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Hsu YC, Wu CY, Chang CY, Tai CM, Tseng CH, Perng DS, Mo LR, Lin JT. Pretreatment viral DNA stratifies mortality risk in patients receiving antiviral therapy for severe acute exacerbation of chronic hepatitis B. Antivir Ther 2012; 18:221-8. [PMID: 23128388 DOI: 10.3851/imp2435] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prognostic factors have not been elucidated for severe acute exacerbation of chronic hepatitis B treated with antiviral therapy. This study aimed to explore the role of baseline viral load in predicting mortality. METHODS This retrospective cohort study screened consecutive chronic hepatitis B patients (n=84) receiving antiviral therapy for severe acute exacerbation, defined as abrupt elevation of serum alanine aminotransferase >10× the upper limit of normal along with hyperbilirubinaemia. Survival pattern was evaluated by the Kaplan-Meier method and predictors for mortality determined by the Cox regression analysis. RESULTS A total of 66 patients were eligible and followed-up for a median of 23 months (range 0.1-75.0). Overall, 20 (30.3%) patients died during the study period, with the vast majority (n=17) succumbing rapidly within 3 months of severe acute exacerbation. The multivariate Cox model revealed that mortality was associated with baseline viral DNA level (HR 1.49 per log copies/ml, 95% CI 1.13, 1.96), international normalized ratio for prothrombin time (HR 2.68 per unit, 95% CI 1.81, 3.98), platelet count (HR 0.87 per 10(4) cells/μl, 95% CI 0.78, 0.98) and age (HR 1.10 per year, 95% CI 1.05, 1.15). A significant interaction existed between viral DNA and prolonged prothrombin time (P=0.005). Stratified analyses further demonstrated that pronounced coagulopathy heralded death irrespective of viral load, whereas serum level of viral DNA stratified mortality risk among those without marked coagulopathy. CONCLUSIONS Pretreatment viral DNA level stratifies risk of death in patients with severe acute exacerbation of chronic hepatitis B before the manifestation of overt liver failure.
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Affiliation(s)
- Yao-Chun Hsu
- Graduate Institute of Clinical Medicine, China Medical University, Taichung, Taiwan
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Ma K, Guo W, Han M, Chen G, Chen T, Wu Z, Yang D, Huang J, Huang Y, Zhao X, Tian D, Song J, Qi J, Ning Q. Entecavir treatment prevents disease progression in hepatitis B virus-related acute-on-chronic liver failure: establishment of a novel logistical regression model. Hepatol Int 2012. [PMID: 26201523 DOI: 10.1007/s12072-012-9344-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatitis B-related acute-on-chronic liver failure (ACLF) has a poor prognosis with very high mortality. Unfortunately, most prognostic predictive models of liver failure are complicated and offer suboptimal sensitivity. Experience in entecavir (ETV)-treated patients with hepatitis B virus (HBV)-ACLF is limited. AIMS This study was designed to evaluate the efficacy and safety of ETV in patients with HBV-ACLF and to develop a novel model (Tongji prognostic predictor model, TPPM) for prognostic prediction of HBV-ACLF patients. METHOD In this retrospective study, 248 patients with HBV-ACLF were enrolled. There were no significant differences in baseline clinical and virologic characteristics between patients treated with and without ETV. RESULTS The 1- and 3-month survival rates of patients in the ETV-treated group (n = 124) were 72.58 and 61.29%, respectively, significantly higher than that in NA-free group (n = 124), which were 53.23 and 45.97%, respectively. By Hosmor and Lemeshow test, TPPM for HBV-ACLF had a very good degree of fit with disease prognosis. Based on this unique group of patients, the TPPM scoring offered a better prediction value in both specificity and sensitivity for 3-month mortality of patients with HBV-ACLF compared with MELD scoring system with statistically significant difference. In the patients with HBV-ACLF, using a cutoff of 0.22 for 3-month predicted mortality by TPPM, the positive predictive value was 93.6% and negative predictive value 91.3%. CONCLUSION ETV treatment prevented disease progression and increased the survival of patients with HBV-ACLF. The established TPPM scoring system offers superior predictor value in both specificity and sensitivity for HBV-ACLF patients when compared with MELD.
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Affiliation(s)
- Ke Ma
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Wei Guo
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Meifang Han
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Guang Chen
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Tao Chen
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Zenguang Wu
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Daofeng Yang
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Jiaquan Huang
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Yuancheng Huang
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Xiping Zhao
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Deying Tian
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Jianxin Song
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Junying Qi
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China
| | - Qin Ning
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, University of Science and Technology, No 1095, Jiefang Avenue, 430030, Wuhan, China.
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Peng CY, Chen CB, Lai HC, Su WP, Chuang PH, Wu HDI, Jeng LB. Predictors for early HBeAg loss during lamivudine therapy in HBeAg-positive chronic hepatitis B patients with acute exacerbation. Hepatol Int 2010; 5:586-96. [PMID: 21442057 DOI: 10.1007/s12072-010-9227-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 11/24/2010] [Indexed: 12/15/2022]
Abstract
PURPOSE To examine the rate of early HBeAg loss and predictors of HBeAg loss in HBeAg-positive chronic hepatitis B (CHB) patients with acute exacerbation (AE) treated with lamivudine. METHODS A total of 146 patients diagnosed with CHB and AEs were included in this retrospective study. Patients were divided into two groups: decompensated and compensated. RESULTS The mean treatment duration for the decompensated and compensated groups was 18.1 and 19.9 months, respectively. Decompensated patients were significantly older and had a higher prevalence of cirrhosis and genotype B infection than compensated patients. Compared to compensated patients, decompensated patients achieved a higher rate of HBeAg loss (25.8 vs. 14.3%; P = 0.0805) at 3 months of therapy, a higher rate of serum HBV DNA negativity (53.2 vs. 29.8%; P = 0.0042), and a lower rate of rtM204V/I mutation (3.2 vs. 16.7%; P = 0.0139) after 12 months of lamivudine therapy. The rates of HBeAg loss after 6 and 12 months of lamivudine therapy were similar between the two groups. Logistic regression analysis revealed that female gender and baseline ALT level ≥1,000 IU/L, but not decompensations, were significant predictors of HBeAg loss at 3 months; however, only female gender was a significant predictor of HBeAg loss after 6 and 12 months of lamivudine therapy. The early HBeAg losers showed a significantly higher sustained remission rate off lamivudine therapy. CONCLUSIONS Female gender and baseline serum ALT level ≥1,000 IU/L were independent predictors of early HBeAg loss during lamivudine therapy in HBeAg-positive CHB patients with AE. ELECTRONIC SUPPLEMENTARY MATERIAL The online version of this article (doi:10.1007/s12072-010-9227-x) contains supplementary material, which is available to authorized users.
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Hsu CY, Lin HC, Huang YH, Su CW, Lee FY, Huo TI, Lee PC, Lee JY, Lee SD. Comparison of the model for end-stage liver disease (MELD), MELD-Na and MELDNa for outcome prediction in patients with acute decompensated hepatitis. Dig Liver Dis 2010; 42:137-42. [PMID: 19595648 DOI: 10.1016/j.dld.2009.06.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Revised: 05/28/2009] [Accepted: 06/10/2009] [Indexed: 02/09/2023]
Abstract
BACKGROUND AND AIM The model for end-stage liver disease (MELD) is used to predict the outcome of patients with cirrhosis. Incorporation of serum sodium (Na) into MELD may further increase its prognostic ability. Two Na-containing MELD models, MELD-Na and MELDNa, were proposed to enhance the prognostic ability. This study compared the predictive accuracy of these models for acute decompensated hepatitis. METHODS We investigated the outcome of 182 patients with acute decompensated hepatitis. RESULTS Twenty (11%) patients died at 3 months. The MELD-Na and MELDNa both had significantly higher area under the receiver operating characteristic curve (AUC) in comparison to MELD (MELD-Na: 0.908, MELDNa: 0.895, MELD: 0.823, p=0.004 and 0.001, respectively). Among 96 patients without specific antiviral treatment, the MELD-Na and MELDNa consistently had significantly higher AUC than the MELD (MELD-Na: 0.901, MELDNa: 0.882, MELD: 0.810, p=0.008 and 0.004, respectively). Three independent indicators, pre-existing cirrhosis (odds ratio [OR]: 5.67, 95% confidence interval [CI]: 1.72-18.7), serum albumin<3.7 g/dL (OR: 5.68, 95% CI: 1.18-27.03) and serum sodium (Na)<138 mequiv./L (OR: 10.0, 95% CI: 2.08-47.62), were associated with 3-month mortality. CONCLUSION MELD-Na and MELDNa provide better prognostic accuracy than the MELD for patients with acute decompensated hepatitis. The adequacy of liver reserve determines the outcome of these patients.
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Affiliation(s)
- C-Y Hsu
- Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Huo TI, Lin HC, Hsia CY, Huang YH, Wu JC, Chiang JH, Chiou YY, Lui WY, Lee PC, Lee SD. The MELD-Na is an independent short- and long-term prognostic predictor for hepatocellular carcinoma: a prospective survey. Dig Liver Dis 2008; 40:882-9. [PMID: 18339595 DOI: 10.1016/j.dld.2008.01.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Revised: 12/17/2007] [Accepted: 01/29/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Serum sodium has been suggested to incorporate into the model for end-stage liver disease to enhance its prognostic ability for cirrhosis. A mathematical equation based on model for end-stage liver disease and sodium, known as "MELD-Na", was developed for outcome prediction for cirrhosis. The severity of liver cirrhosis is a key component to predict survival in patients with hepatocellular carcinoma. This study investigated the prognostic role of MELD-Na for hepatocellular carcinoma. PATIENTS AND METHODS A total of 535 unselected hepatocellular carcinoma patients were prospectively enrolled to evaluate the performance of MELD-Na. RESULTS The MELD-Na was better than model for end-stage liver disease in predicting 6-month mortality by comparing the area under receiver operating characteristic curve (0.782 vs. 0.761, p=0.101). MELD-Na, but not model for end-stage liver disease, was an independent predictor associated with 6-month mortality in multivariate logistic regression analysis (odds ratio: 1.14, p=0.001). In the survival analysis, MELD-Na also independently predicted mortality, with an additional risk of 4.3% per unit increment of the score (p<0.001). Patients with MELD-Na scores between 10 and 20 and scores >20 had 2.1-fold (p<0.001) and 7.5-fold (p<0.001) risk of mortality, respectively, compared to patients with a score <10 in the Cox proportional hazard model. CONCLUSION The MELD-Na score is a feasible and independent prognostic predictor for both short- and long-term outcome predictions in patients with hepatocellular carcinoma.
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Affiliation(s)
- T-I Huo
- Department of Medicine, Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, Taipei, Taiwan.
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Huo TI, Lin HC, Huo SC, Lee PC, Wu JC, Lee FY, Hou MC, Lee SD. Comparison of four model for end-stage liver disease-based prognostic systems for cirrhosis. Liver Transpl 2008; 14:837-44. [PMID: 18508377 DOI: 10.1002/lt.21439] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Serum sodium (Na) has been suggested for incorporation into the Model for End-Stage Liver Disease (MELD) to enhance its prognostic ability for patients with cirrhosis. Three Na-containing models--the Model for End-Stage Liver Disease with the incorporation of serum sodium (MELD-Na), the integrated Model for End-Stage Liver Disease (iMELD), and the Model for End-Stage Liver Disease to sodium (MESO) index--were independently proposed for this purpose. This study investigated the accuracy of these 4 MELD-based models for outcome prediction. The c-statistic equivalent to the area under the receiver operating characteristic curve (AUC), used to predict 3- and 6-month mortality, was calculated and compared in 825 patients with cirrhosis. The MELD score tended to be lower with increasing Na level. At 3 months of enrollment, the iMELD had the highest AUC (0.807) and was followed by the MELD-Na (0.801), MESO (0.784), and MELD (0.773); the difference between the MESO and MELD was statistically significant (P = 0.013). At 6 months, the iMELD still had the highest AUC (0.797) and was followed by the MELD-Na (0.778), MESO (0.747), and MELD (0.735); all comparisons showed significant differences between each other (all P < 0.01), with the exception of iMELD and MELD-Na (P = 0.18). With the most discriminative cutoffs, the specificity and negative predictive value were 70%-85% and 89%-97%, respectively, at 3 and 6 months for the 4 models. Patients with spontaneous bacterial peritonitis (SBP) consistently had significantly higher MELD-derived scores in all 4 models compared to patients without SBP (all P < 0.01). Patients with hepatic encephalopathy also had higher scores in all 4 models, although the statistical significance was established only for the iMELD (41.0 +/- 11.5 versus 37.6 +/- 9.1, P = 0.037). In conclusion, the incorporation of Na into the MELD may enhance prognostic accuracy. Both the iMELD and MELD-Na are better prognostic models for outcome prediction in patients with cirrhosis. Patients with SBP have a higher MELD-derived score. Future studies are warranted to define the optimal MELD-based prognostic model for cirrhosis.
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Affiliation(s)
- Teh-Ia Huo
- Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
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Huo TI, Lee SD, Lin HC. Selecting an optimal prognostic system for liver cirrhosis: the model for end-stage liver disease and beyond. Liver Int 2008; 28:606-13. [PMID: 18433390 DOI: 10.1111/j.1478-3231.2008.01727.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In comparison with the Child-Turcotte-Pugh (CTP) system, recent studies suggested that the model for end-stage liver disease (MELD) may more accurately predict the survival for patients with cirrhosis. In the US, the liver allocation system was changed in 2002 from a status-based algorithm utilizing CTP scores to one using continuous MELD severity scores as a reference system in prioritizing adult patients on the waiting list. Direct evidence that demonstrates the benefits of MELD is the fact that the mortality rates of transplant candidates on the waiting list have remarkably decreased after the implementation of the MELD. The MELD score is closely associated with the degree of portal hypertension as reflected by the hepatic venous pressure gradient. Hyponatraemia occurs as a result of advanced cirrhosis, and a serum sodium (Na) level <126 mEq/L at the time of listing for transplantation is a strong independent predictor of mortality. Several MELD-derived prognostic models that incorporate serum Na into calculation have been proposed in the hopes of further improving the MELD's prognostic accuracy. Additionally, serum parameters such as creatinine and international normalized ratio are subject to interlaboratory variations and may need unifying standartisations. Patients with refractory complications of cirrhosis may need a priority MELD score to prioritize them on the waiting list. Appropriate modifications and the fine-tuning of the MELD based on well-designed prospective studies are necessary in solving the current controversial issues.
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Affiliation(s)
- Teh-Ia Huo
- Department of Medicine, Division of Gastroenterology, Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, Taipei, Taiwan
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