Child-Pugh Versus MELD Score for the Assessment of Prognosis in Liver Cirrhosis: A Systematic Review and Meta-Analysis of Observational Studies

Do Child–Turcotte–Pugh and nutritional assessments predict survival in cirrhosis: A longitudinal study

BACKGROUND

Cirrhotic patients face heightened energy demands, leading to rapid glycogen depletion, protein degradation, oxidative stress, and inflammation, which drive disease progression and complications. These disruptions cause cellular damage and parenchymal changes, resulting in vascular alterations, portal hypertension, and liver dysfunction, significantly affecting patient prognosis.

AIM

To analyze the association between Child–Turcotte–Pugh (CTP) scores and different nutritional indicators with survival in a 15-year follow-up cohort.

METHODS

This was a retrospective cohort study with 129 cirrhotic patients of both sexes aged > 18 years. Diagnosis of cirrhosis was made by liver biopsy. The first year of data collection was 2007, and data regarding outcomes were collected in 2023. Data were gathered from medical records, and grouped by different methods, including CTP, handgrip strength, and triceps skinfold cutoffs. The prognostic values for mortality were assessed using Kaplan–Meier curves and multivariate binary logistic regression models.

RESULTS

The coefficient for CTP was the only statistically significant variable (Wald = 5.193, P = 0.023). This suggests that with a negative change in CTP classification score, the odds of survival decrease 52.6%. The other evaluated variables did not significantly predict survival outcomes in the model. Kaplan–Meier survival curves also indicated that CTP classification was the only significant predictor.

CONCLUSION

Although different classifications showed specific differences in stratification, only CTP showed significant predictive potential. CTP score remains a simple and effective predictive tool for cirrhotic patients even after longer follow-up.

Comparison of different severity scores in correlating hemoglobin levels with the severity of hepatic decompensation: An observational study

BACKGROUND

Chronic liver disease is a growing global health problem, leading to hepatic decompensation characterized by an array of clinical and biochemical complications. Several scoring systems have been introduced in assessing the severity of hepatic decompensation with the most frequent ones are Child-Pugh score, model of end-stage liver disease (MELD) score, and MELD-Na score. Anemia is frequently observed in cirrhotic patients and is linked to worsened clinical outcomes. Although studies have explored anemia in liver disease, few have investigated the correlation of hemoglobin level with the severity of hepatic decompensation.

AIM

To determine the relationship between hemoglobin levels and the severity of decompensated liver disease and comparing the strength of this correlation using the Child-Pugh, MELD, and MELD-Na scores.

METHODS

This cross-sectional study was conducted at a tertiary care hospital with 652 decompensated liver disease patients enrolled in the study. Data was collected on demographics, clinical history, and laboratory findings, including hemoglobin levels, bilirubin, albumin, prothrombin time (international normalized ratio), sodium, and creatinine. The Child-Pugh, MELD, and MELD-Na scores were calculated. Statistical analysis was performed using Statistical Package for the Social Sciences version 26, and correlations between hemoglobin levels and severity scores were assessed using Spearman's correlation coefficient.

RESULTS

The study included 405 males (62.1%) and 247 females (37.9%) with an average age of 58.8 years. Significant inverse correlations were found between hemoglobin levels and Child-Pugh, MELD, and MELD-Na scores (P < 0.01), with the MELD scoring system being the strongest correlator among all. One-way analysis of variance revealed significant differences in hemoglobin levels across the severity groups of each scoring system (P = 0.001). Tukey's post hoc analysis confirmed significant internal differences among each severity group.

CONCLUSION

Understanding the correlation between hemoglobin and liver disease severity can improve patient management by offering insights into prognosis and guiding treatment decisions.

Esophagectomy in patients with liver cirrhosis: systematic review and meta-analysis of short-term outcomes

Patients with esophageal cancer and concomitant liver cirrhosis (LC) pose a surgical challenge because of the increased risk of postoperative complications and mortality. Purpose of this study was to review the existing literature and estimate perioperative short-term outcomes of esophagectomy in this patient population. Systematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. The search was last updated on July 30th, 2024. Primary outcomes were anastomotic leak (AL) and 90 day mortality. Ten observational studies were included for a total of 387 patients with LC. The age of the included patients ranged from 35 to 85 years, 91.2% were males. The main causes of liver cirrhosis were alcoholic (75%) and viral hepatitis (20.4%). Esophageal squamous cell carcinoma was diagnosed in 58.7% of patients. Ivor-Lewis esophagectomy with intrathoracic anastomosis was reported in 69.9% of patients, while McKeown esophagectomy with cervical anastomosis was reported in 30.1% of patients. The estimated pooled prevalence of AL and 90-day mortality were 13% (95% CI = 6-24%; I2 = 72%) and 17% (95% CI = 10-27%; I2 = 72%), respectively. The estimated pooled prevalence of postoperative pulmonary complication, sepsis, and liver failure were 52% (95% CI = 39-65%), 30% (95% CI = 14-52%), and 9% (95% CI = 4-17%), respectively. Esophagectomy can be performed in properly selected patients with LC and concomitant esophageal cancer. Foregut surgeons should be aware of the not negligible postoperative complications rates and mortality. Risk stratification and attentive perioperative care are essential to minimize serious adverse events.

A retrospective cohort study of coagulation function in patients with liver cirrhosis receiving cefoperazone/sulbactam with and without vitamin K1 supplementation

BACKGROUND

Cefoperazone/sulbactam is commonly prescribed for the treatment of infected patients with cirrhosis.

AIM

To investigate the effect of cefoperazone/sulbactam on coagulation in cirrhotic patients and assess the effectiveness of vitamin K1 supplementation in preventing cefoperazone/sulbactam-induced coagulation disorders.

METHOD

This retrospective cohort study compared coagulation function in 217 cirrhotic patients who received cefoperazone/sulbactam with and without vitamin K1 supplementation (vitamin K1 group, n = 108; non-vitamin K1 group, n = 109). Propensity score matching (PSM) was used to to reduce confounders' influence, the SHapley additive exPlanations (SHAP) model to explore the importance of each variable in coagulation disorders.

RESULTS

In the non-vitamin K1 group, the post-treatment prothrombin time (PT) was 16.5 ± 6.5 s and the activated partial thromboplastin time (aPTT) was 34.8 ± 9.4 s. These were significantly higher than pre-treatment values (PT: 14.6 ± 2.4 s, p = 0.005; aPTT: 30.4 ± 5.9 s, p < 0.001). In the vitamin K1 group, no differences were observed in PT, thrombin time, or platelet count, except for a slightly elevated post-treatment aPTT (37.0 ± 10.4 s) compared to that of pre-treatment (34.4 ± 7.2 s, p = 0.033). The vitamin K1 group exhibited a lower risk of PT prolongation (OR: 0.211, 95% CI: 0.047-0.678) and coagulation disorders (OR: 0.257, 95% CI: 0.126-0.499) compared to that of the non-vitamin K1 group. Propensity score matching analysis confirmed a reduced risk in the vitamin K1 group for prolonged PT (OR: 0.128, 95% CI: 0.007-0.754) and coagulation disorders (OR: 0.222, 95% CI: 0.076-0.575). Additionally, the vitamin K1 group exhibited lower incidences of PT prolongation, aPTT prolongation, bleeding, and coagulation dysfunction compared to the non-vitamin K1 group.

CONCLUSION

Cefoperazone/sulbactam use may be linked to a higher risk of PT prolongation and coagulation disorders in cirrhotic patients. Prophylactic use of vitamin K1 can effectively reduce the risk.

Quality of life, anxiety, and depression improve at one-year after liver transplantation in patients with advanced liver disease

Background

Liver transplantation (LT) improves survival in end-stage liver disease. Several reports have addressed the impact of LT on patients' lives, beyond purely medical outcomes. Although the quality of life and mental health have been demonstrated to improve with this procedure, such studies are still missing in Latin America.

Methods

Patients who received LT at the Fundación Santa Fe de Bogotá between 2017 and 2019 were assessed for quality of life (QoL), anxiety, and depression and they were followed up for one year after the procedure. Pre-transplant data were gathered at inclusion on the waiting list, while post-transplant data at 3- and 12 months after LT. European Quality of Life-5 Dimensions (EQ-5D) and European Quality of Life-Visual Analog Scale (EQ-VAS) instruments were used to evaluate QoL. The Hospital Anxiety and Depression Scale (HADS) was used for evaluating anxious and depressive symptoms.

Results

115 recipients met the inclusion criteria. Mean pre-transplant EQ-VAS was 70.78, rising to 87.16 and 92.56 at 3- and 12-months, respectively. Improvements in all EQ-5D dimensions were found in response to LT. According to the HADS questionnaire, anxiety was reduced by 2.35 points and depression by 1.63 points after LT.

Conclusion

in the short term, LT is a successful strategy for enhancing QoL, anxiety, and depression in patients with liver disease. Long-term benefits must be assessed.

Timing of endoscopy in cirrhotic patients with acute variceal bleeding: protocol of a multicenter randomized controlled trial

Background

Endoscopy is important for the diagnosis and treatment of acute upper gastrointestinal bleeding (AUGIB), especially acute variceal bleeding (AVB), in liver cirrhosis. However, the optimal timing of endoscopy remains controversial, primarily because the currently available evidence is of poor quality, and the definition of early endoscopy is also very heterogeneous among studies. Herein, a multicenter randomized controlled trial (RCT) is performed to explore the impact of the timing of endoscopy on the outcomes of cirrhotic patients with AVB.

Methods

A total of 368 cirrhotic patients presenting with AUGIB who are highly suspected to be from AVB will be enrolled. They will be stratified according to the severity of liver function and clinical presentation at admission and then randomly assigned at a 1:1 ratio into early (within 12 h after admission) and delayed (within 12-24 h after admission) endoscopy groups within each stratum. The primary outcomes include the rates of 5-day failure to control bleeding after admission and 6-week rebleeding. The secondary outcomes include 6-week mortality and incidence of adverse events.

Conclusion

Considering existing evidence originates from non-randomized studies, this RCT will provide high-quality evidence to uncover whether cirrhotic patients with AVB should undergo early endoscopy to control bleeding and improve survival.

Trial registration

ClinicalTrials.gov identifier: NCT06031402.

Use of Non-Invasive Biomarkers and Clinical Scores to Predict the Complications of Liver Cirrhosis: A Bicentric Experience

Background and objectives: Liver cirrhosis is a chronic, progressive condition characterized by fibrosis and architectural distortion of the liver, leading to impaired liver function and severe complications. Accurately predicting these complications is crucial to the improvement of patient outcomes. Therefore, this study aimed to evaluate the accuracy of various non-invasive biomarkers and clinical scores in assessing the risk of complications among cirrhotic patients. Materials and methods: We conducted an observational retrospective study involving 236 cirrhotic patients from two tertiary care hospitals in Italy and Romania, in a timespan ranging from January 2021 to March 2024. Data on clinical characteristics, liver function tests, hematological indices, various non-invasive biomarkers, and clinical scores were collected and analyzed. Receiver operating characteristic analysis was performed to assess the accuracy of these biomarkers and clinical scores in predicting complications, including the presence of varices and hepato-renal syndrome. Results: The Child-Pugh score showed the highest accuracy for cirrhosis-related complications, with an area under curve (AUC) = 0.667. The red cell distribution width coefficient of variation followed closely with an AUC = 0.646. While the Child-Pugh score had a high specificity (85.42%), its sensitivity was low (37.97%). In patients with varices, non-invasive scores such as platelet distribution width (PDW) and the RDW-to-platelet ratio (RPR) showed modest predictive ability, with an AUC = 0.594. For hepato-renal syndrome, the Model for End-Stage Liver Disease (MELD) score showed the highest diagnostic accuracy with an AUC = 0.758. Conclusions: The most reliable biomarkers for detecting complications, varices, and hepato-renal syndrome, are, respectively, the Child-Pugh Score, PDW along with RPR, and the MELD score. However, while these scores remain valuable, the moderate diagnostic accuracy of other indices suggests the need for a more integrated approach to risk stratification. Future research should focus on validating these tools across different populations and incorporating emerging biomarkers to enhance predictive accuracy and inform more effective clinical decision-making.

Clinical value of microRNA-130a as a marker of acute liver failure and its involvement in disease development

OBJECTIVE

This study was to investigate the clinical value of microRNA (miR)-130a in acute liver failure (ALF).

METHODS

ALF patients (n = 120, ALF group) and 106 healthy subjects (control group) were enrolled. Serum was collected to detect alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBIL) by automatic biochemical analyzer, and miR-130a by real-time fluorescence quantitative PCR. According to the Child-Pugh score, ALF patients could be divided into grades A, B, and C, and levels of ALT, AST, TBIL, and miR-130a in each grade were observed. Pearson correlation coefficient method was employed to analyze the correlation between miR-130a and Child-Pugh scores and liver function indices. ALF patients were divided into high-low miR-130a expression groups, and poor prognoses were observed. The influence of miR-130a on prognosis was analyzed by Kaplan-Meier curve, and the prognostic value of miR-130a was analyzed by the ROC curve.

RESULTS

miR-130a, ALT, AST, and TBIL were increased in the ALF group. miR-130a, ALT, AST, and TBIL increased with the increase of the Child-Pugh grade. miR-130a levels were positively correlated with ALT, AST, and TBIL levels. The incidence of poor prognoses was 58.33% in the miR-130a high expression group and 30% in the miR-130a low expression group. The prognosis of the miR-130a low expression group was better than that of the miR-130a high expression group, and miR-130a had predictive value for the prognosis of ALF patients.

CONCLUSION

miR-130a is increased in ALF, and it has high value for both diagnosis and prognosis in ALF patients, and patients with high levels of miR-130a have a poor prognosis.

Experience and challenges delivering hepatitis C virus treatment for people who inject drugs in Kenya

Despite having a higher risk of hepatitis C virus (HCV) infections, people who inject drugs (PWID) in sub-Saharan Africa (SSA) have limited access to HCV treatment. There is scarce literature on treatment delivery modalities that overcome logistical and financial barriers. We utilized different service delivery modalities to provide direct-acting antivirals (DAAs) to PWIDs infected with HCV through methadone clinics and needle and syringe program (NSP) sites in Kenya. In collaboration with Kenya's National AIDS and STI Control Programme (NASCOP), we enrolled individuals with active HCV infection confirmed by HCV RNA detection from methadone and NSP sites in Nairobi, Mombasa, and Kilifi counties. Liver function and hepatitis B virus (HBV) status were assessed at baseline. Those eligible for treatment were offered ledipasvir-sofosbuvir treatment provided by NASCOP through directly observed therapy (DOT). Participants completed a follow-up visit 12 weeks after completing treatment to measure sustained viral response (SVR-12). Challenges faced while delivering HCV treatment at participating sites included the limited availability and reliability of laboratory assays, and financial constraints faced by PWIDs to attend daily DOT. Based on our experience, strategies to deliver HCV treatment for PWID in Kenya should consider improving the availability of laboratory tests and prioritizing treatment through methadone centers to achieve good outcomes.

Artificial intelligence-based evaluation of prognosis in cirrhosis

Cirrhosis represents a significant global health challenge, characterized by high morbidity and mortality rates that severely impact human health. Timely and precise prognostic assessments of liver cirrhosis are crucial for improving patient outcomes and reducing mortality rates as they enable physicians to identify high-risk patients and implement early interventions. This paper features a thorough literature review on the prognostic assessment of liver cirrhosis, aiming to summarize and delineate the present status and constraints associated with the application of traditional prognostic tools in clinical settings. Among these tools, the Child-Pugh and Model for End-Stage Liver Disease (MELD) scoring systems are predominantly utilized. However, their accuracy varies significantly. These systems are generally suitable for broad assessments but lack condition-specific applicability and fail to capture the risks associated with dynamic changes in patient conditions. Future research in this field is poised for deep exploration into the integration of artificial intelligence (AI) with routine clinical and multi-omics data in patients with cirrhosis. The goal is to transition from static, unimodal assessment models to dynamic, multimodal frameworks. Such advancements will not only improve the precision of prognostic tools but also facilitate personalized medicine approaches, potentially revolutionizing clinical outcomes.

Evaluating the positive predictive value of code-based identification of cirrhosis and its complications utilizing GPT-4

BACKGROUND AND AIMS

Diagnosis code classification is a common method for cohort identification in cirrhosis research, but it is often inaccurate and augmented by labor-intensive chart review. Natural language processing using large language models (LLMs) is a potentially more accurate method. To assess LLMs' potential for cirrhosis cohort identification, we compared code-based versus LLM-based classification with chart review as a "gold standard."

APPROACH AND RESULTS

We extracted and conducted a limited chart review of 3788 discharge summaries of cirrhosis admissions. We engineered zero-shot prompts using a Generative Pre-trained Transformer 4 to determine whether cirrhosis and its complications were active hospitalization problems. We calculated positive predictive values (PPVs) of LLM-based classification versus limited chart review and PPVs of code-based versus LLM-based classification as a "silver standard" in all 3788 summaries. Compared to gold standard chart review, code-based classification achieved PPVs of 82.2% for identifying cirrhosis, 41.7% for HE, 72.8% for ascites, 59.8% for gastrointestinal bleeding, and 48.8% for spontaneous bacterial peritonitis. Compared to the chart review, Generative Pre-trained Transformer 4 achieved 87.8%-98.8% accuracies for identifying cirrhosis and its complications. Using LLM as a silver standard, code-based classification achieved PPVs of 79.8% for identifying cirrhosis, 53.9% for HE, 55.3% for ascites, 67.6% for gastrointestinal bleeding, and 65.5% for spontaneous bacterial peritonitis.

CONCLUSIONS

LLM-based classification was highly accurate versus manual chart review in identifying cirrhosis and its complications. This allowed us to assess the performance of code-based classification at scale using LLMs as a silver standard. These results suggest LLMs could augment or replace code-based cohort classification and raise questions regarding the necessity of chart review.

Liver function assessment based on hepatobiliary contrast agent-enhanced magnetic resonance imaging

BACKGROUND: Liver function assessment is very important in clinical practice. The use of magnetic resonance imaging for the anatomical and functional evaluation of the liver is possible in actual clinical practice. AIM: To examine the possibility of using hepatobiliary contrast-enhanced magnetic resonance imaging for the evaluation of liver function. MATERIALS AND METHODS: Datasets of patients who underwent gadoxetic acid-enhanced magnetic resonance imaging were retrospectively reviewed. Patients were divided into two groups: group 1 included patients with impaired liver function, and group 2 included those with normal liver function. Based on magnetic resonance imaging in the hepatobiliary phase, the liver parenchyma signal intensity and its ratio to spleen signal intensity and portal vein signal intensity were estimated. Differences among these parameters were compared between groups. The correlation between liver parenchyma signal intensity and laboratory blood tests reflecting liver function (total bilirubin, albumen, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma glutamyl transpeptidase, and prothrombin time) were analyzed. RESULTS: Datasets of 53 patients (25 men and 28 women, aged 24–84 years) were analyzed. Group 1 included 19 patients, whereas group 2 included 34. The median liver parenchyma signal intensity was 919.05 [669.65; 1258.35] in group 1 and 1525.13 [1460.5; 1631.4] in group 2 (p=0.0000001). The median ratio of liver parenchyma signal intensity to spleen signal intensity was 1.2 [1.04;1.7] in group 1 and 1.7 [1.46; 1.96] in group 2 (p=0.00076). The median ratio of liver parenchyma signal intensity to portal vein signal intensity was 1.44 [1.29; 1.83] in group 1 and 1.6 [1.43; 1.83] in group 2 (p=0.1). The estimated correlation values between liver parenchyma signal intensity and blood tests parameters were as follows: total bilirubin (r=–0.61; p=0.000001), albumen (r=0.13; p=0.61), aspartate aminotransferase (r=–0.57; p=0.000009), alanine aminotransferase (r=–0.44; p=0.001), alkaline phosphatase (r=–0.45; p=0.0007), gamma glutamyl transpeptidase (r=–0.5; p=0.0003), prothrombin time (r=–0.34; p=0.04). CONCLUSION: The study reflects the ability to assess liver function using indices (liver parenchyma signal intensity and its ratio to spleen signal intensity) derived from gadoxetic acid-enhanced magnetic resonance imaging. However, this study did not confirm the assumed effectiveness of using the liver parenchyma signal intensity to portal vein signal intensity ratio as an index of liver function. A significant inverse correlation was identified between liver parenchyma signal intensity and blood test parameters in reflecting liver function, except for albumin. The results indicate the possibility of using magnetic resonance imaging to assess liver function.

The effectiveness of exercise prehabilitation on aerobic capacity, muscle strength and body composition in patients with cirrhosis awaiting liver transplantation: a systematic review and meta-analysis protocol

INTRODUCTION

Cirrhosis is the main cause of morbidity and mortality globally, accounting for approximately 1.2 million deaths annually. Impaired aerobic capacity, muscle wasting and reduced muscle strength are significant complications in patients with cirrhosis. Preoperative exercise intervention "prehabilitation" has been recognised as a potential approach to optimise muscle strength, aerobic capacity and body composition as well as quality of life in patients awaiting abdominal surgery. However, there is little evidence on the effects of preoperative exercise on older adults with cirrhosis and awaiting liver transplant. Thus, the primary objective of this systematic review and meta-analysis will be to assess the effects of exercise interventions in improving aerobic capacity, muscle strength and body composition of older adults with cirrhosis and awaiting liver transplant.

METHODS AND ANALYSIS

This systematic review and metaanalysis protocol was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This systematic review will include all peer-reviewed randomised controlled trials (RCTs), including cluster RCTs, controlled (non-controlled), complex clinical trials (CCTs) or cluster trials, cohort, observational studies published in English from inception until July 2024. The following electronic databases will be searched: MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCO) and Scopus (Elsevier) and supplemented by a secondary screening of the reference lists of all included articles. Searches will involve studies with both male and female participants aged ≥ 18 years with cirrhosis and awaiting liver transplant. Primary outcomes will include muscle strength, and aerobic capacity. The secondary outcomes include body composition (e.g. body mass index, and thigh circumference). The Cochrane Collaboration Risk of Bias Tool will be used to evaluate quality of the studies and Review Manager (RevMan) V.5.3 (Copenhagen, Denmark: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). Effect sizes will be expressed as a standardised mean difference, and their 95% confidence intervals will be calculated and presented as a forest plot. The standard χ2 and I2 tests will be used to test heterogeneity.

CONCLUSION

This systematic review and meta-analysis is anticipated to provide meaningful and contemporary evidence on the effects of preoperative exercise in older adults living with cirrhosis and awaiting liver transplant. In addition, the findings will help clinicians with developing safe and effective preoperative exercise regimens for these patients.

Metabolic bariatric surgery, alcohol misuse and liver cirrhosis: a narrative review

Bariatric surgery and liver cirrhosis have considerable overlap. Bariatric procedures intend to reduce metabolic dysfunction-associated steatotic liver disease (MASLD); however, these procedures are thought to increase the propensity for alcohol misuse. This may predispose the bariatric surgical patient to a new form of liver insult in the postoperative period. This review explores the complex relationship between obesity and alcohol misuse in the context of the bariatric surgical patient. There is evidence to support the safety of bariatric procedures in compensated cirrhotic patients, with an improvement of liver function and architecture. However, data suggest that after a two-year period, these patients exhibit an increased propensity for alcohol misuse postoperatively, particularly after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) procedures. A paucity of evidence exists with respect to alcohol-induced liver dysfunction, or MASLD and increased alcohol intake (MetALD) in the post-bariatric surgery patient. This review aims to provide an overview of the current evidence and offer recommendations for further robust studies.

Potential mechanisms of traditional Chinese medicine in the treatment of liver cirrhosis: a focus on gut microbiota

Cirrhosis, a pathological stage that develops from various chronic liver diseases, is characterized by liver fibrosis, pseudolobular formation, and chronic inflammation. When it progresses to the decompensated phase, the mortality rate of cirrhosis can reach 80%. The role of gut microbiota in the progression of liver diseases has received significant attention. Numerous studies have shown that regulating gut microbiota has significant therapeutic effects on preventing and reversing liver cirrhosis. This article reviewed the mechanisms by which gut microbiota influence liver cirrhosis, explaining the effective therapeutic effects of traditional Chinese medicine. Through multi-directional regulation involving signaling pathways, gut microbiota diversity, and restoration of intestinal barrier function, traditional Chinese medicine has been promising in ameliorating liver cirrhosis, providing treatment options and pharmacological guidance for the occurrence and development of liver cirrhosis.

The Metabolomic Footprint of Liver Fibrosis

Both experimental and clinical liver fibrosis leave a metabolic footprint that can be uncovered and defined using metabolomic approaches. Metabolomics combines pattern recognition algorithms with analytical chemistry, in particular, 1H and 13C nuclear magnetic resonance spectroscopy (NMR), gas chromatography-mass spectrometry (GC-MS) and various liquid chromatography-mass spectrometry (LC-MS) platforms. The analysis of liver fibrosis by each of these methodologies is reviewed separately. Surprisingly, there was little general agreement between studies within each of these three groups and also between groups. The metabolomic footprint determined by NMR (two or more hits between studies) comprised elevated lactate, acetate, choline, 3-hydroxybutyrate, glucose, histidine, methionine, glutamine, phenylalanine, tyrosine and citrate. For GC-MS, succinate, fumarate, malate, ascorbate, glutamate, glycine, serine and, in agreement with NMR, glutamine, phenylalanine, tyrosine and citrate were delineated. For LC-MS, only β-muricholic acid, tryptophan, acylcarnitine, p-cresol, valine and, in agreement with NMR, phosphocholine were identified. The metabolomic footprint of liver fibrosis was upregulated as regards glutamine, phenylalanine, tyrosine, citrate and phosphocholine. Several investigators employed traditional Chinese medicine (TCM) treatments to reverse experimental liver fibrosis, and a commentary is given on the chemical constituents that may possess fibrolytic activity. It is proposed that molecular docking procedures using these TCM constituents may lead to novel therapies for liver fibrosis affecting at least one-in-twenty persons globally, for which there is currently no pharmaceutical cure. This in-depth review summarizes the relevant literature on metabolomics and its implications in addressing the clinical problem of liver fibrosis, cirrhosis and its sequelae.

Liver volumetry in cirrhotic patients with or without hepatocellular carcinoma: Its correlation with Child-Pugh, model for end-stage liver diseases and indocyanine green dye test

BACKGROUND AND OBJECTIVES

To evaluate the correlation between non-tumoral liver volume (NTLV) by computed tomography (CT) volumetry and indocyanine green retention at 15 minutes (ICG-r15%), Child-Pugh score (CTP) and model for end-stage liver diseases (MELD) score in cirrhotic patients having hepatocellular carcinoma (HCC) (group A) and in cirrhotics without HCC (group B).

METHODS

As many as 111 consecutive patients with liver cirrhosis, who underwent triple-phase CT abdomen, were retrospectively included in our study. They were classified into group A (cirrhosis with HCC, n = 69) and group B (cirrhosis only, n = 42). Segmental liver volume, tumor and NTLV were calculated using Myrian XP-Liver segmentation software. In group B, NTLV was the same as the total liver volume (TLV). The correlation of NTLV with ICG-r15%, CTP and MELD scores was analyzed using appropriate correlation tests for each group.

RESULTS

NTLV had a good and significant negative correlation with ICG-r15% (ρ =  - 512; p < 0.001) in group A, but not in group B. It also had a significant negative correlation with CTP (ρ =  - 251; p = 0.038) and MELD (ρ =  - 323; p = 0.007) scores only in group A. Furthermore, ICG-r15% had a good and significant positive correlation with CTP and MELD scores in both groups (p < 0.05).

CONCLUSION

NTLV showed a significant negative correlation with ICG-r15% in cirrhotic patients with HCC, but not in cirrhotic patients without HCC. Therefore, CT volumetry can be a valuable tool to predict the functional hepatic volume in patients of cirrhosis with HCC subjected for hepatectomy, where a facility of ICG-r15% is not available. However, further studies are needed to validate our findings in cirrhotic only patients.

Alterations in Intestinal Mucosal Barrier Visualized by Confocal Laser Endomicroscopy in Liver Cirrhosis: A Pilot Trial (AMBIC)

BACKGROUND

Chronic liver disease occurs throughout the world irrespective of region, age, sex, or race, and it is caused by a variety of liver conditions. One of the most frequent infectious complications in liver cirrhosis that severely reduces the median survival is spontaneous bacterial peritonitis. Current guidelines recommend a paracentesis before starting an antibiotic prophylaxis for this complication.

METHODS

Selective intestinal decontamination significantly lowers the rate of first or recurrent SBP in cirrhotic patients, so in this study we aimed to investigate and quantify the intestinal integrity of patients with liver cirrhosis and correlate a pathologically increased permeability with the incidence of SPB. We included 14 patients who met the inclusion criteria. No patient was excluded. For the CLE investigation, we use probe based confocal laser endomicroscopy techniques from Mauna Kea (Cellvizio), enabling in vivo surface imaging. The images (optical biopsies) were analyzed for functional and structural barrier defects after the procedure using Mauna Kea software (version 1.0.09).

RESULTS

Because of the small number of included patients and healthy controls, most results are lacking statistical relevance. We found that the CLE investigation showed an increased intestinal permeability in patients with liver cirrhosis, in concordance with previous published data, based on other assessment methods.

CONCLUSIONS

This study confirms that previously published permeability scores can be applied for patients with liver cirrhosis and is, to our knowledge, the first to investigate the intestinal permeability in vivo in patients with liver cirrhosis. Further data are needed to identify patients at risk and help develop new and less invasive diagnostic criteria for cirrhotic patients who may profit from a prophylactic antibiotic treatment.

Predictive value of blood coagulation and routine blood indices for rebleeding after endoscopic treatment in hepatitis B-related cirrhotic patients with esophagogastric fundal varices: a logistic regression model analysis

OBJECTIVE

To evaluate the predictive value of blood coagulation and routine blood indices for rebleeding after endoscopic treatment of ruptured esophagogastric fundal varices (EGVB) in cirrhotic patients with hepatitis B infection.

METHODS

This retrospective analysis included 248 patients with hepatitis B-related cirrhosis and EGVB who received initial endoscopic treatment from October 2019 to March 2022 and were followed up for 12 months. Patients were divided into rebleeding and non-rebleeding groups. Laboratory indices were analyzed, and univariate and multivariate analyses identified predictors of rebleeding. The efficacy of a logistic regression model was evaluated using Receiver Operating Characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA), and a risk factor nomogram was constructed for assessing the predictive efficiency of those risk factors.

RESULTS

Univariate analysis showed significant differences in portal vein diameters and lower Child-Pugh scores in the rebleeding group in contrast to those in the non-rebleeding group. Key laboratory markers such as platelet count (PLT), albumin (ALB), alanine aminotransferase (ALT), lymphocytes (LYM), and prognostic nutritional index (PNI) were lower, while prothrombin time (PT) and lactate levels (LN) were higher in the rebleeding group than those in the non-rebleeding group. Multivariate analysis identified portal vein diameter, PLT, ALT, PT, LYM, and PNI as significant predictors of rebleeding. The logistic model demonstrated high accuracy (AUC=0.986) and clinical value, validated by ROC curves, calibration curves (C-index =0.986), and DCA results. A risk factor predictive nomogram was successfully constructed.

CONCLUSION

This study developed a logistic regression model with a nomogram for predicting EGVB-related rebleeding in patients with hepatitis B-related cirrhosis, achieving an AUC of 0.986, indicating high accuracy and significant clinical relevance.

Prognostic role of the stromal cell derived factor-1 in patients with hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND

Stromal cell derived factor-1 (SDF-1) plays a pivotal role in the recruitment of stem cells to injured livers. However, the changes of SDF-l in patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) have yet to be elucidated.

AIM

To study the SDF-1 changes in patients with HBV-related ACLF.

METHODS

30 patients with HBV-related ACLF, 27 patients with chronic hepatitis B and 20 healthy individuals are involved in our study. The SDF-l mRNA expression in liver tissue was detected by quantitative real-time polymerase chain reaction. Immunohistochemical staining was performed to illustrate the expression of SDF-l, CXC receptor 4 (CXCR4) and Ki67. The serum SDF-l concentrations were also detected by enzyme-linked immunosorbent assays.

RESULTS

The expression of SDF-1 mRNA from ACLF patients was remarkably higher than that from other patients (both P < 0.05). The expression of SDF-l, CXCR4 and Ki67 from ACLF were the highest among the three groups (all P < 0.01). The serum SDF-l levels in ACLF patients were significantly lower than that in other patients (both P < 0.01). Moreover, in ACLF patients, the serum SDF-1 Levels were positively correlated with serum total bilirubin and international normalized ratio. In addition, the serum SDF-l levels in survival were significantly lower compared with the non-survivals (P < 0.05). The area under the curve for the serum SDF-1 level in predicting 28-d mortality was 0.722 (P < 0.05).

CONCLUSION

This study provides the SDF-1 changes in patients with HBV-related ACLF. The SDF-1 Level at admission may serve as a promising prognostic marker for predicting short-term prognosis.

Spontaneous bacterial peritonitis in patients with portal hypertension

Background. Spontaneous bacterial peritonitis (SBP) is a life-threatening infection in patients with portal hypertension (PH) and ascites. Its prevention and treatment are vital to improve the prognosis in decompensated PH. Alterations in gut microbiota, gut permeability, and systemic immune dysfunction are cornerstones in the development of SBP in patients with PH. This contributes to the translocation of bacteria from the intestinal lumen to the mesenteric lymph nodes, and then to the portal and systemic circulation from where the ascitic fluid can be colonized with the subsequent development of peritonitis. The purpose was to monitor the course of the disease and determine the possibility of correcting pathological factors of SBP such as bacterial contamination and volume of ascitic fluid, nature of bacterial contamination, increased intra-abdominal pressure, hypoalbuminemia, and to evaluate the role of antibacterial therapy, paracentesis in the treatment of patients with SBP in decompensated PG. Materials and methods. Examination and treatment of 242 patients with ascites who were admitted for emergency medical care were carried out. Diagnostic paracentesis was performed to examine ascitic fluid, which allowed to detect neutrophilia > 250 cells in 1 mm3 in 194 (80.2 %) patients and indicated the presence of SBP. These patients made up the first group of observation. In the second group, there were 48 (19.8 %) patients with no clinical and laboratory signs of SBP at the time of hospitalization. Methodology of analysis of actual research material: to find a statistical difference between the distribution of nominal data of patients in this study, we used Pearson’s χ2 test. To establish the strength of the relationship between variables, we determined the polychoric correlation coefficient. When a statistically significant difference was detec-ted, a stratification analysis was performed with determination of the 95% confidence interval of the odds ratio (Clopper-Pearson method) and the risk ratio for the development of complications in PH. Results. Empiric antibacterial therapy, which was carried out from the moment of receiving information about SBP and began with the use of broad-spectrum antibiotics, was successful in 41 % of cases that was confirmed by repeated examination of ascitic fluid. In antibiotic resistance, determining the sensitivity of ascitic microflora led to a delay in an effective anti-inflammatory treatment and affected the results. In the first group, 39 (20.1 %) patients died, in the second group, 22 (50 %), total mortality was 25.2 %. Conclusions. Diagnostic paracentesis combined with the assessment of bacterial contamination of ascitic fluid, evaluation of intra-abdominal pressure, state of osmoregulation based on albumin concentration is a safe and informative method of diagnosing the severity of pathological process in patients with complicated PH. Treatment of SBP requires urgent care, both in terms of elimination of the infectious factor, and normalization of the disturbed mechanisms of reabsorption regulation by peritoneal and hepatorenal processes. High mortality in patients with SBP is due to the development of inflammation in the abdominal cavity against the background of progressive hepatorenal insufficiency and the inability to correct decompensated PH.

Transarterial Chemoembolization Treatment Paradigms for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) accounts for 90% of liver cancer cases worldwide and is currently the most quickly increasing cause of cancer-related deaths in the United States. The 5-year survival rate for primary liver cancer is estimated to be below 20%, and HCC mortality is expected to increase by 41% by 2040. Currently, surgical resection is the first-line approach to definitive treatment of early-stage HCC. However, the majority of patients present with late-stage, unresectable disease due to the asymptomatic nature of early HCC. For patients who present with unresectable HCC, locoregional therapies such as transarterial chemoembolization (TACE) represent an alternative approach to HCC treatment. TACE is a minimally invasive, catheter-based technique that allows for targeted delivery of chemotherapy to tumor sites while occluding tumor-feeding blood vessels. In appropriately selected patients, outcomes for TACE therapy have been shown to be more favorable than supportive care or conservative management. The increasing incidence and mortality of HCC, in addition to the late-stage presentation of most HCC patients, demonstrates the need to expand the role of locoregional therapies in the treatment of HCC. TACE represents an appealing approach to HCC management, including disease control, palliation, and potentially curative-intent strategies. In this review, we will describe the current utility of TACE in the treatment of HCC, characterize the outcomes of patients treated with TACE across different HCC stages, and outline future applications of TACE in the treatment paradigm.

The impact of hepatic and splenic volumetric assessment in imaging for chronic liver disease: a narrative review

Chronic liver disease is responsible for significant morbidity and mortality worldwide. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) can fully visualise the liver and adjacent structures in the upper abdomen providing a reproducible assessment of the liver and biliary system and can detect features of portal hypertension. Subjective interpretation of CT and MRI in the assessment of liver parenchyma for early and advanced stages of fibrosis (pre-cirrhosis), as well as severity of portal hypertension, is limited. Quantitative and reproducible measurements of hepatic and splenic volumes have been shown to correlate with fibrosis staging, clinical outcomes, and mortality. In this review, we will explore the role of volumetric measurements in relation to diagnosis, assessment of severity and prediction of outcomes in chronic liver disease patients. We conclude that volumetric analysis of the liver and spleen can provide important information in such patients, has the potential to stratify patients' stage of hepatic fibrosis and disease severity, and can provide critical prognostic information. CRITICAL RELEVANCE STATEMENT: This review highlights the role of volumetric measurements of the liver and spleen using CT and MRI in relation to diagnosis, assessment of severity, and prediction of outcomes in chronic liver disease patients. KEY POINTS: Volumetry of the liver and spleen using CT and MRI correlates with hepatic fibrosis stages and cirrhosis. Volumetric measurements correlate with chronic liver disease outcomes. Fully automated methods for volumetry are required for implementation into routine clinical practice.

Decreased Hepatic Functional Reserve Increases the Risk of Piperacillin/Tazobactam-Induced Abnormal Liver Enzyme Levels: A Retrospective Case-Control Study

BACKGROUND

Piperacillin/tazobactam (PIPC/TAZ), which is a combination of a beta-lactam/beta-lactamase inhibitor, often causes liver enzyme abnormalities. The albumin-bilirubin (ALBI) score is a simple index that uses the serum albumin and total bilirubin levels for estimating hepatic functional reserve. Although patients with low hepatic reserve may be at high risk for drug-induced liver enzyme abnormalities, the relationship between PIPC/TAZ-induced abnormal liver enzymes levels and the ALBI score remains unknown.

OBJECTIVE

This study aimed to elucidate the relationship between PIPC/TAZ-induced abnormal liver enzyme levels and the ALBI score.

METHODS

This single-center retrospective case-control study included 335 patients. The primary outcome was PIPC/TAZ-induced abnormal liver enzyme levels. We performed COX regression analysis with male gender, age (≥75 years), alanine aminotransferase level (≥20 IU/L), and ALBI score (≥-2.00) as explanatory factors. To investigate the influence of the ALBI score on the development of abnormal liver enzyme levels, 1:1 propensity score matching between the ≤-2.00 and ≥-2.00 ALBI score groups was performed using the risk factors for drug-induced abnormal liver enzyme levels.

RESULTS

The incidence of abnormal liver enzyme levels was 14.0% (47/335). COX regression analysis revealed that an ALBI score ≥-2.00 was an independent risk factor for PIPC/TAZ-induced abnormal liver enzyme levels (adjusted hazard ratio: 3.08, 95% coefficient interval: 1.207-7.835, P = 0.019). After 1:1 propensity score matching, the Kaplan-Meier curve revealed that the cumulative risk for PIPC/TAZ-induced abnormal liver enzyme levels was significantly higher in the ALBI score ≥-2.00 group (n = 76) than in the <-2.00 group (n = 76) (P = 0.033).

CONCLUSION AND RELEVANCE

An ALBI score ≥-2.00 may predict the development of PIPC/TAZ-induced abnormal liver enzyme levels. Therefore, frequent monitoring of liver enzymes should be conducted to minimize the risk of severe PIPC/TAZ-induced abnormal liver enzyme levels in patients with low hepatic functional reserve.

Associations of gallbladder and gallstone parameters with clinical outcomes in patients with cirrhosis

Background

Morphologic changes in the gallbladder and gallstones are common in cirrhotic patients, but their associations with outcomes of cirrhotic patients are unclear.

Methods

We retrospectively enrolled 206 cirrhotic patients and measured their gallbladder length and width, gallbladder wall thickness, presence of gallstones, and gallstones' length and width in axial contrast-enhanced computed tomography (CT) images. X-tile software was utilized to calculate the optimal cutoff values of these parameters for evaluating survival and hepatic decompensation events in the cirrhosis group. Their associations with survival were explored by Cox regression analyses and Kaplan-Meier curve analyses. Their associations with hepatic decompensation events were evaluated by competing risk analyses and Nelson-Aalen cumulative risk curve analyses where death was a competing event.

Results

Cirrhotic patients with gallbladder length < 72 mm had a significantly higher cumulative survival rate than those with a length of ≥ 72 mm (P = 0.049 by log-rank test), but gallbladder width, gallbladder wall thickness, presence of gallstones, and gallstones' length and width were not significantly associated with survival (P = 0.10, P = 0.14, P = 0.97, P = 0.73, and P = 0.73 by log-rank tests, respectively). Cirrhotic patients with gallbladder wall thickness < 3.4 mm had a significantly lower cumulative rate of hepatic decompensation events than those with a wall thickness of ≥ 3.4 mm (P = 0.02 by Gray's test), but gallbladder length and width, presence of gallstones, and gallstones' length and width were not significantly associated with hepatic decompensation events (P = 0.15, P = 0.15, P = 0.54, P = 0.76, and P = 0.54 by Gray's tests, respectively).

Conclusion

Changes in gallbladder length and gallbladder wall thickness, rather than gallstone parameters, may be in parallel with the long-term outcomes of cirrhotic patients.

Machine Learning-powered 28-day Mortality Prediction Model for Hospitalized Patients with Acute Decompensation of Liver Cirrhosis

Objectives

Chronic liver disease and cirrhosis are persistent global health threats, ranking among the top causes of death. Despite medical advancements, their mortality rates have remained stagnant for decades. Existing scoring systems such as Child-Turcotte-Pugh and Mayo End-Stage Liver Disease have limitations, prompting the exploration of more accurate predictive methods using artificial intelligence and machine learning (ML).

Methods

We retrospectively reviewed the data of all adult patients with acute decompensated liver cirrhosis admitted to a tertiary hospital during 2015-2021. The dataset underwent preprocessing to handle missing values and standardize continuous features. Traditional ML and deep learning algorithms were applied to build a 28-day mortality prediction model.

Results

The subjects were 173 cirrhosis patients, whose medical records were examined. We developed and evaluated multiple models for 28-day mortality prediction. Among traditional ML algorithms, logistic regression outperformed was achieving an accuracy of 82.9%, precision of 55.6%, recall of 71.4%, and an F1-score of 0.625. Naive Bayes and Random Forest models also performed well, both achieving the same accuracy (82.9%) and precision (54.5%). The deep learning models (multilayer artificial neural network, recurrent neural network, and Long Short-Term Memory) exhibited mixed results, with the multilayer artificial neural network achieving an accuracy of 74.3% but lower precision and recall. The feature importance analysis identified key predictability contributors, including admission in the intensive care unit (importance: 0.112), use of mechanical ventilation (importance: 0.095), and mean arterial pressure (importance: 0.073).

Conclusions

Our study demonstrates the potential of ML in predicting 28-day mortality following hospitalization with acute decompensation of liver cirrhosis. Logistic Regression, Naive Bayes, and Random Forest models proved effective, while deep learning models exhibited variable performance. These models can serve as useful tools for risk stratification and timely intervention. Implementing these models in clinical practice has the potential to improve patient outcomes and resource allocation.

Prognostic Role of Basal Serum Alpha-Fetoprotein in Patients with Hepatocellular Carcinoma Suitable for Curative Treatment

Background and Objectives: Serum alpha-fetoprotein (AFP) is a recognized affordable oncological marker in patients with hepatocellular carcinoma (HCC). However, AFP's prognostic role has been assessed mainly after specific treatments, and no unanimously recognized cut-offs have been identified. The aim of this study is to investigate the prognostic role of different basal AFP cut-offs on survival and HCC course. Materials and Methods: In this single-center, retrospective study, all patients newly diagnosed with HCC between January 2009 and December 2021 were prospectively enrolled. Only patients suitable for curative HCC treatments were included in the analyses. Patients were stratified according to AFP cut-offs of 20, 200, 400, and 1000 ng/mL, which were correlated with survival outcomes and clinical parameters. Results: A total of 266 patients were analyzed, with a median follow-up time of 41.5 months. Median overall survival (OS) of all cohort was 43 months. At the multivariate Cox-regression analysis, AFP value ≥ 1000 ng/mL correlated with impaired OS (1-year OS: 67% vs. 88%, 5-year OS: 1% vs. 43%; p = 0.005); other risk factors were tumor dimension ≥ 5 cm (HR 1.73; p = 0.002), Child-Pugh class B-C (HR 1.72; p = 0.002), BCLC stage A (vs. 0) (HR 2.4; p = 0.011), and malignant portal vein thrombosis (HR 2.57; p = 0.007). AFP ≥ 1000 ng/mL was also associated with a reduced recurrence-free survival (HR 2.0; p = 0.038), while starting from AFP ≥ 20 ng/mL, a correlation with development of HCC metastases over time (HR 3.5; p = 0.002) was seen. AFP values ≥ 20 ng/mL significantly correlated with tumor size and higher histological grading; starting from AFP values ≥ 400 ng/mL, a significant correlation with Child-Pugh class B-C and female gender was also observed. Conclusions: Basal AFP correlates with relevant outcomes in patients with HCC. It could help identify patients at a higher risk of worse prognosis who might benefit from personalized surveillance and treatment programs. Prospective studies are needed to confirm these results.

Liver Stiffness Measurement and Risk Prediction of Hepatocellular Carcinoma After HCV Eradication in Veterans With Cirrhosis

BACKGROUND & AIMS

Patients with cirrhosis secondary to chronic hepatitis C virus (HCV) are at risk for hepatocellular carcinoma (HCC) despite a sustained virological response (SVR). We examined whether post-SVR liver stiffness measurement (LSM) could be used to stratify HCC risk.

METHODS

This was a retrospective cohort study of 1850 participants identified from the Veterans Health Administration, with HCV cirrhosis and SVR, followed up over 5099 person-years, from the time of post-SVR elastography until death, HCC, or the end of the study.

RESULTS

The risk of HCC increased by 3% with every 1-kPa increase in LSM (adjusted hazard ratio [aHR], 1.03, 95% confidence interval [CI], 1.01-1.04; P < .001) and decreased with the number of years from SVR (aHR, 0.79; 95% CI, 0.70-0.90; P = .0003). The adjusted annual risk of HCC was 2.03% among participants with post-SVR LSM <10 kPa, 2.48% in LSM 10-14.9 kPa (aHR, 1.71; 95% CI, 1.01-2.88; P = .046), 3.22% for LSM 15-19.9 kPa (aHR, 1.59; 95% CI, 0.78-3.20; P = .20), 5.07% among LSM 20-24.9 kPa (aHR, 2.55; 95% CI, 1.30-5.01; P = .01), and 5.44% in LSM ≥25 kPa (aHR, 3.03; 95% CI, 1.74-5.26; P < .0001). The adjusted annual risk of HCC was < 0.4% in participants with LSM <5 kPa and without diabetes mellitus.

CONCLUSIONS

LSM predicts rates of HCC in patients with HCV cirrhosis after SVR at multiple cutoff levels and offers a single test to predict portal hypertension-related complications and HCC. Patients with LSM <5 kPa in the absence of diabetes mellitus had a low risk of HCC in which surveillance could be discontinued.

Association of echocardiography-related parameters with the prognosis of decompensated cirrhosis: a retrospective cohort study

BACKGROUND

Cardiac morphology and function, which are conventionally evaluated by echocardiography, are often abnormal in decompensated cirrhosis. We aimed to evaluate the association of echocardiography-related parameters with prognosis in cirrhosis.

METHODS

This retrospective study included 104 decompensated cirrhotic patients, in whom cardiac structure and function were measured by echocardiography, including mitral inflow early diastolic velocity/mitral inflow late diastolic velocity (E/A), left atrium diameter, left ventricular end-diastolic dimension, interventricular septal thickness, left ventricular posterior wall thickness, right atrial transverse diameter, right atrial longitudinal diameter, right ventricular dimension (RVD), stroke volume, cardiac output, left ventricular ejection fraction, and fractional shortening. Cox regression and competing risk analyses and Kaplan-Meier and Nelson-Aalen cumulative risk curves were used to evaluate their associations with further decompensation and death in cirrhotic patients, if appropriate.

RESULTS

Lower RVD was a predictor of further decompensation in Cox regression (adjusted by Child-Pugh score: p = 0.138; adjusted by MELD score: p = 0.034) and competing risk analyses (p = 0.003), and RVD ≤17 mm was significantly associated with higher cumulative incidence of further decompensation in Kaplan-Meier (p = 0.002) and Nelson-Aalen cumulative risk curves (p = 0.002). E/A ≤ 0.8 was a significant predictor of death in Cox regression (adjusted by Child-Pugh score: p = 0.041; adjusted by MELD score: p = 0.045) and competing risk analyses (p = 0.024), and E/A ≤ 0.8 was significantly associated with higher cumulative incidence of death in Kaplan-Meier (p = 0.023) and Nelson-Aalen cumulative risk curves (p = 0.024). Other echocardiography-related parameters were not significantly associated with further decompensation or death.

CONCLUSION

RVD and E/A may be considered for the prognostic assessment of decompensated cirrhosis.

Probiotics are beneficial for liver cirrhosis: a systematic review and meta-analysis of randomized control trials

Introduction

Gut dysbiosis may play a pivotal role in the pathogenesis of cirrhosis and the severity of complications. Numerous studies have investigated the probiotics as treatments for cirrhosis. However, there is still a lack of definitive evidence confirming the beneficial effects of probiotics on cirrhosis.

Methods

Databases including PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched for randomized controlled trials that compared the effects of probiotic intervention and control treatments, including placebo, no treatment, and active control, on cirrhosis, published from inception to February 2024. Outcomes included hepatic encephalopathy (HE) reversal, safety and tolerability of probiotics, liver function, quality of life, and other cirrhotic-related outcomes. A meta-analysis was conducted to synthesize evidence.

Results

Thirty studies were included. The quantitative synthesis results showed that compared with the control group, probiotics significantly reverse minimal hepatic encephalopathy (MHE) (risk ratio [RR] 1.54, 95% confidence interval [CI] 1.03 to 2.32) and improve HE (RR 1.94, 95% CI 1.24 to 3.06). Additionally, probiotics demonstrated higher safety and tolerability by causing a lower incidence of serious adverse events (RR 0.71, 95% CI 0.58 to 0.87). Probiotics could potentially improve liver function by reducing the Model for End-Stage Liver Disease (MELD) scores (standardized mean difference [SMD] -0.57, 95% CI -0.85 to -0.30), and displayed favorable changes in quality of life (SMD 0.51, 95% CI 0.27 to 0.75) and gut flora (SMD 1.67, 95% CI 1.28 to 2.06).

Conclusion

This systematic review and meta-analysis offers compelling evidence that probiotics are beneficial for cirrhosis by demonstrating reversal of HE, potential for liver function improvements, enhancements in quality of life, and regulation of gut dysbiosis. Furthermore, the apparent safety profile suggests that probiotics are a promising intervention for treating cirrhosis.

Clinical trial registration number

CRD42023478380.

Machine Learning-Based Assessment of Survival and Risk Factors in Non-Alcoholic Fatty Liver Disease-Related Hepatocellular Carcinoma for Optimized Patient Management

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, with an incidence that is exponentially increasing. Hepatocellular carcinoma (HCC) is the most frequent primary tumor. There is an increasing relationship between these entities due to the potential risk of developing NAFLD-related HCC and the prevalence of NAFLD. There is limited evidence regarding prognostic factors at the diagnosis of HCC. This study compares the prognosis of HCC in patients with NAFLD against other etiologies. It also evaluates the prognostic factors at the diagnosis of these patients. For this purpose, a multicenter retrospective study was conducted involving a total of 191 patients. Out of the total, 29 presented NAFLD-related HCC. The extreme gradient boosting (XGB) method was employed to develop the reference predictive model. Patients with NAFLD-related HCC showed a worse prognosis compared to other potential etiologies of HCC. Among the variables with the worst prognosis, alcohol consumption in NAFLD patients had the greatest weight within the developed predictive model. In comparison with other studied methods, XGB obtained the highest values for the analyzed metrics. In conclusion, patients with NAFLD-related HCC and alcohol consumption, obesity, cirrhosis, and clinically significant portal hypertension (CSPH) exhibited a worse prognosis than other patients. XGB developed a highly efficient predictive model for the assessment of these patients.

Development and validation of a nomogram to predict allograft survival after pediatric liver transplantation

BACKGROUND

Liver transplantation is the main treatment for cholestatic liver disease and some metabolic liver diseases in children. However, no accurate prediction model to determine the survival probability of grafts prior to surgery exists. This study aimed to develop an effective prognostic model for allograft survival after pediatric liver transplantation.

METHODS

This retrospective cohort study included 2032 patients who underwent pediatric liver transplantation between January 1, 2006, and January 1, 2020. A nomogram was developed using Cox regression and validated based on bootstrap sampling. Predictive and discriminatory accuracies were determined using the concordance index and visualized using calibration curves; net benefits were calculated for model comparison. An online Shiny application was developed for easy access to the model.

RESULTS

Multivariable analysis demonstrated that preoperative diagnosis, recipient age, body weight, graft type, preoperative total bilirubin, interleukin-1β, portal venous blood flow direction, spleen thickness, and the presence of heart disease and cholangitis were independent factors for survival, all of which were selected in the nomogram. Calibration of the nomogram indicated that the 1-, 3-, and 5-year predicted survival rates agreed with the actual survival rate. The concordance indices for graft survival at 1, 3, and 5 years were 0.776, 0.757, and 0.753, respectively, which were significantly higher than those of the Pediatric End-Stage Liver Disease and Child-Pugh scoring systems. The allograft dysfunction risk of a recipient could be easily predicted using the following URL: https://aspelt.shinyapps.io/ASPELT/ / CONCLUSION: The allograft survival after pediatric liver transplantation (ASPELT) score model can effectively predict the graft survival rate after liver transplantation in children, providing a simple and convenient evaluation method for clinicians and patients.

Navigating Cirrhosis: A Comprehensive Review of Liver Scoring Systems for Diagnosis and Prognosis

This comprehensive review navigates the landscape of liver scoring systems for the diagnosis and prognosis of cirrhosis. Cirrhosis, a chronic and progressive liver disease, presents significant challenges in its diagnosis and management. The review begins by defining and providing an overview of cirrhosis, emphasizing its clinical implications. Highlighting the significance of liver scoring systems, including the Child-Pugh score, end-stage liver disease, albumin-bilirubin (ALBI) score, and fibrosis-4 (FIB-4) index, the study explores their role in assessing liver dysfunction severity and predicting outcomes. A meticulous analysis identifies the strengths and limitations of these scoring systems, offering valuable insights for clinicians. The recommendations emphasize incorporating these tools into routine clinical practice for early intervention and personalized treatment plans. Interdisciplinary collaboration is underscored as crucial for a holistic approach to cirrhosis management. The conclusion calls for future research to refine existing scoring systems, explore emerging biomarkers and imaging techniques, and conduct prospective studies to enhance precision. By embracing these recommendations, the medical community can advance the understanding and management of cirrhosis, ultimately improving patient outcomes and revolutionizing liver disease approaches.

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs.

How to cite this article

Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

Sarcopenia increases mortality risk in liver transplantation: a systematic review and meta-analysis

INTRODUCTION

Liver transplantation is an efficacious treatment option for those with liver cirrhosis. However, the prognostic role of sarcopenia in these patients is unknown. Given this background, we conducted a systematic review and meta-analysis of the impact of sarcopenia on mortality in patients listed, evaluated and undergoing liver transplantation.

EVIDENCE ACQUISITION

Several databases were searched from the inception to December 2022 for observational studies regarding sarcopenia in liver transplant and mortality. We calculated the risk of mortality in sarcopenia vs. no sarcopenia using the most adjusted estimate available and summarizing the data as risk ratios (RRs) with their 95% confidence intervals (CIs). A random-effect model was considered for all analyses.

EVIDENCE SYNTHESIS

Among 1135 studies initially considered, 33 articles were included for a total of 12,137 patients (mean age: 55.3 years; 39.4% females). Over a median of 2.6 years and after adjusting for a median of 3 covariates, sarcopenia increased the risk of mortality approximately 2-fold (RR: 2.01; 95% CI: 1.70-2.36). After accounting for publication bias, the re-calculated RR was 1.75 (95% CI: 1.49-2.06). The quality of the studies was generally low, as determined by the Newcastle Ottawa Scale.

CONCLUSIONS

Sarcopenia was significantly linked with an increased risk of mortality in patients listed, evaluated, and undergoing a liver transplantation, indicating the need of interventional studies in this special population with the main aim to reverse this potential reversible condition and decrease mortality risk.

Prognostic value of preoperative serum ferritin in hepatocellular carcinoma patients undergoing transarterial chemoembolization

The present study investigated the prognostic impact of preoperative serum ferritin (SF) levels on the survival of patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). Clinicopathological characteristics and laboratory biomarkers of 223 patients with HCC who underwent TACE were retrospectively reviewed. The Kaplan-Meier method was used to calculate the overall survival (OS), and the log-rank test was used to evaluate statistical significance. Univariate and multivariate analyses were performed using Cox proportional hazards regression to evaluate the prognostic impact of SF in these patients. The present findings identified extrahepatic metastases [hazard ratio (HR)=0.490,95%; confidence interval (CI)=0.282-0.843; P=0.010)] and vascular invasion (HR=0.373; 95% CI=0.225-0.619; P<0.0001) as independent prognostic factors for OS. However, preoperative SF levels could not independently predict OS when compared with other prognostic factors (HR=0.810; 95% CI=0.539-1.216; P=0.309). In conclusion, preoperative SF level is an unreliable biochemical predictor of survival in patients with HCC undergoing TACE.

miR-541 is associated with the prognosis of liver cirrhosis and directly targets JAG2 to inhibit the activation of hepatic stellate cells

BACKGROUND

The activation of hepatic stellate cells (HSCs) has been emphasized as a leading event of the pathogenesis of liver cirrhosis, while the exact mechanism of its activation is largely unknown. Furthermore, the novel non-invasive predictors of prognosis in cirrhotic patients warrant more exploration. miR-541 has been identified as a tumor suppressor in hepatocellular carcinoma and a regulator of fibrotic disease, such as lung fibrosis and renal fibrosis. However, its role in liver cirrhosis has not been reported.

METHODS

Real-time PCR was used to detect miR-541 expression in the liver tissues and sera of liver cirrhosis patients and in the human LX-2. Gain- and loss-of-function assays were performed to evaluate the effects of miR-541 on the activation of LX-2. Bioinformatics analysis and a luciferase reporter assay were conducted to investigate the target gene of miR-541.

RESULTS

miR-541 was downregulated in the tissues and sera of patients with liver cirrhosis, which was exacerbated by deteriorating disease severity. Importantly, the lower expression of miR-541 was associated with more episodes of complications including ascites and hepatic encephalopathy, a shorter overall lifespan, and decompensation-free survival. Moreover, multivariate Cox's regression analysis verified lower serum miR-541 as an independent risk factor for liver-related death in cirrhotic patients (HR = 0.394; 95% CI: 0.164-0.947; P = 0.037). miR-541 was also decreased in LX-2 cells activated by TGF-β and the overexpression of miR-541 inhibited the proliferation, activation and hydroxyproline secretion of LX-2 cells. JAG2 is an important ligand of Notch signaling and was identified as a direct target gene of miR-541. The expression of JAG2 was upregulated in the liver tissues of cirrhotic patients and was inversely correlated with miR-541 levels. A rescue assay further confirmed that JAG2 was involved in the function of miR-541 when regulating LX-2 activation and Notch signaling.

CONCLUSIONS

Dysregulation of miR-541/JAG2 axis might be a as a new mechanism of liver fibrosis, and miR-541 could serve as a novel non-invasive biomarker and therapeutic targets for liver cirrhosis.

Demographic, clinical and psychological predictors of malnutrition among people with liver cancer

PURPOSE

This study aimed to explore the nutritional status and examine the demographic, clinical, nutritional, and psychosocial characteristics associated with malnutrition among people with liver cancer.

METHODS

A descriptive cross-sectional design was used. Data were collected from a convenience sample of 162 liver cancer outpatients at a tertiary university hospital. Nutritional status was evaluated using the Patient-Generated Subjective Global Assessment (PG-SGA). Self-administered structured questionnaires were administered, and medical records were reviewed for demographic, clinical, nutritional, and psychosocial characteristics.

RESULTS

Based on PG-SGA scores, 27 patients (16.7%) were classified into the malnutrition group. The stages of liver cancer, chemotherapy, physical and psychological symptom distress, global distress index, levels of alpha-fetoprotein and protein induced by vitamin K absence or antagonists, body mass index, appetite, hemoglobin and albumin levels, and depression were statistically significantly associated with malnutrition. Logistic regression model revealed that physical symptom distress, liver cancer stage, depression, and body mass index influenced statistically significantly malnutrition.

CONCLUSIONS

In this study, clinical, nutritional, and psychosocial characteristics predicted malnutrition among people with liver cancer. Nurses should consider these characteristics when evaluating the nutritional status of people with liver cancer.

MELD 3.0 in Advanced Chronic Liver Disease

The MELD (model for end-stage liver disease) 3.0 score was developed to replace the MELD-Na score that is currently used to prioritize liver allocation for cirrhotic patients awaiting liver transplantation in the United States. The MELD 3.0 calculator includes new inputs from patient sex and serum albumin levels and has new weights for serum sodium, bilirubin, international normalized ratio, and creatinine levels. It is expected that use of MELD 3.0 scores will reduce overall waitlist mortality modestly and improve access for female liver transplant candidates. The utility of MELD 3.0 and PELDcre (pediatric end-stage liver disease, creatinine) scores for risk stratification in cirrhotic patients undergoing major abdominal surgery, placement of a transjugular intrahepatic portosystemic shunt, and other interventions requires further study. This article reviews the background of the MELD score and the rationale to create MELD 3.0 as well as potential implications of using this newer risk stratification tool in clinical practice.

Using noninvasive clinical parameters to predict mortality and morbidity after cardiac interventions in patients with cirrhosis: A systematic review

BACKGROUND

Cardiovascular disease commonly affects advanced liver disease patients. They undergo cardiac interventions to improve cardiac outcomes. Cirrhosis increases complication risk, including bleeding, renal and respiratory failure, and further decompensation, including death, posing a clinical dilemma to proceduralists. Predicting outcomes is crucial in managing patients with cirrhosis. Our aim was to systematically review clinical parameters to assess the mortality and complication risk in patients with cirrhosis undergoing cardiac interventions.

METHODS

We searched cirrhosis and cardiovascular intervention terminology in PubMed and Excerpta Medica Database (EMBASE) from inception to January 8, 2023. We included studies reporting clinical scores (e.g. Model for End-stage Liver Disease (MELD), Child-Pugh-Turcotte (CPT), cardiovascular interventions, mortality, and morbidity outcomes). We independently abstracted data from eligible studies and performed qualitative summaries.

RESULTS

Eight studies met the inclusion criteria. Procedures included tricuspid valve surgery, catheterization-related procedures, aortic valve replacement (AVR), pericardiectomy, and left ventricular assist device (LVAD) placement. MELD primarily predicted mortality (n = 4), followed by CPT (n = 2). Mortality is significantly increased for MELD > 15 after tricuspid valve surgery. Albumin, creatinine, and MELD were significantly associated with increased mortality after transcatheter AVR (TAVR), although specific values lacked stratification. CPT was significantly associated with increased mortality after cardiac catheterization or pericardiectomy. In LVAD placement, increasing MELD increased the unadjusted odds for perioperative mortality.

CONCLUSIONS

Our systematic review showed that clinical parameters predict mortality and morbidity risk in patients with cirrhosis undergoing cardiac procedures.

Development and validation of modified Liaoning score for predicting the prognosis of liver cirrhosis: a retrospective, international multicenter, observational study

BACKGROUND

Liaoning score has been developed and validated to predict the risk of esophageal varices in liver cirrhosis. This study aimed to further modify the Liaoning score by combining clinical and laboratory parameters to predict the long-term outcome of cirrhotic patients.

METHODS

First, 474 cirrhotic patients were retrospectively enrolled from Shenyang, China as the training cohort. Independent predictors for death were identified by competing risk analyses, and then a new prognostic model, called as modified Liaoning score, was developed. Its performance was externally validated at three centers from Fuzhou, China (n = 1944), Jinan, China (n = 485), and São Paulo, Brazil (n = 221).

RESULTS

Age, total bilirubin (TBIL), albumin (ALB), serum creatinine (SCr), and Liaoning score were independently associated with death in the training cohort. Modified Liaoning score = 0.159×Liaoning score + 0.010×TBIL(µmol/L)+0.029×age(years)+0.011×SCr(µmol/L)-0.037×ALB(g/L). The area under curve of modified Liaoning score was 0.714 (95%CI = 0.655-0.773), which was higher than that of Child-Pugh score (0.707, 95%CI = 0.645-0.770), MELD score (0.687, 95%CI = 0.623-0.751), and Liaoning score (0.583, 95%CI = 0.513-0.654). A modified Liaoning score of ≥ 1.296 suggested a higher cumulative incidence of death in liver cirrhosis (p < 0.001). Modified Liaoning score still had the highest prognostic performance in Chinese and Brazilian validation cohorts.

CONCLUSIONS

Modified Liaoning score can be considered for predicting the long-term outcome of cirrhotic patients.

Outcomes of liver transplantation for hepatopulmonary syndrome in patients with concomitant respiratory disease

BACKGROUND & AIMS

Concomitant respiratory disease is a common finding in patients with hepatopulmonary syndrome (HPS). Among patients who underwent liver transplantation (LT) for HPS, we compared characteristics and outcome of patients with versus without concomitant respiratory disease.

METHODS

This single center retrospective observational study included patients with HPS who underwent LT between 1999 and 2020.

RESULTS

During the study period, 32 patients with HPS received a LT; nine (28%) with concomitant respiratory disease of whom one required a combined lung-liver transplantation. Patients with concomitant respiratory disease had higher PaCO2 (38 vs. 33 mm Hg, p = .031). The 30-day postoperative mortality was comparable, but the estimated cumulative probability of resolution of oxygen therapy after LT in HPS patients with versus those without concomitant respiratory disease was lower: 63% versus 91% at 12 months and 63% versus 100% at 18 months (HR 95% CI .140-.995, p = .040). In addition to the presence of concomitant respiratory disease (p = .040), history of smoking (p = .012), and high baseline 99mTcMAA shunt fraction (≥20%) (p = .050) were significantly associated with persistent need of oxygen therapy. The 5-year estimated cumulative probability of mortality in patients with concomitant respiratory disease was worse: 50% versus 23% (HR 95% CI .416-6.867, p = .463).

CONCLUSIONS

The presence of a concomitant respiratory disease did not increase the short-term postoperative mortality after LT in patients with HPS. However, it resulted in a longer need for oxygen therapy.

Liver Severity Score-Based Modeling to Predict Six-Week Mortality Risk Among Hospitalized Cirrhosis Patients With Upper Gastrointestinal Bleeding

Background

Patients with cirrhosis who have gastrointestinal bleeding have high short-term mortality, but the best modality for risk calculation remains in debate. Liver severity indices, such as Child-Turcotte-Pugh (CTP) and Model-for-End-Stage-Liver Disease (MELD) score, are well-studied in portal hypertensive bleeding, but there is a paucity of data confirming their accuracy in non-portal hypertensive bleeding and overall acute upper gastrointestinal bleeding (UGIB), unrelated to portal hypertension.

Aims

This study aims to better understand the accuracy of current mortality risk calculators in predicting mortality for patients with any type of UGIB, which could allow for earlier risk stratification and targeted intervention prior to endoscopy to identify the bleeding source.

Methods

In a large US single-center cohort, we investigated and recalibrated the model performance of CTP and MELD scores to predict six-week mortality risk for both sources of UGIB (portal hypertensive and non-portal hypertensive).

Results

Both CTP- and MELD-based models have excellent discrimination in predicting six-week mortality for all types of bleeding sources. However, only a CTP-based model demonstrates calibration for all bleeding, regardless of bleeding etiology. Median predicted 6-week mortality by CTP class A, B, and C estimates a risk of 1%, 7%, and 35% respectively.

Conclusions

Our study corroborates findings in the literature that CTP- and MELD-based models have similar discriminative abilities for predicting 6-week mortality in hospitalized cirrhosis patients presenting with either portal hypertensive or non-portal hypertensive UGIB. CTP class is an effective clinical decision tool that can be used, even prior to endoscopy, to accurately risk stratify a patient with known cirrhosis presenting with any UGIB into low, moderate, and severe risk groupings.

Clinical Characteristics and Survival of Hepatocellular Carcinoma: Insights from Single-Centre Experience in Saudi Arabia

Background Hepatocellular carcinoma (HCC) represents the most common primary liver malignancy, with a high fatality rate. Relatively, Saudi Arabia has a high incidence of HCC, which is detected in later stages with a poor prognosis. This study aims to investigate the patterns, outcomes, and mortality predictors of HCC in Saudi Arabia. Method A retrospective study from April 2018 to June 2022 included patients with HCC who were diagnosed and managed at the Najran Oncology Center, Saudi Arabia. Through our cancer registry, the patients' clinical, laboratory, radiological, and survival profiles were extracted and analyzed to assess factors associated with mortality using a univariate analysis. The overall survival was calculated by the Kaplan-Meier method. Results The study involved 52 patients with an average age of 74.6 years, predominantly male (the male-to-female ratio is 2.25:1). Viral infections were the primary cause of liver disease in 40.3% (n=21) of patients. At diagnosis, the Child-Pugh class distribution included 23.1% (n=12) patients in class A, 36.5% (n=19) patients in class B, and 40.4% (n=21) patients in class C. Uninodular tumors with ≤50% liver extension were observed in 65.4% (n=34) of cases, and 30.8% (n=16) had portal vein thrombosis. Elevated alpha-fetoprotein (AFP) levels were noted in 48.1% (n=25) of patients, with 23.1% (n=12) exceeding 400 ng/mL. Curative resection was performed in 32.7% (n=17) of patients. The mean survival time was 23±11.8 months (median of 22.5 months, minimum of six, and maximum of 49 months). Relapse occurred in seven (13.5%) cases, while new metastasis occurred in 20 (38.5%) cases. During the study period, 26 (50.0%) patients died. The main cause of death was disease progression in 15 (28.8%) patients. Univariate analysis showed that AFP>400 ng/mL (OR: 4.68; 95% CI: 1.87-11.66, p=0.001), presence of relapse (OR: 0.16; 95% CI: 0.03-0.78, p=0.023), abdominal ascites (OR: 3.38; 95% CI: 1.25-9.14, p=0.016), advanced the Cancer of the Liver Italian Program (CLIP) score (OR: 0.60; 95% CI: 0.41-0.88, p=0.009) were associated with higher mortality rate and were statistically significant. Conclusion Most cases of HCC in our patients were attributed to viral hepatitis, with the majority having liver cirrhosis. Higher AFP (>400 ng/mL), relapse, abdominal ascites, and a higher cancer CLIP score were associated with poorer outcomes. Targeted screening and health education should be advocated; in addition, social determinants should be proactively addressed.

Predictors of 30-day mortality in patients diagnosed with hepatic encephalopathy on admission to the emergency department

BACKGROUND

The aim of this study is to compare the laboratory findings and disease severity scores of patients diagnosed with hepatic encephalopathy (HE) in the emergency department (ED) to predict 30-day mortality.

METHOD

The patients over 18 years old and diagnosed HE in the ED of a tertiary hospital were included in the study. Demographic and clinical characteristics, laboratory parameters, predisposing causes and outcomes of the patients included in the study were recorded in the data form. Severity of liver disease was assessed by Child Pugh Score (CPS), End-stage liver disease model (MELD), MELD-Na and MELD-Lactate scores.

RESULTS

Two hundred fifty-four patients diagnosed with HE were included in the study. 59.1% of the patients were male. The mean age of the patients was 65.2 ± 12.6 years. The mortality rate of the patients was 47.2%. When the receiver operating characteristic (ROC) analysis, which determines the predictive properties of laboratory parameters and disease severity scores, was examined, the area under curve value of the MELD-Lactate score (0.858 95% CI 0.812-0.904, P  < 0.001) was the highest. Binary logistic regression analysis for the estimation of patients' 30-day mortality showed that CPS and MELD-Lactate scores and blood ammonia and B-type natriuretic peptide levels were independent predictors of mortality.

CONCLUSION

According to the study data, MELD-Lactate and BNP levels in patients diagnosed with HE in the ED may help the clinician in the prediction of 30-day mortality in the early period.

Prognostic value of neutrophil count to albumin ratio in patients with decompensated cirrhosis

Our study aimed to investigate the prognostic value of neutrophil count to albumin ratio (NAR) in predicting short-term mortality of patients with decompensated cirrhosis (DC). A total of 623 DC patients were recruited from a retrospective observational cohort study. They were admitted to our hospital from January 2014 to December 2015. NAR of each patient was calculated and analyzed for the association with 90-day liver transplantation-free (LT-free) outcome. The performance of NAR and the integrated model were tested by a receiver-operator curve (ROC) and C-index. The 90-day LT-free mortality of patients with DC was 10.6%. NAR was significantly higher in 90-day non-survivors than in survivors (The median: 1.73 vs 0.76, P < 0.001). A threshold of 1.40 of NAR differentiated patients with a high risk of death (27.45%) from those with a low risk (5.11%). By multivariate analysis, high NAR was independently associated with poor short-term prognosis (high group: 5.07 (2.78, 9.22)). NAR alone had an area under the ROC curve of 0.794 and C-index of 0.7789 (0.7287, 0.8291) in predicting 90-day mortality. The integrated MELD-NAR (iMELD) model had a higher area under the ROC (0.872) and C-index (0.8558 (0.8122, 0.8994)) than the original MELD in predicting 90-day mortality. NAR can be used as an independent predictor of poor outcomes for patients with DC during short-term follow-up.

Markers of inflammation predict survival in newly diagnosed cirrhosis: a prospective registry study

The inflammatory activity in cirrhosis is often pronounced and related to episodes of decompensation. Systemic markers of inflammation may contain prognostic information, and we investigated their possible correlation with admissions and mortality among patients with newly diagnosed liver cirrhosis. We collected plasma samples from 149 patients with newly diagnosed (within the past 6 months) cirrhosis, and registered deaths and hospital admissions within 180 days. Ninety-two inflammatory markers were quantified and correlated with clinical variables, mortality, and admissions. Prediction models were calculated by logistic regression. We compared the disease courses of our cohort with a validation cohort of 86 patients with cirrhosis. Twenty of 92 markers of inflammation correlated significantly with mortality within 180 days (q-values of 0.00-0.044), whereas we found no significant correlations with liver-related admissions. The logistic regression models yielded AUROCs of 0.73 to 0.79 for mortality and 0.61 to 0.73 for liver-related admissions, based on a variety of modalities (clinical variables, inflammatory markers, clinical scores, or combinations thereof). The models performed moderately well in the validation cohort and were better able to predict mortality than liver-related admissions. In conclusion, markers of inflammation can be used to predict 180-day mortality in patients with newly diagnosed cirrhosis. Prediction models for newly diagnosed cirrhotic patients need further validation before implementation in clinical practice.Trial registration: NCT04422223 (and NCT03443934 for the validation cohort), and Scientific Ethics Committee No.: H-19024348.