Improving primary prophylaxis of variceal bleeding by adapting therapy to the clinical stage of cirrhosis. A competing-risk meta-analysis of individual participant data

BACKGROUND & AIMS

Non-selective β-blockers (NSBBs) and endoscopic variceal-ligation (EVL) have similar efficacy preventing first variceal bleeding. Compensated and decompensated cirrhosis are markedly different stages, which may impact treatment outcomes. We aimed to assess the efficacy of NSBBs vs EVL on survival in patients with high-risk varices without previous bleeding, stratifying risk according to compensated/decompensated stage of cirrhosis.

METHODS

By systematic review, we identified RCTs comparing NSBBs vs EVL, in monotherapy or combined, for primary bleeding prevention. We performed a competing-risk, time-to-event meta-analysis, using individual patient data (IPD) obtained from principal investigators of RCTs. Analyses were stratified according to previous decompensation of cirrhosis.

RESULTS

Of 25 RCTs eligible, 14 failed to provide IPD and 11 were included, comprising 1400 patients (656 compensated, 744 decompensated), treated with NSBBs (N = 625), EVL (N = 546) or NSBB+EVL (N = 229). Baseline characteristics were similar between groups. Overall, mortality risk was similar with EVL vs. NSBBs (subdistribution hazard-ratio (sHR) = 1.05, 95% CI = 0.75-1.49) and with EVL + NSBBs vs either monotherapy, with low heterogeneity (I2  = 28.7%). In compensated patients, mortality risk was higher with EVL vs NSBBs (sHR = 1.76, 95% CI = 1.11-2.77) and not significantly lower with NSBBs+EVL vs NSBBs, without heterogeneity (I2  = 0%). In decompensated patients, mortality risk was similar with EVL vs. NSBBs and with NSBBs+EVL vs. either monotherapy.

CONCLUSIONS

In patients with compensated cirrhosis and high-risk varices on primary prophylaxis, NSBBs significantly improved survival vs EVL, with no additional benefit noted adding EVL to NSBBs. In decompensated patients, survival was similar with both therapies. The study suggests that NSBBs are preferable when advising preventive therapy in compensated patients.

Ileocecal Mesentery Arteriovenous Malformation as a Rare Cause of Ectopic Variceal Bleeding in a 58-Year-Old Male With Cirrhosis

Ectopic varices can be defined as dilated portosystemic venous collaterals that are located at a site other than the esophagus or stomach. These varices can be seen in patients with underlying portal hypertension, but bleeding from them is quite rare. The bleeding usually occurs in patients with a history of intra-abdominal surgery and adhesions. These varices are commonly found in the duodenum or rectum, but they can be present anywhere along the gastrointestinal tract. Currently, there are no well-established guidelines regarding the diagnosis and management of these variceal bleeds, and further investigations with randomized controlled or large-scale trials are required. Here, we report an unusual case of ectopic variceal bleeding from an ileal arteriovenous malformation (AVM), which presented as syncope associated with an acute abdomen in a patient with no prior history of intra-abdominal surgery.

Purastat as an Adjunct Treatment Option in Acute Esophageal Varices Bleeding: A Case Report

Esophageal varices are dilated submucosal esophageal veins that connect the portal and systemic circulations. Bleeding esophageal varices is a well-recognized complication of liver cirrhosis.It is known that in active variceal bleeding, treatment needs to be started promptly. Treatments comprise band ligation, sclerotherapy, removable stent placement, balloon tamponade, and transjugular intrahepatic portosystemic shunt (TIPS).We report a case in which hemodynamic stability can be maintained with the use of Purastat to control bleeding.

Liver Frailty Index for Prediction of Short-Term Rehospitalization in Patients with Liver Cirrhosis

Background: Stratifying patients with liver cirrhosis for risk of rehospitalization is challenging with established scoring systems for chronic liver disease. Frailty captures the physical characteristics of patients with cirrhosis. Its value for predicting short-term rehospitalizations in hospitalized patients remains to be defined. Methods: Eighty-three non-electively hospitalized patients with liver cirrhosis were analyzed in this study. Frailty was assessed during the last 48 h of hospital stay with the liver frailty index (LFI). Patients were followed for 30-day rehospitalization. Results: In total, 26 (31%) patients were rehospitalized within 30 days. The median LFI was 4.5, and 43 (52%) patients were identified as frail. Rehospitalized patients had a significant higher LFI compared to patients without a rehospitalization within 30 days. In multivariable analysis, LFI as a metric variable (OR 2.36, p = 0.02) and lower platelet count (OR 0.98, p < 0.01) were independently associated with rehospitalization. LFI and its subtest chair stands had the best discriminative ability to predict rehospitalization, with AUROCs of 0.66 and 0.67, respectively. An LFI cut-off of >4.62 discriminated best between patients with and without elevated risk for rehospitalization within 30 days. Conclusions: Measures of frailty could be useful to identify patients at higher risk for short-term rehospitalization.

Proton pump inhibitor use is associated with a variety of infections in patients with liver cirrhosis

There is evidence that intake of proton pump inhibitors (PPI) increases the risk for spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis. However, data regarding the impact of PPI intake on occurrence of infections other than SBP are still lacking.We hypothesized that PPI use is associated with a higher rate of infections other than SBP in patients with liver cirrhosis.The current case-control study sample included patients with liver cirrhosis from the Disease Analyzer database (IQVIA), which compiles data such as risk factors, drug prescriptions and diagnoses obtained from general practitioners and specialists in Germany. In total, 2,823 patients with infections were matched with 2,823 patients without infections by propensity scores. For quantification of PPI use the prescribed quantity of PPI during the past 12 months before index date was analyzed.Frequency of PPI users was significantly higher in patients with infections than in patients without infections (47.9% vs 37.9%). In regression analysis, PPI use was significantly associated with the occurrence of infections overall (OR 1.55, 95% CI 1.39-1.72, P < .001), and associated with the occurrence of lower respiratory tract infections, urinary tract infections and infectious gastroenteritis. There was no association between PPI use and skin infections. Pantoprazole and omeprazole were the most frequently prescribed PPIs and were both independently associated with the occurrence of infections.PPI use may be associated with infections other than SBP in patients with liver cirrhosis. Prescription of PPI should be limited to patients with a clear indication.

Impact of Acute Kidney Injury on Mortality of Patients Hospitalized for Complications of Cirrhosis

BACKGROUND/AIMS

The mortality of hospitalized patients for complications of cirrhosis is very high. We examined the independent predictors of mortality, particularly the impact of increments in creatinine, in 339 consecutive patients (636 admissions) who were admitted for complications of cirrhosis.

METHODS

Clinical characteristics, biochemical parameters including serum creatinine levels at various time intervals, and mortality data were recorded for all admissions. Data were analyzed for initial as well for all repeated admissions to identify independent predictors of mortality.

RESULTS

The in-hospital mortality, 30-day, 90-day, 180 days, and 365 days mortality were 6%, 15%, 23%, 30%, and 41% respectively. Those admitted with spontaneous bacterial peritonitis had the worst survival. Increase in creatinine was noted in 29% of patients and they had lower 30-day (78% vs.91%) and 90-day (73% vs. 82%) survival than those without increase in creatinine. Any increment in serum creatinine (≥0.1 mg/dL) within 48 h after admission (peak 48 h - admission) was associated with a step-wise increase in mortality, but only if peak creatinine reached above 1.2 mg/dL. If peak creatinine levels were below 1.2 mg/dL, increases in serum creatinine had no impact on survival. Cox regression analysis showed that increments in serum creatinine of 0.3 mg/dL or higher had the worst outcome (HR 2.51, CI 1.65-3.81). Etiology of cirrhosis or the use of PPI, beta blockers or rifaxamin did not predict mortality. Other independent predictors of mortality were age, reason for admission, hyponatremia, and INR.

CONCLUSION

In patients with cirrhosis, any increment in serum creatinine within 48 h from hospitalization is associated with a higher mortality provided the peak serum creatinine within 48 h is above 1.2 mg/dL.

The Stroop smartphone application is a short and valid method to screen for minimal hepatic encephalopathy

Minimal hepatic encephalopathy (MHE) detection is difficult because of the unavailability of short screening tools. Therefore, MHE patients can remain undiagnosed and untreated. The aim of this study was to use a Stroop smartphone application (app) (EncephalApp_Stroop) to screen for MHE. The app and standard psychometric tests (SPTs; 2 of 4 abnormal is MHE, gold standard), psychometric hepatic encephalopathy score (PHES), and inhibitory control tests (ICTs) were administered to patients with cirrhosis (with or without previous overt hepatic encephalopathy; OHE) and age-matched controls from two centers; a subset underwent retesting. A separate validation cohort was also recruited. Stroop has an "off" state with neutral stimuli and an "on" state with incongruent stimuli. Outcomes included time to complete five correct runs as well as number of trials needed in on (Ontime) and off (Offtime) states. Stroop results were compared between controls and patients with cirrhosis with or without OHE and those with or without MHE (using SPTs, ICTs, and PHES). Receiver operating characteristic analysis was performed to diagnose MHE in patients with cirrhosis with or without previous OHE. One hundred and twenty-five patients with cirrhosis (43 previous OHE) and 134 controls were included in the original cohort. App times were correlated with Model for End-Stage Liver Disease (Offtime: r = 0.57; Ontime: r = 0.61; P < 0.0001) and were worst in previous OHE patients, compared to the rest and controls. Stroop performance was also significantly impaired in those with MHE, compared to those without MHE, according to SPTs, ICTs, and PHES (all P < 0.0001). A cutoff of >274.9 seconds (Ontime plus Offtime) had an area under the curve of 0.89 in all patients and 0.84 in patients without previous OHE for MHE diagnosis using SPT as the gold standard. The validation cohort showed 78% sensitivity and 90% specificity with the >274.9-seconds Ontime plus Offtime cutoff. App result patterns were similar between the centers. Test-retest reliability in controls and those without previous OHE was good; a learning effect on Ontime in patients with cirrhosis without previous OHE was noted.

CONCLUSION

The Stroop smartphone app is a short, valid, and reliable tool for screening of MHE.

Modulation of the fecal bile acid profile by gut microbiota in cirrhosis

BACKGROUND & AIMS

The 7α-dehydroxylation of primary bile acids (BAs), chenodeoxycholic (CDCA) and cholic acid (CA) into the secondary BAs, lithocholic (LCA) and deoxycholic acid (DCA), is a key function of the gut microbiota. We aimed at studying the linkage between fecal BAs and gut microbiota in cirrhosis since this could help understand cirrhosis progression.

METHODS

Fecal microbiota were analyzed by culture-independent multitagged-pyrosequencing, fecal BAs using HPLC and serum BAs using LC-MS in controls, early (Child A) and advanced cirrhotics (Child B/C). A subgroup of early cirrhotics underwent BA and microbiota analysis before/after eight weeks of rifaximin.

RESULTS

Cross-sectional: 47 cirrhotics (24 advanced) and 14 controls were included. In feces, advanced cirrhotics had the lowest total, secondary, secondary/primary BA ratios, and the highest primary BAs compared to early cirrhotics and controls. Secondary fecal BAs were detectable in all controls but in a significantly lower proportion of cirrhotics (p<0.002). Serum primary BAs were higher in advanced cirrhotics compared to the rest. Cirrhotics, compared to controls, had a higher Enterobacteriaceae (potentially pathogenic) but lower Lachonospiraceae, Ruminococcaceae and Blautia (7α-dehydroxylating bacteria) abundance. CDCA was positively correlated with Enterobacteriaceae (r=0.57, p<0.008) while Ruminococcaceae were positively correlated with DCA (r=0.4, p<0.05). A positive correlation between Ruminococcaceae and DCA/CA (r=0.82, p<0.012) and Blautia with LCA/CDCA (r=0.61, p<0.03) was also seen. Prospective study: post-rifaximin, six early cirrhotics had reduction in Veillonellaceae and in secondary/primary BA ratios.

CONCLUSIONS

Cirrhosis, especially advanced disease, is associated with a decreased conversion of primary to secondary fecal BAs, which is linked to abundance of key gut microbiome taxa.