Neutrophil gelatinase-associated lipocalin and cystatin C in cirrhosis and portal hypertension: Relations to organ extraction and dysfunction

Predictive value of renal shear wave elastography in liver cirrhosis

BACKGROUND

In liver cirrhosis, prognosis is profoundly affected by renal function. This study evaluates the usefulness of renal stiffness measurement by point-shear wave elastography and renal perfusion by duplex.

METHODS

In this case-control study, organ stiffness was quantified using point-shear wave elastography and duplex sonography to calculate the arterial resistive (RI) and pulsatility indices (PI) in 123 patients, including patients with liver cirrhosis with (LC+A) and without ascites (LC-A) and patients without liver cirrhosis (NLC).

RESULTS

PI and RI were significantly increased in LC-A and LC+A compared to NLC (p<0.001) and correlated with MELD and Child Pugh scores. Point-shear wave elastography showed significantly lower renal stiffness in LC+A compared to LC-A (p<0.01) and NLC (p<0.001). Renal stiffness correlated inversely with MELD and Child Pugh scores. Reduced renal stiffness, but not PI or RI, was associated with the presence of hepatorenal syndrome (p<0.001). Reduced renal stiffness was associated with an increased risk of death due to complications of liver cirrhosis within 3 years (p<0.01).

CONCLUSION

Point-shear wave elastography and duplex sonography correlate with progression of liver cirrhosis, but only shear wave elastography represents a valuable prognostic tool for hepatorenal syndrome and mortality in patients with liver cirrhosis.

Cystatin C/albumin ratio for early diagnosis of esophageal varices in liver cirrhosis

The mortality rate related to variceal bleeding is high in patients with liver cirrhosis. Early detection and treatment of varices can reduce the risk of hemorrhage and thus decrease the mortality rate related to variceal bleeding. The study comprised 81 cirrhotic patients in training set, who were categorized into 2 groups: the patients with esophageal varices (EVs group) and the patients without esophageal varices (non-EVs group). The disparity in Cystatin C/albumin ratio (CAR) was assessed between these 2 groups. Subsequently, a regression model was constructed by generating a receiver operating characteristic (ROC) curve to calculate the area under the curve (AUC). Then an external validation was performed in 25 patients. Among patients with cirrhosis in training set, a statistically significant difference in CAR was observed between the EVs group and non-EVs group (P < .05). At the CAR cutoff value of 2.79*10-5, the AUC for diagnosing EVs were 0.666. Further, a multivariate logistic regression model was constructed, after adjusting the model, the AUC for EVs diagnosis were 0.855. And the external validation showed that the model could not be considered as a poor fit. CAR exhibits potential as an early detection marker for EVs in liver cirrhosis, and the regression model incorporating CAR demonstrates a strong capability for early EVs diagnosis.

Improved prediction of mortality by combinations of inflammatory markers and standard clinical scores in patients with acute-on-chronic liver failure and acute decompensation

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is a sinister prognosis, and there is a need for accurate biomarkers and scoring systems to better characterize ACLF patients and predict prognosis. Systemic inflammation and renal failure are hallmarks in ACLF disease development and progression. We hypothesized that the combination of specific inflammatory markers in combination with clinical scores are better predictors of survival than the originally developed CLIF-C acute decompensation (AD) and CLIF-C ACLF scores.

METHODS

We reevaluated all previously measured inflammatory markers in 522 patients from the CANONIC study, 342 without and 180 with ACLF. We used the Harrell's C-index to determine the best marker alone or in combination with the original scores and calculated new scores for prediction of mortality in the original CANONIC cohort.

RESULTS

The best markers to predict 90-day mortality in patients without ACLF were the plasma macrophage activation markers soluble (s)CD163 and mannose receptor (sMR). Urinary neutrophil gelatinase associated lipocalin (UNGAL) and sCD163 were predictors for 28-day mortality in patients with ACLF. The newly developed CLIF-C AD + sMR score in patients without ACLF improved 90-day mortality prediction compared with the original CLIF-C AD score (C-index 0.82 [0.78-0.86] vs 0.74 [0.70-0.78, P = 0.004]). Further, the new CLIF-C ACLF + sCD163 + UNGAL improved the original CLIF-C ACLF score for 28-day mortality (0.85 [0.79-0.91] vs 0.75 [0.70-0.80], P = 0.039).

CONCLUSIONS

The capability of these inflammatory markers to improve the original prognostic scores in cirrhosis patients without and with ACLF points to a key role of macrophage activation and inflammation in the development and progression of AD and ACLF.

Prognosis predictability of serum and urine renal markers in patients with decompensated cirrhosis: A multicentre prospective study

BACKGROUND AND AIMS

This prospective observational study aimed to evaluate the best serum and urine markers to assess predictability for the prognosis of patients with decompensated cirrhosis.

METHODS

Serum creatinine and cystatin C (CysC), and urinary N-acetyl-beta-D glucosaminidase (uNAG) and neutrophil gelatinase-associated lipocalin (uNGAL) levels were measured from hospitalized patients with decompensated cirrhosis.

RESULTS

In total, 328 patients (mean age, 57.2 ± 12.0 years; 237 men) with decompensated cirrhosis were included. Alcoholic liver disease was the most frequent underlying liver disease (68.0%). Acute kidney injury (AKI) was concomitantly present in 41 patients (12.5%) at baseline. INR, serum creatinine and CysC levels, and uNAG and uNGAL levels were significantly higher in patients with AKI. During hospitalization, AKI had progressed in 37 patients (11.3%). In 287 patients without AKI, the incidence of AKI at 3, 6, 9 and 12 months was 15.4%, 22.2%, 28.6% and 32.5% respectively. On multivariate analysis, serum CysC and uNAG levels were independent predictors of AKI, and their optimal cut-off values were 1.055 mg/L and 23.1 U/g urinary Cr respectively. When patients were classified into three groups with these cut-off values of serum CysC and uNAG levels (group 1, both low; group 2, one of two high; and group 3, both high), progression of AKI during hospitalization (P = .001), incidence of AKI in patients without AKI at baseline (P = .001) and mortality rate (P < .001) differed significantly according to serum CysC and uNAG levels.

CONCLUSION

Serum CysC and uNAG levels are useful prognostic markers for renal outcomes and mortality in patients with decompensated cirrhosis.

A Qualitative Analysis of South African Health Professionals’ Discussion on Distrust and Unwillingness to Refer Organ Donors

Introduction:

South Africa is faced with very low deceased organ donor numbers. Often, sociocultural practices, which are thought to be fundamentally opposed to deceased organ donation, are hailed as the cause. However, other factors such as context, social perceptions, and clinical environment may play a role.

Aim:

The aim of this article is to present research that explored communication in organ transplant and identified barriers to organ donation decisions in a province of South Africa.

Methods:

Qualitative methods were used. Thirty semistructured interviews with transplant professionals and 2 focus groups with transplant coordinators took place across 6 health institutions in Gauteng Province.

Results:

Barriers that may prevent transplant professionals from referring potential donors were identified: The wider public and transplant professionals may be suspicious of biomedicine and have a perception that people could be killed for their organs. Organ donation was sometimes framed as “murder,” “killing,” or a “bunch of vultures.” Doctors may be unwilling to refer brain-dead patients, as this was seen as failing in one’s professional duty to cure the patient. The role of sociocultural practices was inconclusive, with the sample divided based on the extent of their influence.

Conclusion:

Low donor numbers may be a manifestation of barriers to referral in the clinical setting. These barriers interplay in a context of suspicion and are framed by a clinical transplant discourse that is sometimes loaded with negative connotation. Sociocultural practices are influential, but they may not be the overriding cause of low donor numbers.