Model for End-Stage Liver Disease Sodium as a Predictor of Surgical Risk in Cirrhotic Patients With Ascites

Prognostic Nomograms for Hospital Survival and Transplant-Free Survival of Patients with Hepatorenal Syndrome: A Retrospective Cohort Study

Hepatorenal syndrome (HRS) is a life-threatening complication of cirrhosis with a poor prognosis. To develop novel and effective nomograms which could numerically predict both the hospital survival and transplant-free survival of HRS, we retrospectively enrolled a cohort of 149 patients. A backward stepwise method based on the smallest Akaike information criterion value was applied to select the covariates to be included in the Cox proportional hazards models. The Harrell C-index, area under the receiver operating characteristic curve (AUC), Brier score, and Kaplan–Meier curves with the log-rank test were used to assess nomograms. The bootstrapping method with 1000 resamples was performed for internal validation. The nomogram predicting hospital survival included prothrombin activity, HRS clinical pattern, Child–Pugh class, and baseline serum creatinine. The C-index was 0.72 (95% confidence interval (CI), 0.65–0.78), and the adjusted C-index was 0.72 (95% CI, 0.66–0.79). The nomogram predicting transplant-free survival included sex, prothrombin activity, HRS clinical pattern, model for end-stage liver disease–Na score, and peak serum creatinine. The C-index of the nomogram was 0.74 (95% CI, 0.69–0.79), and the adjusted C-index was 0.74 (95% CI, 0.68–0.79). The AUC and Brier score at 15, 30, and 45 days calculated from the hospital survival nomogram and those at 6, 12, and 18 months calculated from the transplant-free survival nomogram revealed good predictive ability. The two models can be used to identify patients at high risk of HRS and promote early intervention treatment.

A model to predict inhospital mortality in patients with cirrhosis, ascites and hyponatremia

BACKGROUND AND OBJECTIVE

Hypervolemic hyponatremia is a late complication of portal hypertension. Hyponatremia is associated with a higher mortality in hospitalized patients. In this study, we evaluated the risk factors for inhospital mortality and developed a mortality prediction model in patients with cirrhosis and hyponatremia.

METHODS

Using the national inpatient sample data for years 2016 and 2017, we identified cirrhotic patients hospitalized with ascites and hyponatremia (n = 9153). We identified independent risk factors of inhospital mortality and developed a prediction model in a training group and assessed its accuracy in a validation group. To enhance the clinical utility, we further stratified patients into low-, intermediate-, and high-risk mortality risk groups using cutoff points selected by decision tree analysis.

RESULTS

The inhospital mortality in our cohort was 10.2% (n = 846). Multivariable analysis showed that age at least 65 years, variceal bleeding, sepsis, coagulopathy, and acute-on-chronic liver failure (ACLF defined as two or more organ failures) were independent risk factors for mortality. The prediction model using these five risk factors had an AUROC of 0.80 [95% confidence interval (CI), 0.78-0.82] for the training data and 0.83 (95% CI, 0.80-0.86) for the validation data. The mortality risks in the low-, intermediate-, and high-risk groups were 4% (95% CI, 3-4), 29% (95% CI, 28-33), and 43% (95% CI, 37-50), respectively.

CONCLUSION

We have developed a clinically meaningful inhospital prognostic model with excellent discrimination that will enable clinicians to risk stratify hospitalized patients with hyponatremia, ascites, and cirrhosis.

The incidence and outcome of postoperative hepatic encephalopathy in patients with cirrhosis

BACKGROUND

Cirrhosis is associated with increased perioperative risks related to hepatic decompensation. However, data are lacking regarding the incidence and outcomes of postoperative hepatic encephalopathy (HE).

OBJECTIVE

To determine the incidence of HE postoperatively, factors associated with its development, and its association with in-hospital mortality.

METHODS

Retrospective cohort study of 583 patients with cirrhosis undergoing non-hepatic surgery over a 10-year period. Outcomes included postoperative HE and in-hospital mortality and were, respectively, evaluated using multi-state modeling and Fine-Gray competing risk regression (with postoperative HE as a time-varying covariate).

RESULTS

Overall, the median Model for End-Stage Liver Disease Sodium was 10, 61.7% had a history of ascites, 49.9% esophageal varices, and 34.6% HE. The most common surgeries including abdominal/non-bowel (33.3%), orthopedic (18.0%), and bowel (12.2%). A total of 42 (7.2%) patients developed HE postoperatively during admission. The cumulative risk of HE was 7.2%, which was most associated with a history of HE, ASA class, postoperative AKI, and postoperative infection. In-hospital mortality occurred in 34 (5.8%) individuals. Only ASA class was independently associated (HR 2.46, 95%CI 1.21-5.02), but there was a trend for postoperative HE (HR 1.71, 95%CI 0.73-3.98).

DISCUSSION

HE is an uncommon but not rare postoperative complication that increases the risk of patient harm. This study implies its development is predictable. Consequently, at-risk patients should have consultation with a hepatologist before undergoing elective surgery.