Another formula to determine the prognosis of patients with acute liver failure

Stratified alpha-fetoprotein pattern accurately predicts mortality in patients with acute-on-chronic hepatitis B liver failure

BACKGROUND

Alpha-fetoprotein (AFP) has been shown to predict the prognosis of liver disease in several studies. This study aimed to evaluate the prognostic value of stratified AFP in patients with acute-on-chronic hepatitis B liver failure (ACHBLF).

METHODS

A total of 192 patients were included and AFP were categorized into quartiles. The prognostic value was determined for overall survival (OS) and assessed by Kaplan-Meier analysis. Univariate and multivariate Cox proportional hazard regression analyses studied the association of all independent parameters with disease prognosis.

RESULTS

The optimal cut-off points of AFP were: (Q1) 252.3-4800.0 ng/ml, (Q2) 76.0-252.2 ng/ml, (Q3) 18.6-75.9 ng/ml, and (Q4) 0.7-18.5 ng/ml. Based on the Kaplan-Meier analysis of the OS, each AFP quartile revealed a progressively worse OS and apparent separation (log-rank P = 0.006). The second-highest quartiles of AFP (Q2) always demonstrated an extremely favorable short-term survival. Combining the lowest AFP quartiles with a serum sodium < 131mmol/L or an INR ≥ 3.3 showed a poor outcome (90-days survival of 25.0% and 11.9% respectively).

CONCLUSIONS

Stratified AFP could strengthen the predictive power for short-term survival of patients with ACHBLF. Combining AFP quartiles with low serum sodium and high INR may better predict poor outcome in ACHBLF patients.

Prognostic nomogram for acute-on-chronic hepatitis B liver failure

Background & Aims

To establish an effective prognostic nomogram for acute-on-chronic hepatitis B liver failure (ACHBLF).

Materials and Methods

The nomogram was based on clinical data of 203 ACHBLF patients who admitted to the First Affiliated Hospital of Fujian Medical University from 2009 to 2014. The area under the receiver-operating characteristic curve (AUC) and calibration curve were carried out to verify the predictive accuracy ability of the nomogram. The result was validated in internal and external validation cohorts. Kaplan-Meier survival curve was used in survival analysis.

Results

We developed a new prognostic nomogram to predict 3-month mortality based on risk factors selected by multivariate analysis. This nomogram consisted three independent factors: age, liver to abdominal area ratio (LAAR) and model for end-stage liver disease (MELD) score. The AUC of this nomogram for survival prediction was 0.877 (95% CI 0.831–0.923), which was higher than that of MELD score, MELD-Na and Child-Turcotte-Pugh (CTP). Good agreement of calibration plot for the probability of survival at 3-month was shown between the prediction by nomogram and actual observation. These results were supported by internal and external validation studies.

Conclusions

The ACHBLF nomogram could predict the short-term survival for ACHBLF patients.

Alpha-fetoprotein: A biomarker for the recruitment of progenitor cells in the liver in patients with acute liver injury or failure

AIM

The optimal conditions for hepatocyte proliferation should be clarified in an attempt to improve the impaired liver regeneration observed in patients with acute liver failure (ALF). In order to evaluate the significance of the serum α-fetoprotein (AFP). level and prothrombin time international normalized ratio (PT-INR) as possible biomarkers of the proliferation of liver stem/progenitor cells (LPC) and mature hepatocytes (MH), respectively, we focused on donors of living donor liver transplantation (LDLT) and patients with acute liver injury (ALI), including ALF.

METHODS

Seventy-three patients with ALI/ALF and 11 donors for LDLT were evaluated. LPC induction was histologically evaluated using cytokeratin (CK)-7 staining in 45 ALI/ALF patients.

RESULTS

The AFP level was not apparently elevated during the observation period in any of the LDLT donors, whereas the serum AFP levels were substantially increased in the patients with ALI/ALF and significantly correlated with the number of CK-7 positive LPC in the liver, except for very severe damaged liver. All patients exhibiting an early peak in the AFP level prior to PT-INR elevation died.

CONCLUSION

The serum AFP level may reflect the induction of LPC in ALI/ALF patients. The substantial and persistent induction of LPC until sufficient regeneration of MH may be needed for a recovery from ALF. We herein demonstrate that the serum AFP level may be a serum marker of LPC in patients with ALI/ALF. A comparison of the serial changes in the AFP levels and PT-INR in our study patients showed impaired proliferation of LPC and delayed recovery of MH in the patients who died.

Acute liver failure: A curable disease by 2024?

Over the last three decades acute liver failure (ALF) has been transformed from a rare and poorly understood condition with a near universally fatal outcome, to one with a well characterized phenotype and disease course. Complex critical care protocols are now applied and emergency liver transplantation (ELT) is an established treatment option. These improvements in care are such that the majority of patients may now be expected to survive (Fig. 1). Key features of the condition have changed dramatically over time, with a remarkable fall in the incidence of cerebral edema and intracranial hypertension, a much feared complication. In this review, we summarize the current understanding of key aspects of the classification, pathophysiology and management of ALF, and discuss the foreseeable challenges that will need to be addressed for further improvements to be achieved.

The liver to abdominal area ratio (LAAR): a novel imaging score for prognostication in cirrhosis

BACKGROUND

Anecdotally, liver size is important in determining prognosis in patients with end-stage liver disease (ESLD).

AIMS

To assess if a ratio of liver area and abdominal area on cross-sectional imaging could accurately predict mortality in ESLD.

METHODS

A retrospective-prospective cohort study was performed on patients with ESLD in a training set. The censor point used was date of patient death or liver transplant (LT). The liver to abdominal area ratio (LAAR) was calculated using the formula {LAAR = [liver area (cm(2))/abdominal area (cm(2))] × 100}. A validation set was collected from a different institution.

RESULTS

Three hundred and sixteen patients were identified. Complete imaging and survival data were available in 158 subjects, 100 male (63%). The LAAR score detected progression to death/LT in our cohort (P < 0.003). Its prognostic accuracy at 90, 360 and 720 days, using the optimal cut-off (32.1), from baseline CT date to death/LT using the log-rank test was P = 0.28, P = 0.06 (OR 1.347, 95% CI 0.94-1.94) and P < 0.0001 (OR 1.89, 95% CI 1.25-2.85) respectively. On multivariate analysis, LAAR (P = 0.008), MELD (P = 0.004) and MELD-Na (P = 0.03) were independently associated with the primary study outcome measurement at 720 days. The validation set of 52 patients confirmed the utility of the LAAR to determine risk of death or need for LT, AUROC 0.89 (0.78-0.97), and P < 0.0001.

CONCLUSIONS

The liver to abdominal area ratio (LAAR) score offers a new paradigm in disease modelling in end-stage liver disease (ESLD) and offers prognostic accuracy at 2 years from computer tomography (CT) imaging.

Serum sodium based modification of the MELD does not improve prediction of outcome in acute liver failure

Background

Acute liver failure (ALF) is a devastating clinical syndrome with a high mortality rate. The MELD score has been implied as a prognostic tool in ALF. Hyponatremia is associated with lethal outcome in ALF. Inclusion of serum sodium (Na) into the MELD score was found to improve its predictive value in cirrhotic patients. Therefore the aim of this study was to determine whether inclusion of serum Na improves the predictive value of MELD in ALF compared to established criteria.

Methods

In a prospective single center study (11/2006–12/2010), we recruited 108 consecutive ALF patients (64% females / 36% males), who met the criteria defined by the “Acute Liver Failure Study Group Germany”. Upon admission, clinical and laboratory data were collected, King’s College Criteria (KCC), Model of End Stage Liver Disease score (MELD), and serum sodium based modifications like the MELD-Na score and the United Kingdom Model of End Stage Liver Disease score (UKELD) were calculated and area under the receiver operating characteristic curve analyses were performed regarding the prediction of spontaneous recovery (SR) or non-spontaneous recovery (NSR; death or transplantation).

Results

Serum bilirubin was of no prognostic value in ALF, and Na also failed to predict NSR in ALF. The classical MELD score was superior to sodium-based modifications and KCC.

Conclusions

We validated the prognostic value of MELD-Na and UKELD in ALF. Classic MELD score calculations performed superior to KCC in the prediction of NSR. Serum Na and Na-based modifications of MELD did not further improve its prognostic value.

Stereology: a novel technique for rapid assessment of liver volume

Background

The purpose of this study was to test the stereology method using several grid sizes for measuring liver volume and to find which grid provides an accurate estimate of liver volume.

Materials and methods

Liver volume was measured by volumetry in 41 sets of liver MRI. MRI was performed before and after different weight-reducing regimens. Grids of 3, 4, 5, and 6 cm were used to measure liver volume on different occasions by stereology. The liver volume and the changes in volume before and after treatment were compared between stereology and volumetry.

Results

There was no significant difference in measurements between stereology methods and volumetry (p > 0.05). The mean differences in liver volume between stereology based on 3-, 4-, 5-, and 6-cm grids and volumetry were 37, 3, 132, and 23 mL, respectively, and the differences in measurement of liver volume change were 21, 2, 19, and 76 mL, respectively. The mean time required for measurement by stereology was 59–190 s.

Conclusion

Stereology employing 3- and 4-cm grids can rapidly provide accurate results for measuring liver volume and changes in liver volume.

Main Messages

• Statistical methods can be used for measuring area/volume in radiology.

• Measuring liver volume by stereology by 4-cm grids can be done in less than two minutes.

• Follow-up of liver volume is highly accurate with stereological methods.

A model to determine 3-month mortality risk in patients with acute-on-chronic hepatitis B liver failure

BACKGROUND & AIMS

Liver failure has high mortality. There are accurate but controversial models to determine mortality of patients with acute-on-chronic hepatitis B liver failure (ACHBLF). We developed a logistic regression model (LRM) and tested its ability to predict the 3-month mortality of patients with ACHBLF.

METHODS

The LRM was constructed using data from an internal cohort of 242 consecutive patients with ACHBLF and was tested on an external cohort of 210 patients with the same conditions. The receiver operating characteristic curves were calculated for the LRM, model of end-stage liver disease (MELD), Child-Pugh score (CPS), and a previously reported LRM that has not yet been validated in patients with ACHBLF. Predictions of 3-month mortality obtained with 4 models from the same datasets were compared using areas under receiver operating characteristic curves.

RESULTS

The LRM identified 5 independent factors associated with survival of patients with ACHBLF: hepatic encephalopathy (odds ratio [OR], 2.165; 95% confidence interval [CI], 1.015-4.616), hepatorenal syndrome (OR, 9.767; 95% CI, 4.273-22.328), cirrhosis (OR, 2.339; 95% CI, 1.110-4.930), hepatitis B e antigen (OR, 2.874; 95% CI, 1.376-6.003), and prothrombin activity/age (OR, 0.12; 95% CI, 0.037-0.395). Data from the internal and external cohorts indicated that the LRM had significantly greater prognostic accuracy than the MELD, CPS, or previous LRM.

CONCLUSIONS

We developed a logistic regression model that predicted the 3-month mortality of patients with ACHBLF with greater accuracy than the MELD, CPS, or the previous LRM.

A new treatment strategy for acute liver failure

Acute liver failure (ALF) is a syndrome defined by coagulopathy and encephalopathy and no effective treatments have been established, except for liver transplantation. However, considering the limited supply of donors, we should endeavor to prevent the progression of this syndrome in its early stage to improve the prognosis of patients with ALF. Recently, several authors have reported that over-activation of intrahepatic macrophages plays an important role in the progression of ALF and we have developed a new treatment method, transcatheter arterial steroid injection therapy (TASIT), to suppress macrophage activation. We have now used TASIT for 5 years and have found that TASIT is effective for patients with over-activation of macrophages in the liver but not for those with lesser activation of macrophages. Therefore, to identify the most appropriate patients for TASIT, we tried to categorize patients with ALF or acute liver injury according to markers for the degree of intrahepatic macrophage activation. This approach was helpful to select the appropriate treatment including liver transplantation. We believe that it is essential to analyze disease progression in each patient before selecting the most appropriate treatment.

Cytokeratin 18-based modification of the MELD score improves prediction of spontaneous survival after acute liver injury

BACKGROUND & AIMS

Predicting the probability of patients with acute liver failure (ALF) to recover spontaneously is of major clinical importance. As apoptotic and necrotic cell death are crucial in the pathogenesis of ALF, we determined whether selected cell-death markers predict outcome of patients with ALF and/or discriminate between etiologies.

METHODS

In a prospective study (11/2006-06/2009), 68 ALF patients were recruited consecutively. Data were collected over four weeks or until discharge, death or LTx, including CK18/M65 and M30 ELISA and glutathione S-transferase, subtype alpha. Data at date of admission and at the date of peak levels of M65 were individually analyzed and correlated with the patients' prognosis and etiology.

RESULTS

The predictive sensitivity of total serum M65 for lethal outcome was comparable to the Model for End-Stage Liver Disease (MELD) score at time of admission and at its peak value. In contrast, serum bilirubin levels had no prognostic value, neither at admission nor at later time points. In order to accurately predict the clinical prognosis of ALF patients, we tested a modified MELD score where CK18 M65 substituted bilirubin. This CK18/M65-based MELD score significantly better predicted the prognosis of ALF patients compared with the current MELD score or KCC. A combination of tested parameters contributed to improved discrimination of ALF etiologies by applying cell death and established laboratory parameters.

CONCLUSIONS

The CK18 M65-based MELD score has superior sensitivity and specifically predicts survival of ALF patients. Further prospective clinical studies could validate its potential role to predict requirement of LTx in ALF patients.

Fulminant hepatic failure: when to transplant

Fulminant hepatic failure is a life-threatening condition that can lead to rapid deterioration and death if timely treatment is not instituted. Many patients recover with supportive care. Patients with deteriorating signs and laboratory parameters require prompt assessment and listing for liver transplantation. Outcome following transplantation is a function of severity of illness before transplantation, timeliness of liver transplantation and graft quality and function. With appropriate immunosuppression and close follow-up most patients can lead near normal lives following liver transplantation.