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Swaroop S, Vaishnav M, Arora U, Biswas S, Aggarwal A, Sarkar S, Khanna P, Elhence A, Kumar R, Goel A, Shalimar. Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis. J Clin Exp Hepatol 2024; 14:101291. [PMID: 38544766 PMCID: PMC10964076 DOI: 10.1016/j.jceh.2023.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/01/2023] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India. METHODS We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population. RESULTS We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%). CONCLUSIONS Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.
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Affiliation(s)
- Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya Sarkar
- Department of Anaesthesia, All India Institute of Medical Sciences, Kalyani, West Bengal, India
| | - Puneet Khanna
- Department of Anaesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Amit Goel
- Department of Hepatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
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Lin YT, Chen WT, Wu TH, Liu Y, Liu LT, Teng W, Hsieh YC, Wu YM, Huang CH, Hsu CW, Chien RN. A Validated Composite Score Demonstrates Potential Superiority to MELD-Based Systems in Predicting Short-Term Survival in Patients with Liver Cirrhosis and Spontaneous Bacterial Peritonitis-A Preliminary Study. Diagnostics (Basel) 2023; 13:2578. [PMID: 37568941 PMCID: PMC10417459 DOI: 10.3390/diagnostics13152578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a severe complication in cirrhosis patients with ascites, leading to high mortality rates if not promptly treated. However, specific prediction models for SBP are lacking. AIMS This study aimed to compare commonly used cirrhotic prediction models (CTP score, MELD, MELD-Na, iMELD, and MELD 3.0) for short-term mortality prediction and develop a novel model to improve mortality prediction. METHODS Patients with the first episode of SBP were included. Prognostic values for mortality were assessed using AUROC analysis. A novel prediction model was developed and validated. RESULTS In total, 327 SBP patients were analyzed, with HBV infection as the main etiologies. MELD 3.0 demonstrated the highest AUROC among the traditional models. The novel model, incorporating HRS, exhibited superior predictive accuracy for in-hospital in all patients and 3-month mortality in HBV-cirrhosis, with AUROC values of 0.827 and 0.813 respectively, surpassing 0.8. CONCLUSIONS MELD 3.0 score outperformed the CTP score and showed a non-significant improvement compared to other MELD-based scores, while the novel SBP model demonstrated impressive accuracy. Internal validation and an HBV-related cirrhosis subgroup sensitivity analysis supported these findings, highlighting the need for a specific prognostic model for SBP and the importance of preventing HRS development to improve SBP prognosis.
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Affiliation(s)
- Yan-Ting Lin
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
| | - Wei-Ting Chen
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
- College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
| | - Tsung-Han Wu
- College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
- Department of General Surgery, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Yu Liu
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
| | - Li-Tong Liu
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
| | - Wei Teng
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
- College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
| | - Yi-Chung Hsieh
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
- College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
| | - Yen-Mu Wu
- College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
- Department of Infectious Disease, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan;
| | - Chien-Hao Huang
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
- College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
| | - Chao-Wei Hsu
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
- College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
| | - Rong-Nan Chien
- Department of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan (Y.L.); (L.-T.L.); (Y.-C.H.)
- College of Medicine, Chang-Gung University, Taoyuan 33302, Taiwan
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Abstract
BACKGROUND Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival. METHODS This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications. RESULTS There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis. CONCLUSION Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- AVB, acute variceal bleeding
- BMI, body mass index
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- CTP, Child Turcotte Pugh Score
- DAAs, direct-acting antiviral agents
- GGT, gamma glutamyl transpeptidase
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HE, hepatic encephalopathy
- HR, hazard ratio
- HRQoL, health-related quality of life
- HVPG, hepatic vein pressure gradient
- MELD, Model for End Stage Liver disease
- MetS, metabolic syndrome
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- NSBB, Non-selective beta blockers
- NVHCP, National Viral Hepatitis Control programme
- SAAG, Serum-ascites albumin gradient
- SBP, spontaneous bacterial peritonitis
- WHO, World Health Organization
- cirrhosis, ascites
- hepatic encephalopathy
- hepatocellular carcinoma
- portal hypertension
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Abstract
The liver comprises both parenchymal and non-parenchymal cells with varying functions. Cirrhosis is often complicated by the development of portal hypertension and its associated complications. Hence, assessment of liver in cirrhosis should include assessment of its structural, function of both hepatic and non-hepatic tissue and haemodynamic assessment of portal hypertension. There is no single test that can evaluate all functions of liver and assess prevalence and severity of portal hypertension. Commonly available tests like serum bilirubin, liver enzymes (alanine [ALT] and aspartate aminotransferase [AST], serum alkaline phosphatase [ALP], gamma glutamyl transpeptidase [GGT]), serum albumin and prothrombin time for assessment of liver functions partly assess liver functions. quantitative liver functions like indocyanine clearance tests [ICG-K], methacetin breath test [MBT] were developed to assess dynamic status of liver but has its own limitation and availability. Imaging based assessment of liver by transient elastography, MRI based 99 mTc-coupled asialoglycoprotein mebrofenin scan help the clinician to assess liver function, functional volume of liver left after surgery and portal hypertension [PH]. Hepatic venous pressure gradient still remains the gold standard for the assessment of portal hypertension but is invasive and not available in all centres. Combinations of blood parameters in form of various indices like fibrosis score of 4 [FIB-4], Lok index, scores like model for end stage liver disease (MELD) and Child-Turcotte Pugh score are commonly used for assessing liver function in clinical practice.
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Key Words
- 99mTc-GSA, technetium-99m galactosyl human serum albumin
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- ARFI, Acoustic Radiation Force Impulse
- AST, aspartate aminotransferase
- BUN, blood urea nitrogen
- CLD, chronic liver disease
- ESLD, end-stage liver disease
- FIB-4, fibrosis score of 4
- GGT, gamma glutamyl transpeptidase
- HVPG, Hepatic venous pressure gradient
- ICG-K, indocyanine clearance tests
- INR, International normalised ratio
- LFTs, liver function tests
- MBT, methacetin breath test
- NAFLD, non-alcoholic fatty liver disease
- PBS, primary biliary cholangitis
- PHT, portal hypertension
- PSC, primary Sclerosing cholangitis
- cirrhosis
- liver function tests
- portal hypertension
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Affiliation(s)
- Praveen Sharma
- Address for correspondence: Praveen Sharma, Associate Professor, Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.
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Comparison of transient elastography and Model for End-Stage Liver Disease-sodium to Model for End-Stage Liver Disease-sodium alone to predict mortality and liver transplantation. Eur J Gastroenterol Hepatol 2021; 33:e753-e757. [PMID: 34231523 DOI: 10.1097/meg.0000000000002243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Model for End-Stage Liver Disease (MELD) alone and with sodium (MELD-Na) have decreasing predictive capacity as trends in liver disease evolve. We sought to combine transient elastography (TE) with MELD-Na to improve its predictive ability. METHODS This is a retrospective cohort study comparing the use of TE, MELD-Na, and composite MELD-Na-TE to predict liver transplantation and all-cause mortality, with hepatic decompensation as a secondary outcome. Cox proportional hazards regression was used to measure predictive ability and control for confounders. RESULTS Of the 214 patients, the mean age was 53 years with 35% being female and 76% being Caucasian. Hepatitis C (59%) and nonalcoholic fatty liver disease (22%) were the most frequent liver disease etiologies. On univariable analysis, MELD-Na [hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.06-1.2, P < 0.001], TE (HR 1.04, 95% CI 1.03-1.06, P < 0.001) and composite MELD-Na-TE (HR 1.13, 95% CI 1.08-1.19, P < 0.001) were associated with death or transplant. On multivariable analysis, MELD-Na was no longer significant (HR 1.08, 95% CI 0.95-1.22, P = 0.27) after adjusting for TE (HR 1.05, 95% CI 1.03-1.07, P < 0.001) while composite MELD-Na-TE remained significant (HR 1.16, 95% CI 1.09-1.24, P < 0.001). Composite MELD-Na-TE predicts mortality or liver transplant with the highest C-statistic of 0.81. Age (HR 1.05, 95% CI 1-1.09, P = 0.04), TE (HR 1.04, 95% CI 1.03-1.06, P < 0.001) and composite MELD-Na-TE (HR 1.11, 95% CI 1.06-1.15, P < 0.001) were significantly associated with hepatic decompensation. CONCLUSION Composite MELD-Na-TE better predicts liver transplantation, death, and hepatic decompensation compared to MELD/MELD-Na or TE alone.
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Model for end-stage liver disease score predicts complications after liver transplantation. Langenbecks Arch Surg 2020; 406:55-65. [PMID: 33140185 DOI: 10.1007/s00423-020-02018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Increased model for end-stage liver disease (MELD) score measured in the early postoperative course is associated with one-year mortality and graft loss. However, the correlation with postoperative complications has not been investigated. The aim of this study was to investigate the association between postoperative MELD score and subsequent complications. METHODS Adult liver transplant recipients transplanted from January 2011 until December 2016 were included. MELD score days 1-5 were correlated with complications day 6-30, subdivided into type and severity according to Clavien-Dindo classification. RESULTS We included 246 adult liver transplant recipients. Between days 6 and 30, 671 complications occurred in 201 of the patients (82%) corresponding to 64% of all postoperative complications in the whole postoperative period (days 0-30). In multivariate analyses adjusted for recipient gender and age, preoperative MELD score, and Eurotransplant Donor Risk Index, postoperative MELD score was significantly associated with having one or more complications, any type of complication except cardiovascular and renal complications, and complication severity. CONCLUSIONS Postoperative MELD score days 1-5 were associated with complications arising in the subsequent period 6-30 days after transplantation. An increased MELD score should heighten the clinician's awareness of a possible complication.
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The effect of cirrhosis on trauma outcomes: A systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 88:536-545. [PMID: 31389920 DOI: 10.1097/ta.0000000000002464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The negative effect of cirrhosis on mortality following traumatic injury has been quantified in multiple observational studies. However, to our knowledge, the information contained in these studies has never been synthesized. The aims of this study were: (1) to determine the magnitude of the effect of liver cirrhosis on mortality, morbidity, and hospital course among trauma patients and (2) to analyze sources of study heterogeneity that may lead to differing estimates in the observed mortality rate among patients with cirrhosis. METHODS A systematic search of EMBASE and PubMed was conducted. Data were extracted from eligible studies and analyzed using a random-effects model to compare trauma outcomes in cirrhotic and noncirrhotic patients (PROSPERO Registration CRD42018088464). Mortality was the primary outcome. Secondary outcomes included complication rate, length of hospital stay, length of intensive care unit stay, and mechanical ventilation days. RESULTS Title and abstract review of 15,958 articles led to the identification of 31 relevant articles. Ultimately, 18 observational studies were included in this meta-analysis. The pooled effect sizes for mortality (odds ratio [OR], 4.52; 95% confidence interval [CI], 3.13-6.54) and complication rate (OR, 1.92; 95% CI, 1.30-2.85) were higher in the cirrhotic group than the noncirrhotic group. Trauma patients with cirrhosis also incurred longer hospital stays (mean difference, 3.81 days; 95% CI, 1.22-6.41) and longer ICU stays (mean difference, 2.40 days; 95% CI, 0.65-4.15). There was no difference in days spent on mechanical ventilation. CONCLUSION Preexisting liver cirrhosis is associated with increased mortality rate, complication rate, and length of hospitalization among trauma patients, even after adjusting for confounding factors and potential sources of between-study heterogeneity. Trauma patients with cirrhosis would benefit from heightened surveillance and injury prevention interventions. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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Luo M, Mu R, Liu JF, Bai FH. Novel computerized psychometric tests as primary screening tools for the diagnosis of minimal hepatic encephalopathy. World J Clin Cases 2020; 8:3377-3389. [PMID: 32913845 PMCID: PMC7457114 DOI: 10.12998/wjcc.v8.i16.3377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/05/2020] [Accepted: 07/14/2020] [Indexed: 02/06/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) is a critical neurocognitive complication of decompensated liver cirrhosis and portosystemic shunting, which results in a wide range of cognitive deficits including impairments in working attention, psychomotor speed, and executive function. Current guidelines have recommended paper-and-pencil psychometric tests for the diagnosis of MHE. Most high-risk cirrhotic patients are required to be examined; however, paper-and-pencil psychometric tests are neither convenient nor rapid to perform in the clinic. Recently, novel computerized psychometric tests, including the inhibitory control test, EncephalApp Stroop App, and critical flicker frequency, have been proven to be rapid, effective, and convenient methods for screening MHE in clinical practice and for identifying high-risk cirrhotic patients for further validation using rigid neuropsychometric examinations. However, diagnostic accuracy of these tests is influenced by educational background, age, and cultural differences. This review summarizes clinical evidence of the application of novel computerized psychometric tests for screening MHE.
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Affiliation(s)
- Ming Luo
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
| | - Rui Mu
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
| | - Jian-Fang Liu
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
| | - Fei-Hu Bai
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
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Yao Y, Yang D, Huang Y, Dong M. Predictive value of insulin-like growth factor 1-Child-Turcotte-Pugh score for mortality in patients with decompensated cirrhosis. Clin Chim Acta 2020; 505:141-147. [PMID: 32119835 DOI: 10.1016/j.cca.2020.02.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/13/2020] [Accepted: 02/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies have used a modified version of the Child-Turcotte-Pugh (CTP) score to include insulin-like growth factor 1 (IGF-1) concentrations, denoted the Insulin-like Growth Factor 1-Child-Turcotte-Pugh (IGF-CTP) system. We evaluated the predictive power of IGF-CTP for 1-year mortality in patients with decompensated cirrhosis (DC). METHODS A total of 386 patients with DC were retrospectively analyzed. Comparison of distribution of patients with decompensated cirrhosis according to Insulin-like Growth Factor-1-Child-Turcotte-Pugh and Child-Turcotte-Pugh scores were performed. Area under the receiver operating characteristic curves (AUROCs) for IGF-CTP, CTP and the Model for End-stage Liver Disease (MELD) scores were evaluated to compare predictive value. Univariate and multivariate analyses were carried out to determine potential risk factors for 1-y mortality. RESULTS During the 1-y follow-up, 94 patients died. Significantly more patients (both surviving and non-surviving) were classified as IGF-CTP stage C than CTP stage C. The AUROC of IGF-CTP was significantly higher than that of CTP and MELD in the training and validation cohorts. Multivariate analysis indicated IGF-CTP score and IGF-1 to be independently associated with mortality. CONCLUSION The IGF-CTP score is independently associated with mortality for patients with DC, and offers more accurate prediction of 1-y mortality than either CTP or MELD score for these patients.
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Affiliation(s)
- Yifan Yao
- Department of Laboratory Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, 79 Qingchun Road, Hangzhou 310003, China.
| | - Donglei Yang
- Department of Laboratory Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, 79 Qingchun Road, Hangzhou 310003, China
| | - Yandi Huang
- Department of Laboratory Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, 79 Qingchun Road, Hangzhou 310003, China
| | - Minya Dong
- Department of Laboratory Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, 79 Qingchun Road, Hangzhou 310003, China
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Godfrey EL, Malik TH, Lai JC, Mindikoglu AL, Galván NTN, Cotton RT, O'Mahony CA, Goss JA, Rana A. The decreasing predictive power of MELD in an era of changing etiology of liver disease. Am J Transplant 2019; 19:3299-3307. [PMID: 31394020 DOI: 10.1111/ajt.15559] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 06/24/2019] [Accepted: 07/19/2019] [Indexed: 01/25/2023]
Abstract
The field of liver transplantation has shifted considerably in the MELD era, including changing allocation, immunosuppression, and liver failure etiologies, as well as better supportive therapies. Our aim was to evaluate the predictive accuracy of the MELD score over time. The United Network for Organ Sharing provided de-identified data on 120 156 patients listed for liver transplant from 2002-2016. The ability of the MELD score to predict 90-day mortality was evaluated by a concordance (C-) statistic and corroborated with competing risk analysis. The MELD score's concordance with 90-day mortality has downtrended from 0.80 in 2003 to 0.70 in 2015. While lab MELD scores at listing and transplant climbed in that interval, score at waitlist death remained steady near 35. Listing age increased from 50 to 54 years. HCV-positive status at listing dropped from 33 to 17%. The concordance of MELD and mortality does not differ with age (>60 = 0.73, <60 = 0.74), but is lower in diseases that are increasing most rapidly-alcoholic liver disease and non-alcoholic fatty liver disease-and higher in those that are declining, particularly in HCV-positive patients (HCV positive = 0.77; negative = 0.73). While MELD still predicts mortality, its accuracy has decreased; changing etiology of disease may contribute.
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Affiliation(s)
- Elizabeth L Godfrey
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Tahir H Malik
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ayse L Mindikoglu
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - N Thao N Galván
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ronald T Cotton
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Christine A O'Mahony
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Integrated model for end-stage liver disease maybe superior to some other model for end-stage liver disease-based systems in addition to Child-Turcotte-Pugh and albumin-bilirubin scores in patients with hepatitis B virus-related liver cirrhosis and spontaneous bacterial peritonitis. Eur J Gastroenterol Hepatol 2019; 31:1256-1263. [PMID: 31498284 DOI: 10.1097/meg.0000000000001481] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES For mortality prediction of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis, no direct comparisons have been made among the eight models, Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease (MELD), MELD-Na, integrated MELD (iMELD) score, MELD to sodium (MESO) index, modification of the MELD scoring system (Refit MELD), Refit MELD-Na and Albumin-Bilirubin (ALBI) score. MATERIALS AND METHODS Between January 2005 and July 2017, 314 patients who met the criteria for liver cirrhosis with the first episode of SBP were enrolled in this retrospective study. Clinical and laboratory data were obtained at diagnosis. Patients were followed up until February 2018 or death. RESULTS Patients were predominantly middle-aged male. Hepatitis B virus (HBV) infection accounted for the majority of the etiologies (41.7%) with 33.6% of the patients received antivirals. The in-hospital mortality rate was 39.8%. The cumulative 3-month and 6-month mortality rates were 51.6 and 60.2%, respectively. For patients with HBV related, not hepatitis C virus or alcohol related, liver cirrhosis, iMELD had the highest area under receiver operating characteristic curve (AUC) and was significantly superior to MELD, MESO, and Refit MELD in addition to CTP and ALBI scores in predicting 3-month and 6-month mortality. CONCLUSION For patients with HBV-related liver cirrhosis and SBP, iMELD had the highest AUC among these eight models and was significantly superior to MELD, MESO, and Refit MELD in addition to CTP and ALBI scores in predicting 3-month and 6-month mortalities.
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Yoshida EM, Mason A, Peltekian KM, Shah H, Thiele S, Borrelli R, Fischer A. Epidemiology and liver transplantation burden of primary biliary cholangitis: a retrospective cohort study. CMAJ Open 2018; 6:E664-E670. [PMID: 30578275 PMCID: PMC6303180 DOI: 10.9778/cmajo.20180029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is a wealth of data documenting the epidemiology of primary biliary cholangitis (PBC) globally; however, the epidemiology of PBC has not been as well studied in Canada. Our study characterized the Canadian prevalence of PBC and the number of liver transplantations because of PBC. METHODS For this retrospective cohort study we used national hospital administrative records from the Canadian Institute for Health Information, with the exception of Quebec for the prevalence estimate and Quebec and British Columbia for the transplant analysis. Prevalent patients were identified through a diagnostic code for PBC of the Canadian version of the 10th revision of the International Classification of Diseases. PBC transplant patients were identified from their transplant record. Descriptive statistics were used to summarize the characteristics of the study cohorts. RESULTS In 2015, 8680 patients with PBC were identified in Canada, translating to a prevalence of 318 cases per million. Annual prevalence by province varied, ranging from 283 (95% confidence interval [CI] 269-297) cases per million to 465 (95% CI 426-504) cases per million, and the 6-year PBC liver transplantation rate ranged from 3.17 (95% CI 1.27-6.54) to 5.92 (95% CI 3.71-9.08) per million. The Atlantic provinces exhibited the highest PBC prevalence and close to the highest 6-year liver transplantation rate (465 [95% CI 426-504] cases per million and 5.70 [95% CI 426-504, 3.19-9.56] cases per million, respectively). We observed the lowest PBC prevalence (283 [95% CI 269-297] cases per million) and the second lowest 6-year liver transplantation rate in Ontario (3.37 [95% CI 2.47-4.50] cases per million). INTERPRETATION The prevalence of PBC that we found in Canada is similar to the prevalence reported in other studies, but our work also indicates geographic variation within this country. Given our finding of geographic clustering of PBC across Canada, we hypothesize that environmental and genetic factors contribute to the pathogenesis of this condition.
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Affiliation(s)
- Eric M Yoshida
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Andrew Mason
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Kevork M Peltekian
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Hemant Shah
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Sherri Thiele
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Richard Borrelli
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Aren Fischer
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont.
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Butt AA, Ren Y, Lo Re V, Taddei TH, Kaplan DE. Comparing Child-Pugh, MELD, and FIB-4 to Predict Clinical Outcomes in Hepatitis C Virus-Infected Persons: Results From ERCHIVES. Clin Infect Dis 2018; 65:64-72. [PMID: 28369305 DOI: 10.1093/cid/cix224] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/15/2017] [Indexed: 12/15/2022] Open
Abstract
Background Identifying hepatitis C virus (HCV)-positive persons at high risk of early complications can help prioritize treatment decisions. We conducted this study to compare Child-Turcotte-Pugh (CP), MELD, and FIB-4 scores for predicting clinical outcomes and to identify those at low risk of complications. Methods Within electronically retrieved cohort of HCV-infected veterans, we identified HCV-positive persons and excluded those with human immunodeficiency virus (HIV), hepatitis B surface antigen (HBsAg), prevalent hepatic decompensation (HD), hepatocellular carcinoma (HCC), and those treated for HCV. We calculated incidence rates for HD, HCC, and all-cause mortality at 1, 3, and 5 years after HCV diagnosis. Using receiver operating characteristic (ROC) curves, we determined the optimal cut-off values for each score for these outcomes. Results Among 21 116 persons evaluated, 89.7% were CP Class-A, 79.9% had MELD<9, and 43.4% had FIB-4<1.45. AUROC for HD at 1, 3, and 5 years was higher for FIB-4 (0.84-0.86) compared with MELD (0.70-0.76) (P < .001). AUROC for HCC at 1, 3, and 5 years was 0.81-0.82 for FIB-4 but 0.61-0.68 for CP and MELD scores. (P < .001) AUROC for all-cause mortality at 3 and 5 years was 0.65-0.68. The optimal cut-off scores to identify persons at low risk of complications were as follows: CP <5; MELD <8; FIB-4 <3 for HD and HCC, and <2 for all-cause mortality, below which <1.5% developed HD and HCC and ≤2.5% died at 3 years. Conclusions FIB-4 score is a better predictor of HD and HCC in HCV-positive persons. A score of <3 is associated with a low risk of HD and HCC 1 and 3 years after HCV diagnosis.
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Affiliation(s)
- Adeel A Butt
- VA Pittsburgh Healthcare System, Pennsylvania.,Weill Cornell Medical College, Doha, Qatar, and New York, New York.,Hamad Healthcare Quality Institute and Hamad Medical Corporation, Doha, Qatar
| | - Yanjie Ren
- VA Pittsburgh Healthcare System, Pennsylvania
| | - Vincent Lo Re
- University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven.,Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - David E Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Assessment of cerebral microbleeds by susceptibility-weighted imaging at 3T in patients with end-stage organ failure. Radiol Med 2018; 123:441-448. [PMID: 29455423 DOI: 10.1007/s11547-018-0863-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 02/07/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Cerebral microbleeds (CMBs) are small rounded lesions representing cerebral hemosiderin deposits surrounded by macrophages that results from previous microhemorrhages. The aim of this study was to review the distribution of cerebral microbleeds in patients with end-stage organ failure and their association with specific end-stage organ failure risk factors. MATERIALS AND METHODS Between August 2015 and June 2017, we evaluated 15 patients, 9 males, and 6 females, (mean age 65.5 years). Patients population was subdivided into three groups according to the organ failure: (a) chronic kidney failure (n = 8), (b) restrictive cardiomyopathy undergoing heart transplantation (n = 1), and (c) end-stage liver failure undergoing liver transplantation (n = 6). The MR exams were performed on a 3T MR unit and the SWI sequence was used for the detection of CMBs. CMBs were subdivided in supratentorial lobar distributed, supratentorial non-lobar distributed, and infratentorial distributed. RESULTS A total of 91 microbleeds were observed in 15 patients. Fifty-nine CMBs lesions (64.8%) had supratentorial lobar distribution, 17 CMBs lesions (18.8%) had supratentorial non-lobar distribution and the remaining 15 CMBs lesions (16.4%) were infratentorial distributed. An overall predominance of supratentorial multiple lobar localizations was found in all types of end-stage organ failure. The presence of CMBs was significantly correlated with age, hypertension, and specific end-stage organ failure risk factors (p < 0.001). CONCLUSIONS CMBs are mostly founded in supratentorial lobar localization in end-stage organ failure. The improved detection of CMBs with SWI sequences may contribute to a more accurate identification of patients with cerebral risk factors to prevent complications during or after the organ transplantation.
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Radisavljevic MM, Bjelakovic GB, Nagorni AV, Stojanovic MP, Radojkovicn MD, Jovic JZ, Ignjatovic AM, Radisavljevic MM, Simonovic MM. Predictors of Mortality in Long-Term Follow-Up of Patients with Terminal Alcoholic Cirrhosis: Is It Time to Accept Remodeled Scores? Med Princ Pract 2017; 26:169-175. [PMID: 27676412 PMCID: PMC5588345 DOI: 10.1159/000451057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 09/27/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To identify the prognostic score that is the best predictor of outcome in patients hospitalized with decompensated liver cirrhosis. MATERIAL AND METHODS In this prospective study, 126 patients were enrolled and followed up for 29 months. For each patient, prognostic scores were calculated; these included the Child-Turcotte-Pugh score (CTP score), CTP creatinine-modified I score, CTP creatinine-modified II score, Model for End-Stage Liver Disease (MELD score), MELD model for end-stage liver disease sodium-modified score, Integrated MELD score, updated MELD score, United Kingdom MELD, and the MELD score remodeled by serum sodium index (MESO index). Cox regression analysis was used to assess the ability of each of the scores for predicting mortality in patients with alcoholic cirrhosis. Their discriminatory ability was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS The updated MELD score had the highest predictive value (3.29) among the tested scores (95% CI: 2.26-4.78). ROC curve analysis demonstrated that the MELD score of 22.50 (AUC = 0.914, 95% CI: 0.849-0.978; p < 0.001) had the best discriminative ability for identifying patients with a high risk of mortality; the next best was the MESO index of 16.00 (AUC = 0.912, 95% CI: 0.847-0.978; p < 0.001). CONCLUSION The risk of mortality was highest in patients with the highest updated MELD score, and those with MELD scores >22.50 and a MESO index >16.00.
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Affiliation(s)
- Mirjana M. Radisavljevic
- Department of Gastroenterology, Belgrade, Serbia
- *Dr. Mirjana M. Radisavljevic, Department of Gastroenterology, Clinical Center of Nis, Stanoja Bunusevca Street 16/41, RS-18000 Nis (Serbia), E-Mail
| | | | | | | | | | - Jasna Z. Jovic
- Department of Department of Gastroenterology, Medical Military Academy Belgrade, Belgrade, Serbia
| | | | | | - Maja M. Simonovic
- Department of Clinic for Mental Health, Clinical Center of Nis, Belgrade, Serbia
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Peng Y, Qi X, Guo X. Child-Pugh Versus MELD Score for the Assessment of Prognosis in Liver Cirrhosis: A Systematic Review and Meta-Analysis of Observational Studies. Medicine (Baltimore) 2016; 95:e2877. [PMID: 26937922 PMCID: PMC4779019 DOI: 10.1097/md.0000000000002877] [Citation(s) in RCA: 281] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Child-Pugh and MELD scores have been widely used for the assessment of prognosis in liver cirrhosis. A systematic review and meta-analysis aimed to compare the discriminative ability of Child-Pugh versus MELD score to assess the prognosis of cirrhotic patients.PubMed and EMBASE databases were searched. The statistical results were summarized from every individual study. The summary areas under receiver operating characteristic curves, sensitivities, specificities, positive and negative likelihood ratios, and diagnostic odds ratios were also calculated.Of the 1095 papers initially identified, 119 were eligible for the systematic review. Study population was heterogeneous among studies. They included 269 comparisons, of which 44 favored MELD score, 16 favored Child-Pugh score, 99 did not find any significant difference between them, and 110 did not report the statistical significance. Forty-two papers were further included in the meta-analysis. In patients with acute-on-chronic liver failure, Child-Pugh score had a higher sensitivity and a lower specificity than MELD score. In patients admitted to ICU, MELD score had a smaller negative likelihood ratio and a higher sensitivity than Child-Pugh score. In patients undergoing surgery, Child-Pugh score had a higher specificity than MELD score. In other subgroup analyses, Child-Pugh and MELD scores had statistically similar discriminative abilities or could not be compared due to the presence of significant diagnostic threshold effects.Although Child-Pugh and MELD scores had similar prognostic values in most of cases, their benefits might be heterogeneous in some specific conditions. The indications for Child-Pugh and MELD scores should be further identified.
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Affiliation(s)
- Ying Peng
- From the Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang (YP, XQ, XG); and Postgraduate College, Dalian Medical University, Dalian, China (YP)
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Hassan EA, Abdel Rehim ASE. Creatinine modified Child-Turcotte-Pugh and integrated model of end-stage liver disease scores as predictors of spontaneous bacterial peritonitis-related in-hospital mortality: Applicable or not. J Gastroenterol Hepatol 2015; 30:1205-10. [PMID: 25678363 DOI: 10.1111/jgh.12918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIMS Despite intensive management, spontaneous bacterial peritonitis (SBP) is associated with poor prognosis especially in hospitalized patients. Therefore, the aim of this study was to determine prognostic factors for SBP-related in-hospital mortality, and to evaluate the predictive power of Child-Pugh (CP), model of end-stage liver disease (MELD), creatinine modified Child-Turcotte-Pugh (CrCTP), and integrated MELD (iMELD) for identifying the best score to predict mortality. METHODS Predictors of SBP-related in-hospital mortality were assessed using regression analysis over 100 cirrhotic patients. Predictive abilities of CP, MELD, CrCTP, and iMELD were compared using the area under receiver operating characteristic curve (AUC). RESULTS SBP-related in-hospital mortality was 22%. Age, serum creatinine, bilirubin, sodium, CrCTP, MELD, and iMELD were associated with mortality. Using AUC, CrCTP, and iMELD was significantly better than CP and MELD in predicting in-hospital mortality, where iMELD had the highest AUC (0.862). The cut-off with the best ability to predict in-hospital mortality was 43.5 for iMELD. CONCLUSION Age, serum creatinine, bilirubin, and sodium were associated with SBP-related in-hospital mortality. The incorporation of these variables into CP and MELD significantly improves their predictive ability. iMELD followed by CrCTP provided useful prognostic information for critically ill patients with SBP.
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Affiliation(s)
- Elham Ahmed Hassan
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Chaib E, Amaku M, Coutinho FAB, Lopez LF, Burattini MN, D’Albuquerque LAC, Massad E. A mathematical model for optimizing the indications of liver transplantation in patients with hepatocellular carcinoma. Theor Biol Med Model 2013; 10:60. [PMID: 24139285 PMCID: PMC4016553 DOI: 10.1186/1742-4682-10-60] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 10/10/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The criteria for organ sharing has developed a system that prioritizes liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) who have the highest risk of wait-list mortality. In some countries this model allows patients only within the Milan Criteria (MC, defined by the presence of a single nodule up to 5 cm, up to three nodules none larger than 3 cm, with no evidence of extrahepatic spread or macrovascular invasion) to be evaluated for liver transplantation. This police implies that some patients with HCC slightly more advanced than those allowed by the current strict selection criteria will be excluded, even though LT for these patients might be associated with acceptable long-term outcomes. METHODS We propose a mathematical approach to study the consequences of relaxing the MC for patients with HCC that do not comply with the current rules for inclusion in the transplantation candidate list. We consider overall 5-years survival rates compatible with the ones reported in the literature. We calculate the best strategy that would minimize the total mortality of the affected population, that is, the total number of people in both groups of HCC patients that die after 5 years of the implementation of the strategy, either by post-transplantation death or by death due to the basic HCC. We illustrate the above analysis with a simulation of a theoretical population of 1,500 HCC patients with tumor size exponentially. The parameter λ obtained from the literature was equal to 0.3. As the total number of patients in these real samples was 327 patients, this implied in an average size of 3.3 cm and a 95% confidence interval of [2.9; 3.7]. The total number of available livers to be grafted was assumed to be 500. RESULTS With 1500 patients in the waiting list and 500 grafts available we simulated the total number of deaths in both transplanted and non-transplanted HCC patients after 5 years as a function of the tumor size of transplanted patients. The total number of deaths drops down monotonically with tumor size, reaching a minimum at size equals to 7 cm, increasing from thereafter. With tumor size equals to 10 cm the total mortality is equal to the 5 cm threshold of the Milan criteria. CONCLUSION We concluded that it is possible to include patients with tumor size up to 10 cm without increasing the total mortality of this population.
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Affiliation(s)
- Eleazar Chaib
- Department of Gastroenterology, Liver and Pancreas Transplantation Surgery Unit, LIM 37, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Marcos Amaku
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Francisco AB Coutinho
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Luis F Lopez
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Marcelo N Burattini
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Luiz AC D’Albuquerque
- Department of Gastroenterology, Liver and Pancreas Transplantation Surgery Unit, LIM 37, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
| | - Eduardo Massad
- Department of Medical Informatics, LIM 01, School of Medicine, University of Sao Paulo, Av.Dr. Arnaldo 455, Sao Paulo CEP 01246-903, Brazil
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Hassan EA, Abd El-Rehim ASED. A revised scope in different prognostic models in cirrhotic patients: Current and future perspectives, an Egyptian experience. Arab J Gastroenterol 2013; 14:158-64. [PMID: 24433645 DOI: 10.1016/j.ajg.2013.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 04/28/2013] [Accepted: 08/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND STUDY AIM The prognosis of cirrhosis is of great interest for liver transplantation and new therapies of related complications. Traditional prognostic models such as Child-Pugh (CP) and Model for End-stage Liver Disease (MELD) were developed to predict mortality in decompensated cirrhosis, but lack parameter(s) related to complications. Recently, new models such as creatinine-modified Child-Turcotte-Pugh (CrCTP) and sodium-based MELD variants were developed to improve prognostic accuracy and enhance outcome predictive capability. Our aim was to investigate the prognostic ability of these models and their relation to complications among Egyptian cirrhotic patients to determine the best one and to assess adding new variables to improve the prognostic ability of that model. PATIENTS AND METHODS A total of 1000 cirrhotic patients were enrolled in a retrospective study; traditional and new prognostic models such as CP, MELD, CrCTP, integrated MELD (iMELD), MELD plus sodium (MELD-Na, MELDNa) and MELD:sodium ratio (MESO) were calculated. The predictive abilities of prognostic models were compared using the area under receiver operating characteristic curve (AUC) and 1-year survival rates were evaluated by Kaplan-Meier survival analysis. An index of cirrhosis-related complications was added to reveal the best prognostic model. RESULTS Using AUC, MELD and its sodium variants was significantly better than CP and CrCTP scores in predicting risk of 1-year mortality, where MELD-sodium (MELD-Na) had the highest AUC (0.743). Adding an index of cirrhosis-related complications (C) to MELD-Na creating a new scoring system (MELD-Na-C) improved its prognostic accuracy (AUC 0.753). Kaplan-Meier survival curves predicted increased mortality with higher prognostic scores. CONCLUSIONS All prognostic models were good predictors of 1-year mortality in patients with decompensated cirrhosis; however, MELD-Na was the best for outcome prediction. MELD-Na-C was a new model enhancing the predictive accuracy in assessing cirrhotic patients with related complications.
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Affiliation(s)
- Elham Ahmed Hassan
- Department of Tropical Medicine and Gastroenterology, Assiut University, Assiut, Egypt
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