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Matoba D, Noda T, Kobayashi S, Sasaki K, Iwagami Y, Yamada D, Tomimaru Y, Takahashi H, Doki Y, Eguchi H. Analysis of Short-Term and Long-Term Outcomes of Living Donor Liver Transplantation for Patients with a High Model for End-Stage Liver Disease Score. Transplant Proc 2023:S0041-1345(23)00149-5. [PMID: 37120341 DOI: 10.1016/j.transproceed.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/13/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND The Model of End-Stage Liver Disease (MELD) scoring system can predict short-term survival among patients awaiting liver transplantation and is used to allocate organs prioritizing liver transplantation. Patients with high MELD scores have been reported to have worse early graft dysfunction and survival. However, recent studies have shown that patients with high MELD scores had satisfactory graft survival, although they showed more postoperative complications. In this study, we examined the effect of the MELD score on the short-term and long-term prognosis of living donor liver transplantation (LDLT). METHODS This study included 102 patients who underwent LDLT in our institution between 2005 and 2020. The patients were divided into 3 groups according to MELD score (low MELD group: ≤20, moderate MELD group: 21-30, and high MELD group: ≥31). Perioperative factors were compared among the 3 groups, and cumulative overall survival rates were calculated using the Kaplan-Meier method. RESULTS The patients' characteristics were comparable, and the median age was 54 years. Hepatitis C virus cirrhosis was the most common primary disease (n = 40), followed by hepatitis B virus (n = 11). The low MELD group consisted of 68 patients (median score: 16, 10-20); the moderate MELD group, 24 patients (median score: 24, 21-30); and the high MELD group, 10 patients (median score: 35, 31-40). The mean operative time (1241 min versus 1278 min versus 1158 min, P = .19) and mean blood loss (7517 mL vs 11162 mL vs 8808 mL, P = .71) were not significantly different among the 3 groups. The vascular and biliary complication rates were similar. The periods of intensive care unit and hospital stay tended to be longer in the high MELD group, but the difference was insignificant. The 1-year postoperative survival rate (85.3 % vs 87.5 % vs 90.0 %, P = .90) and overall survival rate were also not significantly different among the 3 groups. CONCLUSIONS Our study showed that LDLT patients with high MELD scores do not have a worse prognosis than those with low scores.
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Affiliation(s)
- Daijiro Matoba
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.
| | - Kazuki Sasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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Living-Donor Liver Transplantation for Hepatocellular Carcinoma: Impact of the MELD Score and Predictive Value of NLR on Survival. Curr Oncol 2022; 29:3881-3893. [PMID: 35735419 PMCID: PMC9221955 DOI: 10.3390/curroncol29060310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/18/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Patients with hepatocellular carcinoma (HCC) tend to be referred for liver transplantation (LT) at an early stage of cirrhosis, with lower pre-LT Model of End-Stage Liver Disease (MELD) scores. We investigated the impact of high MELD scores on post-LT outcomes in patients with HCC and validated the prognostic significance of the neutrophil-to-lymphocyte ratio (NLR). Patients and Method: This retrospective single-center cohort study enrolled 230 patients with HCC who underwent LDLT from 2004−2019 in our institute. We defined a high MELD score as ≥20. Results: The MELD < 20 and MELD ≥ 20 groups comprised 205 and 25 cases, respectively. Although there was no significant difference in disease-free survival between the two groups (p = 0.629), the incidence of septic shock (p = 0.019) was significantly higher in the high MELD group. The one-, three-, and five-year overall survival rates were not significantly different between the two groups (p = 0.056). In univariate analysis, a high pre-LT NLR was associated with poorer survival in the high MELD group (p = 0.029, hazard ratio [HR]: 1.07, 90% confidence interval [CI]: 1.02−1.13). NLR cut-off values of ≥10.7 and <10.7 were predictive of mortality, with an AUC of 0.705 (90% CI: 0.532−0.879). The one-, three-, and five-year post-LT survival rates were significantly higher among the recipients with an NLR < 10.7 than those with an NLR ≥ 10.7 (p = 0.005). Conclusions: Pre-LT MELD score ≥ 20 was associated with a higher risk of developing post-LT septic shock and mortality. The pre-LT serum NLR is a useful predictive factor for clinical outcomes in patients with HCC with high MELD scores.
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Choudhary NS, Saraf N, Saigal S, Soin AS. Liver Transplantation for Acute on Chronic Liver Failure. J Clin Exp Hepatol 2017; 7:247-252. [PMID: 28970712 PMCID: PMC5620362 DOI: 10.1016/j.jceh.2017.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute-on chronic liver failure (ACLF) is defined as acute insult on previous liver disease that causes sudden worsening of liver functions. METHODS ACLF is characterized by high incidence of organ failure and prognosis is remarkably worse than patients with cirrhosis. Incidence of organ failures is very high despite best medical care and timely liver transplant before development of multi organ failure is associated with good survival rates. RESULTS At present, there are no reliable score or ways to correctly identify patients who are going to recover from patients who will need transplantation. Organ failures are important part of prognosis and to define need or futility of early liver transplantation. CONCLUSION Asian Pacific Association for the Study of the Liver (APASL) published their recommendations regarding ACLF in 2014. Several important studies regarding course/nature of disease and transplantation for ACLF became available after 2014 APASL recommendations and still there are some unanswered areas. The current review discusses various issues regarding liver transplantation in patients with ACLF.
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Affiliation(s)
| | - Neeraj Saraf
- Address for correspondence: Neeraj Saraf, Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Sector 38, Gurgaon, Haryana 122001, India.Institute of Liver Transplantation and Regenerative Medicine, Medanta, The MedicitySector 38GurgaonHaryana122001India
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4
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Choudhury A, Jindal A, Maiwall R, Sharma MK, Sharma BC, Pamecha V, Mahtab M, Rahman S, Chawla YK, Taneja S, Tan SS, Devarbhavi H, Duan Z, Yu C, Ning Q, Jia JD, Amarapurkar D, Eapen CE, Goel A, Hamid SS, Butt AS, Jafri W, Kim DJ, Ghazinian H, Lee GH, Sood A, Lesmana LA, Abbas Z, Shiha G, Payawal DA, Dokmeci AK, Sollano JD, Carpio G, Lau GK, Karim F, Rao PN, Moreau R, Jain P, Bhatia P, Kumar G, Sarin SK. Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models. Hepatol Int 2017; 11:461-471. [PMID: 28856540 DOI: 10.1007/s12072-017-9816-z] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 07/30/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Acute-on-chronic liver failure (ACLF) is a progressive disease associated with rapid clinical worsening and high mortality. Early prediction of mortality and intervention can improve patient outcomes. We aimed to develop a dynamic prognostic model and compare it with the existing models. METHODS A total of 1402 ACLF patients, enrolled in the APASL-ACLF Research Consortium (AARC) with 90-day follow-up, were analyzed. An ACLF score was developed in a derivation cohort (n = 480) and was validated (n = 922). RESULTS The overall survival of ACLF patients at 28 days was 51.7%, with a median of 26.3 days. Five baseline variables, total bilirubin, creatinine, serum lactate, INR and hepatic encephalopathy, were found to be independent predictors of mortality, with AUROC in derivation and validation cohorts being 0.80 and 0.78, respectively. AARC-ACLF score (range 5-15) was found to be superior to MELD and CLIF SOFA scores in predicting mortality with an AUROC of 0.80. The point scores were categorized into grades of liver failure (Gr I: 5-7; II: 8-10; and III: 11-15 points) with 28-day cumulative mortalities of 12.7, 44.5 and 85.9%, respectively. The mortality risk could be dynamically calculated as, with each unit increase in AARC-ACLF score above 10, the risk increased by 20%. A score of ≥11 at baseline or persisting in the first week was often seen among nonsurvivors (p = 0.001). CONCLUSIONS The AARC-ACLF score is easy to use, dynamic and reliable, and superior to the existing prediction models. It can reliably predict the need for interventions, such as liver transplant, within the first week.
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Affiliation(s)
- A Choudhury
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.,Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - A Jindal
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.,Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - R Maiwall
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.,Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - M K Sharma
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.,Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - B C Sharma
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.,Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - V Pamecha
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - M Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - S Rahman
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Y K Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S S Tan
- Department of Gastroenterology and Hepatology, Selayang Hospital, Kepong, Malaysia
| | - H Devarbhavi
- Department of Gastroenterology and Hepatology, St John Medical College, Bangalore, India
| | - Z Duan
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Chen Yu
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Q Ning
- Department of Infectious Disease, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Ji Dong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - D Amarapurkar
- Department of Gastroenterology and Hepatology, Bombay Hospital and Medical Research Centre, Mumbai, India
| | - C E Eapen
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - A Goel
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - S S Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - A S Butt
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - W Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - D J Kim
- Hallym University Chuncheon Sacred Heart Hospital, Center for Liver and Digestive Diseases, Chuncheon, Gangwon-Do, Republic of Korea
| | - H Ghazinian
- Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia
| | - G H Lee
- Department of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - L A Lesmana
- Division of Hepatology, University of Indonesia, Jakarta, Indonesia
| | - Z Abbas
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - G Shiha
- Department of Internal Medicine, Egyptian Liver Research Institute and Hospital, Cairo, Egypt
| | - D A Payawal
- Department of Hepatology, Cardinal Santos Medical Center, Manila, Philippines
| | - A K Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - J D Sollano
- Cardinal Santos Medical Center, Metro Manila, Philippines
| | - G Carpio
- Cardinal Santos Medical Center, Metro Manila, Philippines
| | - G K Lau
- The Institute of Translational Hepatology, Beijing, China
| | - F Karim
- Sir Salimur Rehman Medical College, Mitford Hospital, Dhaka, Bangladesh
| | - P N Rao
- Asian Institute of Gastroenterology, Hyderabad, India
| | - R Moreau
- Inserm, U1149, Centre de recherche sur l'Inflammation (CRI), UMR_S 1149, Labex INFLAMEX, Université Paris Diderot Paris 7, Paris, France
| | - P Jain
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.,Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - P Bhatia
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.,Department of Clinical Research, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - G Kumar
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.,Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India
| | - S K Sarin
- Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India. .,Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India.
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5
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Yadav SK, Saraf N, Saigal S, Choudhary NS, Goja S, Rastogi A, Bhangui P, Soin AS. High MELD score does not adversely affect outcome of living donor liver transplantation: Experience in 1000 recipients. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Sanjay K. Yadav
- Institute of Liver Transplant and Regenerative Medicine; Medanta-The Medicity; Gurgaon Delhi (NCR) India
| | - Neeraj Saraf
- Institute of Liver Transplant and Regenerative Medicine; Medanta-The Medicity; Gurgaon Delhi (NCR) India
| | - Sanjiv Saigal
- Institute of Liver Transplant and Regenerative Medicine; Medanta-The Medicity; Gurgaon Delhi (NCR) India
| | - Narendra S. Choudhary
- Institute of Liver Transplant and Regenerative Medicine; Medanta-The Medicity; Gurgaon Delhi (NCR) India
| | - Sanjay Goja
- Institute of Liver Transplant and Regenerative Medicine; Medanta-The Medicity; Gurgaon Delhi (NCR) India
| | - Amit Rastogi
- Institute of Liver Transplant and Regenerative Medicine; Medanta-The Medicity; Gurgaon Delhi (NCR) India
| | - Prashant Bhangui
- Institute of Liver Transplant and Regenerative Medicine; Medanta-The Medicity; Gurgaon Delhi (NCR) India
| | - Arvinder S. Soin
- Institute of Liver Transplant and Regenerative Medicine; Medanta-The Medicity; Gurgaon Delhi (NCR) India
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6
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Shi KQ, Cai YJ, Lin Z, Dong JZ, Wu JM, Wang XD, Song M, Wang YQ, Chen YP. Development and validation of a prognostic nomogram for acute-on-chronic hepatitis B liver failure. J Gastroenterol Hepatol 2017; 32:497-505. [PMID: 27490495 DOI: 10.1111/jgh.13502] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Determining individual risk of short-term mortality in patients with acute-on-chronic hepatitis B liver failure (ACHBLF) is a difficult task. We aimed to develop and externally validate a prognostic nomogram for ACHBLF patients. METHODS The nomogram was built to estimate the probability of 30-day, 60-day, 90-day, and 60-month survival based on an internal cohort of 246 patients with ACHBLF. The predictive accuracy and discriminative ability of nomogram were determined by a concordance index (C-index), calibration curve, and time-dependent receiver operating characteristics (tdROC), comparing with model for end-stage liver disease (MELD) score. The results were validated using bootstrap resampling and an external cohort of 138 patients. Furthermore, we plotted decision curves to evaluate the clinical usefulness of nomogram. RESULTS Independent factors derived from multivariable Cox analysis of training cohort to predict mortality were age, total bilirubin, serum sodium, and prothrombin activity, which were all assembled into nomogram. The calibration curves for probability of survival showed optimal agreement between nomogram prediction and actual observation. The C-index of nomogram was higher than that of MELD score for predicting survival (30-day, 0.809 vs 0.717, P < 0.001; 60-day, 0.792 vs 0.685, P < 0.001; 90-day, 0.779 vs 0.678, P < 0.001; 6-month, 0.781 vs 0.677, P < 0.001). Additionally, tdROC and decision curves also showed that nomogram was superior to MELD score. The results were confirmed in validation cohort. CONCLUSIONS The prognostic nomogram provided an individualized risk estimate of short-term survival in patients with ACHBLF, offering to clinicians to improve their abilities to assess patient prognosis.
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Affiliation(s)
- Ke-Qing Shi
- Department of Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi-Jing Cai
- Department of Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhuo Lin
- Department of Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jin-Zhong Dong
- Department of Infection and Liver Diseases, Ningbo First Hospital, Ningbo, China
| | - Jian-Min Wu
- Institute of Genomic Medicine, Wenzhou Medical University, Wenzhou, China
| | - Xiao-Dong Wang
- Department of Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mei Song
- Department of Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu-Qun Wang
- Department of Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yong-Ping Chen
- Department of Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Abstract
Acute-on-chronic liver failure (ACLF) is a distinct entity that differs from acute liver failure and decompensated cirrhosis in timing, presence of treatable acute precipitant, and course of disease, with a potential for self-recovery. The core concept is acute deterioration of existing liver function in a patient of chronic liver disease with or without cirrhosis in response to an acute insult. The insult should be a hepatic one and presentation in the form of liver failure (jaundice, encephalopathy, coagulopathy, ascites) with or without extrahepatic organ failure in a defined time frame. ACLF is characterized by a state of deregulated inflammation. Initial cytokine burst presenting as SIRS, progression to CARS and associated immunoparalysis leads to sepsis and multi-organ failure. Early identification of the acute insult and mitigation of the same, use of nucleoside analogue in HBV-ACLF, steroid in severe alcoholic hepatitis, steroid in severe autoimmune hepatitis and/or bridging therapy lead to recovery, with a 90-day transplant-free survival rate of up to 50 %. First-week presentation is crucial concerning SIRS/sepsis, development, multiorgan failure and consideration of transplant. A protocol-based multi-disciplinary approach including critical care hepatology, early liver transplant before multi-organ involvement, or priority for organ allocation may improve the outcome. Presentation with extrahepatic organ involvement or inclusion of sepsis as an acute insult in definition restricts the therapy, i.e., liver transplant or bridging therapy, and needs serious consideration. Augmentation of regeneration, cell-based therapy, immunotherapy, and gut microbiota modulation are the emerging areas and need further research.
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Hepatology and Liver Transplant, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India.
| | - Ashok Choudhury
- Department of Hepatology and Liver Transplant, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India
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Anand AC, Dhiman RK. Acute on Chronic Liver Failure-What is in a 'Definition'? J Clin Exp Hepatol 2016; 6:233-240. [PMID: 27746620 PMCID: PMC5052400 DOI: 10.1016/j.jceh.2016.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 08/26/2016] [Indexed: 12/12/2022] Open
Abstract
Acute on chronic liver failure (ACLF) is a recently recognized syndrome and its definition has been evolving over last two decades. Currently, there is no universal consensus about the definition as kind of cases being seen in the Western world appear to be somewhat different from those that are seen in Asia Pacific region. But every one agrees that definition of ACLF should include following components. (a) The status of pre-existing liver disease, (b) defining the acute insult that leads to rapid deterioration of liver status, (c) time frame during which the acute insult can lead to rapid deterioration, (d) the quantification and definition of liver failure status after deterioration, which will determine the severity of ACLF, and (e) prediction of prognosis after analyzing first four components in the short and long terms. There is some consensus that number of organ failures may be the main determinant of prognosis. Whatever the definition is being used, the central role that superadded infections play in ACLF cannot be denied and need to be tackled aggressively. Apart from that, recovery may be possible if the acute insult or the baseline disease is curable, i.e. with the use of nucleoside analogs for hepatitis B, and corticosteroids for severe autoimmune hepatitis. Development of dynamic criteria with observations in Hospital may improve our understanding of prognosis as well as our approach to the management of ACLF.
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Affiliation(s)
- Anil C. Anand
- Department of Hepatology and Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110076, India,Address for correspondence: Anil C. Anand, Senior Consultant Department of Hepatology and Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110076, India.Senior Consultant Department of Hepatology and Gastroenterology, Indraprastha Apollo HospitalSarita ViharNew Delhi110076India
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9
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Zhang J, Gao S, Duan Z, Hu KQ. Overview on acute-on-chronic liver failure. Front Med 2016; 10:1-17. [PMID: 26976617 DOI: 10.1007/s11684-016-0439-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 01/28/2016] [Indexed: 12/11/2022]
Abstract
Liver failure (LF) is defined as severe dysfunction in hepatic synthesis, detoxification, and metabolism induced by various etiologies. Clinical presentation of LF typically includes severe jaundice, coagulation disorder, hepatic encephalopathy, and ascites. LF can be classified into acute LF, acute-on-chronic LF (ACLF), and chronic LF. ACLF has been demonstrated as a distinct syndrome with unique clinical presentation and outcomes. The severity, curability, and reversibility of ACLF have attracted considerable attention. Remarkable developments in ACLF-related conception, diagnostic criteria, pathogenesis, and therapy have been achieved. However, this disease, especially its diagnostic criteria, remains controversial. In this paper, we systemically reviewed the current understanding of ACLF from its definition, etiology, pathophysiology, pathology, and clinical presentation to management by thoroughly comparing important findings between east and west countries, as well as those from other regions. We also discussed the controversies, challenges, and needs for future studies to promote the standardization and optimization of the diagnosis and treatment for ACLF.
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Affiliation(s)
- Jing Zhang
- Department of Hepatitis C and Drug Induced Liver Injury, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
- Collaborative Innovation Center of Infectious Diseases, Beijing, 100069, China
| | - Shan Gao
- Beijing Artificial Liver Treatment & Training Center, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
- Collaborative Innovation Center of Infectious Diseases, Beijing, 100069, China
| | - Zhongping Duan
- Beijing Artificial Liver Treatment & Training Center, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China.
- Collaborative Innovation Center of Infectious Diseases, Beijing, 100069, China.
| | - Ke-Qin Hu
- Division of Gastroenterology and Hepatology, University of California, Irvine, Medical Center, Orange, CA, 92868, USA.
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Sarin SK, Choudhury A. Acute-on-chronic liver failure: terminology, mechanisms and management. Nat Rev Gastroenterol Hepatol 2016; 13:131-49. [PMID: 26837712 DOI: 10.1038/nrgastro.2015.219] [Citation(s) in RCA: 238] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a distinct clinical entity and differs from acute liver failure and decompensated cirrhosis in timing, presence of acute precipitant, course of disease and potential for unaided recovery. The definition involves outlining the acute and chronic insults to include a homogenous patient group with liver failure and an expected outcome in a specific timeframe. The pathophysiology of ACLF relates to persistent inflammation, immune dysregulation with initial wide-spread immune activation, a state of systematic inflammatory response syndrome and subsequent sepsis due to immune paresis. The disease severity and outcome can be predicted by both hepatic and extrahepatic organ failure(s). Clinical recovery is expected with the use of nucleoside analogues for hepatitis B, and steroids for severe alcoholic hepatitis and, possibly, severe autoimmune hepatitis. Artificial liver support systems help remove toxins and metabolites and serve as a bridge therapy before liver transplantation. Hepatic regeneration during ongoing liver failure, although challenging, is possible through the use of growth factors. Liver transplantation remains the definitive treatment with a good outcome. Pre-emptive antiviral agents for hepatitis B before chemotherapy to prevent viral reactivation and caution in using potentially hepatotoxic drugs can prevent the development of ACLF.
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Affiliation(s)
- Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
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Model for End-Stage Liver Disease (MELD) score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients. Transplant Proc 2015; 46:3502-6. [PMID: 25498080 DOI: 10.1016/j.transproceed.2014.07.075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/05/2014] [Accepted: 07/15/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe clinical entity and liver transplantation is the only definitive therapy to salvage these patients. However, the timing of liver transplant for these patients remains unclear. METHODS Seventy-eight patients undergoing liver transplantation because of hepatitis B ACLF were retrospectively analyzed from June 2004 to December 2010. The areas under the receiver operating characteristic curve (AUC) of Model for End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) score for the post-transplantation outcomes were calculated. RESULTS The median age was 44 years (range, 25-64 years), serum bilirubin 418.53 μmol/L (range, 112.90-971.40 μmol/L), INR 3.177 (range, 1.470-9.850), and creatinine 70.84 μmol/L (range, 12.39-844.1 μmol/L); the median MELD score was 32 (range, 21-53) and CTP score 12 (8-15). The AUCs of MELD and CTP scores for 3-month mortality were 0.581 (95% confidence interval [CI], 0.421-0.742; sensitivity, 87.5%; specificity, 32.8%) and 0.547 (95% CI, 0.401-0.693; sensitivity, 75%; specificity, 41%), respectively. Meanwhile, there were no significant differences in hospital mortality (P = .252) or morbidity (P = .338) between the patients with MELD score ≥30 and those <30. CONCLUSIONS MELD score had no predictive ability for the outcomes of patients with hepatitis B ACLF after orthotopic liver transplantation.
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Haddad L, Cassenote AJF, Andraus W, de Martino RB, Ortega NRDS, Abe JM, D’Albuquerque LAC. Factors Associated with Mortality and Graft Failure in Liver Transplants: A Hierarchical Approach. PLoS One 2015; 10:e0134874. [PMID: 26274497 PMCID: PMC4537224 DOI: 10.1371/journal.pone.0134874] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 07/14/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Liver transplantation has received increased attention in the medical field since the 1980s following the introduction of new immunosuppressants and improved surgical techniques. Currently, transplantation is the treatment of choice for patients with end-stage liver disease, and it has been expanded for other indications. Liver transplantation outcomes depend on donor factors, operating conditions, and the disease stage of the recipient. A retrospective cohort was studied to identify mortality and graft failure rates and their associated factors. All adult liver transplants performed in the state of São Paulo, Brazil, between 2006 and 2012 were studied. METHODS AND FINDINGS A hierarchical Poisson multiple regression model was used to analyze factors related to mortality and graft failure in liver transplants. A total of 2,666 patients, 18 years or older, (1,482 males; 1,184 females) were investigated. Outcome variables included mortality and graft failure rates, which were grouped into a single binary variable called negative outcome rate. Additionally, donor clinical, laboratory, intensive care, and organ characteristics and recipient clinical data were analyzed. The mortality rate was 16.2 per 100 person-years (py) (95% CI: 15.1-17.3), and the graft failure rate was 1.8 per 100 py (95% CI: 1.5-2.2). Thus, the negative outcome rate was 18.0 per 100 py (95% CI: 16.9-19.2). The best risk model demonstrated that recipient creatinine ≥ 2.11 mg/dl [RR = 1.80 (95% CI: 1.56-2.08)], total bilirubin ≥ 2.11 mg/dl [RR = 1.48 (95% CI: 1.27-1.72)], Na+ ≥ 141.01 mg/dl [RR = 1.70 (95% CI: 1.47-1.97)], RNI ≥ 2.71 [RR = 1.64 (95% CI: 1.41-1.90)], body surface ≥ 1.98 [RR = 0.81 (95% CI: 0.68-0.97)] and donor age ≥ 54 years [RR = 1.28 (95% CI: 1.11-1.48)], male gender [RR = 1.19(95% CI: 1.03-1.37)], dobutamine use [RR = 0.54 (95% CI: 0.36-0.82)] and intubation ≥ 6 days [RR = 1.16 (95% CI: 1.10-1.34)] affected the negative outcome rate. CONCLUSIONS The current study confirms that both donor and recipient characteristics must be considered in post-transplant outcomes and prognostic scores. Our data demonstrated that recipient characteristics have a greater impact on post-transplant outcomes than donor characteristics. This new concept makes liver transplant teams to rethink about the limits in a MELD allocation system, with many teams competing with each other. The results suggest that although we have some concerns about the donors features, the recipient factors were heaviest predictors for bad outcomes.
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Affiliation(s)
- Luciana Haddad
- Digestive Transplant Unit—Gastroenterology Department, São Paulo University, São Paulo, Brazil
- * E-mail:
| | - Alex Jones Flores Cassenote
- Postgraduate Program in Infectious and Parasitic Diseases, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
- University of São Paulo, Faculty of Medicine, Center of Fuzzy Systems in Health, São Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Digestive Transplant Unit—Gastroenterology Department, São Paulo University, São Paulo, Brazil
| | | | | | - Jair Minoro Abe
- Institute for Advanced Studies, University of São Paulo, São Paulo, Brazil
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Wu FL, Shi KQ, Chen YP, Braddock M, Zou H, Zheng MH. Scoring systems predict the prognosis of acute-on-chronic hepatitis B liver failure: an evidence-based review. Expert Rev Gastroenterol Hepatol 2014; 8:623-32. [PMID: 24762209 DOI: 10.1586/17474124.2014.906899] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute-on-chronic hepatitis B liver failure is a devastating condition that is associated with mortality rates of over 50% and is consequent to acute exacerbation of chronic hepatitis B in patients with previously diagnosed or undiagnosed chronic liver disease. Liver transplantation is the definitive treatment to lower mortality rate, but there is a great imbalance between donation and potential recipients. An early and accurate prognostic system based on the integration of laboratory indicators, clinical events and some mathematic logistic equations is needed to optimize treatment for patients. As parts of the scoring systems, the MELD was the most common and the donor-MELD was the most innovative for patients on the waiting list for liver transplantation. This review aims to highlight the various features and prognostic capabilities of these scoring systems.
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Affiliation(s)
- Fa-Ling Wu
- Department of Infection and Liver Diseases, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Yang X, Lu Q, Tang T, Liao R, Yang Z. Prediction of the prognosis after liver transplantation in severe hepatitis B–induced liver failure and clinical decision for liver transplantation. J Surg Res 2013; 183:846-51. [DOI: 10.1016/j.jss.2013.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 11/06/2012] [Accepted: 01/17/2013] [Indexed: 12/13/2022]
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15
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Experience of Combined Liver-Kidney Transplantation for Acute-on-Chronic Liver Failure Patients With Renal Dysfunction. Transplant Proc 2013; 45:2307-13. [DOI: 10.1016/j.transproceed.2013.02.127] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/06/2013] [Accepted: 02/16/2013] [Indexed: 12/25/2022]
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Xia Q, Dai X, Zhang Y, Guo Y, Xu X, Yang Q, Du W, Liu X, Chen Y, Huang J, Li L. A modified MELD model for Chinese pre-ACLF and ACLF patients and it reveals poor prognosis in pre-ACLF patients. PLoS One 2013; 8:e64379. [PMID: 23755119 PMCID: PMC3673980 DOI: 10.1371/journal.pone.0064379] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 04/11/2013] [Indexed: 12/12/2022] Open
Abstract
Background & Aims Acute-on-chronic liver failure (ACLF) is one of the most deadly, prevalent, and costly diseases in Asia. However, no prognostic model has been developed that is based specifically on data gathered from Asian patients with ACLF. The aim of the present study was to quantify the survival time of ACLF among Asians and to develop a prognostic model to estimate the probability of death related to ACLF. Methods We conducted a retrospective observational cohort study to analyze clinical data from 857 patients with ACLF/pre-ACLF who did not undergo liver transplantation. Kaplan–Meier and Cox proportional hazards regression model were used to estimate survival rates and survival affected factors. The area under the receiver operating characteristic curve (auROC) was used to evaluate the performance of the models for predicting early mortality. Results The mortality rates among patients with pre-ACLF at 12 weeks and 24 weeks after diagnosis were 30.5% and 33.2%, respectively. The mortality rates among patients with early-stage ACLF at 12 weeks and 24 weeks after diagnosis were 33.9% and 37.1%, respectively. The difference in survival between pre-ACLF patients and patients in the early stage of ACLF was not statistically significant. The prognostic model identified 5 independent factors significantly associated with survival among patients with ACLF and pre-ACLF: the model for end-stage liver disease (MELD) score; age, hepatic encephalopathy; triglyceride level and platelet count. Conclusion The findings of the present study suggest that the Chinese diagnostic criteria of ACLF might be broadened, thus enabling implementation of a novel model to predict ACLF-related death after comprehensive medical treatment.
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Affiliation(s)
- Qi Xia
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiahong Dai
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yimin Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yongzheng Guo
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiaowei Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qian Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Weibo Du
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiaoli Liu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yuemei Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianrong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- * E-mail:
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Survival outcomes of right-lobe living donor liver transplantation for patients with high Model for End-stage Liver Disease scores. Hepatobiliary Pancreat Dis Int 2013; 12:256-62. [PMID: 23742770 DOI: 10.1016/s1499-3872(13)60042-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Controversy exists over whether living donor liver transplantation (LDLT) should be offered to patients with high Model for End-stage Liver Disease (MELD) scores. This study tried to determine whether a high MELD score would result in inferior outcomes of right-lobe LDLT. METHODS Among 411 consecutive patients who received right-lobe LDLT at our center, 143 were included in this study. The patients were divided into two groups according to their MELD scores: a high-score group (MELD score ≥25; n=75) and a low-score group (MELD score <25; n=68). Their demographic data and perioperative conditions were compared. Univariable and multivariable analyses were performed to identify risk factors affecting patient survival. RESULTS In the high-score group, more patients required preoperative intensive care unit admission (49.3% vs 2.9%; P<0.001), mechanical ventilation (21.3% vs 0%; P<0.001), or hemodialysis (13.3% vs 0%; P=0.005); the waiting time before LDLT was shorter (4 vs 66 days; P<0.001); more blood was transfused during operation (7 vs 2 units; P<0.001); patients stayed longer in the intensive care unit (6 vs 3 days; P<0.001) and hospital (21 vs 15 days; P=0.015) after transplantation; more patients developed early postoperative complications (69.3% vs 50.0%; P=0.018); and values of postoperative peak blood parameters were higher. However, the two groups had comparable hospital mortality. Graft survival and patient overall survival at one year (94.7% vs 95.6%; 95.9% vs 96.9%), three years (91.9% vs 92.6%; 93.2% vs 95.3%), and five years (90.2% vs 90.2%; 93.2% vs 95.3%) were also similar between the groups. CONCLUSIONS Although the high-score group had significantly more early postoperative complications, the two groups had comparable hospital mortality and similar satisfactory rates of graft survival and patient overall survival. Therefore, a high MELD score should not be a contraindication to right-lobe LDLT if donor risk and recipient benefit are taken into full account.
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Duan BW, Lu SC, Wang ML, Liu JN, Chi P, Lai W, Wu JS, Guo QL, Lin DD, Liu Y, Zeng DB, Li CY, Meng QH, Ding HG, Chen XY, Liao HY, Ma LQ, Chen Y, Zhang J, Xiang HP, Duan ZP, Li N. Liver transplantation in acute-on-chronic liver failure patients with high model for end-stage liver disease (MELD) scores: a single center experience of 100 consecutive cases. J Surg Res 2013; 183:936-43. [PMID: 23558257 DOI: 10.1016/j.jss.2013.03.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 02/19/2013] [Accepted: 03/01/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation (LT) is the only curative option. However, there are little published data on risk factors and outcomes of LT for ACLF. METHODS The objective of this study was to analyze preoperative, intraoperative, postoperative, and overall survival data on 100 consecutive cases with ACLF in order to try to determine for which patients LT are futile. RESULTS One hundred consecutive patients with pathology-confirmed ACLF who underwent LT from June 2004 to September 2012 were enrolled. The preoperative data showed that all patients were in a serious condition with a median high model for end-stage liver disease (MELD) score of 32, total bilirubin of 440.20 umol/L, international normalized ratio (INR) of 3.012, and at least one organ dysfunction as assessed by a Sequential Organ Failure Assessment (SOFA) score of ≥9. The patients had either deceased or a living donor LT with an overall mortality of 20%. The 1-, 3-, and 5-year cumulative survival rates were 76.8%, 75.6%, and 74.1%, respectively, and graft 1-, 3-, and 5-y accumulative survival rates were 73.3%, 72.1%, and 70.6%, respectively. However, the area under receiver operating characteristic of SOFA score, MELD score, as well as Child-Pugh score were 0.552, 0.547, and 0.547, respectively. CONCLUSIONS Both deceased and living donor LT are effective therapeutic options for patients with ACLF and the short- and long-term survival rates are encouraging. It is important to conduct more prospective and multi-center studies to define preoperatively which patients would benefit from LT.
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Affiliation(s)
- Bin-Wei Duan
- Department of Hepatobiliary Surgery and You-An Liver Transplant Center, Beijing You-An Hospital, Capital Medical University, Beijing, China
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Wlodzimirow KA, Eslami S, Abu-Hanna A, Nieuwoudt M, Chamuleau RAFM. A systematic review on prognostic indicators of acute on chronic liver failure and their predictive value for mortality. Liver Int 2013; 33:40-52. [PMID: 22429562 DOI: 10.1111/j.1478-3231.2012.02790.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 02/23/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND An early and proper diagnosis of acute on chronic liver failure (ACLF), together with the identification of indicators associated with disease severity is critical for outcome prediction and therapy. OBJECTIVE To systematically identify and summarize prognostic indicators for patients with ACLF and to evaluate the predictive value of these indicators. METHODS Embase and Ovid-Medline were searched for English-language articles. The search criteria focused on identifying clinical trials and observational studies reporting on indicators used for prediction of mortality in patients with ACLF. RESULTS Of 2382 studies identified, 19 were included for detailed analysis. Thirteen different definitions of ACLF were found. The main differences were related to acute deterioration in liver function, coagulopathy and hyperbilirubinaemia/jaundice. Seventy three prognostic indicators and their association with mortality were extracted and categorized into seven categories: general markers (n = 13), viral markers (n = 6), bio-markers (n = 22), hemodynamics (n = 1), morphology/histology (n = 17), scoring systems (n = 10) and treatments (n = 4). CONCLUSIONS The ambiguity and variability in the definition of ACLF and in its predictive indicators hampers comparability among studies. There is a need for a single uniform definition of ACLF. Also absence of a gold standard is an obstacle to render one indicator superior to another. The age, hepatic encephalopathy, model for end-stage liver disease score, total bilirubin and International normalized ratio (prothrombin time) appeared to be promising candidates for evaluation in future studies. The result of this review may be useful as a starting point in developing a standard list of indicators for clinical outcome that concur with the clinicians' subjective views on prognosis in ACLF.
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Affiliation(s)
- Kama A Wlodzimirow
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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Zhang M, Yin F, Chen B, Li Y, Yan L, Wen T, Li B. Posttransplant mortality risk assessment for adult-to-adult right-lobe living donor liver recipients with benign end-stage liver disease. Scand J Gastroenterol 2012; 47:842-52. [PMID: 22546008 DOI: 10.3109/00365521.2012.682089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A model for living donor liver transplantation (LDLT) outcomes, in concert with pretransplant disease severity assessment, would facilitate informed decision-making on both sides considering donation and transplantation. So far, however, few of studies have focused on models specifically for adult-to-adult right-lobe LDLT recipients with benign end-stage liver diseases. Therefore, we aimed to develop such a prognostic model based on easily obtainable and objective pretransplant characteristics. METHODS With data retrospectively collected on 120 recipients, we used Cox proportional-hazards regression to analyze six donor characteristics and 33 pretransplant recipient variables for correlation with posttransplant mortality. In both a modeling set and a prospective validation set with 30 recipients, the performances of the new Cox model, MELD, and MELD-Na+ were assessed by measuring both calibration ability and discriminative power with the Hosmer-Lemeshow test and receiver operating characteristic analysis, respectively. RESULTS By univariate and multivariate analysis, donor age, serum total bilirubin, creatinine, and HBV-DNA level were significantly associated with posttransplant mortality. The Cox model, employing these four variables, yielded good calibration ability in the modeling set χ² = 2.465, p = 0.653) and the validation set χ² = 2.836, p = 0.586), and high discriminative power in the modeling set (c-statistic = 0.826, p = 0.001) and validation set (c-statistic = 0.816, p = 0.028). The calibration ability and discriminative power of MELD and MELD-Na+ in both sets were poor. CONCLUSIONS The newly derived Cox model was valuable in posttransplant mortality risk assessment for adult-to-adult right-lobe LDLT recipients with benign end-stage liver diseases.
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Affiliation(s)
- Ming Zhang
- Liver Transplantation Center, West China Hospital, Sichuan University Medical School, Chengdu, P.R. China
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Ling Q, Xu X, Wei Q, Liu X, Guo H, Zhuang L, Chen J, Xia Q, Xie H, Wu J, Zheng S, Li L. Downgrading MELD improves the outcomes after liver transplantation in patients with acute-on-chronic hepatitis B liver failure. PLoS One 2012; 7:e30322. [PMID: 22291934 PMCID: PMC3265473 DOI: 10.1371/journal.pone.0030322] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 12/19/2011] [Indexed: 12/23/2022] Open
Abstract
Background High score of model for end-stage liver diseases (MELD) before liver transplantation (LT) indicates poor prognosis. Artificial liver support system (ALSS) has been proved to effectively improve liver and kidney functions, and thus reduce the MELD score. We aim to evaluate whether downgrading MELD score could improve patient survival after LT. Methodology/Principal Findings One hundred and twenty-six LT candidates with acute-on-chronic hepatitis B liver failure and MELD score ≥30 were included in this prospective study. Of the 126 patients, 42 received emergency LT within 72 h (ELT group) and the other 84 were given ALSS as salvage treatment. Of the 84 patients, 33 were found to have reduced MELD score (<30) on the day of LT (DGM group), 51 underwent LT with persistent high MELD score (N-DGM group). The median waiting time for a donor was 10 for DGM group and 9.5 days for N-DGM group. In N-DGM group there is a significantly higher overall mortality (43.1%) than that in ELT group (16.7%) and DGM group (15.2%). N-DGM (vs. ECT and DGM) was the only independent risk factor of overall mortality (P = 0.003). Age >40 years and the interval from last ALSS to LT >48 h were independent negative influence factors of downgrading MELD. Conclusions/Significance Downgrading MELD for liver transplant candidates with MELD score ≥30 was effective in improving patient prognosis. An appropriate ALSS treatment within 48 h prior to LT is potentially beneficial.
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Affiliation(s)
- Qi Ling
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiao Xu
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qiang Wei
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoli Liu
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haijun Guo
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Li Zhuang
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jiajia Chen
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qi Xia
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haiyang Xie
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jian Wu
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shusen Zheng
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- * E-mail: (LL) (LL); (SZ) (SZ)
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Hong SH, Kim JE, Cho ML, Heo YJ, Choi JH, Choi JH, Lee J. Comparison of the Child-Turcotte-Pugh classification and the model for end-stage liver disease score as predictors of the severity of the systemic inflammatory response in patients undergoing living-donor liver transplantation. J Korean Med Sci 2011; 26:1333-8. [PMID: 22022187 PMCID: PMC3192346 DOI: 10.3346/jkms.2011.26.10.1333] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 08/10/2011] [Indexed: 12/11/2022] Open
Abstract
The aim of this study was to evaluate and compare the Child-Turcotte-Pugh (CTP) classification system and the model for end-stage liver disease (MELD) score in predicting the severity of the systemic inflammatory response in living-donor liver transplantation patients. Recipients of liver graft were allocated to a recipient group (n = 39) and healthy donors to a donor group (n = 42). The association between the CTP classification, the MELD scores and perioperative cytokine concentrations in the recipient group was evaluated. The pro-inflammatory cytokines measured included interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α; the anti-inflammatory cytokines measured included IL-10 and IL-4. Cytokine concentrations were quantified using sandwich enzyme-linked immunoassays. The IL-6, TNF-α, and IL-10 concentrations in the recipient group were significantly higher than those in healthy donor group patients. All preoperative cytokine levels, except IL-6, increased in relation to the severity of liver disease, as measured by the CTP classification. Additionally, all cytokine levels, except IL-6, were significantly correlated preoperatively with MELD scores. However, the correlations diminished during the intraoperative period. The CTP classification and the MELD score are equally reliable in predicting the severity of the systemic inflammatory response, but only during the preoperative period.
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Affiliation(s)
- Sang-Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jeong-Eun Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Mi-La Cho
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Yu-Jung Heo
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jong-Ho Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jung-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jaemin Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, Catholic University of Korea, College of Medicine, Seoul, Korea
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Nakae H, Eguchi Y, Saotome T, Yoshioka T, Yoshimura N, Kishi Y, Naka T, Furuya T. Multicenter study of plasma diafiltration in patients with acute liver failure. Ther Apher Dial 2011; 14:444-50. [PMID: 21175541 DOI: 10.1111/j.1744-9987.2010.00864.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Plasma diafiltration (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers. A prospective, multicenter study was undertaken to evaluate the changes in bilirubin, IL-18, and cystatin C, as well as the 28-day and 90-day survival rates, with the use of PDF according to the level of severity as measured by the Model for End-Stage Liver Disease (MELD) score. Twenty-one patients with liver failure were studied: 10 patients had fulminant hepatitis and PDF therapies were performed 28 times; 11 had acute liver failure with the therapy performed 96 times. Levels of total bilirubin, IL-18, and cystatin C decreased significantly after treatment. The 28-day survival rate was 70.0% and that at 90 days was 16.7%. According to the severity of the MELD score, each of the results compared well with the use of Molecular Adsorbent Recirculating System or Prometheus therapy. In conclusion, PDF appears to be one of the most useful blood purification therapies for use in cases of acute liver failure in terms of medical economics and the removal of water-soluble and albumin-bound toxins.
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Affiliation(s)
- Hajime Nakae
- Department of Emergency and Critical Care Medicine, Akita University School of Medicine, Hondo, Akita 010-8543, Japan.
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Pre-transplant MELD and sodium MELD scores are poor predictors of graft failure and mortality after liver transplantation. Hepatol Int 2011; 5:841-9. [PMID: 21484127 DOI: 10.1007/s12072-011-9257-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 01/17/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND Incorporating serum sodium concentrations into the model for end-stage liver disease (MELD) score may increase its sensitivity for identifying priority patients for orthotopic liver transplantation (OLT). We, therefore, evaluated and compared the ability of the sodium MELD and MELD scores to predict graft and patient survival after OLT. METHODS The United Network for Organ Sharing (UNOS) registry includes all US adult OLTs performed between January 2000 and August 2008. For 15,156 patients who met inclusion criteria, MELD score was calculated; for 6,193 patients whose serum sodium concentrations was between 120 and 135 mEq/dl, immediately before OLT, sodium MELD score was calculated. The corresponding hazard ratios (HR) for MELD and sodium MELD on graft and patient survival were assessed using the Cox proportional hazards regression models. The concordance probability estimate (CPE) was used to evaluate predictive ability of each time-to-event model. RESULTS MELD and sodium MELD scores were both significant predictors in univariable Cox regression models for graft failure [HR (95% CI) for every 10 units increase in the predictor: 1.10 (1.04, 1.17), P = 0.001, and 1.05 (1.00, 1.10), P = 0.03, respectively], and for mortality (1.14 (1.07, 1.21), P < 0.001, and 1.07 (1.02, 1.12), P = 0.01, respectively), with CPE of 0.52-0.53. CONCLUSION While MELD and sodium MELD were each significantly associated with survival after OLT, their predictive abilities were poor. The sodium MELD score does not improve prediction accuracy over the MELD score. Weak prediction may result from unaccounted variability in recipient and donor status, as well as surgical and postoperative factors.
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Batista TP, Sabat BD, Melo PSV, Miranda LEC, Fonseca-Neto OCL, Amorim AG, Lacerda CM. Impact of MELD allocation policy on survival outcomes after liver transplantation: a single-center study in northeast Brazil. Clinics (Sao Paulo) 2011; 66:57-64. [PMID: 21437437 PMCID: PMC3044564 DOI: 10.1590/s1807-59322011000100011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 10/13/2010] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To analyze the impact of model for end-stage liver disease (MELD) allocation policy on survival outcomes after liver transplantation (LT). INTRODUCTION Considering that an ideal system of grafts allocation should also ensure improved survival after transplantation, changes in allocation policies need to be evaluated in different contexts as an evolutionary process. METHODS A retrospective cohort study was carried out among patients who underwent LT at the University of Pernambuco. Two groups of patients transplanted before and after the MELD allocation policy implementation were identified and compared using early postoperative mortality and post-LT survival as end-points. RESULTS Overall, early postoperative mortality did not significantly differ between cohorts (16.43% vs. 8.14%; p = 0.112). Although at 6 and 36-months the difference between pre-vs. post-MELD survival was only marginally significant (p = 0.066 and p = 0.063; respectively), better short, medium and long-term post-LT survival were observed in the post-MELD period. Subgroups analysis showed special benefits to patients categorized as nonhepatocellular carcinoma (non-HCC) and moderate risk, as determined by MELD score (15-20). DISCUSSION This study ensured a more robust estimate of how the MELD policy affected post-LT survival outcomes in Brazil and was the first to show significantly better survival after this new policy was implemented. Additionally, we explored some potential reasons for our divergent survival outcomes. CONCLUSION Better survival outcomes were observed in this study after implementation of the MELD criterion, particularly amongst patients categorized as non-HCC and moderate risk by MELD scoring. Governmental involvement in organ transplantation was possibly the main reason for improved survival.
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Affiliation(s)
- Thales Paulo Batista
- Department of Surgery and Liver Transplantation, Oswaldo Cruz University Hospital, University of Pernambuco, Recife, PE, Brazil.
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Xiao L, Fu ZR, Ding GS, Fu H, Ni ZJ, Wang ZX, Shi XM, Guo WY, Ma J. Prediction of survival after liver transplantation for chronic severe hepatitis B based on preoperative prognostic scores: a single center's experience in China. World J Surg 2010; 33:2420-6. [PMID: 19693632 PMCID: PMC7102514 DOI: 10.1007/s00268-009-0183-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The aim of this study was to estimate the utility of a preoperative model of end-stage liver disease (MELD) score and Child-Turcotte-Pugh (CTP) score in predicting the prognosis after othotopic liver transplantation (OLT) for chronic severe hepatitis B (CSHB) and explore the prognostic factors. Methods The outcome of 137 patients who underwent OLT using donors after cardiac death (DCDs) for CSHB in our center was reviewed retrospectively. Survival analysis was performed using the Kaplan-Meier method; the log-rank test was used for univariate analysis; and the Cox proportional hazards regression model was used for prognostic factors screening. Results The overall mortality rate was 33.6% (46/137); and 1-month, 6-month, 1-year, and 5-year patient survival rates were 75.8, 72.0, 71.0, and 60.1%, respectively. Most patients (33/46) died during the first month after OLT. The area under the curve values generated by the receiver operating characteristics curves were 0.82 [95% confidence interval (CI) 0.72–0.92] and 0.68 (95% CI 0.58–0.79), respectively (P < 0.01), for the MELD and CTP models in predicting 1-month mortality after OLT. Patients with a preoperative MELD score <33.8 or a CTP score <12.5 had significantly better prognosis than those with higher scores (P < 0.05). Other mortality predictors include hepatic encephalopathy, preoperative infection, serum creatinine ≥1.5 mg/dl. Conclusions The MELD score was more efficient than the CTP score for evaluating the short-term prognosis in patients with CSHB undergoing OLT using DCDs, which should be taken into consideration during graft allocation.
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Affiliation(s)
- Liang Xiao
- Department of Liver Transplantation, Shanghai Changzheng Hospital, 415 Fengyang Road, Shanghai 200003, People's Republic of China
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Sun QF, Ding JG, Xu DZ, Chen YP, Hong L, Ye ZY, Zheng MH, Fu RQ, Wu JG, Du QW, Chen W, Wang XF, Sheng JF. Prediction of the prognosis of patients with acute-on-chronic hepatitis B liver failure using the model for end-stage liver disease scoring system and a novel logistic regression model. J Viral Hepat 2009; 16:464-70. [PMID: 19413694 DOI: 10.1111/j.1365-2893.2008.01046.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The objective of this study was to determine the predictive value of the model for end-stage liver disease (MELD) scoring system in patients with acute-on-chronic hepatitis B liver failure (ACLF-HBV), and to establish a new model for predicting the prognosis of ACLF-HBV. A total of 204 adult patients with ACLF-HBV were retrospectively recruited between July 1, 2002 and December 31, 2004. The MELD scores were calculated according to the widely accepted formula. The 3-month mortality was calculated. The validity of the MELD model was determined by means of the concordance (c) statistic. Clinical data and biochemical values were included in the multivariate logistic regression analysis based on which the regression model for predicting prognosis was established. The receiver-operating characteristic curves were drawn for the MELD scoring system and the new regression model and the areas under the curves (AUC) were compared by the z-test. The 3-month mortality rate was 57.8%. The mean MELD score for the patients who died was significantly greater than those who survived beyond 3 months (28.7 vs 22.4, P = 0.003). The concordance (c) statistic (equivalent to the AUC) for the MELD scoring system predicting 3-month mortality was 0.709 (SE = 0.036, P < 0.001, 95% confidence interval 0.638-0.780). The independent factors predicting prognosis were hepatorenal syndrome (P < 0.001), liver cirrhosis (P = 0.009), HBeAg (P = 0.013), albumin (P = 0.028) and prothrombin activity (P = 0.011) as identified in multivariate logistic regression analysis. The regression model that was constructed by the logistic regression analysis produced a greater prognostic value (c = 0.891) than the MELD scoring system (z = 4.333, P < 0.001). The MELD scoring system is a promising and useful predictor for 3-month mortality of ACLF-HBV patients. Hepatorenal syndrome, liver cirrhosis, HBeAg, albumin and prothrombin activity are independent factors affecting the 3-month mortality. The newly established logistic regression model appears to be superior to the MELD scoring system in predicting 3-month mortality in patients with ACLF-HBV.
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Affiliation(s)
- Q-F Sun
- Department of Infectious Diseases, The Third Affiliated Hospital of Wenzhou Medical College, Rui'an, Zhejiang, China.
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Kawamura E, Habu D, Morikawa H, Enomoto M, Kawabe J, Tamori A, Sakaguchi H, Saeki S, Kawada N, Shiomi S. A randomized pilot trial of oral branched-chain amino acids in early cirrhosis: validation using prognostic markers for pre-liver transplant status. Liver Transpl 2009; 15:790-7. [PMID: 19562716 DOI: 10.1002/lt.21758] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Because of the chronic shortage of liver donors, hepatologists are required to prolong the liver transplant waiting period by preserving the hepatic reserve of scheduled recipients. This study examined the effectiveness of oral branched-chain amino acids (BCAAs), using outcome markers indicating pretransplant hepatic reserve. Fifty-six consecutive eligible patients with Child class A cirrhosis without major complications were randomly assigned to receive oral BCAA granules (12.45 g/day) for least 1 year or no BCAAs. Differences between groups in the Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, asialoscintigraphic clearance index (CI), and complications were examined. Of 50 remaining patients, 27 received BCAAs, and 23 received no BCAAs (mean duration, 3.2 years). The mean annual changes in the MELD score, CTP score, and asialoscintigraphic CI were smaller in the BCAA group than in the control group (-0.06 +/- 0.23 versus 0.10 +/- 0.40, P = 0.024, 0.06 +/- 0.30 versus 0.30 +/- 0.48, P = 0.037, and 0.00 +/- 0.02 versus 0.02 +/- 0.04, P = 0.040, respectively). The mean annual changes in the serum total bilirubin and the serum albumin in the BCAA group were better preserved than those in the control group (-0.07 +/- 0.20 versus 0.12 +/- 0.18 mg/dL, P < 0.001, and 0.07 +/- 0.13 versus -0.02 +/- 0.19 g/dL, P = 0.005, respectively); other laboratory variables were not significant. The incidence of overall major cirrhotic complications was lower in the BCAA group than in the control group [14.8% (4 of 27 patients) versus 30.4% (7 of 23 patients) at 3 years, P = 0.043]; only ascites was significant individually. In conclusion, early interventional oral BCAAs might prolong the liver transplant waiting period by preserving hepatic reserve in cirrhosis.
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Affiliation(s)
- Etsushi Kawamura
- Department of Nuclear Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan.
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Radha Krishna Y, Saraswat VA, Das K, Himanshu G, Yachha SK, Aggarwal R, Choudhuri G. Clinical features and predictors of outcome in acute hepatitis A and hepatitis E virus hepatitis on cirrhosis. Liver Int 2009; 29:392-8. [PMID: 19267864 DOI: 10.1111/j.1478-3231.2008.01887.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Acute hepatitis A and E are recognized triggers of hepatic decompensation in patients with cirrhosis, particularly from the Indian subcontinent. However, the resulting acute-on-chronic liver failure (ACLF) has not been well characterized and no large studies are available. Our study aimed to evaluate the clinical profile and predictors of 3-month mortality in patients with this distinctive form of liver failure. METHODS ACLF was diagnosed in patients with acute hepatitis A or E [abrupt rise in serum bilirubin and/or alanine aminotransferase with positive immunoglobulin M anti-hepatitis A virus (HAV)/anti-hepatitis E virus (HEV)] presenting with clinical evidence of liver failure (significant ascites and/or hepatic encephalopathy) and clinical, biochemical, endoscopic (oesophageal varices at least grade II in size), ultrasonographical (presence of nodular irregular liver with porto-systemic collaterals) or histological evidence of cirrhosis. Clinical and laboratory profile were evaluated, predictors of 3-month mortality were determined using univariate and multivariate logistic regression and a prognostic model was constructed. Receiver-operating curves were plotted to measure performance of the present prognostic model, model for end-stage liver disease (MELD) score and Child-Turcotte-Pugh (CTP) score. RESULTS ACLF occurred in 121 (3.75%) of 3220 patients (mean age 36.3+/-18.0 years; M:F 85:36) with liver cirrhosis admitted from January 2000 to June 2006. It was due to HEV in 80 (61.1%), HAV in 33 (27.2%) and both in 8 (6.1%). The underlying liver cirrhosis was due to HBV (37), alcohol (17), Wilson's disease (8), HCV (5), autoimmune (6), Budd-Chiari syndrome (2), haemochromatosis (2) and was cryptogenic in the rest (42). Common presentations were jaundice (100%), ascites (78%) and hepatic encephalopathy (55%). Mean (SD) CTP score was 11.4+/-1.6 and mean MELD score was 28.6+/-9.06. Three-month mortality was 54 (44.6%). Complications seen were sepsis in 42 (31.8%), renal failure in 45 (34%), spontaneous bacterial peritonitis in 27 (20.5%), UGI bleeding in 15(11%) and hyponatraemia in 50 (41.3%). On univariate analysis, ascites, hepatic encephalopathy, renal failure, GI bleeding, total bilirubin, hyponatraemia and coagulopathy were significant predictors of mortality. Multivariate analysis revealed grades 3 and 4 HE [odds ratio (OR 32.1)], hyponatraemia (OR 9.2) and renal failure (OR 16.8) as significant predictors of 3-month mortality and a prognostic model using these predictors was constructed. Areas under the curve for the present predicted prognostic model, MELD, and CTP were 0.952, 0.941 and 0.636 respectively. CONCLUSIONS ACLF due to hepatitis A or E super infection results in significant short-term mortality. The predictors of ominous outcome include grades 3 and 4 encephalopathy, hyponatraemia and renal failure. Present prognostic model and MELD scoring system were better predictors of 3-month outcome than CTP score in these patients. Early recognition of those with dismal prognosis may permit timely use of liver replacement/supportive therapies.
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Affiliation(s)
- Yellapu Radha Krishna
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Bo W, Yan L. The Difference and the Transition of Indication for Adult Living Donor Liver Transplantation Between the West and the East. Transplant Proc 2008; 40:3507-11. [DOI: 10.1016/j.transproceed.2008.06.096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 04/17/2008] [Accepted: 06/16/2008] [Indexed: 02/07/2023]
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