Prediction of the prognosis of liver cirrhosis in Japanese using Cox's proportional hazard model

Models for prediction of mortality from cirrhosis with special reference to artificial neural network: a critical review

Prediction of mortality of patients with cirrhosis of liver, a common and potentially fatal disease, is important for timely listing of patients for liver transplantation. The Child-Pugh scoring system has been widely used for predicting the outcome of liver cirrhosis. The Model for End-Stage Liver Disease (MELD) score has recently become popular for prediction of short-term mortality for organ allocation. A few studies that evaluated artificial neural network (ANN)-based model for prediction of outcome of cirrhosis of liver in terms of mortality have consistently shown it to be superior to Child-Pugh scoring and logistic regression-based models; it is worth noting that MELD score is also derived using the logistic regression model. Due to the inherent ability of neural network-based systems in identifying complex nonlinear interactions, ANN-based models are expected to perform better than most linear models, such as regression-based models. More studies are needed on ANN-based models for prediction of mortality of patients with cirrhosis of liver and its value in prioritization of organ allocation for treatment of patients with cirrhosis of liver.

Different concentrations of I-123 MIBG and In-111 pentetreotide in the two main liver lobes in children: persisting regional functional differences after birth?

PURPOSE

At examinations in children with I-123 metaiodobenzylguanidine or with In-111 pentetreotide using SPECT, we have observed a different distribution of the radiopharmaceuticals between the left and right main liver lobes. This phenomenon was studied in retrospect from clinical examinations.

PATIENTS AND METHODS

Seventeen children (mean age, 51 months; range, 11-150 months) with neuroblastoma or ganglioneuroma examined with both radiopharmaceuticals within 1 week using SPECT were assessed. There was no history of liver disease and all liver lobes showed uniform activity distribution. Simultaneous radiologic examinations were all normal with regard to the liver. No child with a pathologic liver chemistry test was included. The activity ratios between the left and right main liver lobes were calculated from transverse tomographic sections.

RESULTS

The mean left:right lobar activity ratio for I-123 metaiodobenzylguanidine was 1.26+/-0.12 (null hypothesis=1.00; P<0.001) and for In-111 pentetreotide 0.88+/-0.06 (null hypothesis=1.00; P<0.001). There was no age-dependent distribution of the tracers. The correlation between the tracer uptake of the different liver lobes was very weak.

CONCLUSION

A functional difference between the 2 main liver lobes in utero is believed to reflect differences of the vascular supply. The current findings indicate a persisting functional heterogeneity of the liver after birth not caused by perfusion differences. A relatively higher uptake of I-123 MIBG and a lower uptake of In-111 pentetreotide of the left liver lobe are normal findings.

Different concentrations of various radiopharmaceuticals in the two main liver lobes: a preliminary study in clinical patients

BACKGROUND

At clinical scintigraphic examinations of the abdomen using single photon emission computed tomography (SPECT), we have observed a different distribution between the left and right main liver lobes of various radiopharmaceuticals. This was studied retrospectively in clinical patients.

METHODS

Examinations with [123I]-metaiodobenzylguanidine MIBG; (n=19), a 99mTc-labelled monoclonal antibody against granulocytes (n=18), and 111In-pentetreotide (n=26) were assessed. There was no known history of, or risk factor for liver disease, and all lobes showed a uniform activity distribution. Twenty healthy volunteers underwent consecutive examinations with 99mTc-dimethyliminodiacetic acid (HIDA). The activity ratios between the left and right main liver lobes were calculated from the transverse tomographic (SPECT) sections.

RESULTS

The left: right lobar activity ratio for [123I]-MIBG was (mean+/-SD) 1.25+/-0.21 (null hypothesis=1.00; P<0.001); for the antibody, acquisition after 3-5 h was 0.98+/-0.06 (NS) and after 20-24 h, 0.99+/-0.11 (NS); for 111In-pentetreotide, 0.90+/-0.09 (P<0.001); for 99mTc-HIDA, immediate acquisition, 0.68+/-0.12 (P<0.001) and acquisition at 7 min, 0.66+/-0.12 (P<0.001).

CONCLUSIONS

The differences in tracer uptake between the liver lobes cannot be caused only by differences in blood flow. One explanation of the higher uptake of [123I]-MIBG by the left lobe may be a greater presence of catecholamines and a higher sympathetic nerve density in this liver portion. Consequently, there may be a functional difference between the two main liver lobes.

High relative fat-free mass is important for maintaining serum albumin levels in patients with compensated liver cirrhosis

AIM: In patients with liver cirrhosis, hypoalbuminemia causes edema and ascites, and a reduction in the quality of life. Since musculature is catabolized to supply amino acids for albumin synthesis in malnutritional cirrhotic patients, muscular volume is hypothesized to play an important role in albumin production. Therefore, we investigated the correlation between serum albumin levels and the fat-free mass (FFM) in cirrhotic patients.

METHODS: Fifty-seven patients (26 males and 31 females) with compensated liver cirrhosis were evaluated. Patients with edema or ascites were excluded from the study. Healthy volunteers (n = 104; 48 males and 56 females) were also evaluated as controls. FFM was measured using 5-500 kHz multifrequency bioelectric impedance analysis. To minimize the difference in FFM distribution between males and females, we introduced a new marker, relative FFM (rFFM), which represents the ratio of FFM in a patient relative to that in a volunteer of the same height. Following FFM measurement, the serum albumin levels of patients were assayed monthly.

RESULTS: In patients with active cirrhosis (alanine aminotransaminase [ALT] >50 U/L), both albumin (the difference between maximum and minimum levels) and the standard deviation of albumin levels (SD-albumin) during the observation period showed a significant correlation with rFFM. Multiple linear regression analysis using variables such as rFFM, platelet number, and serum cholesterol levels, choline esterase, albumin, bilirubin, and ALT revealed that rFFM and ALT were significant and independent factors that influenced albumin or SD-albumin in cirrhotic patients.

CONCLUSION: Our results indicate that cirrhotic patients with high rFFM showed less of a decrease in albumin levels, and that the muscle volume is one of the most important factors for maintaining serum albumins level in active cirrhosis. Exercise and protein-rich nutrition at the early stage of liver cirrhosis may be advisable for maintaining or increasing muscular volume.

Development and validation of a model to diagnose cirrhosis in patients with hepatitis C

OBJECTIVE

Although noninvasive markers predictive of cirrhosis in patients with chronic hepatitis C have been examined, none has proved sufficiently accurate for clinical use. The aim of this study was to develop an accurate model that can be easily used by clinicians to predict the probability of cirrhosis in hepatitis C patients from readily available clinical and laboratory information.

METHODS

We identified 264 consecutive patients with established chronic hepatitis C infection and extracted multiple physical examination and biochemical variables (recorded before liver biopsy). Similar data were extracted from charts at another hospital.

RESULTS

Logistic regression identified the following independent predictors of cirrhosis: platelet count < or = 140,000/ mm3, spider nevi, AST > 40 IU/L, and male gender. Male and female patients with normal values for platelet count and AST and no spider nevi had low probabilities of cirrhosis: 1.8% (95% CI = 0.4-7) and 0.03% (95% CI = 0.003-0.04), respectively. Male patients with abnormal values on all three other predictors had a probability of cirrhosis of 99.8% (95% CI = 98.7-100). Over 48% of study patients had a low (< or = 1.8%) or a very high (> or = 99.8%) predicted probability of cirrhosis. The model had area under the receiver operating characteristic curve of 0.938 (95% CI = 0.91-0.97) and 93.4% in an internal validation. The model accurately distinguished patients with and without cirrhosis (area under the receiver operating characteristic curve = 93.3%) in 102 hepatitis C patients from another hospital.

CONCLUSIONS

In patients with hepatitis C, four readily available variables together predict cirrhosis accurately. Successful validation in hepatitis C patients at another hospital with lower prevalence of cirrhosis suggests this model's potential for broad applicability.

Long-term prognosis and prognostic factors of liver cirrhosis in the 1980s

The prognosis of 174 patients with cirrhosis during the 1980s (1981-89) was analysed. The estimated survival rates were 87.3% in 3 years and 68.5% in 5 years. During the follow-up period, 58 patients died: 20 of hepatocellular carcinoma (37.7%); 11 of hepatic failure (20.8%); eight of gastrointestinal bleeding (15.1%); and 14 of other causes (26.4%). Multivariate analysis revealed that serum albumin, indocyanine green retention rate at 15 min and white blood cell count were significantly associated with prognosis. The results were also compared to our previous study covering the 1970s (1971-80). The estimated survival rate was significantly improved compared to that during the 1970s (54.3% in 5 years, P < 0.001). In the 1980s, hepatic failure mortality significantly decreased (P < 0.01), and non-liver-related mortality significantly increased (P < 0.05). In summary, the prognosis of cirrhosis has improved in recent years, and changes of death cause and prognostic factors were observed. It was concluded that to evaluate the severity and prognosis of cirrhosis, new indices and appropriate classification were necessary.