Hepatic Hemodynamics and Elevation of Liver Stiffness as Possible Predictive Markers of Late-onset Hepatic Failure

Association between effective hepatic blood flow and the severity and prognosis of hepatitis B virus-related acute on chronic liver failure

BACKGROUND

Hepatic inflammation resulted in hepatocyte necrosis and microcirculatory dysfunction in acute on chronic liver failure (ACLF) with cirrhosis or not. The influence of effective hepatic blood flow (EHBF) on the severity of liver failure has not been fully elucidated.

AIM

The aim of this study was to assess the correlation between the EHBF and the severity and the prediction of 90-day mortality rate of hepatitis B virus-related ACLF (HBV-ACLF).

METHODS

In this retrospective study, patients hospitalized for HBV-ACLF or decompensated cirrhosis and who underwent an indocyanine green (ICG) clearance test between June 2016 and July 2018 were enrolled. EHBF was measured by the ICG clearance test and patients were categorized into the ACLF without cirrhosis (HBV-ACLF-no-Cir), ACLF with cirrhosis (HBV-ACLF-Cir) and decompensated cirrhosis (HBV-De-Cir).

RESULTS

A total of 522 patients (HBV-ACLF-no-Cir: 84, HBV-ACLF-Cir: 111 and HBV-De-Cir: 327) were enrolled. The mean EHBF in the HBV-De-Cir was significantly higher than that in the HBV-ACLF-no-Cir and HBV-ACLF-Cir (0.36 vs. 0.21 vs. 0.20 L/min, P < 0.001). EHBF was significantly correlated with the total bilirubin, prothrombin activity and model for end-stage liver disease (MELD) in the HBV-ACLF-no-Cir. The predicted 90-day mortality rate using the MELD, EHBF, ICG-retention rate at 15 min (R15%) and EHBF-R15% scores were similar. The sensitivity and specificity of the EHBF varied between 68.5-80.2% and 45.8-73.7%, respectively. The EHBF-MELD score had the highest specificity.

CONCLUSION

EHBF was significantly lower in the patients with ACLF compared to decompensated cirrhosis. The EHBF were closely related to the severity of HBV-ACLF and can be used for predicting the 90-day mortality rate of HBV-ACLF.

Diverse correlations between fibrosis-related factors and liver stiffness measurement by transient elastography in chronic hepatitis B

BACKGROUND

Several fibrosis-related factors influence liver stiffness measurements (LSM); however, these changes have not been investigated in the context of the various disease stages of chronic hepatitis B (CHB).

AIM

The aim of this study was to assess the correlations between fibrosis-related factors and LSM in different disease stages of CHB.

PATIENTS AND METHODS

Patients with mild CHB (n=305) and cirrhotic hepatitis B (cirrhotic HB) (n=137) were compared with determine the relationship between LSM and fibrosis-related factors including parameters of liver inflammation [aminotransferase (ALT), aspartate transaminase (AST), total bilirubin (Tbil)], albumin, globulin, peripheral blood cells (neutrophil granulocytes, red blood cells, platelets), abdominal ultrasound B-scan parameters including right liver thickness, portal vein inradium, diameter of spleen (DS), thickness of spleen (TS), and splenic vein inradium (SV).

RESULTS

In patients with mild CHB, LSM was correlated strongly with ALT (r=0.3534, P<0.0001), AST (r=0.3976, P<0.0001), and ALT+AST (r=0.3760, P<0.0001). LSM was correlated closely with Tbil (r=0.2237, P<0.0001), albumin (r=-0.3126, P<0.0001), albumin/globulin (r=-0.3086, P<0.0001), SV (r=0.3317, P<0.0001), DS (r=0.4157, P<0.0001), and spleen volume (DS×TS) (r=-0.4399, P<0.0001). Red blood cells were correlated negatively with LSM in both mild CHB and cirrhotic HB patients (r=-0.1981, P=0.0203; r=-0.1593, P=0.0053). LSM was not correlated with age, peripheral blood cell parameters, right liver thickness, portal vein inradium, or TS in mild CHB or cirrhosis HB patients. However, in patients with cirrhotic HB, LSM values were not correlated significantly with other fibrosis-related factors, except for Tbil (r=0.2272, P=0.0076).

CONCLUSION

Our findings suggest that the magnitude of these correlations differs significantly between mild CHB and cirrhotic HB patients.

Appropriate timing to start and optimal response evaluation of high-dose corticosteroid therapy for patients with acute liver failure

BACKGROUND

Corticosteroid therapy has been commonly administered to patients with acute liver injury (ALI)/acute liver failure (ALF) in Japan to prevent the development of hepatic encephalopathy, but the appropriate timing to start corticosteroid therapy has not been determined and optimal response evaluation of the therapy has not been conducted. We prospectively investigated the optimal timing to start therapy on the established severity indication: the Japan Hepatic Encephalopathy Prediction Model (JHEPM) and prothrombin time (PT).

METHODS

This prospective observational study enrolled 469 patients with ALI/ALF from 2004 to 2015. We evaluated 44 patients with ALF on high-dose corticosteroid therapy before hepatic coma development. The predictive performance for coma development was assessed using the receiver operator curve method in both PT and JHEPM probability the day before administering high-dose corticosteroid therapy.

RESULTS

Among these patients, nine developed hepatic coma after the therapy. Selection bias was adjusted using propensity score method. High-dose corticosteroid therapy tended to decrease the risk of coma development although there was no statistical significance. The cut-off value of 53%, 1.95, and 39% in JHEPM probability, PT-international normalized ratio (PT-INR), and PT activity, respectively, showed high sensitivity and specificity.

CONCLUSIONS

We propose the appropriate timing to start high-dose corticosteroid therapy in patients with ALI/ALF; 40% of JHEPM probability, 1.53 of PT-INR, and 52% of PT because these values were theoretically discriminated at 98% coverage to the patients with coma. Because the study contained selection bias, the appropriate timing for therapy should be confirmed in a future prospective study.