Can the MEGX test and serum bile acids improve the prognostic ability of Child-Pugh's score in liver cirrhosis?

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

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.

Clinical characteristics and predictors of esophagogastric variceal bleeding among patients with HCV-induced liver cirrhosis: An observational comparative study

OBJECTIVES

To investigate the clinical characteristics, risk factors, and predictors of esophagogastric variceal bleeding in patients with hepatitis C virus (HCV)-induced liver cirrhosis.

METHODS

This comparative observational study was carried out on 100 patients suffering from post hepatitis cirrhosis and portal hypertension who were admitted to the Internal Medicine Department, Al-Azhar University Hospital, Damietta Egypt. Patients were classified into two groups: 50 of them presented with esophagogastric varices with acute variceal bleeding, and 50 patients presented without bleeding. Data were collected, coded, revised, and entered into the Stata software version 16.

RESULTS

The mean age of patients with bleeding was slightly higher than those without bleeding (55.58 ± 5.89 vs. 52.54 ± 9.01 years), p = 0.049. Mild ascites, positive H.Pylori, and Child-Pugh score B and C were an independent predictors of esophagogastric variceal bleeding (OR = 0.036, 95% CI: 0.0004-0.36; p = 0.005), (OR = 7.36, 95% CI: 1.44-37.59; p = 0.016), (OR = 19.0, 95% CI: 2.02-186.3; p = 0.010), and (OR = 40.51, 95% CI: 2.18-751.31; p = 0.013). The sensitivity of this model was 93.88%, specificity was 53.85%, PPV was 88.46%, NPV was 70.0%, correctly classified patients were 85.48%, and AUC was 90.27%. In the second model, pepsinogen level higher than 43.5 μg/l, AST (>54.5), Bilirubin (>1.45), and Hemoglobin (>11.5) were a significant independent predictors of esophagogastric variceal bleeding (OR = 1.18, 95% CI: 1.09-1.27; p<0.001), (OR = 1.14, 95% CI: 1.03-1.27; p = 0.007), (OR = 5.55, 95% CI: 1.21-25.43; p = 0.027), and (OR = 0.05, 95% CI: 0.008-0.32; p = 0.002), respectively. The sensitivity of this model was 92%, specificity was 98%, PPV was 97.87%, NPV was 92.45%, correctly classified patients were 95%, and AUC was 98.68%.

CONCLUSION

The independent predictors of esophagogastric variceal bleeding were ascites, positive H. pylori, Child-Pugh score B and C, pepsinogen level higher than 43.5 μg/l, AST (>54.5), bilirubin (>1.45), and hemoglobin (>11.5). Laboratory investigations are more reliable in predicting variceal bleeding and excluding non-variceal bleeding; however, clinical symptoms should not be neglected, especially H. pylori infection, ascites, and Child-Pugh score.

Insulin-like growth factor 1/Child-Turcotte-Pugh composite score as a predictor of treatment outcomes in patients with advanced hepatocellular carcinoma treated with sorafenib

Background: Sorafenib was the first systemic therapy approved for the treatment of Child-Turcotte-Pugh (CTP) class A patients with advanced hepatocellular carcinoma (HCC). However, there are no biomarkers to predict survival and treatment outcomes and guide HCC systemic therapy. Type 1 insulin-like growth factor (IGF-1)/CTP composite score has emerged as a potential hepatic reserve assessment tool. Our study investigated the association of the IGF/CTP score with overall survival (OS) and progression-free survival (PFS) of HCC patients treated with sorafenib.

Materials and Methods: In this prospective study, patients with HCC were treated with sorafenib and followed up until progression/death. We calculated the IGF/CTP score and used the Kaplan-Meier method and log-rank test to estimate and compare the time-to-event outcomes between patient subgroups.

Results: 171 patients were included, 116 of whom were CTP class A. Median PFS for IGF/CTP score AA and AB patients were 6.88 and 4.28 months, respectively (p = 0.1359). Median OS for IGF/CTP score AA and AB patients were 14.54 and 7.60 months, respectively (p = 0.1378). The PFS and OS was superior in AA patients, but the difference was not significant, likely due to the sample size. However, there was a significant difference in early OS and PFS curves between AA and AB (p = 0.0383 and p = 0.0099), respectively.

Conclusions: In CTP class A patients, IGF/CTP score B was associated with shorter PFS and OS, however, study was underpowered to reach statistical significance. If validated in larger cohorts, IGF/CTP score may serve as stratification tool in clinical trials, a hepatic reserve assessment tool for HCC outcomes prediction and to assist in therapy decisions.

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

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.

Correlation between Liver Elasticity by Ultrasound Elastography and Liver Functional Reserve

No worldwide consensus on the assessment tool for liver functional reserve is currently available. The aim of this study was to evaluate the correlation between liver elasticity of both hepatic lobes and liver functional reserve tests. This prospective observational study comprised 40 patients scheduled for hepatectomy. Liver elasticity was assessed by Virtual Touch Quantification (VTQ). The mean VTQ value for the right and left lobes was defined as the mVTQ. Liver functional reserve was measured with technetium-99m-diethylenetriaminepentaacetic acid-galactosyl-human serum albumin scintigraphy as LHL15 and HH15 and the indocyanine green (ICG) excretion test as ICG-R15 and ICG-K. All examinations were measured after biliary decompression confirmed serum a total bilirubin level ≤2 mg/dL. Mean VTQ values were moderately correlated with LHL15 (r = -0.42, p < 0.01), HH15 (r = 0.48, p < 0.01), ICG-R15 (r = 0.53, p < 0.01) and ICG-K (r = -0.61, p < 0.01) values. In conclusion, the liver elasticity determined by VTQ would be a useful predictor of liver functional reserve in patients scheduled for hepatectomy.

Potential use of metabolic breath tests to assess liver disease and prognosis: has the time arrived for routine use in the clinic?

The progression of liver disease may be unique among organ system diseases in that progressive fibrosis compromises not only the sufficiency of hepatocyte mass but also impairs blood flow to the liver, resulting in porto-systemic shunting. Although liver biopsy as an assessment of fibrosis has become the key biomarker of and target for new therapies, it is invasive and subject to sampling error, and cannot quantify metabolic function or porto-systemic shunting. Measurement of the hepatic venous pressure gradient accommodates some of the deficiencies of biopsy but requires expertise not widely available and misses minor changes in hepatocellular mass and thereby information about metabolic function. Thus, an unmet need in clinical hepatology remains unfulfilled: a noninvasive biomarker which quantitates both the hepatocellular insufficiency and porto-systemic shunting inherent in progressive hepatic fibrosis. Ideally, such a biomarker should correlate with clinical endpoints including liver-related survival and cirrhotic complications, be performed at the point-of-care, and be affordable and easy to use. This review, an expert opinion, summarizes background and recent data suggesting that metabolic breath tests may now meet these requirements and have a valid place in clinical hepatology to supplant the time-honoured assessment of hepatic fibrosis.

Validation of a Modified Child-Turcotte-Pugh Classification System Utilizing Insulin-Like Growth Factor-1 for Patients with Hepatocellular Carcinoma in an HBV Endemic Area

BACKGROUND

Recently, a modified insulin-like growth factor-1 (IGF)-Child-Turcotte-Pugh (CTP) classification was proposed to improve the original CTP classification. This study aimed to validate the new IGF-CTP classification system as a prognostic maker for patients with hepatocellular carcinoma (HCC) in a hepatitis B virus endemic area.

METHODS

We conducted a post-hoc analysis of a prospective cohort study. We used Harrell's C-index and U-statistics to compare the prognostic performance of both IGF-CTP and CTP classifications for overall survival. We evaluated the relationship between HCC stage and the four components of the IGF-CTP classification (serum levels of IGF-1, albumin, and total bilirubin and prothrombin time [PT]) using nonparametric trend analysis.

RESULTS

We included a total of 393 patients in this study. In all, 55 patients died during the median follow-up of 59.1 months. There was a difference between IGF-CTP class and CTP class in 14% of patients. Overall, the IGF-CTP classification system had a higher prognostic value (C-index = 0.604, 95% confidence interval [CI] = 0.539-0.668) than the CTP system (C-index = 0.558, 95% CI = 0.501-0.614), but the difference was not statistically significant (P = .07 by U-statistics). A lower serum level of IGF-1 was related to a more advanced cancer stage (P < .01). The remaining components of the IGF-CTP classification were not significantly related to tumor stage (P = .11 for total bilirubin; P = .33 for albumin; and P = .39 for PT).

CONCLUSIONS

The IGF-CTP classification was slightly better than the original CTP classification for predicting survival of patients with HCC in a chronic hepatitis B endemic area. This is most likely due to the fact that serum IGF-1 levels reflect underlying HCC status.

Modified CLIP with objective liver reserve assessment retains prognosis prediction for patients with advanced hepatocellular carcinoma

BACKGROUND AND AIM

The Cancer of the Liver Italian Program (CLIP) score is a commonly used staging system for hepatocellular carcinoma (HCC) helpful with predicting prognosis of advanced HCC. CLIP uses the Child-Turcotte-Pugh (CTP) score to evaluate liver reserve. A new scoring system, the albumin-bilirubin (ALBI) grade, has been proposed as they objectively evaluate liver reserve. We examined whether the modification of CLIP with ALBI retained its prognosis prediction for patients with advanced HCC.

METHODS

We included patients who received first-line antiangiogenic therapy for advanced HCC. Liver reserve was assessed using CTP and ALBI scores, which were then incorporated into CLIP and ALBI-CLIP, respectively. To assess their efficacies of prognostic prediction, the Cox's proportional hazard model and concordance indexes were used.

RESULTS

A total of 142 patients were included; 137 of them were classified CTP A and 5 patients CTP B. Patients could be divided into four or five groups with different prognosis according to CLIP and ALBI-CLIP, respectively. Higher R(2) (0.249 vs 0.216) and lower Akaike information criterion (995.0 vs 1001.1) were observed for ALBI-CLIP than for CLIP in the Cox's model predicting overall survival. ALBI-CLIP remained an independent predictor for overall survival when CLIP and ALBI-CLIP were simultaneously incorporated in Cox's models allowing variable selection with adjustment for hepatitis etiology, treatment, and performance status. The concordance index was also higher for ALBI-CLIP than for CLIP (0.724 vs 0.703).

CONCLUSIONS

Modification of CLIP scoring with ALBI, which objectively assesses liver reserve, retains and might have improved prognosis prediction for advanced HCC.

Validation of an IGF-CTP scoring system for assessing hepatic reserve in Egyptian patients with hepatocellular carcinoma

Background

The Child-Turcotte-Pugh score (CTP) is the standard tool for hepatic reserve assessment in hepatocellular carcinoma (HCC). Recently, we reported that integrating plasma insulin-like growth factor-1 (IGF-1) level into the CTP score was associated with better patient risk stratification in two U.S. independent cohorts. Our current study aimed to validate the IGF-CTP score in patients who have different demographics and risk factors.

Patients and Methods

We prospectively recruited 100 Egyptian patients and calculated their IGF-CTP score compared to CTP score. C-index was used to compare the prognostic significance of the two scoring systems. Finally, we compared our results with our U.S. cohorts published data.

Results

IGF-CTP score showed significant better patient stratification compared to CTP score in the international validation cohort. Among CTP class A patients, who usually considered for active treatment and clinical trial enrollment, 32.5% were reclassified as IGF-CTP class B with significantly shorter OS than patients reclassified as class A with hazard ratio [HR] = 6.15, 95% confidence interval [CI] = 2.18-17.37.

Conclusion

IGF-CTP score showed significantly better patient stratification and survival prediction not only in the U.S. population but also in international validation population, who had different demographics and HCC risk factors.

Serum Bile Acids Are Associated with Pathological Progression of Hepatitis B-Induced Cirrhosis

Recent metabonomic studies have identified an important role of bile acids in patients with liver cirrhosis. Serum bile acids, such as glycocholate (GCA), glycochenodeoxycholate (GCDCA), taurocholate (TCA), and taurochenodeoxycholate (TCDCA), increased significantly in liver cirrhosis patients. Our recently published urinary metabonomic study showed that glycocholate 3-glucuronide, taurohyocholate, TCA, glycolithocholate 3-sulfate, and glycoursodeoxycholate (GUDCA) were markedly increased in hepatitis B-induced cirrhotic patients (n = 63) compared with healthy controls (n = 31). The urinary levels of GUDCA were able to differentiate among three stages of cirrhotic patients with Child-Pugh (CP) score A, B, and C. In this study, we recruited two new cohorts of patients with hepatitis-B-induced cirrhosis and healthy control subjects and quantitatively profiled their serum bile acids using ultra-performance liquid chromatography triple quadrupole mass spectrometry. Serum bile acid profile and corresponding differential bile acids were characterized, in addition to the blood routine, liver, and renal function tests. The alterations of bile acids contributing to the intergroup variation between healthy controls and cirrhotic patients and among pathological stages of CP grade A, B and C were also investigated. Five bile acids, GCA, GCDCA, TCA, TCDCA, and GUDCA, were significantly altered among different stages of liver cirrhosis (n = 85), which was validated with an independent cohort of cirrhotic patients (n = 53). Our results show that dynamic alteration of serum bile acids is indicative of an exacerbated liver function, highlighting their potential as biomarkers for staging the liver cirrhosis and monitoring its progression.

Use of the methacetin breath test to classify the risk of cirrhotic complications and mortality in patients evaluated/listed for liver transplantation

BACKGROUND & AIMS

The MELD score predicts short-term mortality in patients with cirrhosis; however, some patients with low scores develop complications and die unexpectedly. Consequently, we evaluated the diagnostic accuracy of the methacetin breath test (MBT), an assay of liver metabolic function, and the MELD score, to predict the risk of complications of cirrhosis and liver-related death.

METHODS

One hundred sixty-five patients with cirrhosis received oral (13)C-methacetin; (13)CO2 was measured in expired breath (BreathID; Exalenz). The cumulative percent dose recovery of (13)CO2 at 20 min with a threshold of ⩽0.55% (high-risk) and >0.55% (low risk) most accurately predicted liver-related death and the risk of cirrhotic complications within one year. MELD thresholds of ⩾15 and ⩾19 were also examined to predict the same endpoints.

RESULTS

Dose recovery ⩽0.55% and MELD ⩾19 both predicted liver-related death (HR 12.6 [95% CI 1.6-98.3]; p=0.016, and HR 5.5 [1.6-18.9]; p=0.007, respectively); MELD ⩾15 did not. Dose recovery ⩽0.55% (HR 1.9 [1.1-3.2]; p=0.03) also predicted the risk of ⩾1 complication(s), and was particularly able to foretell the risk of development/exacerbation of ascites (HR 4.7 [1.8-11.9]; p=0.001), which was not achieved by either MELD threshold. Finally, in patients with MELD <19, dose recovery ⩽0.55% predicted the risk of death (p=0.017), development of ⩾1 cirrhotic complication(s) (p=0.062), and development/exacerbation of ascites (p=0.0009).

CONCLUSIONS

In this pilot study, methacetin breath testing predicted the risk of liver-related death and development/exacerbation of ascites more accurately than MELD ⩾15 or ⩾19. In patients with low MELD (<19points), MBT may be useful to identify patients in whom the frequency of clinical observation should be intensified.

Urinary metabolite profiling offers potential for differentiation of liver-kidney yin deficiency and dampness-heat internal smoldering syndromes in posthepatitis B cirrhosis patients

Zheng is the basic theory and essence of traditional Chinese medicine (TCM) in diagnosing diseases. However, there are no biological evidences to support TCM Zheng differentiation. In this study we elucidated the biological alteration of cirrhosis with TCM “Liver-Kidney Yin Deficiency (YX)” or “Dampness-Heat Internal Smoldering (SR)” Zheng and the potential of urine metabonomics in TCM Zheng differentiation. Differential metabolites contributing to the intergroup variation between healthy controls and liver cirrhosis patients were investigated, respectively, and mainly participated in energy metabolism, gut microbiota metabolism, oxidative stress, and bile acid metabolism. Three metabolites, aconitate, citrate, and 2-pentendioate, altered significantly in YX Zheng only, representing the abnormal energy metabolism. Contrarily, hippurate and 4-pyridinecarboxylate altered significantly in SR Zheng only, representing the abnormalities of gut microbiota metabolism. Moreover, there were significant differences between two TCM Zhengs in three metabolites, glycoursodeoxycholate, cortolone-3-glucuronide, and L-aspartyl-4-phosphate, among all differential metabolites. Metabonomic profiling, as a powerful approach, provides support to the understanding of biological mechanisms of TCM Zheng stratification. The altered urinary metabolites constitute a panel of reliable biological evidence for TCM Zheng differentiation in patients with posthepatitis B cirrhosis and may be used for the potential biomarkers of TCM Zheng stratification.

Systemic vascular resistance in cirrhosis: a predictor of severity?

Background

The aim of this study was to investigate whether systemic vascular resistance (SVR) correlates with validated prospective scoring systems such as Model for End-stage Liver Disease (MELD) and its modifications.

Methods

Patients with cirrhosis, who were admitted to hospital with decompensation (as defined by development of ascites, hepatic encephalopathy, and variceal bleeding) and underwent echocardiography were included in this study. Laboratory data required for computing MELD score, serum bilirubin, serum creatinine, international normalized ratio, and serum sodium were collected for every patient. We tabulated hemodynamic and echocardiography parameters that enabled calculation of SVR. We analyzed the correlation between SVR and each of the individual prognostic scores.

Results

A total of 771 patients with a diagnosis of decompensated cirrhosis were included in the study. Two hundred and sixty-two patients were found to have a low sodium level (<135 mEq/L) and 509 were found to have a normal sodium level (>135 mEq/L). In the patients with hyponatremia, we found statistically significant inverse correlations between SVR and validated liver severity models. However, these correlations were not seen in patients with normonatremia.

Conclusion

We observed a statistically significant inverse correlation between SVR and all the validated liver disease severity models used in this study among patients with hyponatremia but not in those with normonatremia.

Development and validation of insulin-like growth factor-1 score to assess hepatic reserve in hepatocellular carcinoma

Background

Child-Turcotte-Pugh (CTP) score is the standard tool to assess hepatic reserve in hepatocellular carcinoma (HCC), and CTP-A is the classic group for active therapy. However, CTP stratification accuracy has been questioned. We hypothesized that plasma insulin-like growth factor 1 (IGF-1) is a valid surrogate for hepatic reserve to replace the subjective parameters in CTP score to improve its prognostic accuracy.

Methods

We retrospectively tested plasma IGF-1 levels in the training set (n = 310) from MD Anderson Cancer Center. Recursive partitioning identified three optimal IGF-1 ranges that correlated with overall survival (OS): greater than 50ng/mL = 1 point; 26 to 50ng/mL = 2 points; and less than 26ng/mL = 3 points. We modified the CTP score by replacing ascites and encephalopathy grading with plasma IGF-1 value (IGF-CTP) and subjected both scores to log-rank analysis. Harrell’s C-index and U-statistics were used to compare the prognostic performance of both scores in both the training and validation cohorts (n = 155). All statistical tests were two-sided.

Results

Patients’ stratification was statistically significantly stronger for IGF-CTP than CTP score for the training (P = .003) and the validation cohort (P = .005). Patients reclassified by IGF-CTP relative to their original CTP score were better stratified by their new risk groups. Most important, patients classified as A by CTP but B by IGF-CTP had statistically significantly worse OS than those who remained under class A by IGF-CTP in both cohorts (P = .03 and P < .001, respectively, from Cox regression models). AB patients had a worse OS than AA patients in both the training and validation set (hazard ratio [HR] = 1.45, 95% confidence interval [CI] = 1.03 to 2.04, P = .03; HR = 2.83, 95% CI = 1.65 to 4.85, P < .001, respectively).

Conclusions

The IGF-CTP score is simple, blood-based, and cost-effective, stratified HCC better than CTP score, and validated well on two independent cohorts. International validation studies are warranted.

A revised scope in different prognostic models in cirrhotic patients: Current and future perspectives, an Egyptian experience

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.

Urinary metabolite variation is associated with pathological progression of the post-hepatitis B cirrhosis patients

Cirrhosis is a common and terminal outcome of many chronic liver conditions. A urinary metabonomic study using gas chromatography-mass spectrometry (GC-MS) and ultra performance liquid chromatography time-of-flight mass spectrometry (UPLC-TOFMS) was carried out to elucidate the pathophysiological basis of posthepatitis B cirrhosis in 63 posthepatitis B cirrhosis patients and 31 health controls. Urinary metabolic profile and corresponding differential metabolites associated with Child-Pugh (CP) grading of liver function were characterized, in addition to the blood routine, liver, and renal function tests. Multivariate statistical tools including principal component analysis (PCA) and orthogonal partial least-squares-discriminant analysis (OPLS-DA) were employed in the metabolite analysis along with a univariate statistical method, Wilcoxon-Mann-Whitney test. The alterations of differential metabolites contributing to the intergroup variation between healthy controls and cirrhotic patients, and among cirrhosis of CP grade A, B and C were also investigated. Six metabolites, α-hydroxyhippurate, tyrosine-betaxanthin, 3-hydroxyisovalerate, canavaninosuccinate, estrone, and glycoursodeoxycholate, were significantly altered among cirrhotic patients with CP A, B, and C, reflecting abnormal metabolism of amino acid, bile acids, hormones, and intestinal microbial metabolism. The results show that dynamic alteration of urinary metabolome, characterized by the changes of a panel of the differential metabolite markers, is indicative of an exacerbated liver function, highlighting their diagnostic and prognostic potential for the liver cirrhosis development.

Predicting morbidity and mortality after hepatic resection in patients with hepatocellular carcinoma: the role of Model for End-Stage Liver Disease score

BACKGROUND

The Model for End-Stage Liver Disease (MELD) score is currently used as a disease severity index of cirrhotic patients awaiting liver transplantation. This study evaluated the usefulness of the MELD score in predicting mortality and morbidity of patients with hepatocellular carcinoma (HCC) undergoing hepatic resection.

METHODS

The study cohort consisted of 1,017 patients who underwent hepatic resection for HCC between 1991 and 2005. Patient variables were examined by univariate and multivariate analyses to identify risk factors for morbidity and mortality. Accuracy in predicting mortality was assessed with the area under the receiver operator characteristic curve (AUC) analysis.

RESULTS

The morbidity and mortality rates were 30.7% and 1.9%, respectively. Age, liver cirrhosis, operation time, and MELD score were risk factors for mortality, whereas indocyanine green retention rate at 15-min value, operation time, blood loss, and Child-Turcotte-Pugh score were risk factors for morbidity. Patients with MELD score >8 had higher mortality (4.0% vs. 0.6%, p = 0.004) and higher liver-related morbidities (16.1% vs. 4.3%, p < 0.001), including massive ascites, intra-abdominal hemorrhage, and hepatic failure, compared with patients with MELD score <6. High MELD score also was related to longer postoperative hospital stay (score >8, 14.5 days vs. score <6, 12.6 days, p = 0.015). The AUC for MELD score as a predictor of mortality was 0.718, indicating high clinical usefulness.

CONCLUSIONS

The MELD score relates with mortality and liver-related morbidities in HCC patients who undergo hepatic resection. A MELD score >8 represents the trigger for intensive treatment to improve patient outcome.

A fourth dimension in decision making in hepatology

Today, the assessment of liver function in patients suffering from acute or chronic liver disease is based on liver biopsy and blood tests including synthetic function, liver enzymes and viral load, most of which provide only circumstantial evidence as to the degree of hepatic impairment. Most of these tests lack the degree of sensitivity to be useful for follow-up of these patients at the frequency that is needed for decision making in clinical hepatology. Accurate assessment of liver function is essential to determine both short- and long-term prognosis, and for making decisions about liver and non-liver surgery, TIPS, chemoembolization or radiofrequency ablation in patients with chronic liver disease. Liver function tests can serve as the basis for accurate decision-making regarding the need for liver transplantation in the setting of acute failure or in patients with chronic liver disease. The liver metabolic breath test relies on measuring exhaled (13) C tagged methacetin, which is metabolized only by the liver. Measuring this liver-specific substrate by means of molecular correlation spectroscopy is a rapid, non-invasive method for assessing liver function at the point-of-care. The (13) C methacetin breath test (MBT) is a powerful tool to aid clinical hepatologists in bedside decision-making. Our recent findings regarding the ability of point-of-care (13) C MBT to assess the hepatic functional reserve in patients with acute and chronic liver disease are reviewed along with suggested treatment algorithms for common liver disorders.

Assessment of liver function in acute or chronic liver disease by the methacetin breath test: a tool for decision making in clinical hepatology

Patients suffering from acute or chronic liver disease require on-going assessment of disease progression in terms of the degree of hepatic fibrosis and overall liver impairment. This assessment is pivotal for determining the prognosis and for making decisions about medical treatment and liver transplantation. Currently available methods are either invasive, lack diagnostic accuracy or are limited by technical difficulties such as obesity or biochemical confounders. The metabolic breath test relies on the measurement of tagged metabolites of an organ-specific substrate in the exhaled breath. (13)C-methacetin is metabolized uniquely by the liver, and (13)CO(2) is measured continuously in the exhaled breath. Measuring this liver-specific substrate using molecular correlation spectroscopy provides a rapid, point-of-care, non-invasive method to assess liver function. The use of the (13)C-methacetin breath test (MBT) may provide a powerful tool for clinical hepatologists in decision making at the bedside. This paper reviews recent findings regarding the ability of the point-of-care (13)C-MBT to assess fibrosis, cirrhosis and hepatic functional reserve in patients with acute and chronic liver disease.

Application of a biochemical and clinical model to predict individual survival in patients with end-stage liver disease

AIM: To investigate the capability of a biochemical and clinical model, BioCliM, in predicting the survival of cirrhotic patients.

METHODS: We prospectively evaluated the survival of 172 cirrhotic patients. The model was constructed using clinical (ascites, encephalopathy and variceal bleeding) and biochemical (serum creatinine and serum total bilirubin) variables that were selected from a Cox proportional hazards model. It was applied to estimate 12-, 52- and 104-wk survival. The model’s calibration using the Hosmer-Lemeshow statistic was computed at 104 wk in a validation dataset. Finally, the model’s validity was tested among an independent set of 85 patients who were stratified into 2 risk groups (low risk ≤ 8 and high risk > 8).

RESULTS: In the validation cohort, all measures of fit, discrimination and calibration were improved when the biochemical and clinical model was used. The proposed model had better predictive values (c-statistic: 0.90, 0.91, 0.91) than the Model for End-stage Liver Disease (MELD) and Child-Pugh (CP) scores for 12-, 52- and 104-wk mortality, respectively. In addition, the Hosmer-Lemeshow (H-L) statistic revealed that the biochemical and clinical model (H-L, 4.69) is better calibrated than MELD (H-L, 17.06) and CP (H-L, 14.23). There were no significant differences between the observed and expected survival curves in the stratified risk groups (low risk, P = 0.61; high risk, P = 0.77).

CONCLUSION: Our data suggest that the proposed model is able to accurately predict survival in cirrhotic patients.

Growth hormone-stimulated IGF-1 generation in cirrhosis reflects hepatocellular dysfunction

BACKGROUND/AIMS

Previous studies reported decreased serum IGF-1 levels in cirrhosis. We aimed to correlate GH-stimulated IGF-1 responses with both MELD and Child-Pugh scores and determine the impact of portal hypertension and nutrition on IGF-1 responses.

METHODS

Fifty-three patients (56+/-2 yrs) with cirrhosis were enrolled. Serum IGF-1 levels were measured by RIA before and 24h after a single injection of GH (0.06 mg/kg).

RESULTS

Compared to controls, basal IGF-1 levels were significantly decreased in patients with cirrhosis (17.3+/-6.3 vs 13.6+/-5.1, P<0.001). Increments in IGF-1 levels were significantly lower in cirrhotic patients (controls: 133% vs 49% in MELD score <10, 38% in MELD score 11-18, and 13% in MELD score 19-24, p<0.001). 37% of patients had blunted IGF-1 responses. Increments in IGF-1 levels correlated with albumin (r=0.6), portal congestive index (r=0.4), and MAMC (r=0.25). By multivariate analysis, only CP (OR 5.7) and MELD scores (OR 4.5) accurately differentiated between blunted or non-blunted IGF-1 responses and not portal hypertension (OR 0.9) or malnutrition (OR 1.35).

CONCLUSIONS

Cirrhosis is associated with low IGF-1 levels and an attenuated response to exogenous GH. These findings correlate better with the extent of hepatic dysfunction rather than the presence of portal hypertension or malnutrition.

Prognostic value of quantitative liver function tests in viral cirrhosis: a prospective study

BACKGROUND AND AIMS

Widespread application of quantitative liver function tests as a prognostic tool is controversial. In this study we assessed the predictivity of serial evaluations of galactose elimination capacity (GEC) and the monoethylglycinexylidide (MEGX) test on survival in viral cirrhosis, and secondarily we compared these tests with Child-Turcotte-Pugh (CTP) and Model for End Stage Liver Disease (MELD) scores.

METHODS

In a cohort of 35 patients with viral cirrhosis, GEC and MEGX were evaluated every 6 months for 24 months and compared with CTP and MELD scores at the same time intervals. The end points were patient death or liver transplantation.

RESULTS

Statistically significant differences between dead/transplanted patients and survivors were found for basal values of GEC, MEGX, CTP and MELD. Receiver-operating characteristics curves of CTP and MELD scores showed a higher prognostic accuracy than GEC and MEGX. On multivariate analysis, neither GEC nor MEGX were independent predictors of survival. Repeated-measures analysis of GEC and MEGX did not increase the prognostic accuracy of these tests and did not add useful prognostic information on patient outcome during the following 6 months.

CONCLUSIONS

Our data suggest that neither single nor repeated determinations of GEC and MEGX are superior to CTP and MELD scores in predicting prognosis of patients with viral cirrhosis.

Preoperative preparation of patients with advanced liver disease

OBJECTIVE

To review the characteristic features of patients with advanced liver disease that may lead to increased perioperative morbidity and mortality rates.

DESIGN

Literature review.

RESULTS

Patients with end-stage liver disease are at high risk of major complications and death following surgery. The most common complications are secondary to acute liver failure and include severe coagulopathy, encephalopathy, adult respiratory distress syndrome, acute renal failure, and sepsis. The degree of malnutrition, control of ascites, level of encephalopathy, prothrombin time, concentration of serum albumin, and concentration of serum bilirubin predict the risk of complications and death following surgery. Other determinants of adverse outcome include emergency surgery, advanced age, and cardiovascular disease. Portal hypertension is a prominent feature of advanced liver disease, and it predisposes the patient to variceal hemorrhage, hepatorenal syndrome, hepatopulmonary syndrome, and uncontrolled ascites. Portal hypertension can be ameliorated by percutaneous or surgical portasystemic shunting procedures. If well-defined contraindications are not present, patients with advanced liver disease should be evaluated for orthotopic liver transplantation from a cadaver donor or possible living-related liver transplantation.

CONCLUSIONS

Optimal preparation, which addresses the common features of advanced liver disease, may decrease the risk of complications or death following surgery. Preparation should include correcting coagulopathy, minimizing preexisting encephalopathy, preventing sepsis, and optimizing renal function.

Improvement of prognostic power of the Child-Pugh classification of liver cirrhosis by hyaluronan

BACKGROUND/AIMS

Modifications of the Child-Pugh classification of liver cirrhosis by incorporation of hyaluronan were tested to improve the prognostic power for long term evaluation of liver cirrhosis in 126 patients observed over a period of 10 years.

METHODS

Serum concentrations of HA were determined at study entry. Statistical analysis included Kaplan-Meier life tables and stepwise multivariant Cox-regression analysis for each parameter of Child-Pugh classification and hyaluronan. Prognostic models were developed by exchanging prothrombin time, albumin and encephalopathy by HA in different combinations.

RESULTS

Based on a good single correlation between hyaluronan (0.62) and clinical course (P<0.01) we conclude that models with hyaluronan instead of albumin or encephalopathy and with or without shifted threshold values of bilirubin and albumin are superior for the prediction of the long term prognosis. In Cox-regression analysis, apart from hyaluronan and bilirubin, no other parameters contributed to an improvement.

CONCLUSIONS

We conclude that a modification of the Child-Pugh classification of liver cirrhosis by inclusion of HA significantly improves the predictive power of CP, especially in alcoholic etiology. A prospective validation of the newly defined scores needs to be done in the future.

Reduced use of intensive care after liver transplantation: patient attributes that determine early transfer to surgical wards

Part 1 of our report, presented in the same issue of the Journal, shows that immediate postoperative extubation and direct transfer to the surgical ward is safe and reduces reliance on the intensive care unit in most liver transplant recipients. However, there is no method to preoperatively predict which patients will need ventilatory support after surgery. To address this issue, we examined the relationship between perioperative patient attributes and extubation outcome in patients entered into our immediate postoperative extubation study from 1996 to 1998. Variables chosen stemmed from considerations in the literature. We examined the influence of 13 preoperative and 6 intraoperative factors on extubation outcome. Preoperative attributes included sex, race, diagnosis, United Network for Organ Sharing status, Child-Pugh score, presence of a portosystemic shunt, ascites, encephalopathy, coagulation, age, body mass index (BMI), creatinine level, and year of surgery. Intraoperative factors were type of surgery, surgeon, anesthesiologist, number of red blood cells administered, length of surgery, and surgical start time. Female sex (P =.02), BMI of 32 or greater (P =.015), portosystemic shunt (P =.022), and encephalopathy (P =.041) were associated with no attempt by the physician to extubate, whereas encephalopathy (P =.01) and BMI of 34 or greater (P =.002) were associated with failure to meet criteria for postoperative extubation (described in part 1 of this study). We conclude there are limited factors that predict an increased risk for postoperative respiratory failure in liver transplant recipients. Our results indicate that physicians are conservative in their approach to extubation immediately after surgery, and sole reliance on physician judgment to determine suitability for postoperative extubation leads to unnecessary use of postoperative cardiopulmonary support.

Histologic determinants of monoethylglycinexylidide formation in patients with chronic hepatitis C

Patients affected by chronic hepatitis C (CHC) display a peculiar histologic picture characterized by the presence of steatosis and bile duct damage in addition to evidence of inflammation, necrosis, and fibrosis. In the staging of these patients, functional evaluation may be considered a complementary tool. The monoethylglycinexylidide (MEGX) test has been used in diagnostic and prognostic assessment of chronic liver disease as a quantitative liver function test. In this study the authors evaluated whether different sampling times for the test could reflect different histologic patterns. The authors studied 82 patients with biopsy-proven CHC who underwent functional evaluation by means of MEGX test. The authors found that MEGX15 better reflected the histologic findings of necrosis and inflammation, and MEGX60 the presence of fibrosis. Neither steatosis nor bile duct damage showed a strong correlation with either sampling time. Moreover, MEGX levels showed a progressive decrease as histologic grading of chronic hepatitis progressively increased. Stepwise regression analysis identified necrosis and inflammation as histologic variables associated with both MEGX15 and MEGX30, and fibrosis as a variable associated with MEGX60. These results suggest that a decline in liver metabolic function corresponds to a progressive increase in liver damage, and that this circumstance should be taken into account when prescribing drugs to patients with CHC.