Reduced prevalence of ischemic events and abnormal supraortic flow patterns in patients with liver cirrhosis

Bilateral Arteriovenous Shunting Through Pial and Perforating Vessels With Multiple Strokes in a Patient With Hepatopulmonary Syndrome

Hepatopulmonary syndrome (HPS) is a condition characterized by chronic liver disease, intrapulmonary arteriovenous shunting, and increased alveolar-arterial oxygen gradient. This case report presents a 54-year-old male patient with a history of stroke, liver cirrhosis, portal vein thrombosis, hypertension, diabetes, and bladder cancer, who presented with worsening headaches and confusion over the course of five years. Digital subtraction angiogram (DSA) revealed multiple bilateral arteriovenous shunts, suggesting a shunting mechanism similar to that observed in HPS. We propose that this unique case could provide valuable insights into the parallels between the pathophysiology of HPS and diffuse arteriovenous shunting in the brain and the increased risk of ischemic and hemorrhagic events in both cases. Further studies are needed to establish a clearer understanding of this relationship and its implications for patients with chronic liver disease.

Ischemic Heart Disease and Liver Cirrhosis: Adding Insult to Injury

The link between heart and liver cirrhosis was recognized decades ago, although much data regarding atherosclerosis and ischemic heart disease are still missing. Ischemic heart disease or coronary artery disease (CAD) and liver cirrhosis could be associated with characteristic epidemiological and pathophysiological features. This connection determines increased rates of morbidity and all-cause mortality in patients with liver cirrhosis. In the era of a metabolic syndrome and non-alcoholic fatty liver disease pandemic, primary prevention and early diagnosis of coronary artery disease could improve the prognosis of liver cirrhosis patients. This review outlines a summary of the literature regarding prevalence, risk assessment and medical and interventional treatment options in this particular population. A collaborative heart–liver team-based approach is imperative for critical management decisions for patients with CAD and liver cirrhosis.

Nationwide cohort study of outcomes of acute myocardial infarction in patients with liver cirrhosis: A nationwide cohort study

Liver cirrhotic predisposes patients to coagulopathy and bleeding. Little is known about outcomes of acute myocardial infarction (AMI) in cirrhotic patients.Data from Taiwan National Health Insurance Research Database during 2001 to 2013 were retrieved for patients admitted with cirrhosis and AMI. We excluded patients with missing information, <20 years old, previous AMI, previous coronary intervention, and liver transplant. Patients were separated into cirrhotic and non-cirrhotic. Primary outcomes included all-cause mortality, recurrent myocardial infarction (MI), major cardiac and cerebrovascular events (MACCE: recurrent MI, revascularization, ischemic stroke, and heart failure), and liver outcomes (hepatic encephalopathy, ascites tapping, spontaneous peritonitis, and esophageal varices bleeding).A total of 3217 cirrhotic patients and 6434 non-cirrhotic patients were analyzed, with a mean follow up of 2.8 ± 3.3 years. In cirrhotic patients with AMI, subsequent coronary and cerebrovascular events were lower in comparison to non-cirrhotic patients, with higher all-cause mortality observed from adverse liver related outcomes and bleeding. There were significantly lower cumulative incidence of both recurrent MI and MACCE in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (hazard ratio [HR] 0.82, confidence interval [CI] 0.71-0.94, P = .006 and HR 0.86, 95% CI 0.79-0.92, P < .001, respectively). There was significantly higher cumulative incidence of liver related outcome in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (HR 2.27, 95% CI 2.06-2.51, P < .001). And there was significantly higher all-cause mortality in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (HR 1.30, 95% CI 1.23-1.38, P < .001).In cirrhotic cohort with AMI, a decreased in coronary and cerebrovascular events were observed. However, these patients also had higher all-cause mortality due to adverse liver outcomes and bleeding.

High prevalence of early atherosclerotic and cardiac damage in patients undergoing liver transplantation: Preliminary results

Liver transplanted patients are at high risk of metabolic syndrome and its complications. We aimed to prospectively evaluate the early onset of cardiovascular alterations in patients submitted to the transplant waiting list. From January 2014 to January 2016, 54 out of 79 patients on the waiting list with decompensated cirrhosis or hepatocellular-carcinoma received the transplant, 50 were followed for 24 months, 2 died post-surgery and 2 were lost to follow-up. A significantly increased prevalence of visceral adiposity (epicardial adipose tissue thickness (p = 0.001) and worsening of carotid damage (p = 0.003) and diastolic dysfunction (E/A p = 0.001) was observed at 6 months after transplant and remained stable at 24 months, corresponding to an increased prevalence of diabetes, metabolic syndrome, hypertension and dyslipidemia. The duration of steroid therapy, withdrawn in the majority of patients at 3 months, did not influence cardiovascular damage. No significant difference in early progression of cardiovascular damage was observed between patients who did or did not receive a graft with steatosis. CONCLUSION: The occurrence of early cardiovascular alterations in the first 6 months after OLT accounts for the reported cardiovascular events in the first years after transplant. In light of these results, new strategies aimed at preventing or delaying cardiovascular alterations should be provided, starting from the first weeks after transplant.

Risk of Stroke in Liver Cirrhosis: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Liver cirrhosis can lead to abnormal coagulation, rendering patients at risk for bleeding but also thrombotic complications. We conducted a systematic review and meta-analysis to explore the epidemiology of stroke in liver cirrhosis and the potential association between them.

MATERIALS AND METHODS

Studies were searched through the PubMed, EMBASE, and Cochrane Library databases. Incidence and prevalence of unspecific stroke, hemorrhagic stroke, intracranial hemorrhage, subarachnoid hemorrhage, and ischemic stroke were pooled by using a random-effect model. Meta-regression analyses were employed to explore the sources of heterogeneity. As for the cohort studies, hazard ratios (HRs) with 95% CIs were pooled to evaluate the association between liver cirrhosis and stroke.

RESULTS

Twenty-seven studies with 93,191 cirrhotic patients were included, of which 23 explored the incidence and 10 explored the prevalence. The pooled incidence of unspecific stroke, hemorrhagic stroke, intracranial hemorrhage, and ischemic stroke was 4.1%, 1.3%, 2.0%, and 3.7%, respectively. The pooled prevalence of unspecific and ischemic stroke was 9.0% and 2.6%, respectively. Heterogeneity among studies was significant in most of meta-analyses. Meta-regression analyses indicated that the sample size might explain the potential source of heterogeneity (P=0.018). Liver cirrhosis significantly increased the risk of subarachnoid (HR=2.36; 95% CI, 1.80-3.09; P=0.000) and intracranial hemorrhage (HR=1.48; 95% CI, 1.06-2.05; P=0.020), but not unspecific (HR=1.02; 95% CI, 0.49-2.14; P=0.960), ischemic (HR=0.79; 95% CI, 0.46-1.35; P=0.380), or hemorrhagic stroke (HR=1.88; 95% CI, 0.52-6.81; P=0.335).

CONCLUSIONS

Stroke is uncommon in cirrhotic patients. However, considering a positive relationship of liver cirrhosis with subarachnoid and intracranial hemorrhage, the prophylactic strategy may be selectively adopted in cirrhotic patients.

Association Between Alcoholic Cirrhosis and Hemorrhagic Stroke: A Nationwide Population-based Study

AIMS

This study investigated whether patients with alcoholic cirrhosis have a high risk of hemorrhagic stroke.

METHODS

In this study, 17,094 patients diagnosed with cirrhosis between 2000 and 2010 were identified using the Taiwan National Health Insurance claims data. Identified patients were randomly selected and propensity score matched with individuals without cirrhosis according to age, sex, comorbidities and index year.

RESULTS

The overall incidence rate of stroke was 4.41 and 12.1 per 1000 person-years in the chronic liver disease and cirrhosis (CLDC) with hepatitis B virus (HBV) or hepatitis C virus (HCV) cohort and the alcoholic CLDC cohort, respectively. The alcoholic CLDC cohort exhibited a 4.53-fold higher risk of hemorrhagic stroke (adjusted subhazard ratio [aSHR] = 4.53, 95% confidence interval [CI] = 3.05-6.71) than did the non-CLDC cohort, and the CLDC with HBV or HCV cohort exhibited a 1.40-fold higher risk of hemorrhagic stroke (aSHR = 1.40, 95% CI = 1.10-1.78) than did the non-CLDC cohort. The alcoholic CLDC cohort and the CLDC with HBV or HCV cohort showed an aSHR of 1.80 (95% CI = 1.36-2.40) and 0.95 (95% CI = 0.83-1.07) for ischemic stroke, respectively, compared with the non-CLDC cohort.

CONCLUSION

Alcoholic patients with CLDC had a higher risk of hemorrhagic stroke compared with non-alcoholic patients with CLDC and patients without CLDC.

Screening of Cardiovascular Disease in Nonalcoholic Fatty Liver Disease: Whom and How?

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide. Patients with NAFLD are at a higher risk of developing cardiovascular disease (CVD). In fact, CVD-related mortality is more common in patients with NAFLD in comparison to liver-related mortality. This association is related to the common metabolic risk factors such as obesity, dyslipidemia, diabetes, and hypertension shared by both NAFLD and CVD, and also there is independent association of NAFLD with CVD because of risk factors such as insulin resistance, systemic inflammation, and atherogenic dyslipidemia. While there is abundant literature on association of NAFLD with CVD, there is sparse literature regarding the screening for CVD in patients with NAFLD. In the current review article, we discuss as to which patients with NAFLD to screen and how to screen for CVD.

Favorable clinical outcome of nonalcoholic liver cirrhosis patients with coronary artery disease: A population-based study

AIM

To elucidate the prevalence and risk of mortality of nonalcoholic liver cirrhosis (LC) patients with coronary artery disease (CAD).

METHODS

The study cohort included newly diagnosed nonalcoholic LC patients age ≥ 40 years old without a diagnosis of CAD from 2006 until 2011 from a longitudinal health insurance database. The mean follow-up period for the study cohort was 1152 ± 633 d. The control cohort was matched by sex, age, residence, and index date. Hazard ratios (HRs) were calculated using the Cox proportional hazard model and the Kaplan-Meier method.

RESULTS

After exclusion, a total of 3409 newly diagnosed nonalcoholic cirrhotic patients were identified from one million samples from the health insurance database. We found that CAD (5.1% vs 17.4%) and hyperlipidemia (20.6% vs 24.1%) were less prevalent in nonalcoholic LC patients than in normal subjects (all P < 0.001), whereas other comorbidities exhibited an increased prevalence. Among the comorbidities, chronic kidney disease exhibited the highest risk for mortality (adjusted HR (AHR) = 1.76; 95%CI: 1.55-2.00, P < 0.001). Ascites or peritonitis exhibited the highest risk of mortality among nonalcoholic cirrhotic patients (AHR = 2.34; 95%CI: 2.06-2.65, P < 0.001). Finally, a total of 170 patients developed CAD after a diagnosis of nonalcoholic LC. The AHR of CAD in nonalcoholic LC patients was 0.56 (95%CI: 0.43-0.74, P < 0.001). The six-year survival rates for nonalcoholic LC patients with and without CAD were 52% and 50%, respectively (P = 0.012).

CONCLUSION

We conclude that CAD was less prevalent and associated with a reduced risk of mortality in nonalcoholic cirrhotic patients.

Pronounced Coronary Arteriosclerosis in Cirrhosis: Influence on Cardiac Function and Survival?

BACKGROUND

The relation between excessive alcohol consumption and coronary arteriosclerosis has remained controversial. The etiology of cirrhosis has been considered a substantial risk factor for development of arteriosclerotic lesions. The coronary artery calcium-score derived from coronary CT angiography is a robust marker of coronary arteriosclerosis.

AIMS

To study the burden of coronary arteriosclerosis in cirrhotic patients of various etiologies and association to cardiac dysfunction and survival.

METHODS

Fifty-seven patients with cirrhosis without cardiovascular disease underwent coronary CT angiography, tissue Doppler echocardiography, electrocardiogram and registration of clinical and biochemical characteristics.

RESULTS

In patients with cirrhosis the median coronary artery calcium-score was increased in comparison with age and race-adjusted healthy reference values (men: 328 vs. 9 HU and women: 136 vs. 0 HU; p < 0.001). Moreover, the coronary artery calcium-score in alcohol-related cirrhosis was significantly higher than in nonalcohol-related cirrhosis (362 vs. 46 HU, p < 0.001). Coronary artery calcium-score correlated with age (p = 0.002) but not with established cardiovascular risk factors including smoking, type 2 diabetes, hypertension, gender, or hypercholesterolemia. Coronary artery calcium-score was associated with diastolic dysfunction, lateral e´ (p = 0.025), but not with other markers of cardiac dysfunction. During a median follow-up of 25 months 12 patients (21%) died but coronary artery calcium-score was not associated with survival.

CONCLUSIONS

Coronary arteriosclerosis was particular extensive in patients with alcoholic cirrhosis. However, the current results suggest that coronary arteriosclerosis only have limited influence on cardiac function and survival. Surprisingly, no other established risk factors apart from age seemed to interfere with coronary arteriosclerosis in cirrhotic patients.

Ischemic stroke in liver cirrhosis: epidemiology, risk factors, and in-hospital outcomes

BACKGROUND AND AIMS

Patients with cirrhosis are reportedly more prone to develop hemorrhagic stroke, thereby increasing the risk of death. However, the effect of ischemic stroke on liver diseases remains unclear. In addition, few studies have explored the risk factors for ischemic stroke in patients with liver cirrhosis. Our study aimed to explore the epidemiology, risk factors, and in-hospital outcomes of ischemic stroke in a large cohort of hospitalized patients with cirrhosis.

PATIENTS AND METHODS

In this single-center observational study, we retrospectively reviewed the medical records of patients with liver cirrhosis admitted to our hospital from January 2011 to June 2014. A diagnosis of ischemic stroke was further identified.

RESULTS

Of the 2444 patients with liver cirrhosis, 160 had ischemic stroke, including 128 patients with previous ischemic stroke and 32 patients with new-onset ischemic stroke during their hospitalizations. Compared with patients with cirrhosis without ischemic stroke, those with ischemic stroke were significantly older; had a significantly higher proportion of arterial hypertension and a significantly lower proportion of hepatitis B virus infection; had significantly higher white blood cell, platelet, blood urea nitrogen, and triglyceride levels; and had significantly lower alanine aminotransferase and aspartate aminotransferase levels and prothrombin time. The in-hospital mortality was significantly higher in patients with ischemic stroke than in those without [8.80% (14/160) vs. 3.2% (72/2284), P=0.001].

CONCLUSION

Ischemic stroke was often observed in patients with cirrhosis, and it significantly increased the in-hospital mortality. The association of inflammation, coagulation disorders, and viral hepatitis with development of ischemic stroke in liver cirrhosis should be further evaluated in prospective cohort studies.

Stroke risk and outcomes in patients with chronic kidney disease or end-stage renal disease: Two nationwide studies

Background and aims

Because the risk and outcomes of stroke in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) were unclear, we evaluated these risks using a retrospective cohort study and a nested cohort study.

Methods

We used Taiwan’s National Health Insurance Research Database to identify 1378 patients aged ≥20 years who had ESRD in 2000–2004. An age- and sex-matched CKD cohort (n = 5512) and a control cohort (n = 11,024) were selected for comparison. Events of incident stroke were considered as outcome during the follow-up period in 2000–2013, and we calculated adjusted hazard ratios (HR) and 95% CIs of stroke associated with CKD or ESRD. We further used matching procedure with propensity score to estimate the risk of stroke for control group, CKD patients, and EDRD patients. A nested cohort study of 318,638 hospitalized stroke patients between 2000 and 2010 also was conducted to analyze the impact of CKD and ESRD on post-stroke mortality.

Results

Before propensity-score matching, the incidences of stroke for controls, CKD patients and ESRD patients were 6.57, 13.3, and 21.7 per 1000 person-years, respectively. Compared with control group, the adjusted HRs of stroke were 1.49 (95% CI, 1.32–1.68) and 2.39 (95% CI, 1.39–2.87) for people with CKD or ESRD respectively, and were significantly higher in both sexes and every age group. After propensity-score matching, the HRs of stroke for patients with CKD and ESRD were 1.51 (95% CI 1.24–1.85) and 2.08 (95% CI 1.32–3.26), respectively, during the follow-up period. Among hospitalized stroke patients, adjusted rate ratio (RR) of post-stroke mortality in CKD and ESRD cohorts were 1.44 (95% CI, 1.33–1.56) and 2.62 (95% CI, 2.43–2.82) respectively compared with control.

Conclusions

CKD and ESRD patient groups thus faced significantly higher risk of stroke and post-stroke mortality. Risk factor identification and preventive strategies are needed to minimize stroke risk and post-stroke mortality in these vulnerable patient groups.

Association Between Cirrhosis and Stroke in a Nationally Representative Cohort

Importance

Cirrhosis is associated with hemorrhagic and thrombotic extrahepatic complications. The risk of cerebrovascular complications is less well understood.

Objective

To investigate the association between cirrhosis and various stroke types.

Design, Setting, and Participants

We performed a retrospective cohort study using inpatient and outpatient Medicare claims data from January 1, 2008, through December 31, 2014, for a random 5% sample of 1 618 059 Medicare beneficiaries older than 66 years.

Exposures

Cirrhosis, as defined by a validated diagnosis code algorithm.

Main Outcomes and Measures

The primary outcome was stroke, and secondary outcomes were ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage as defined by validated diagnosis code algorithms.

Results

Among 1 618 059 beneficiaries, 15 586 patients (1.0%) had cirrhosis (mean [SD] age, 74.1 [6.9] years; 7263 [46.6%] female). During a mean (SD) of 4.3 (1.9) years of follow-up, 77 268 patients were hospitalized with a stroke. The incidence of stroke was 2.17% (95% CI, 1.99%-2.36%) per year in patients with cirrhosis and 1.11% (95% CI, 1.10%-1.11%) per year in patients without cirrhosis. After adjustment for demographic characteristics and stroke risk factors, patients with cirrhosis had a higher risk of stroke (hazard ratio [HR], 1.4; 95% CI, 1.3-1.5). The magnitude of association appeared to be higher for intracerebral hemorrhage (HR, 1.9; 95% CI, 1.5-2.4) and subarachnoid hemorrhage (HR, 2.4; 95% CI, 1.7-3.5) than for ischemic stroke (HR, 1.3; 95% CI, 1.2-1.5).

Conclusions and Relevance

In a nationally representative sample of Medicare beneficiaries, cirrhosis was associated with an increased risk of stroke, particularly hemorrhagic stroke. A potential explanation of these findings implicates the mixed coagulopathy observed in cirrhosis.

High burden of coronary atherosclerosis in patients with cirrhosis

BACKGROUND

Population studies report increased cardiovascular mortality in patients with cirrhosis. Coronary artery disease may be a trait of end-stage liver disease, but whether it is frequent or extensive in cirrhosis in general is unknown. Thus, we aimed to assess the prevalence and extent of coronary artery disease in unselected cirrhosis patients.

MATERIALS AND METHODS

Using coronary computed tomography angiography, we investigated 52 patients from all Child-Pugh classes and aetiologies of cirrhosis without known cardiac disease for presence and severity of coronary artery disease in a cross-sectional design. Persons referred with new-onset chest pain served as controls.

RESULTS

The prevalence of coronary artery disease was not significantly different between cirrhosis patients and controls (77% vs. 65%, P=0·19). However, cirrhosis patients had a markedly higher coronary artery calcification (Agatston) score than controls (120 [interquartile range, 0-345] vs. 5 [interquartile range, 0-86] HU, P=0·001). Likewise, patients with cirrhosis had a higher prevalence of extensive (≥5 coronary segments involved; 45% vs. 18%, P=0·01) and multivessel coronary disease (≥2 vessels involved; 75% vs. 53%, P=0·02). Furthermore, the total plaque volume whether noncalcified or calcified was higher in cirrhosis (117 [interquartile range, 0-310] vs. 36 [interquartile range, 0-148] mm³ , P=0·02).

CONCLUSION

Coronary artery disease is equally prevalent in patients with cirrhosis and subjects with new-onset chest pain, but cirrhosis patients have more extensive and severe disease including several coronary high-risk features associated with myocardial ischaemia and a poor clinical outcome. The potential of preventive measures for coronary artery disease in cirrhosis needs attention.

Cirrhosis patients' stroke risks and adverse outcomes: Two nationwide studies

BACKGROUND & AIMS

The association between liver cirrhosis (LC) and stroke is not completely understood. Our purpose was to evaluate stroke risk and post-stroke outcomes in patients with LC.

METHODS

We identified 6944 adults aged 20 years and older, newly diagnosed with LC, using the Taiwan's National Health Insurance Research Database from 2000 to 2005. The comparison cohort consisted of 27,776 adults without LC, randomly selected by frequency matching in age and sex. Events of new-onset stroke were identified from medical claims during the 2000-2013 follow-up period. Adjusted hazard ratios (HR) and 95% confidence intervals (CIs) of stroke associated with LC were calculated in the multiple Cox proportional hazard model. Another nested stroke cohort study of 21,267 hospitalized stroke patients analyzed adjusted odds ratios (ORs) and 95% CIs of adverse events after stroke, among patients with and without LC, between 2000 and 2009.

RESULTS

The incidences of stroke for people with and without LC were 6.1 and 4.3 per 1000 person-years, respectively. Compared with the non-cirrhotic cohort, the adjusted HR of stroke was 1.55 (95% CI 1.28-1.87) for LC patients. Previous LC was associated with risks of epilepsy (OR 1.30, 95% CI 1.09-1.56), admission to intensive care unit (OR 1.23, 95% CI (1.14-1.32) and in-hospital mortality (OR 1.83, 95% CI 1.63-2.05) after stroke.

CONCLUSIONS

LC was associated with higher risk of stroke, and patients with LC had more complications and mortality after stroke. This susceptible population needs strategies to prevent stroke and post-stroke adverse events.

The clinical course of alcoholic cirrhosis: development of comorbid diseases. A Danish nationwide cohort study

BACKGROUND & AIMS

We aimed to determine associations between alcoholic cirrhosis and incidence of comorbidity, and to describe the clinical course of alcoholic cirrhosis in terms of comorbidity development. The comorbid diseases we studied were acute myocardial infarction, heart failure, peripheral arterial disease, chronic obstructive pulmonary disease, chronic kidney disease, epilepsy, diabetes and cancer.

METHODS

This was a registry-based nationwide historical cohort study. We included 10 650 Danish citizens diagnosed with alcoholic cirrhosis at age 45-69 years in 1994-2014 and 43 150 age- and gender-matched persons. None of them had the comorbid diseases we studied at inclusion. We compared rates and cumulative risks of comorbidity development between patients and controls.

RESULTS

Patients with alcoholic cirrhosis had a higher rate of comorbidity (hazard ratio for any comorbidity = 3.74, 95% CI 3.56-3.94), including all the non-cancer comorbidities (hazard ratio for any non-cancer comorbidity = 4.33, 95% CI 4.06-4.62) except acute myocardial infarction. They also had a higher rate of developing cancer (hazard ratio = 2.94, 95% CI 2.70-3.19). Still, relatively few patients actually lived to experience development of non-cancer (10-year risk: 21.4% vs. 13.2% for controls) or cancer comorbidity (10-year risk: 10.9% vs. 10.0%) because they died before they developed any comorbid disease. Hepatocellular carcinoma and oropharyngeal cancer were the only two comorbidities that were much more likely to develop in patients than in controls.

CONCLUSIONS

Alcoholic cirrhosis promotes development of several comorbid diseases, but only few patients with alcoholic cirrhosis live long enough to actually develop them.

Cholecystectomy in Patients with Liver Cirrhosis

Background. The aim of this population-based study was to describe characteristics of patients with liver cirrhosis undergoing cholecystectomy and evaluate the risk for perioperative and postoperative complications during the 30-day postoperative period. Method. All laparoscopic and open cholecystectomy procedures registered between 2006 and 2011 in the Swedish Registry for Gallstone Surgery and ERCP (GallRiks) were included. Patients with liver cirrhosis were identified by linking data to the Swedish National Patient Registry (NPR). Results. Of 62,488 patients undergoing cholecystectomy, 77 (0.12%) had cirrhosis, of which 29 patients (37.7%) had decompensated cirrhosis. Patients with cirrhosis were older and had more often gallstone complications at the time for surgery. Postoperative complications were registered in 13 (16.9%) patients with liver cirrhosis and in 5,738 (9.2%) patients in the noncirrhotic group (P < 0.05). Univariable analysis showed that patients with liver cirrhosis are more likely to receive postoperative blood transfusion (OR = 4.4, CI 1.08-18.0, P < 0.05) and antibiotic treatment >1 day (OR = 2.3, CI 1.11-4.84, P < 0.05) than noncirrhotic patients. Conclusion. Patients with cirrhosis undergoing cholecystectomy have a higher incidence of postoperative complications than patients without cirrhosis. However, cholecystectomy is safe and if presented with adequate indication, surgery should not be delayed due to fears of surgical complications.

Association between Liver Disease and Intracranial Hemorrhage

BACKGROUND

Liver disease is common and associated with clinical and laboratory evidence of coagulopathy. The association between liver disease and intracranial hemorrhage (ICH) remains unclear. Our aim was to assess whether liver disease increases the risk of ICH.

METHODS

We performed a retrospective cohort study based on administrative claims data from California, Florida, and New York acute care hospitals from 2005 through 2011. Of a random 5% sample, we included patients discharged from the emergency department or hospital after a diagnosis of liver disease and compared them to patients without liver disease. Patients with cirrhotic liver disease were additionally analyzed separately. Kaplan-Meier survival statistics were used to calculate cumulative rates of incident ICH, and Cox proportional hazard analysis was used to adjust for demographic characteristics, vascular disease, and Elixhauser comorbidities. Multiple models tested the robustness of our results.

RESULTS

Among 1,909,816 patients with a mean follow-up period of 4.1 (±1.8) years, the cumulative rate of ICH after a diagnosis of liver disease was 1.70% (95% confidence interval [CI], 1.55%-1.87%) compared to .40% (95% CI, .39%-.41%) in patients without liver disease (P <.001 by the log-rank test). Liver disease remained associated with an increased hazard of ICH after adjustment for demographic characteristics and vascular risk factors (hazard ratio [HR], 1.8; 95% CI, 1.6-2.0). This was attenuated in models additionally adjusted for general comorbidities (HR, 1.3; 95% CI, 1.2-1.5).

CONCLUSIONS

There is a modest, independent association between liver disease and the risk of ICH.

ST Elevation Myocardial Infarction Mortality Among Patients With Liver Cirrhosis: A Nationwide Analysis Across a Decade

BACKGROUND

Mortality from ST elevation myocardial infarction (STEMI) is decreasing nationwide, but no report to date examined STEMI mortality among patients with cirrhosis.

GOALS

Determine mortality rates and investigate possible disparities in cardiovascular interventions for patients with and without cirrhosis admitted with STEMI across a decade using a national database.

STUDY

We included all urgent/emergent admissions with STEMI to acute care hospitals across the United States in 1999 and 2009. Exclusion criteria were age less than 18 years or prior liver transplantation. Confounders were accounted for using multivariable regression analyses.

RESULTS

A total of 325,857 and 182,491 patients with STEMI were included in 1999 and 2009, respectively, 741 and 541 of whom had cirrhosis, respectively. In-hospital mortality rate was 31% and 11% for patients with and without cirrhosis in 1999, and 17% and 9% in 2009. The adjusted mortality odds ratio was 2.54 (1.52 to 4.24) in 1999 and 1.45 (0.73 to 2.86) in 2009. Stent placement rate was 11% and 26% for patients with and without cirrhosis in 1999, and increased to 47% and 61% in 2009, respectively. Thrombolytic medication injection rate was 3% and 10% for patients with and without cirrhosis in 1999, and 0% and 2% in 2009, respectively. Coronary artery bypass graft surgery rate was 3% and 9% for patients with and without cirrhosis in 1999, and was 6% and 7% in 2009, respectively.

CONCLUSIONS

STEMI mortality in patients with cirrhosis is higher compared with patients without cirrhosis. However, this mortality difference declined from 1999 to 2009, likely because of higher coronary artery stent utilization for patients with cirrhosis.

Risk of microangiopathy in type 2 diabetes mellitus patients with or without chronic hepatitis C: Results of a retrospective long-term controlled cohort study

BACKGROUND

Patients with chronic hepatitis C have an increased risk of diabetes mellitus but the type and risk of developing diabetes-related complications have not yet been evaluated.

METHODS

In order to compare the incidence of diabetic microangiopathy in patients with new onset diabetes without microangiopathy we recruited 54 hepatitis C virus (HCV)-positive and 119 HCV-negative patients from January 2005 to December 2006. All patients were followed-up every 6 months for liver and diabetic complications and incidence of cardiovascular diseases up to December 2012 when data were retrospectively analyzed.

RESULTS

The two cohorts were comparable at enrolment except for mean body mass index, obesity rate and family history of diabetes (p=0.007). After 7.2 years of follow-up, 13 HCV-positive (24.1%) and 37 HCV-negative patients (31%) showed at least one microangiopathic complication (p=0.34); 5 HCV-positive (9.3%) and 13 HCV-negative patients (10.8%) reported cardiovascular diseases (p=0.2); 14 HCV-positive (24.5%) compared to 0 HCV-negative patients developed liver-related complications (p=0.0003). One HCV-positive patient died due to liver cancer, 1 HCV-negative patient died from myocardial infarction (p=0.3). Increasing age (HR=1.04, 95% CI: 1.00-1.07, p=0.04) and smoking (HR=2.94, 95% CI: 1.06-8.17, p=0.04) were positively associated to diabetic complications.

CONCLUSIONS

Incidence of microangiopathy is not significantly different in diabetics with or without chronic hepatitis C.

Pre-transplant renal impairment predicts posttransplant cardiac events in patients with liver cirrhosis

BACKGROUND

Cardiovascular disease and renal impairment are common in cirrhotic transplant candidates. We aimed to investigate potential association between pretransplant renal function impairment and cardiac events after liver transplantation.

METHODS

Adult cirrhotic patients undergoing first-time liver transplantation between 1999 and 2007 in a single institution with available glomerular filtration rate (GFR), assessed by Cr-EDTA clearance at pre-transplant evaluation, were retrospectively enrolled (n=202). Impaired renal function was defined as GFR less than 60 mL/min/1.73 sqm. Pretransplant QT-time corrected by heart rate (QTc) and left-ventricular dysfunction was also registered. Mortality and cardiac events were analyzed, until death or last follow-up (end 2009).

RESULTS

Renal impairment was present in 24% (48/202). Cardiac events occurred in 28% (56/202) after transplantation, mean follow-up time of 3.8 years (2.2). Events were more common in patients with renal impairment compared with those without (48% versus 21%, P<0.001). In Cox regression analysis, pretransplant renal impairment was found to be an independent predictor of posttransplant cardiac events (HR 2.19, 95% CI 1.25-3.85) and reduced cardiac event-free survival (HR 2.27, 95% CI 1.31-3.94). Prolonged QTc interval was an independent predictor of posttransplant cardiac events in the subgroup with pretransplant electrocardiogram and echocardiogram (n=166 and n=112, HR 4.75, 95% CI 2.07-10.9); however, left-ventricular diastolic dysfunction was not (P>0.05). A pretransplant score comprising renal impairment, prolonged QTc interval, and age older than 52 was developed for prediction of 3- and 12-month cardiac events (c-statistic 0.73 and 0.75, respectively).

CONCLUSIONS

Pretransplant renal impairment is a predictor of cardiac event after liver transplantation together with prolonged QTc interval.

Thromboembolic events among patients with hepatitis C virus infection and cirrhosis: a matched-cohort study

INTRODUCTION

Portal vein thrombosis is a known risk among patients with cirrhosis, but the incidence of other thromboembolic events among patients with liver disease is inadequately delineated. This study examined the incidence of venous and arterial thromboembolic events in patients with cirrhosis and hepatitis C virus (HCV) infection and matched comparators.

METHODS

Patients diagnosed with HCV or cirrhosis of various etiologies were identified from a large medical claims database and matched by age and sex to comparator cohorts. New-onset diagnoses of venous and arterial thromboembolic events were determined. The incidence rate of each event was calculated and rate ratios computed using Poisson regression models, adjusting for baseline factors.

RESULTS

The study included 22,733 HCV-infected patients and 68,198 comparators, and 15,158 cirrhosis patients and 45,473 comparators. The incidence of any thromboembolic event was 233.4 events per 10,000 person-years for the HCV cohort and 138.5 per 10,000 person-years for the comparators; the adjusted incidence rate ratio for any thromboembolic event was 1.62 (95% confidence interval [CI]: 1.48-1.77). For the cirrhosis patients and comparators, the crude rates of any thromboembolic event were 561.1 and 249.7 per 10,000 person-years, respectively. The adjusted incidence rate ratio was 2.28 (95% CI: 2.11-2.47). Arterial events, especially unstable angina and transient ischemic attack, were the most frequent events seen in both the HCV and cirrhosis cohorts, but venous events, especially portal vein thrombosis, showed a more pronounced elevation in patients with liver disease.

CONCLUSIONS

Patients with HCV and cirrhosis of various etiologies are at increased risk of several types of thromboembolic events. Physicians should consider this increased risk when managing patients with liver disease.

Comorbidity in cirrhosis

Cirrhosis patients’ comorbidities are their other diseases than cirrhosis. Comorbidities are neither causes nor consequences of cirrhosis, but they can increase mortality and are therefore clinically important. They are also an important source of confounding in epidemiologic studies. Comorbidity scoring systems have been developed as tools to measure the cirrhosis patient’s total burden of comorbidity, and they are useful in the clinic and for epidemiologic studies. The recently developed CirCom score is the only comorbidity scoring system developed specifically for cirrhosis patients, and it may be preferred over the older, generic, and more complex Charlson comorbidity index. Studies of individual comorbid diseases can provide insight into the interactions between cirrhosis and other diseases and thus into the pathophysiology of cirrhosis. This article reviews the literature on comorbidity in cirrhosis.

Prevalence of pre-transplant electrocardiographic abnormalities and post-transplant cardiac events in patients with liver cirrhosis

Background

Although cardiovascular disease is thouht to be common in cirrhosis, there are no systematic investigations on the prevalence of electrocardiographic (ECG) abnormalities in these patients and data on the occurrence of post-transplant cardiac events in comparison with the general population are lacking. We aimed to study the prevalence and predictors of ECG abnormalities in patients with cirrhosis undergoing liver transplantation and to define the risk of cardiac events post-transplant compared to the general population.

Methods

Cirrhotic patients undergoing first-time liver transplantation between 1999–2007 were retrospectively enrolled. ECGs at pre-transplant evaluation were reviewed using the Minnesota classification and compared to healthy controls. Standardized incidence ratios for post-transplant cardiac events were calculated.

Results

234 patients with cirrhosis were included, 186 with an available ECG (36% with alcoholic and 24% with viral cirrhosis; mean follow-up 4 years). Cirrhotics had a prolonged QTc interval, a Q wave, abnormal QRS axis deviation, ST segment depression and a pathologic T wave more frequently compared to controls (p < 0.05 for all). Arterial hypertension, older age, cirrhosis severity and etiology were related to ECG abnormalities. Compared to the general Swedish population, patients were 14 times more likely to suffer a cardiac event post-transplant (p < 0.001). A prolonged QTc interval and Q wave were related to post-transplant cardiac events (p < 0.05 for all).

Conclusions

Pre-transplant ECG abnormalities are common in cirrhosis and are associated with cardiovascular risk factors and cirrhosis severity and etiology. Post-transplant cardiac events are more common than in the general population.

Increased prevalence of coronary artery disease risk markers in patients with chronic hepatitis C--a cross-sectional study

Objective

Chronic hepatitis C is a global health problem and has been associated with coronary artery disease. Our aim was to examine the prevalence of coronary artery disease risk markers including endothelial biomarkers in patients with chronic hepatitis C and matched comparisons without manifest cardiovascular disease or diabetes in a cross-sectional design.

Methods

Sixty patients with chronic hepatitis C (mean age 51 years) were recruited from the Department of Infectious Diseases at Copenhagen University Hospital, and compared with 60 age-matched non-hepatitis C virus-infected individuals from a general population survey. We examined traditional coronary artery disease risk factors, metabolic syndrome, carotid intima media thickness, and a range of endothelial biomarkers.

Results

Patients with chronic hepatitis C had more hypertension (40% versus 25%, prevalence ratio [PR] 1.6; 95% confidence interval [CI] 0.9–2.7) and smoked more (53% versus 38%, PR 1.4; 95% CI 0.9–2.1). The two groups had similar body mass index (mean 25.0 versus 25.7 kg/m²), whereas those with chronic hepatitis C had less dyslipidemia (including significantly lower low-density lipoprotein and cholesterol/high-density lipoprotein ratio), higher glycosylated hemoglobin level (mean 6.2 versus 5.7, difference of means 0.5; 95% CI 0.3–0.8), and a higher prevalence of metabolic syndrome (28% versus 18%, PR 1.6; 95% CI 0.8–3.0). Increased carotid intima media thickness above the standard 75th percentile was seen more frequently in chronic hepatitis C (9% versus 3%, PR 1.7; 95% CI 0.4–6.7), though difference of means was only 0.04 mm (95% CI 0.00–0.10). Patients with chronic hepatitis C had increased hsCRP (high-sensitivity C-reactive protein), sICAM-1 (soluble intercellular adhesion molecule-1), sVCAM-1 (soluble vascular cell adhesion molecule-1), and soluble E-selectin, but lower levels of tPAI-1 (tissue-type plasminogen activator inhibitor-1), MMP9 (matrix metallopeptidase 9), and MPO (myeloperoxidase) than their comparisons.

Conclusion

Our findings indicate that patients with chronic hepatitis C have increased prevalence of several coronary artery disease risk markers. These results may be important when evaluating the appropriateness of screening for coronary artery disease and its risk factors in chronic hepatitis C.

Cardiovascular risk factors and systemic endothelial function in patients with cirrhosis

OBJECTIVES

Cardiovascular risk factors (CVRF) lead to systemic endothelial dysfunction. It has been suggested that in cirrhosis, cardiovascular risk is low and systemic endothelial function is enhanced. However, there is no prospective study evaluating the relationship between cardiovascular risk and systemic endothelial function in cirrhosis, which was investigated here.

METHODS

In 47 patients with cirrhosis (33 males; median Child-Pugh score 8; median age 55 years), we evaluated: laboratory parameters, hepatic and systemic hemodynamics, CVRF, 10-year global cardiovascular risk by Framingham score, and presence of carotid plaques. Systemic endothelial dysfunction was investigated non-invasively by flow-mediated dilatation (FMD) of the brachial artery by ultrasound and defined as FMD <10%.

RESULTS

Cardiovascular risk (median 7%) was low in 25%, moderate in 26%, moderately high in 40%, and high in 9%. Fifty-three percent of patients had systemic endothelial dysfunction. Systemic endothelial dysfunction (low FMD) increased in parallel with CV risk (linear trend P=0.039) and was higher in patients overweight or obese. Conversely, FMD increased in parallel with Child-Pugh/Mayo Clinic Model for End-stage Liver Disease (MELD) score, bilirubin, serum sodium, plasma renin activity, leukocyte count, platelet count, and with lower arterial pressure, suggesting that enhanced FMD is a feature of advanced liver failure and inflammation. Cardiovascular risk, bilirubin, leukocyte count, and arterial pressure remained independently associated with systemic endothelial dysfunction.

CONCLUSIONS

CV risk was not low in our studied patients with cirrhosis, and systemic endothelial dysfunction was frequent in this population. In cirrhosis, similar to general population, cardiovascular risk impaired systemic FMD, although liver failure attenuated endothelial dysfunction.

Type 2 diabetes mellitus and chronic hepatitis C: which is worse? Results of a long-term retrospective cohort study

BACKGROUND

The long-term outcome in patients with chronic hepatitis C and type 2 diabetes mellitus treated with interferon and ribavirin is unclear. We compared incidence of liver-related events and mortality rates between hepatitis C virus-positive patients with or without diabetes mellitus, and the incidence of diabetes-related events between diabetic patients with and without hepatitis C.

METHODS

Retrospective study of 309 patients with chronic hepatitis C. Incidence of liver-related events, diabetes-related events and mortality rates were assessed over a mean follow-up of 11.02±4.9 years.

RESULTS

50 (16%) chronic hepatitis C patients had diabetes mellitus. Diabetics showed a higher number of diabetes- and liver-related events than non-diabetics (10% vs 1.5%, p=0.006; 18% vs 5.7%, p=0.007, respectively) with a mortality of 14% vs 1.5% (p=0.0003). Baseline cirrhosis (p=0.002) and non-sustained virological response (p=0.01) were independent risk factors for liver events; diabetes mellitus (p=0.01) and hypertension (p=0.0017) were independent factors for diabetes-related events.

CONCLUSIONS

In patients with chronic hepatitis C, comorbidity with diabetes mellitus was associated with a higher mortality rate and incidence of liver/diabetes-related events. Independent risk factors for liver-related events were the non-response to antiviral therapy and cirrhosis at baseline.

Non-alcoholic cirrhosis and the risk of stroke: a 5-year follow-up study

BACKGROUND/AIMS

As habitual heavy alcohol consumption is one of the major causes of cirrhosis in the western world, the majority of studies on the relationship between cirrhosis and stroke have focused on patients with alcohol-related liver diseases. Using a nationwide population-based dataset, this study therefore aimed to examine the risk of stroke among non-alcoholic cirrhosis patients over a 5-year period following their diagnosis with non-alcoholic cirrhosis, as compared with the general population during the same period.

METHODS

We used the 'Longitudinal Health Insurance Database', derived from the Taiwan National Health Insurance program. The study cohort comprised 2336 patients with cirrhosis and the comparison cohort consisted of 11,680 randomly selected subjects. Stratified Cox's proportional hazard regressions were performed to compare the 5-year stroke survival rate for the two cohorts.

RESULTS

In the total sample of 14,016 patients, 1187 patients (8.5%) experienced stroke during the 5-year follow-up period: 176 from the study cohort (7.5% of the patients with cirrhosis) and 1011 from the comparison cohort (8.7% of patients without cirrhosis) (P=0.076). After adjusting for the patients' geographical location, hypertension, diabetes, coronary heart disease, heart failure, atrial fibrillation and hyperlipidaemia, the regression analysis shows that patients with cirrhosis were less likely to experience stroke compared with those without cirrhosis during the 5-year period (hazard ratio=0.59, 95% confidence interval=0.52-0.67, P<0.001).

CONCLUSION

We conclude that patients with non-alcoholic cirrhosis were at a reduced risk for stroke compared with the general population.

Coronary artery disease in patients with liver cirrhosis

BACKGROUND

The prevalence of coronary artery disease (CAD) has been reported to be low in patients with liver cirrhosis. Previous studies have, however, included mostly patients with cirrhosis due to hepatitis C. We aimed to determine the prevalence and predictive factors of CAD in a cohort of consecutive patients with cirrhosis of various etiologies compared to the general population.

METHODS

A total of 127 patients with cirrhosis were evaluated for a history of CAD and cardiovascular risk factors. Arterial blood pressure, fasting plasma glucose, and serum cholesterol were measured. Nutritional status was assessed by anthropometry and estimation of recent weight change. A group of 203 subjects from the general population with similar age and gender distribution, as well as smoking habits as the cirrhotic patients, served as controls.

RESULTS

CAD was more common in cirrhotics compared to controls (20% vs. 12%, P = 0.001). Compared to controls, cirrhotics had lower mean arterial blood pressure and serum cholesterol and a higher prevalence of diabetes, but did not differ significantly in the prevalence of hypertension or family history for CAD. In regression analysis, CAD was independently related to diabetes (odds ratio [OR] 5.47, 95% confidence interval [CI] 2.44-12.28), but not to liver cirrhosis. In the cirrhosis group, only alcoholic cirrhosis (OR 9.50, 95% CI 1.08-83.4) and age (OR 1.23 per year, 95% CI 1.06-1.43) were independently related to CAD.

CONCLUSIONS

Liver cirrhosis, per se, does not seem to confer a protective effect against CAD. In cirrhotics, older age and alcoholic etiology were independently related to CAD.

Systemic abnormalities in liver disease

Systemic abnormalities often occur in patients with liver disease. In particular, cardiopulmonary or renal diseases accompanied by advanced liver disease can be serious and may determine the quality of life and prognosis of patients. Therefore, both hepatologists and non-hepatologists should pay attention to such abnormalities in the management of patients with liver diseases.

Clinical and pathologic risk factors for atherosclerosis in cirrhosis: a comparison between NASH-related cirrhosis and cirrhosis due to other aetiologies

BACKGROUND/AIMS

The precise prevalence of risk factors for atherosclerosis in NASH-related cirrhosis is unknown. The aims of this study were: (1) to compare the prevalence of major risk factors for atherosclerosis between subjects who underwent liver transplantation for NASH-related cirrhosis and those with cirrhosis of other aetiologies and (2) to compare pathologic changes of atherosclerosis within the explants hepatic hilar arteries between the groups.

METHODS

Sixty subjects with NASH-related cirrhosis and 60 subjects with cirrhosis of other aetiologies were reviewed retrospectively. Demographic and clinical characteristics related to atherosclerosis were analyzed and compared. The hepatic hilar arteries of the explanted livers were examined for pathologic changes.

RESULTS

The prevalence of all coronary artery disease (CAD) risk factors and the metabolic syndrome was significantly higher in NASH-related cirrhosis group compared to cirrhosis of other aetiologies. The proportion of patients with a diagnosis of CAD was also significantly higher in the NASH-related cirrhosis group (21.6% vs. 5%, p=0.005). Pathological examination of hilar arteries showed possible atherosclerotic changes in only 4 cases (3 NASH-related cirrhosis; 1 HCV).

CONCLUSIONS

Major risk factors for atherosclerosis are significantly more prevalent in subjects with NASH-related cirrhosis than in subjects with cirrhosis of other aetiologies and are predictive of an increased prevalence of CAD. This study suggests that NASH-related cirrhosis is not protective against atherosclerosis.

Stanford type A aortic dissection with Child B liver cirrhosis

Cardiac surgery using cardiopulmonary bypass in patients with advanced liver cirrhosis has been infrequently performed, and reported to be too risky. Aortic dissection accompanied with liver cirrhosis is extremely rare. A 61-year-old woman who had aortic dissection and Child B liver cirrhosis underwent ascending aorta replacement. Liver protection during cardiopulmonary bypass was successfully accomplished by moderate hypothermia and use of an aortic occlusion balloon to maintain sufficient hepatic blood flow.

The prevalence of atherosclerosis in cirrhotic patients: assessment of two aspects of atherosis and sclerosis

AIM

In general, cirrhotic patients are known to have a low prevalence of cardiovascular disease. Cirrhosis is often accompanied by diabetes mellitus, while blood pressure and serum cholesterol levels are low in liver cirrhosis. We examined the atherosclerosis of patients with chronic liver disease by two phases of atherosis "lipid deposition" and sclerosis "arterial fibrosis."

METHODS

Atherosis was assessed by carotid intima-media thickness and the ratio of the systolic blood pressure at the ankle to the average systolic blood pressure at the right arm (ankle brachial pressure index), while sclerosis was evaluated by brachial ankle pulse wave velocity.

RESULTS

There were no significant differences in intima-media thickness and ankle brachial index among grades of cirrhosis. Brachial ankle pulse wave velocity decreased closely as the severity of cirrhosis progressed (F = 4.90, P < 0.05). In univariate analysis, brachial ankle pulse wave velocity was correlated with systolic blood pressure, age, total bilirubin, albumin, prothrombin time, retention rate of indocyanine green at 15 min, blood ammonia, branched chain amino acids/tyrosine molar rate and fasting blood sugar. Multiple regression analysis showed that systolic blood pressure and total bilirubin were independent factors for the inhibition of vascular sclerosis progression.

CONCLUSION

Although no difference in atherosis between cirrhotic patients and healthy controls was found, vascular sclerosis was decreased with the severity of cirrhosis through hypotension and hyperbilirubinemia.

Plasma total homocysteine and cardiovascular risk in patients submitted to liver transplantation

Patients submitted to orthotopic liver transplantation (OLT) show an increased rate of cardiovascular events. OLT subjects have high homocysteine (Hcy) levels, but no data are available on the association of Hcy with cardiovascular events. In a cross-sectional analysis, 230 subjects were studied at least 6 months after OLT (159 on cyclosporine, 71 on tacrolimus). Routine laboratory data and total Hcy were recorded, as well as the history of diabetes, hypertension, dyslipidemia, and overweight. Cardiovascular events occurring in a follow-up of 2-36 months were registered. OLT subjects had higher-than-normal Hcy (median 16.7 micromol/L, range 6.1-171.8) without difference between the 2 immunosuppressive agents. The prevalence of Hcy >15 micromol/L was also similar, and significantly correlated with creatinine levels. A total of 28 arterial events occurred in 25 patients during follow-up (11 in coronary arteries, 10 in peripheral arteries, and 7 in splanchnic arteries). Deep vein thromboses occurred in 2 patients, and splanchnic vein thromboses in 4 patients. Cardiovascular events were frequently associated to high Hcy and hypertension. Cox regression analysis showed that high Hcy was significantly associated with arterial events. The risk of any arterial event, coronary artery or peripheral artery event increased by nearly 10% for any increase in Hcy of 5 micromol/L. In conclusion, high Hcy may be involved in the pathogenesis of cardiovascular events in OLT patients. The usefulness of Hcy-lowering therapy remains to be verified.