Current status of liver diseases in Korea: liver cirrhosis

Contributions of the life expectancy gap reduction between urban and rural areas to the increase in overall life expectancy in South Korea from 2000 to 2019

BACKGROUND

This study aimed to quantify the contribution of narrowing the life expectancy gap between urban and rural areas to the overall life expectancy at birth in Korea and examine the age and death cause-specific contribution to changes in the life expectancy gap between urban and rural areas.

METHODS

We used the registration population and death statistics from Statistics Korea from 2000 to 2019. Assuming two hypothetical scenarios, namely, the same age-specific mortality change rate in urban and rural areas and a 20% faster decline than the observed decline rate in rural areas, we compared the increase in life expectancy with the actual increase. Changes in the life expectancy gap between urban and rural areas were decomposed into age- and cause-specific contributions.

RESULTS

Rural disadvantages of life expectancy were evident. However, life expectancies in rural areas increased more rapidly than in urban areas. Life expectancy would have increased 0.3-0.5 less if the decline rate of age-specific mortality in small-to-middle urban and rural areas were the same as that of large urban areas. Life expectancy would have increased 0.7-0.9 years further if the decline rate of age-specific mortality in small-to-middle urban and rural areas had been 20% higher. The age groups 15-39 and 40-64, and chronic diseases, such as neoplasms and diseases of the digestive system, and external causes significantly contributed to narrowing the life expectancy gap between urban and rural areas.

CONCLUSION

Pro-health equity interventions would be a good strategy to reduce the life expectancy gap and increase overall life expectancy, particularly in societies where life expectancies have already increased.

The Korea National Disability Registration System

The Korea National Disability Registration System (KNDRS) was established in 1989 to provide social welfare benefits based on predefined criteria for disability registration and an objective medical assessment using a disability grading system. Disability registration requires (1) a medical examination by a qualified specialist physician and (2) a medical advisory meeting to review the degree of disability. Medical institutions and specialists for the diagnosis of disabilities are legally stipulated, and medical records for a specified period are required to support the diagnosis. The number of disability types has gradually expanded, and 15 disability types have been legally defined. As of 2021, 2.645 million people were registered as disabled, accounting for approximately 5.1% of the total population. Among the 15 disability types, disabilities of the extremities account for the largest proportion (45.1%). Previous studies have investigated the epidemiology of disabilities using data from the KNDRS, combined predominantly with data from the National Health Insurance Research Database (NHIRD). Korea has a mandatory public health insurance system that covers the entire Korean population, and the National Health Insurance Services manages all eligibility information, including disability types and severity ratings. In short, the KNDRS-NHIRD is a significant data resource for research on the epidemiology of disabilities.

Clinical usefulness of Mac-2 binding protein glycosylation isomer for diagnosing liver cirrhosis and significant fibrosis in patients with chronic liver disease: A retrospective single-center study

Accurate diagnosis of liver cirrhosis (LC) and significant fibrosis in patients with chronic liver disease (CLD) is important. The Mac-2 binding protein glycosylation isomer (M2BPGi) has emerged as a novel serum biomarker for liver fibrosis; however, insufficient clinical data of M2BPGi are available in patients with CLD. Therefore, we performed a retrospective cohort study to investigate the clinical usefulness of serum M2BPGi for assessing LC and significant fibrosis in CLD patients. We retrospectively reviewed the CLD patients with measured serum M2BPGi at Kosin University Gospel Hospital between January 2016 and December 2019. Multivariate logistic regression analyses were conducted to identify the independent factors associated with LC. The diagnostic power of serum M2BPGi for LC and significant fibrosis (≥F2) was evaluated and compared to that of other serum biomarkers using receiver operating characteristic curve and area under the curve (AUC). A total of 454 patients enrolled in this study. M2BPGi (adjusted odds ratio [aOR], 1.77; 95% confidence interval [CI], 1.52-2.07) and fibrosis index based on four factors (aOR, 1.23; 95% CI, 1.11-1.37) were identified as significant independent factors for LC. The AUC of M2BPGi for LC (0.866) and significant fibrosis (0.816) were comparable to those of fibrosis index based on four factors (0.860, 0.773), aspartate aminotransferase-to-platelet ratio index (0.806, 0.752), and gamma-glutamyl transpeptidase-to-platelet ratio (0.759, 0.710). The optimal cut-off values for M2BPGi for LC and significant fibrosis were 1.37 and 0.89, respectively. Serum M2BPGi levels were significantly correlated with liver stiffness measurements (ρ = 0.778). Serum M2BPGi is a reliable noninvasive method for the assessment of LC and significant fibrosis in patients with CLD.

Changing Trends in Liver Cirrhosis Etiology and Severity in Korea: the Increasing Impact of Alcohol

BACKGROUND

Chronic hepatitis B is the most common cause of liver cirrhosis in South Korea. However, alcoholic liver disease has shown an increasing trend. Although the clinical implications surrounding liver cirrhosis have been changing over the years, few studies have recently examined cirrhosis epidemiology. Therefore, we aimed to investigate changes in liver cirrhosis etiology and severity in Korea.

METHODS

We retrospectively reviewed 16,888 records of cirrhotic patients from six tertiary hospitals in Korea from 2008 to 2017. Continuous and non-continuous variables were processed via linear and Poisson regression, expressed as beta (B) coefficients and as exponentiated values of coefficients (Exp[B]), respectively.

RESULTS

Chronic hepatitis B showed a decreasing trend (Exp[B] = 0.975, P < 0.001), whereas alcohol showed an increasing trend (Exp[B] = 1.013, P = 0.003), occupying the most common etiology in 2017. The Child-Turcotte-Pugh (CTP) score and decompensated liver cirrhosis prevalence did not change over the 10-year period. The incidence of variceal bleeding, severe ascites, hepatic encephalopathy, and spontaneous bacterial peritonitis significantly decreased from 12.3% to 7.7%, 7.8% to 4.1%, 1.0% to 0.5%, and 1.9% to 1.1%, respectively (P < 0.05 for all). In the subgroup analysis, the chronic hepatitis B group showed improving CTP scores (B = -0.025, P < 0.001) and decreasing decompensated liver cirrhosis rates (Exp[B] = 0.977, P = 0.016), whereas the alcohol group demonstrated increasing CTP class C (Exp[B] = 1.031, P = 0.005) and model for end-stage liver disease scores (B = 0.081, P = 0.005) over 10 years.

CONCLUSION

The chronic hepatitis B group exhibited improved results, whereas the alcohol group still presented poor liver functions and outcomes. Future national policies and systematic approaches addressing the incidence, prevention, and treatment of alcoholic liver cirrhosis are indispensable.

Association between new-onset liver cirrhosis and suicide risk in South Korea: A nationwide cohort study

Background/Aims

Current evidence suggests that liver cirrhosis (LC) causes severe psychological stress and depression, which are risk factors for suicide. Although previous studies reported the association between LC and suicidal thoughts, little is known of its effect on suicidal deaths. Therefore, this study was undertaken to investigate the effect of new-onset LC on suicide.

Methods

From the National Health Insurance Service-National Sample Cohort of South Korea, 5,809 incident LC patients and 11,618 risk-set controls matched by propensity score were selected for follow-up. The incidence rate of suicide was estimated using a generalized estimating equation with a Poisson distribution. Effect size was presented as a hazard ratio (HR) using Cox’s proportional hazards model.

Results

The incidence rate of suicide was 143.3 cases per 100,000 person years (95% confidence interval [CI], 100.2–205.1) among the LC cohort. The LC patients were 2.37 times more likely to commit suicide compared with matched controls (HR, 2.37; 95% CI, 1.44–3.88). Increased suicide risk was evident within the first 2 years of the follow-up period (HR, 2.59; 95% CI, 1.20–5.60) and among the 18–49-year-old age group (HR, 3.72; 95% CI, 1.45–9.56).

Conclusions

Our study found increased risk of suicide in patients with new onset LC, especially during the early period following diagnosis and in younger patients. To decrease this suicide risk, a regular and continuous social support system is required.

The life expectancy gap between North and South Korea from 1993 to 2008

Background

Comparative research on health outcomes in North and South Korea offers a unique opportunity to explore political and social determinants of health. We examined the age- and cause-specific contributions to the life expectancy (LE) gap between the two Koreas.

Methods

We calculated the LE at birth in 1993 and 2008 among North and South Koreans, and cause-specific contributions to the LE discrepancy between the two Koreas in 2008. The cause-specific mortality data from South Korea were used as proxies for the cause-specific mortality data in North Korea in 2008.

Results

The LE gap between the two Koreas was approximately 1 year in 1993, but grew to approximately 10 years in 2008. This discrepancy was attributable to increased gaps in mortality among children younger than 1 year and adults 55 years of age or older. The major causes of the increased LE gap were circulatory diseases, digestive diseases, infant mortality, external causes, cancers and infectious diseases.

Conclusions

This study underscores the urgency of South Korean and international humanitarian aid programs to reduce the mortality rate of the North Korean people.

Prognosis of Spontaneous Bacterial Peritonitis in Hepatocellular Carcinoma Patients

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a serious infectious complication in patients with liver cirrhosis. However, information about prognosis of SBP in hepatocellular carcinoma (HCC) patients is limited. We investigated the clinical course of SBP in HCC patients.

METHODS

This study enrolled patients diagnosed with SBP between 2005 and 2017. Medical records of patients were reviewed and clinical course was compared between the non-HCC and HCC groups.

RESULTS

In total, 123 SBP cases including 49 HCC cases were enrolled. Men were predominant (48/74, 64.9% vs. 34/49, 69.4%; P = 0.697); median age was 58 years in both non-HCC and HCC groups (P = 0.887). The most common etiology was alcohol (32/74, 43.2%) in non-HCC group and hepatitis B (30/49, 61.2%) in HCC group (P = 0.009). Antibiotic resistance rate was higher in non-HCC than in HCC group (29.7% vs. 12.2%; P = 0.028); in-hospital mortality did not differ between the groups (25/74, 33.8% vs. 13/49, 26.5%; P = 0.431). Development rate of hepatorenal syndrome did not differ between non-HCC and HCC group (14/74, 18.9% vs. 10/49, 20.4%; P = 1.000), but hepatic encephalopathy was less common in HCC group (26/74, 35.2% vs. 9/49, 18.3%; P = 0.008). The most important predictor of in-hospital mortality in patients with HCC was white blood cell count above 11,570 cells/mm³ (odds ratio, 6.629; 95% confidence interval, 1.652-26.590; P = 0.008).

CONCLUSION

Prognosis of SBP in HCC patients is relatively less severe. This result may be related with reduced antibiotics resistance and lower development rates of other complications, such as hepatic encephalopathy. Degree of systemic inflammation may be the most important factor for in-hospital mortality.

How can we improve the performance of Model for End-Stage Liver Disease sodium score in patients with hepatitis B virus-related decompensated liver cirrhosis commencing antiviral treatment?

BACKGROUND AND AIM

We aimed to develop a more efficient prognostic model to predict 1-year mortality in patients with hepatitis B virus-related decompensated cirrhosis beginning antiviral treatment.

METHODS

Using Cox regression analysis, survival analyses were performed on 554 patients with decompensated cirrhosis who were followed up from the start of nucleos(t)ide analogue antiviral treatment.

RESULTS

At baseline, ascites and hepatic encephalopathy were found in 78.0% and 18.1% of patients, respectively. Eighty-six events (77 deaths and 9 emergency liver transplants) occurred within the first year of treatment. Severity of ascites, presence of hepatic encephalopathy, and the Model for End-Stage Liver Disease (MELD)-sodium (MELDNa) score were independent risk factors for 1-year mortality. The new prognostic model (the revised MELDNa) constructed by adding ascites and encephalopathy to the MELDNa score significantly improved the area under the receiver operating characteristics curve for predicting 1-year events at baseline compared with the Child-Turcotte-Pugh system, MELD and MELDNa models, and Fontana index (0.905 vs 0.867, 0.843, 0.871, and 0.815, respectively; P < 0.05). Furthermore, repetitive application of revised MELDNa at 0, 1, 2, 3, and 6 months of treatment could predict 81.4% (70/86) of 1-year events, which was significantly (P < 0.05) higher than the sensitivity of the Child-Turcotte-Pugh system (68.6%), MELD (70.9%) and MELDNa (68.6%) scores, and Fontana index (64.0%), achieving similar specificities of ~96%.

CONCLUSIONS

Ascites and encephalopathy should be considered together with the MELDNa score when predicting short-term mortality and planning liver transplant in patients with decompensated hepatitis B virus-related cirrhosis starting antiviral treatment.

Clinical Outcomes of Peritoneal Dialysis in End-Stage Renal Disease Patients with Liver Cirrhosis: A Propensity Score Matching Study

Background

Clinical results of long-term peritoneal dialysis (PD) therapy in patients with liver cirrhosis (LC) and end-stage renal disease (ESRD) are controversial. This study evaluated the clinical outcomes of LC patients undergoing PD.

Methods

Clinical records were retrospectively collected from a single center between January 2007 and December 2014. An analysis of PD patients with LC and without liver disease was performed using propensity score matching. We further restricted matching by age, gender, and the presence of diabetes mellitus. Two cohorts of 33 patients each were selected. Early technical complications were defined as the presence of catheter-related complications, including malposition, leakage, omental wrapping, obstruction, and requiring a transfer to hemodialysis (HD) within 6 months of initiating PD.

Results

Mean PD duration was lower in LC patients (57.2 ± 46.1 months) than in controls (85.8 ± 64.2 months). Blood urea nitrogen, creatinine, and albumin levels were significantly lower in LC patients than in the control group. Cystatin C and cystatin C-based glomerular filtration rates were not significantly different in the LC group compared with those in the controls. We found that the risks for early technical complications, peritonitis, and long-term PD and patient survival were not higher in patients with LC than in those without LC. Ascites were easily controlled, and hepatic encephalopathy did not affect PD maintenance in LC patients.

Conclusions

The clinical outcomes, including technical complications, peritonitis, and patients’ survival, suggest that PD can be used as a renal replacement therapy in ESRD patients with LC.

Iron deficient erythropoiesis might play key role in development of anemia in cancer patients

Introduction

Multifactorial pathogenesis is involved in anemia of cancer patients and defining the causes of anemia is not always simple.

Methods

The incidence of anemia among 4 major cancers (gastric, colorectal, lung cancer and hepatocellular carcinoma), and biochemical features of anemia using ferritin, CRP, hepcidin and soluble transferrin receptor (sTfR) were assessed. Anemia was defined either by hemoglobin (Hb) ≤11 g/dL or a drop of Hb 2 g/dL or more during anticancer treatment.

Results

Among the 345 patients including 152 lung cancer, 101 gastric cancer, 69 colorectal cancer and 23 hepatocellular carcinoma, 49 patients (14.2%) had anemia at their initial diagnosis of cancer. During treatment, 129 (37.4%) experienced anemia, and 34 (26.4%) were treated mostly by transfusion. Biochemical feature of anemia was examined with 39 patients' samples. When comparing to the reference value from general population, cancer patients showed numerically higher ferritin, sTfR, CRP and hepcidin level. Among the cancer patients, anemic patients had significantly higher ferritin (p = 0.050) and sTfR (p = 0.009) level compared to non-anemic patients.

Conclusion

Anemia is a common issue in cancer patients and is largely undertreated with sub-optimal diagnoses of cause. The rates of anemia increase significantly during anti-cancer treatment and appear to be largely associated with iron deficiency.

Subclinical Ascites Does Not Affect the Long-term Prognosis in Hepatitis B Virus-related Cirrhosis Patients Receiving Antivirals

BACKGROUND AND AIMS

This study evaluated the clinical significance of subclinical ascites in patients with hepatitis B virus-related cirrhosis treated with lamivudine (LMV) or entecavir (ETV).

METHODS

This multicenter retrospective study involved 8 hospitals. Patients were classified by degree of ascites: (1) no ascites (no ascites on imaging, no diuretics), (2) subclinical ascites (small amount of ascites on imaging, no diuretics), and (3) clinical ascites (moderate to severe ascites or diuretics).

RESULTS

Out of 501 patients, 336 (68%), 51 (10%), and 114 (23%) patients were classified as no-ascites, subclinical ascites, and clinical ascites, respectively. In all, 100 (20%) and 401 (80%) were treated with LMV and ETV, respectively. Over 58±24 months of follow-up, 105 patients (21%) developed hepatocellular carcinoma. The cumulative incidence of hepatocellular carcinoma did not differ between LMV-treated and ETV-treated patients (P=0.61); it was higher in the clinical-ascites group than the no-ascites (P=0.054) and subclinical-ascites (P=0.03) groups, but it was comparable between the latter 2 (P=0.225). Forty-five patients (9%) died during follow-up. Survival was significantly shorter in the clinical-ascites group than the other 2 (both P<0.005), but it was comparable between no-ascites and subclinical-ascites groups (P=0.444). Multivariate analysis showed that mortality was significantly associated with prothrombin time [hazard ratio (HR)=2.42; 95% confidence interval (CI), 1.59-3.70], serum albumin (HR=0.54; 95% CI, 0.29-0.99), and presence of clinical ascites (HR=3.58; 95% CI, 1.54-8.30).

CONCLUSIONS

Subclinical ascites did not affect prognosis in patients with hepatitis B virus-related cirrhosis receiving antiviral treatment.

AST to Platelet Ratio Index Predicts Mortality in Hospitalized Patients With Hepatitis B-Related Decompensated Cirrhosis

Aspartate aminotransferase to platelet ratio index (APRI) has originally been considered as a noninvasive marker for detecting hepatic fibrosis in patients with chronic hepatitis B and C. APRI has been used for predicting liver-related mortality in patients with chronic hepatitis C virus infection or alcoholic liver disease. However, whether APRI could be useful for predicting mortality in chronic hepatitis B virus (HBV) infection remains unevaluated. This study aims to address this knowledge gap. A total of 193 hospitalized chronic HBV-infected patients (cirrhosis, n = 100; noncirrhosis, n = 93) and 88 healthy subjects were retrospectively enrolled. All patients were followed up for 4 months. Mortality that occurred within 90 days of hospital stay was compared among patients with different APRI. APRI predictive value was evaluated by univariate and multivariate regression embedded in a Cox proportional hazards model. APRI varied significantly in our cohort (range, 0.16-10.00). Elevated APRI was associated with increased severity of liver disease and 3-month mortality in hospitalized patients with HBV-related cirrhosis. Multivariate analysis demonstrated that APRI (odds ratio: 1.456, P < 0.001) and the model for end-stage liver disease score (odds ratio: 1.194, P < 0.001) were 2 independent markers for predicting mortality. APRI is a simple marker that may serve as an additional predictor of 3-month mortality in hospitalized patients with HBV-related decompensated cirrhosis.

Neutrophil-to-Lymphocyte Ratio Predicts Early Mortality in Patients with HBV-Related Decompensated Cirrhosis

Background. The neutrophil-to-lymphocyte ratio (NLR) is an inflammation index that has been shown to independently predict poor clinical outcomes. We aimed to evaluate the clinical value of NLR in the prediction of 30-day mortality in patients with HBV-related decompensated cirrhosis (HBV-DeCi). Methods. This was a retrospective cohort study that included 148 patients with HBV-DeCi. Results. An elevated NLR was associated with increased severity of liver disease and mortality within 30 days. Multivariate analysis suggested that NLR, similar to the model for end-stage liver disease (MELD) score, is an additional independent predictor of 30-day mortality (P < 0.01). Conclusion. Our results suggest that a high NLR can be considered a new independent biomarker for predicting 30-day mortality in patients with HBV-DeCi.

Changing trends of hospitalisation of liver cirrhosis in Beijing, China

Objective

To examine if the hospitalisation trends of liver cirrhosis are changing with the changes of risk factors of the disease in China.

Design

Secondary analysis of hospitalisation records in the 31 top-ranking hospitals in Beijing.

Results

Between 2006 and 2010, hospitalisation from viral hepatitis cirrhosis (VHC) decreased by 10% (95% CI=5–14%, p<0.001), but non-viral hepatitis cirrhosis (NVHC) and alcoholic cirrhosis (AC) increased by 35% (26–46%, p<0.001) and 33% (19%– 47%, p<0.001), respectively. The age patterns of hospitalisation varied with different types of liver cirrhosis. The hospitalisation risks for patients with VHC and AC were significantly high in the age groups 40–49 and 50–59 years, but risks for those with NHVC were high in all age groups of 40 years or above. Overall male-to-female hospitalisation ratios for VHC, NVHC and AC were 2.71, 1.14 and 59.9, respectively. The sex ratio became smaller with time from 2006 to 2010 in hospitalised patients with VHC, but it substantially increased in those with NVHC during the same period.

Conclusions

Hospitalisation rates for liver cirrhosis in Beijing are changing with time. The changes of viral hepatitis infection and alcohol consumption in the general population may cause these changes.

B-cell-associated immune profiles in patients with decompensated cirrhosis

OBJECTIVE

Previous observations on immune dysfunction in decompensated cirrhosis have raised the possibility of B-cell impairment.

METHODS

B-cell subsets in decompensated cirrhotic patients were investigated. Twenty-six decompensated cirrhotic patients and 26 healthy controls were included in this study. The percentages of B-cell subsets, such as mature, memory, immature B cells, and interleukin (IL)-10+-B-cell subpopulations, were measured using fluorescent activated cell sorting. B-cell-associated cytokines (IL-10, IL-21 and IL-4) were determined using an enzyme-linked immunosorbent assay.

RESULTS

The percentage of total B cells and mature B cells increased in patients with decompensated cirrhosis compared to healthy controls. The proportions of memory B cells were significantly lower in the decompensated cirrhosis group than the control group. However, the frequency of immature B cells and the percentage of IL-10-expressing cells that were CD19+, memory, mature, or immature B cells were not significantly different between the two groups. Serum levels of IL-10, IL-21, and IL-4 were significantly lower in the decompensated cirrhosis group compared to the control group.

CONCLUSION

These results indicate significant alterations in peripheral blood B-cell subsets in patients with decompensated cirrhosis. Specifically, a profound reduction of memory B cells was observed in spite of an increase in total B-cell populations in decompensated cirrhotic patients. This implies the underlying mechanisms of impaired immune response in these patients.

Clinical application of transient elastography in patients with chronic viral hepatitis receiving antiviral treatment

Accurate evaluation of the degree of liver fibrosis in patients with chronic liver diseases (CLD) is crucial, as liver fibrosis is important in determining the prognosis of liver diseases. Currently, liver biopsy (LB) is considered the gold standard for staging liver fibrosis or cirrhosis. However, utilization of LB in clinical practice is often limited because of its invasive nature, sampling error and interobserver variability. Recently, transient elastography (TE) was introduced as a noninvasive, highly reproducible technique for assessing the degree of liver fibrosis. After extensive studies, TE is now regarded as a reliable surrogate marker for grading the severity of liver fibrosis in patients with CLD. In the past few years, the role of TE in monitoring liver stiffness and determining prognosis in patients with chronic hepatitis B (CHB) or chronic hepatitis C (CHC) who are undergoing antiviral treatment has been investigated. In patients with CHB, liver stiffness values decrease with antiviral treatment. TE can also be used to predict the incidence of liver-related events during antiviral treatment. In patients with CHC, TE can be used to monitor potential regression of liver fibrosis after antiviral treatment and may predict the treatment outcome of CHC. In addition, TE is an adjunct tool for distinguishing inactive hepatitis B virus carriers from patients with chronic active hepatitis. This review article discusses the important findings from recent studies focusing on the clinical application of TE in patients with chronic viral hepatitis who are undergoing antiviral treatments.

Prognostic value of the combined use of transient elastography and fibrotest in patients with chronic hepatitis B

BACKGROUND & AIMS

Liver stiffness (LS) measurement using transient elastography and the FibroTest (FT) are alternatives to liver biopsy (LB) in assessing liver fibrosis. We investigated the prognostic role of the combined use of LS and FT in predicting liver-related events (LREs) in patients with chronic hepatitis B (CHB).

METHODS

Consecutive patients with CHB who underwent LB, along with LS and FT on the same day were recruited. LRE was defined as hepatic decompensation, hepatocellular carcinoma (HCC) or liver-related death.

RESULTS

A total of 151 patients (86 male) were analyzed. During follow-up (median 59.9 months), overall 18 (11.9%) patients experienced LREs. The areas under receiver-operating characteristic curves of LS, FT, LS + FT and LS × FT in predicting LRE were 0.701, 0.668, 0.702 and 0.741 respectively. After adjusting for age and histological fibrosis staging, significant variables in univariate analysis (both P < 0.05), LS + FT and LS × FT were independent predictors of LREs with hazard ratios (HRs) of 1.080 and 1.126 (all P < 0.05) respectively. When subjects were divided into three groups according to quartile stratification (low quartile, interquartile and high quartile) using LS + FT and LS × FT, cumulative LRE development rate significantly increased with a corresponding increase in value among three groups respectively (log-rank test, all P < 0.05).

CONCLUSION

The combined use of LS and FT significantly predicted forthcoming LRE development, but with only a slight additional benefit compared to LS or FT alone.

Non-invasive prediction of development of hepatocellular carcinoma using transient elastography in patients with chronic liver disease

Prognosis of patients with chronic liver disease is determined by the extent and progression of liver fibrosis, which may ultimately lead to hepatocellular carcinoma (HCC). Liver biopsy (LB) is regarded as the gold standard to estimate the extent of liver fibrosis. However, because LB has several limitations, the foremost being its invasiveness, several non-invasive methods for assessing liver fibrosis have been proposed. Of these, transient elastography (TE) provides an accurate representation of the extent of liver fibrosis. Furthermore, recent studies have focused on the usefulness of TE for assessing the risk of HCC development and HCC recurrence after curative treatment, and developed novel models to calculate the risk of HCC development based on TE findings. These issues are discussed in this expert review.

Health-related quality of life and survival in Chinese patients with chronic liver disease

Background

To investigate the relationship between health-related quality of life (HRQOL) and survival in Chinese patients with chronic liver disease (CLD).

Methods

HRQOL was measured with the Chinese version of Short Form 36 (SF-36). SF-36 scores, demographic and clinical data were collected at baseline and after 18 months follow-up. Kaplan-Meier and Cox Proportional Hazard Regression survival analyses were used for interpretation of data. Surviving patients were censored in the analyses.

Results

A total of 415 Chinese patients with CLD and 86 healthy controls were enrolled. During the follow-up period 50 patients died. SF-36 scores in healthy controls and surviving patients were higher compared with those in deceased patients. Scores of physical component summary (PCS) in healthy controls, surviving and deceased patients were 54.1 ± 5.2, 48.9 ± 7.7 and 33.5 ± 8.2 respectively (p < 0.001). Scores of mental component summary (MCS) in healthy controls, surviving and deceased patients were 56.6 ± 8.2, 53.0 ± 5.6 and 37.1 ± 12.1 (p < 0.001) respectively. Survival was significantly associated with PCS and MCS scores, and the presence of ascites.

Conclusions

HRQOL was associated with survival in patients with CLD. PCS and MCS scores were predictors of survival.

Predictive factors that influence the survival rates in liver cirrhosis patients with spontaneous bacterial peritonitis

BACKGROUND/AIMS

Spontaneous bacterial peritonitis (SBP) has been known to greatly influence the survival rate of patients with liver cirrhosis. However, the factors that affect the survival rate in patients with SBP need to be clarified.

METHODS

This study enrolled 95 liver cirrhosis patients diagnosed with SBP. The laboratory findings of their serum and ascitic fluid were examined and the characteristics of the isolated microorganisms in their peritoneal fluid were analyzed.

RESULTS

The proportion of patients with culture-positive SBP was 41.1%, and 47 microorganisms were isolated from the ascitic fluid. The proportions of cultured bacteria that were Gram negative and Gram positive were 57.4% and 40.4%, respectively. The proportions of Escherichia coli, Klebsiella species, and Streptococcus species were 25.5%, 19.1%, and 19.1%, respectively. Enterococcus species represented 12.8% of the microorganisms cultured. The overall survival rates at 6, 12, and 24 months were 44.5%, 37.4%, and 32.2%, respectively. There was no relationship between the bacterial factors and the survival rate in SBP. Multivariate analysis revealed that the presence of hepatocellular carcinoma (HCC; P=0.001), higher serum bilirubin levels (≥3 mg/dL, P=0.002), a prolonged serum prothrombin time (i.e., international normalized ratio >2.3, P<0.001), renal dysfunction (creatinine >1.3 mg/dL, P<0.001), and lower glucose levels in the ascitic fluid (<50 mg/dL, P<0.001) were independent predictive factors of overall survival rate.

CONCLUSIONS

HCC, higher serum bilirubin levels, a prolonged serum prothrombin time, renal dysfunction, and lower ascitic glucose levels are associated with higher mortality rates in cirrhotic patients with SBP.

Clinical application of liver stiffness measurement using transient elastography in chronic liver disease from longitudinal perspectives

Accurate determination of the presence and degree of fibrosis in liver is of great importance, because the prognosis and management strategies for chronic liver disease depend mainly on these factors. To date, liver biopsy (LB) remains the “gold standard” for assessing the severity of liver fibrosis; however, LB is often limited by its invasiveness, sampling error, and intra/inter-observer variability in histological interpretation. Furthermore, repeated LB examinations within a short time interval are indeed ineligible in a real clinical practice. Thus, due to the pressing need for non-invasive surrogates for liver fibrosis, transient elastography (TE), as a novel ultrasound based technology, has allowed a noninvasive measurement of liver stiffness and has gained in popularity over recent years. In the past few years, additional roles for transient TE beyond the initial purpose of a non-invasive surrogate for LB have included the prediction of the most two critical consequences of fibrosis progression: the development of portal hypertension-related complications and hepatocellular carcinoma. This indicates that the role of transient TE is not merely limited to reducing the need for LB, but transient TE can enable the establishment of tailored management strategies by providing more detailed prognostic information. In particular, under the concept in which the clinical course of liver fibrosis is dynamic and bidirectional, especially when appropriate intervention is commenced, transient TE can be used to track the dynamic changes in fibrotic burden during antiviral or antifibrotic treatment. This review discussed extended applications of transient TE in prediction of the development of real clinical endpoints from a longitudinal perspective.

Prognosis of hepatitis B-related liver cirrhosis in the era of oral nucleos(t)ide analog antiviral agents

BACKGROUND AND AIM

We investigated long-term outcomes and prognostic factors in patients with hepatitis B virus (HBV)-related liver cirrhosis in the era of oral nucleos(t)ide analog antiviral agents.

METHODS

Between January 1999 and February 2009, a total of 240 consecutive patients who had HBV-related cirrhosis without malignancy were treated with lamivudine and second line nucleos(t)ide analogs. The group of historical controls consisted of 481 consecutive patients with HBV-related cirrhosis who were managed without any antiviral treatment prior to 1999.

RESULTS

In 78% of the patients who received antiviral treatment, sustained viral suppression (serum HBV DNA < 10(5) copies/mL) was achieved during a mean follow-up period of 46 months. The occurrences of death, hepatic decompensation, and hepatocellular carcinoma (HCC) were less frequent in the treated cohort than in untreated historical controls, with the 5-year cumulative incidences being 19.4% versus 43.9% (log-rank P < 0.001), 15.4% versus 45.4% (P = 0.001), and 13.8% versus 23.4% (P = 0.074), respectively. For patients who received antiviral treatment, suboptimal viral suppression (HBV DNA > 10(5) copies/mL at last follow-up) was an important independent risk factor of death (P < 0.001) and hepatic decompensation (P = 0.019), and was linked to an increased risk of HCC (P = 0.042). Although the Child-Pugh grade remained a useful prognostic factor, no significant differences were found between patients with Child-Pugh grade B and C cirrhosis at the beginning of antiviral treatment (P = 0.656).

CONCLUSIONS

Oral antiviral agents have improved the prognosis of patients with HBV-related cirrhosis and affected the prognostic values of factors constituting the Child-Pugh system, necessitating a more efficient prognostic system.

Serum selenium levels in Korean hepatoma patients

The aim of this study was to determine serum selenium (Se) levels during the development of liver disease as well as the possible Se supplementation benefits in liver disease patients. Serum was collected from 187 patients with liver diseases and 120 normal healthy people living in Seoul. The samples were collected at the Kangnam St. Mary's Hospital College of Medicines, The Catholic University of Korea, in accordance with procedures approved by the Institutional Review Board of the Catholic University of Korea. Serum Se levels were quantified by inductively coupled plasma mass spectrometry and were compared between healthy and liver diseases patients. Se levels were 92.65 ± 32.50 μg/l in hepatitis infection, 92.33 ± 30.66 μg/l in hepatitis B virus infection and 96.41 ± 51.50 μg/l in hepatitis C virus infection, 96.42 ± 32.80 μg/l in cirrhosis, and 67.47 ± 14.30 μg/l in hepatoma patients. Findings were significantly lower in hepatitis and hepatoma as compared with the healthy participants (P < 0.001). The Se level of the healthy population was 108.38 ± 29.50, 119.37 ± 28.31 for males and 97.87 ± 26.99 μg/l for females. Our data shows the same parallelism between liver disease progression and decrease of Se levels except in the case of liver cirrhosis. And also, our study confirms the previous findings of significantly lower Se levels in Korean hepatoma patients. Se levels that decrease parallel to liver disease progression should be further integrated and analyzed with liver function blood biomarkers.

Retrospective analysis of factors influencing the development and progression of hepatic encephalopathy in patients with hepatitis B virus-related cirrhosis

AIM: To investigate the factors influencing the development and progression of hepatic encephalopathy (HE) in patients with hepatitis B virus (HBV)-related cirrhosis (HBCE).

METHODS: The clinical data for 78 patients with HBCE and 52 patients with HBV-related cirrhosis without HE (HBCNE) treated at the First Affiliated Hospital of Dalian Medical University from March 2002 to May 2011 were retrospectively analyzed. Factors analyzed include gender, age, precipitating factors, ascites, esophageal-gastric varices (EGV), splenomegaly, grade of HE, Child-Pugh grade, blood ammonia (NH4), serum sodium (Na), serum cholinesterase (CHE), serum total bilirubin (TBil), serum albumin (ALB), blood urea nitrogen (BUN), serum creatinine (Cr), and prothrombin time (PT).

RESULTS: Infection was the most common precipitating factor to induce HE in patients with HBV-related cirrhosis (35.6%). Grade Ⅱ HE was most common (36.8%), followed by grade Ⅳ HE (25.3%). Child-Pugh grade, ascites, NH4, Na, CHE, TBil, ALB, BUN, and PT were significantly different between the HBCE and HBCNE groups (0:8:79 vs 0:21:31, 19:68 vs 36:16, 20.74 ± 70.44 vs 46.53 ± 10.67, 136.01 ± 6.65 vs 141.48 ± 3.34, 1927.34 ± 70.52 vs 3342.01 ± 38.03, 91.75 ± 84.56 vs 58.98 ± 14.46, 25.53 ± 3.84 vs 29.48 ± 2.58, 13.57 ± 14.76 vs 6.41 ± 1.57, 21.34 ± 7.12 vs 18.59 ± 1.66; all P < 0.05). The level of NH4 in patients with grade Ⅳ HE was significantly higher than those in patients with gradeⅠ, Ⅱ or Ⅲ HE (156.91 ± 62.94 vs 104.13 ± 73.07, 112.69 ± 60.87, 104.67 ± 82.00; all P < 0.05). Compared to patients with gradeⅠHE, the levels of Na in patients with grade Ⅱ, Ⅲ or Ⅳ HE significantly decreased (135.22 ± 6.05, 134.91 ± 7.79, 134.55 ± 6.25 vs 139.73 ± 5.15; all P < 0.05), and CHE declined in patients with grade Ⅳ HE (1605.19 ± 76.01 vs 2325.46 ± 71.31, P < 0.05). The level of BUN in patients with grade Ⅳ HE was higher than those in patients with gradeⅠor Ⅱ HE (21.65 ± 23.69 vs 6.53 ± 3.41, 10.62 ± 7.37; both P < 0.05).

CONCLUSION: Preventing and controlling infection could decrease the incidence of HE in patients with HBV-related cirrhosis. High levels of NH4, TBil and BUN, low levels of Na, CHE and ALB, Child-Pugh grade C, ascites, and prolonged PT could increase the incidence of HBCE. High levels of NH4 and BUN, and low levels of Na and CHE are associated with more severe HE.

Hepatocellular carcinoma in Budd-Chiari syndrome: A single center experience with long-term follow-up in South Korea

AIM: To evaluate long-term clinical course of Budd-Chiari syndrome (BCS) and predictive factors associated with the development of hepatocellular carcinoma (HCC) and survival.

METHODS: We analyzed 67 patients with BCS between June 1988 and May 2008. The diagnosis of BCS was confirmed by hepatic venous outflow obstruction shown on abdominal ultrasound sonography, computed tomography, magnetic resonance imaging, or venography. The median follow-up period was 103 ± 156 [interquartile range (IQR)] mo.

RESULTS: The median age of the patients was 47 ± 16 (IQR) years. At diagnosis, 54 patients had cirrhosis, 25 (37.3%) Child-Pugh class A, 23 (34.3%) Child-Pugh class B, and six (9.0%) patients Child-Pugh class C. During the follow-up period, HCC was developed in 17 patients, and the annual incidence of HCC in patients with BCS was 2.8%. Patients in HCC group (n = 17) had higher hepatic venous pressure gradient (HVPG) than those in non-HCC group (n = 50) (21 ± 12 mmHg vs 14 ± 7 mmHg, P = 0.019). The survival rate of BCS patients was 86.2% for 5 years, 73.8% for 10 years, and 61.2% for 15 years. In patients with BCS and HCC, survival was 79% for 5 years, 43.1% for 10 years, and 21.5% for 15 years.

CONCLUSION: The incidence of HCC in patients with BCS was similar to that in patients with other etiologic cirrhosis in South Korea. The HVPG is expected to provide additional information for predicting HCC development in BCS patients.