C AD score, a specific prognostic score for hospitalised cirrhotic patients with acute decompensation (AD), but without ACLF, and to compare this with the Child-Pugh, MELD, and MELD-Na scores. METHODS The derivation set included 1016 CANONIC study patients without ACLF. Proportional hazards models considering liver transplantation as a competing risk were used to identify score parameters. Estimated coefficients were used as relative weights to compute the CLIF-C ADs. External validation was performed in 225 cirrhotic AD patients. CLIF-C ADs was also tested for sequential use. RESULTS Age, serum sodium, white-cell count, creatinine and INR were selected as the best predictors of mortality. The C-index for prediction of mortality was better for CLIF-C ADs compared with Child-Pugh, MELD, and MELD-Nas at predicting 3- and 12-month mortality in the derivation, internal validation and the external dataset. CLIF-C ADs improved in its ability to predict 3-month mortality using data from days 2, 3-7, and 8-15 (C-index: 0.72, 0.75, and 0.77 respectively). CONCLUSIONS The new CLIF-C ADs is more accurate than other liver scores in predicting prognosis in hospitalised cirrhotic patients without ACLF. CLIF-C ADs therefore may be used to identify a high-risk cohort for intensive management and a low-risk group that may be discharged early.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Marco Pavesi
- Data Management Center, EASL-CLIF Consortium, Barcelona, Spain
| | | | - Alex Amorós
- Data Management Center, EASL-CLIF Consortium, Barcelona, Spain
| | - Javier Fernandez
- Hospital Clínic, University of Barcelona, IDIBAPS, CIBEReHD, IRSIN, Spain
| | - Peter Holland-Fischer
- Liver Failure Group, Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Rohit Sawhney
- Liver Failure Group, Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Rajeshwar Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | | | | | - Pere Ginès
- Hospital Clínic, University of Barcelona, IDIBAPS, CIBEReHD, IRSIN, Spain.
| | | | | | | | - Wim Laleman
- University Hospital Gasthuisberg, Leuven, Belgium
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15
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Lladó L, Bustamante J. IV Reunión de Consenso de la Sociedad Española de Trasplante Hepático 2012. Excepciones al Model for End-stage Liver Disease en la priorización para trasplante hepático. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:83-91. [DOI: 10.1016/j.gastrohep.2013.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 06/21/2013] [Accepted: 06/30/2013] [Indexed: 02/07/2023]
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17
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MacNicholas R, Olliff S, Elias E, Tripathi D. An update on the diagnosis and management of Budd-Chiari syndrome. Expert Rev Gastroenterol Hepatol 2012; 6:731-44. [PMID: 23237258 DOI: 10.1586/egh.12.56] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Budd-Chiari syndrome is a rare disorder caused by hepatic venous outflow obstruction and resulting hepatic dysfunction. Despite a lack of prospective randomized trials, much progress has been made in its management over the last 20 years. The main goals of treatment are to ameliorate hepatic congestion and prevent further thrombosis. The selective use of anticoagulation, vascular stents, transjugular intrahepatic portosystemic stent-shunt and liver transplant has resulted in a significant increase in survival. The diagnosis, initial management and long-term follow-up of patients with Budd-Chiari syndrome is reviewed. The concept of individualization of treatment and a stepwise approach to invasive procedures is also discussed.
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18
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Francoz C, Belghiti J, Castaing D, Chazouillères O, Duclos-Vallée JC, Duvoux C, Lerut J, Le Treut YP, Moreau R, Mandot A, Pageaux G, Samuel D, Thabut D, Valla D, Durand F. Model for end-stage liver disease exceptions in the context of the French model for end-stage liver disease score-based liver allocation system. Liver Transpl 2011; 17:1137-51. [PMID: 21695771 DOI: 10.1002/lt.22363] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Model for End-Stage Liver Disease (MELD) score-based allocation systems have been adopted by most countries in Europe and North America. Indeed, the MELD score is a robust marker of early mortality for patients with cirrhosis. Except for extreme values, high pretransplant MELD scores do not significantly affect posttransplant survival. The MELD score can be used to optimize the allocation of allografts according to a sickest first policy. Most often, patients with small hepatocellular carcinomas (HCCs) and low MELD scores receive extra points, which allow them appropriate access to transplantation comparable to the access of patients with advanced cirrhosis and high MELD scores. In addition to patients with advanced cirrhosis and HCC, patients with a number of relatively uncommon conditions have low MELD scores and a poor prognosis in the short term without transplantation but derive excellent benefits from transplantation. These conditions, which correspond to the so-called MELD score exceptions, justify the allocation of a specific score for appropriate access to transplantation. Here we report the conclusions of the French consensus meeting. The goals of this meeting were (1) to identify which conditions merit MELD score exceptions, (2) to list the criteria needed for defining each of these conditions, and (3) to define a reasonable time interval for organ allocation for each MELD exception in the general context of organ shortages. MELD exceptions were discussed in an attempt to reconcile the concepts of transparency, equity, justice, and utility.
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Affiliation(s)
- Claire Francoz
- Departments of Hepatology, Beaujon Hospital, Clichy, France.
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Vitale A, Morales RR, Zanus G, Farinati F, Burra P, Angeli P, Frigo AC, Del Poggio P, Rapaccini G, Di Nolfo MA, Benvegnù L, Zoli M, Borzio F, Giannini EG, Caturelli E, Chiaramonte M, Trevisani F, Cillo U. Barcelona Clinic Liver Cancer staging and transplant survival benefit for patients with hepatocellular carcinoma: a multicentre, cohort study. Lancet Oncol 2011; 12:654-62. [PMID: 21684210 DOI: 10.1016/s1470-2045(11)70144-9] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Allocation of deceased-donor livers to patients with chronic liver failure is improved by prioritising patients by 5-year liver transplantation survival benefit. The Barcelona Clinic Liver Cancer (BCLC) staging has been proposed as the standard means to assess for prognosis of patients with hepatocellular carcinoma. We aimed to create a prediction model linking the BCLC stage of patients with hepatocellular carcinoma to their 5-year liver transplant benefit. METHODS A large cohort of consecutive patients with hepatocellular carcinoma (n=1328) from the ITA.LI.CA database (n=2951) were judged as potentially eligible for liver transplantation according to the following criteria: absence of macroscopic vascular invasion or metastases, age 70 years or younger, and absence of relevant extra-hepatic comorbidities. To assess the correlation between BCLC staging and non-liver transplantation survival, we did Cox univariate and multivariate analyses including the following covariates: BCLC stage, year of diagnosis, age, sex, cause of cirrhosis, model for end-stage liver disease score, α-fetoprotein concentrations, and treatment. Liver-transplantation survival benefit for patients was calculated, using Monte Carlo simulation analysis, as the patient's 5-year life expectancy with liver transplantation (estimated by the Metroticket model) minus the 5-year life expectancy without liver transplantation according to BCLC stage. FINDINGS 83 (6%) of 1328 patients had BCLC 0 stage disease, 614 (46%) had BCLC A, 500 (38%) had BCLC B-C, and 131 (10%) had BCLC D. In the Cox non-liver transplantation survival multivariate model, hazard ratios associated with increasing BCLC stages were 1.530 (95% CI 1.107-2.116) for BCLC A versus BCLC 0, 1.572 (1.350-1.830) for BCLC B-C versus BCLC A, and 1.470 (1.164-1.856) for BCLC D versus BCLC B-C. Results of the Monte Carlo simulation analysis confirmed the significant effect of BCLC classification on transplant benefit; in the adjusted model, a median 5-year transplant benefit of 11.19 months (IQR 10.73-11.67) for BCLC 0, 13.49 months (11.51-15.57) for BCLC A, 17.36 months (15.06-19.28) for BCLC B-C, and 28.46 months (26.38-30.34) for BCLC D. INTERPRETATION Liver transplantation could result in survival benefit for patients with hepatocellular carcinoma and advanced liver cirrhosis (BCLC stage D) and in those with intermediate tumours (BCLC stages B-C), regardless of the nodule number-size criteria (ie, Milan criteria), provided that macroscopic vascular invasion and extra-hepatic disease are absent. FUNDING None.
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Affiliation(s)
- Alessandro Vitale
- Unità di Chirurgia Epatobiliare e Trapianto Epatico, Azienda Ospedaliera, Università di Padova, Padova, Italy.
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Montano-Loza AJ, Tandon P, Kneteman N, Bailey R, Bain VG. Rotterdam score predicts early mortality in Budd-Chiari syndrome, and surgical shunting prolongs transplant-free survival. Aliment Pharmacol Ther 2009; 30:1060-9. [PMID: 19723029 DOI: 10.1111/j.1365-2036.2009.04134.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Budd-Chiari syndrome carries significant mortality, but factors predicting this outcome are uncertain. AIM To determine factors associated with 3-month mortality and compare outcomes after surgical shunting or liver transplantation. METHODS From 1985 to 2008, 51 patients with Budd-Chiari syndrome were identified. RESULTS By logistic regression analysis, features associated with higher risk of 3-month mortality were Rotterdam class III, Clichy >6.6, model for end-stage liver disease (MELD) >20 and Child-Pugh C. Rotterdam class III had the best performance to discriminate 3-month mortality with sensitivity of 0.89 and specificity of 0.63, whereas Clichy >6.60 had sensitivity of 0.78 and specificity of 0.69; MELD >20 had sensitivity of 0.78 and specificity of 0.75 and Child-Pugh C had sensitivity of 0.67 and specificity of 0.72. Eighteen patients underwent surgical shunts and 14 received liver transplantation with no significant differences in survival (median survival 10 +/- 3 vs. 8 +/- 2 years; log-rank, P = 0.9). CONCLUSIONS Rotterdam score is the best discrimination index for 3-month mortality in Budd-Chiari syndrome and should be used preferentially to determine treatment urgency. Surgical shunts constitute an important therapeutic modality that may help save liver grafts and prolong transplantation-free survival in a selected group of patients with Budd-Chiari syndrome.
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Development and validation of a comprehensive new hepatobiliary software. Part II: Segmental liver function. Nucl Med Commun 2009; 30:945-55. [PMID: 19855312 DOI: 10.1097/mnm.0b013e32832ed3ea] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was undertaken to develop comprehensive new hepatobiliary software to quantify segmental and lobar liver function and to obtain FDA approval. METHODS Hepatobiliary software written on JAVA platform and loaded on to a PC accepts 99mTc-HIDA dicom image data transferred from a gamma camera. Liver boundary was determined by threshold-based auto edge detection and liver height at right midclavicular (RMCL) line. Geometric mean area of the physiologic right lobe, physiologic left lobe and total liver area were measured. Segmental liver function was determined using the 5th minute frame as the default (100%). RESULTS In 24 control participants, mean (+/-SD) liver height at RMCL was 14.7+/-0.12 cm. Geometric mean area of the physiologic right lobe was 116+/-3 cm2, left lobe 96+/-4 cm2, and total liver area 212+/-3 cm. Right upper lobe (segments 7 and 8) contributed 31+/-0.7%, right lower lobe (segments 5 and 6) 34+/-0.6%, left medial (segments 4A and 4B) 24+/-1%, left lateral (segments 2 and 3) 10+/-2%, and caudate lobe (segment 1) 1+/-0.02% of total liver function. In 23 patients, contrast three-dimensional computerized tomographic volume of the right lobe was 1194+/-419 ml, left lobe 434+/-221 ml, and total liver volume 1628+/-490 ml. Right lobe area was 120+/-30 cm2, left lobe (plus caudate) 88+/-29 cm2 with total liver area of 208+/-51 cm. Right upper lobe (segments 7 and 8) contributed 33+/-10%, right lower lobe (segments 5 and 6) 34+/-7%, left medial (segments 4A and 4B) 23+/-6%, left lateral (segments 2 and 3) 9+/-3%, and caudate lobe (segment 1) 1+/-0.4% of total liver function. There was good correlation of RMCL height, and area of right lobe and total liver with computerized tomographic liver volume. Correlation of percentage volume with percentage function was excellent. CONCLUSION New FDA approved software provides quantitative assessment of segmental, lobar, and total liver size and function from a planar 99mTc-HIDA cholescintigraphy and may enable universal standardization in nuclear hepatology. Quantification may aid surgeons in the determination of the amount of tissue resection during liver surgery.
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Rautou PE, Moucari R, Escolano S, Cazals-Hatem D, Denié C, Chagneau-Derrode C, Charpignon C, Lédinghen VD, Grenouillet-Delacre M, Habersetzer F, Nousbaum JB, Denninger MH, Valla DC, Plessier A. Prognostic indices for Budd-Chiari syndrome: valid for clinical studies but insufficient for individual management. Am J Gastroenterol 2009; 104:1140-6. [PMID: 19337247 DOI: 10.1038/ajg.2009.63] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Several prognostic indices (PIs) have been proposed for Budd-Chiari syndrome (BCS). However, patient characteristics, causal factors, and treatment outcomes have changed since these indices have been elaborated. Validation in a recent patient population and comparison of predictive accuracy between these PIs are needed. METHODS A database of 96 BCS patients diagnosed between 1995 and 2005 was analyzed. Cox survival models were fitted with time to liver transplantation or death, and time to invasive therapy or death, as end points. The prognostic values of known indices (Child-Pugh score, model for end-stage liver disease (MELD), Clichy, Rotterdam BCS index, New Clichy, and BCS-TIPS (transjugular intrahepatic portosystemic shunt)) at diagnosis were assessed in Cox models using the chi-square test, the Kent and O'Quigley measure of dependence, and unrestricted bootstrapping analysis. Areas under receiver operating characteristic curves (AUROCs) were built for both end points and compared. RESULTS All prognostic indices, except BCS-TIPS, were significant predictors of transplant-free and invasive therapy-free survival. However, only 31 and 37% of the variance in transplant-free and invasive therapy-free survival, respectively, were explained by the best performing indices. For transplant-free survival, AUROCs were < 0.70. For invasive therapy-free survival, AUROCs were < 0.80. For both end points, BCS-TIPS PI AUROCs were significantly lower than others. CONCLUSIONS Most PIs are valid for transplant-free survival and invasive therapy-free survival in a population of current BCS patients, and thus can be used for stratification in clinical studies. However, predictive accuracy is insufficient to be used for individual patients.
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Affiliation(s)
- Pierre-Emmanuel Rautou
- Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP and INSERM U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3, Université Paris 7-Denis-Diderot, Clichy, France
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