Nationwide survey analysis of esophagogastric varices in portal hypertension based on endoscopic management in China

Aims:The endoscopic treatment of esophagogastric varices is challenging,and the nationwide application of endoscopic therapies for various types of esophagogastric varices and different clinical scenarios remains unclear.This study investigated the use of endoscopic therapy for portal hypertension in China.Methods:This study used a questionnaire survey initiated by the Liver Health Consortium in China to investigate the use of endoscopic therapies for portal hypertension.Questionnaires were released online from January 30,2023 to February 28,2023 and filled out by chief physicians or senior instructors responsible for endoscopic therapies in participating hospitals across 31 provinces(autonomous regions and municipalities)in China.Comparisons of guideline adherence between primary and referral medical centers were performed using the chi‐square test or Fisher's exact test.Results:In total,836 hospitals participated in the survey.For primary and secondary prophylaxis of esophagogastric variceal bleeding(EGVB),adherence to the national guidelines was 72.5%(606/836)and 39.2%(328/836),respectively.Significant differences were observed in the rate of adherence between the primary and referral centers for primary(79.9%[111/139]vs.71.0%[495/697],p=0.033)and secondary prophylaxis(27.3%[38/139]vs.41.6%[290/697],p=0.002).Of the hospitals,78.2%(654/836)preferred endoscopic therapies for acute EGVB,and the timing of endoscopy was usually within 12 h(48.5%,317/654)and 12-24 h(36.9%,241/654)after bleeding.Endoscopic therapy was more likely to be the first choice of treatment for acute EGVB in referral centers than in primary centers(82.6%[576/697]vs.56.1%[78/139],p<0.001).Regarding the management of gastroesophageal varices type 2 and isolated gastric varices type 1,the most prevalent procedures were cyanoacrylate injection combined with sclerotherapy(48.2%[403/836]and 29.9%[250/836],respectively);however,substantial hospitals preferred clip-assisted therapies(12.4%[104/836]and 26.4%[221/836],respectively).Nonselective beta‐blockers were routinely used in 73.4%(614/836)of hospitals during the perioperative period of EGVB management,and propranolol(88.8%,545/614)and carvedilol(37.5%,230/614)were the most widely used nonselective beta-blockers.Conclusions:This survey clarified that various endoscopic procedures have been implemented nationwide in China.Participating hospitals have actively performed emergent endoscopy for acute EGVB;however,these hospitals do not adequately follow recommendations regarding primary and secondary prophylaxis of EGVB.In the future,standardizing the selection of endoscopic procedures and improving compliance with guidelines is crucial.

One-year status of hepatic venous pressure gradient measurement from 85 hospitals in China

Aims:Surveys and research on the applications of the hepatic venous pressure gradient(HVPG)are important for understanding the current status and future development of this technology in China.This article aimed to investigate the status of hepatic venous pressure gradient measurement in China in 2022.Methods:We investigated the overall status of HVPG technology in China-including hospital distribution,hospital level,annual number of cases,catheters used,average cost,indications,and current challenges by using online questionnaire.By counting the number and percentages of cases of these results,we hope to clarify the current status of HVPG measurements in China.Results:According to the survey,85 hospitals in China used HVPG technology in 2022 distributed across 29 provinces.A total of 4989 HVPG measurements were performed in all of the surveyed hospitals in 2022,of which 2813 cases(56.4%)were measured alone.The average cost of HVPG measurement was 5646.8±2327.9 CNY.Of the clinical teams who performed the measurements(sometimes multiple per hospital),94.3%(82/87)used the balloon method,and the majority of the teams(72.4%,63/87)used embolectomy catheters.Conclusions:This survey clarified the clinical application status of HVPG in China and confirmed that some medical institutions in China have established a foundation for this technology.It is still necessary to continue promoting and popularizing this technology in the future.

基于血清学指标的联合模型诊断代偿期肝硬化轻微型肝性脑病的价值

目的探讨血清学指标对代偿期肝硬化轻微型肝性脑病(MHE)的诊断价值,构建基于血清学指标的联合模型并评估其对MHE的诊断价值。方法前瞻性、多中心研究。选取2021年10月至2022年8月来自我国15个省(自治区、直辖市)的23家医院就诊的代偿期肝硬化患者263例。收集患者临床资料及实验室检查结果,并计算终末期肝病模型(MELD)评分。使用基线血氨测量值/正常参考值上限(AMM-ULN)集中校正各中心血氨测量结果,以我国《肝硬化肝性脑病诊疗指南》标准,数字连接试验-A、数字符号试验均异常作为诊断MHE的标准。基于R语言caret包将患者随机(7∶3)分为训练集(n=185)和验证集(n=78)。通过Logistic回归构建诊断MHE的联合模型;受试者工作特征曲线下面积(AUC)、Hosmer-Lemeshow拟合优度检验及校准曲线图评估诊断性能,并用Bootstrap法(n=200)进行内部验证;Delong检验比较AUC之间的差异。结果训练集中,MHE占37.8%(70/185),MHE组AMM-ULN、白蛋白、血小板、碱性磷酸酶、国际标准化比值、终末期肝病模型评分以及教育年限与无MHE组比较,差异有统计学意义(P均<0.05)。多因素Logistic回归分析显示,AMM-ULN(OR=1.78,95%CI 1.05~3.14,P=0.038)和MELD评分(OR=1.11,95%CI 1.04~1.20,P=0.002)是MHE的独立危险因素,AUC分别为0.663和0.625。联合AMM-ULN、MELD评分和教育年限的联合模型诊断MHE的AUC为0.755,特异度和敏感度分别为85.2%和55.7%。Hosmer-Lemeshow拟合优度检验表明模型具有较好的校准度(P=0.733),联合模型内部验证AUC为0.752。Delong检验显示联合模型诊断效能优于单独使用血氨(P=0.020)和MELD评分(P=0.003)。验证集中,联合模型诊断MHE的AUC为0.794,Hosmer-Lemeshow拟合优度检验显示有较好的校准度(P=0.841)。结论基于AMM-ULN、MELD评分和教育年限的联合模型可提高对MHE的诊断价值。

Prevalence and risk factors for minimal hepatic encephalopathy in cirrhotic patients with different etiologies

Aims:Minimal hepatic encephalopathy(MHE)significantly affects the prognosis of patients with cirrhosis.This study was performed to determine whether there is a difference in the prevalence of MHE among patients with cirrhosis of different etiologies and whether the etiology directly influences the occurrence of MHE.Methods:This multicenter,cross-sectional study enrolled 1879 patients with confirmed cirrhosis at 40 hospitals from October 25,2021,to January 10,2023(Trial registration:https://clinicaltrials.gov/[NCT05140837]).The patients'demographics,etiologies of cirrhosis,and laboratory test results were collected.The psychometric hepatic encephalopathy score(PHES)was determined in all patients to screen for MHE.Multivariate logistic analyses were performed to identify the risk factors for MHE.Results:In total,736 patients with cirrhosis were analyzed.The prevalence of MHE was 42.0%(n=309).The primary etiology among all patients was hepatitis B virus(HBV)-related cirrhosis(71.9%[529/736]).The prevalence of MHE was significantly higher in patients with alcoholic cirrhosis(57.1%[40/70])than in those with HBV-related cirrhosis(40.6%[215/529],p=0.009)or hepatitis C virus(HCV)-related cirrhosis(38.2%[26/68],p=0.026).Age(odds ratio[OR],1.042;95%confidence interval[CI],1.024-1.059;p<0.001),duration of education(OR,0.935;95%CI,0.899-0.971;p=0.001),etiology(OR,1.740;95%CI,1.028-2.945;p=0.039),and high MELD-Na scores(OR,1.038;95%CI,1.009-1.067;p=0.009)were independent risk factors for MHE.When patients with cirrhosis of different etiologies were analyzed separately,the results showed that age(OR,1.035;95%CI,1.014-1.057;p=0.001)and duration of education(OR,0.924;95%CI,0.883-0.966;p=0.001)were risk factors for MHE among patients with HBV-related cirrhosis,whereas age(OR,1.138;95%CI,1.033-1.254;p=0.009)and creatinine concentration(OR,16.487;95%CI,1.113-244.160;p=0.042)were risk factors for MHE in patients with HCV-related cirrhosis.No risk factors for MHE were found in patients with autoimmune cirrhosis.For patients with alcoholic cirrhosis,the platelet count(OR,1.014;95%CI,1.000-1.027;p=0.045)was a risk factor for MHE.The PHES subtest results were inconsistent among patients who had MHE with cirrhosis of different etiologies.Patients with HBV-related cirrhosis performed better on Number Connection Test B and the serial dotting test than those with alcoholic cirrhosis(p=0.007 and p<0.001),better on Number Connection Test B than those with HCV-related cirrhosis(p=0.020),and better on the line tracing test than those with autoimmune cirrhosis(p=0.037).Conclusion:The etiology of cirrhosis affected the prevalence of MHE and risk factors for MHE.The domains of major cognitive impairment varied among patients with cirrhosis of different etiologies.Further studies are required to verify these findings.

Immunogenicity and safety of a booster COVID-19 vaccination in patients with chronic liver disease:A multicenter study

Aim:Patients with chronic liver disease(CLD),especially cirrhosis,are at a high risk of severe illness or death from coronavirus disease-2019(COVID-19)and may have a suboptimal immune response to the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)vaccine.This study aimed to evaluate the safety and immunogenicity of the COVID-19 booster vaccination in patients with CLD.Methods:The study protocol was prospectively registered at ClinicalTrials.gov(No.NCT05204602)after approval by the Ethics Committee.Adult participants with CLD were enrolled in this multicenter prospective study.They completed two doses of the inactivated COVID-19 vaccine and received booster doses at least 6 months later.Adverse reactions were recorded within 14 days after the booster dose.Serum samples of the enrolled patients were collected before and after booster vaccination and tested for SARS-CoV-2 receptor-binding domain(RBD)immunoglobulin G and neutralizing anti-bodies.The chi-squared or Fisher's exact test was used to compare categorical data,and the Mann-Whitney U test was used to compare continuous variables.Two-sided p<0.05 were considered statistically significant.Results:In total,63 patients were enrolled from four hospitals in China,including 29 patients with cirrhosis.The median age of all patients was 55 years,and 61.9%(39/63)were male.The vaccines were well tolerated;most adverse reactions were mild and transient,and injection site pain(6.4%;4/63)and fatigue(3.2%,2/63)were the most frequent local and systemic adverse events.Following the booster vaccination,our results showed that in the whole cohort,the levels and positive rates of anti-RBD IgG and neutralizing antibodies were significantly higher than baseline levels(all p<0.05).Conclusions:The inactivated COVID-19 booster vaccine was safe and significantly increased antibody levels and positivity rates following standard vaccination regimens in patients with CLD,especially those with cirrhosis.

Tolerance and acceptance of hepatic venous pressure gradient measurement in cirrhosis(CHESS1904):An international multicenter study

Aim:To determine the tolerance and acceptance of hepatic venous pressure gradient(HVPG)measurements in patients with liver cirrhosis.Methods:This prospective international multicenter study included 271 patients with cirrhosis who were scheduled to undergo HVPG measurement between October 2019 and June 2020.Data related to the tolerance and acceptance of HVPG measurements were collected using descriptive questionnaires.Results:HVPG measurements were technically successful in all 271 patients,with 141(52.0%)undergoing HVPG measurement alone.The complication rate was 0.4%.Postoperative pain was significantly lower than preoperative expected pain(p<0.001)and intraoperative pain(p<0.001),and intraoperative pain was also significantly lower than preoperative expected pain(p=0.036).No,mild,moderate,severe,and intolerable discomfort scores were reported by 36.9%,44.6%,11.1%,6.3%,and 0.4%of these patients,respectively,during HVPG measurement and by 54.6%32.5%,11.4%,1.5%,and 0%,respectively,after HVPG measurement.Of these patients,39.5%had little understanding and 10%had no understanding of the value of HVPG measurement,with 35.1%and 4.1%regarding HVPG measurements as being of little or no help,respectively.Most patients reported that they would definitely(15.5%),probably(46.9%),or possibly(29.9%)choose to undergo additional HVPG measurements again,and 62.7%regarded the cost of the procedure as acceptable.Conclusion:HVPG measurement was safe and well‐tolerated in patients with cirrhosis,but patient education and communication are warranted to improve the acceptance of this procedure.