Predictors of mortality after transjugular portosystemic shunt

AIM:To investigate if echocardiographic and hemodynamic determinations obtained at the time of transjugular intrahepatic portosystemic shunt(TIPS)can provide prognostic information that will enhance risk stratification of patients.METHODS:We reviewed medical records of 467 patients who underwent TIPS between July 2003 and December 2011 at our institution.We recorded information regarding patient demographics,underlying liver disease,indication for TIPS,baseline laboratory values,hemodynamic determinations at the time of TIPS,and echocardiographic measurements both before and after TIPS.We recorded patient comorbidities that may affect hemodynamic and echocardiographic determinations.We also calculated Model for Endstage Liver Disease(MELD)score and Child Turcotte Pugh(CTP)class.The following pre-and post-TIPS echocardiographic determinations were recorded:Left ventricular ejection fraction,right ventricular(RV)systolic pressure,subjective RV dilation,and subjective RV function.We recorded the following hemodynamic measurements:Right atrial(RA)pressure before and after TIPS,inferior vena cava pressure before and after TIPS,free hepatic vein pressure,portal vein pressure before and after TIPS,and hepatic venous pressure gradient(HVPG).RESULTS:We reviewed 418 patients with portal hypertension undergoing TIPS.RA pressure increased by a mean ± SD of 4.8 ± 3.9 mmH g(P < 0.001),HVPG decreased by 6.8 ± 3.5 mmH g(P < 0.001).In multivariate linear regression analysis,a higher MELD score,lower platelet count,splenectomy and a higher portal vein pressure were independent predictors of higher RA pressure(R = 0.55).Three variables predicted 3-mo mortality after TIPS in a multivariate analysis:Age,MELD score,and CTP grade C.Change in the RA pressure after TIPS predicted long-term mortality(per 1 mm Hg change,HR = 1.03,95%CI:1.01-1.06,P < 0.012).CONCLUSION:RA pressure increased immediately after TIPS particularly in patients with worse liver function,portal hypertension,emergent TIPS placement and history of splenectomy.The increase in RA pressure after TIPS was associated with increased mortality.Age,splenectomy,MELD score and CTP grade were independent predictors of long-term mortality after TIPS.

Metabolomics studies identify novel diagnostic and prognostic indicators in patients with alcoholic hepatitis

AIM: To identify plasma analytes using metabolomics that correlate with the diagnosis and severity of liver disease in patients with alcoholic hepatitis(AH).METHODS: We prospectively recruited patients with cirrhosis from AH(n = 23) and those with cirrhosis with acute decompensation(AD) from etiologies other than alcohol(n = 25). We used mass spectrometry to identify 29 metabolic compounds in plasma samples from fasted subjects. A receiver operating characteristics analysis was performed to assess the utility of biomarkers in distinguishing acute AH from alcoholic cirrhosis. Logistic regression analysis was performed to build a predictive model for AH based on clinical characteristics. A survival analysis was used to construct Kaplan Meier curves evaluating transplant-free survival.RESULTS: A comparison of model for end-stage liver disease(MELD)-adjusted metabolomics levels between cirrhosis patients who had AD or AH showed that patients with AH had significantly higher levels of betaine, and lower creatinine, phenylalanine, homocitrulline, citrulline, tyrosine, octenoyl-carnitine, and symmetric dimethylarginine. When considering combined levels, betaine and citrulline were highly accurate predictors for differentiation between AH and AD(area under receiver operating characteristics curve = 0.84). The plasma levels of carnitine [0.54(0.18, 0.91); P = 0.005], homocitrulline [0.66(0.34, 0.99); P < 0.001] and pentanoyl-carnitine [0.53(0.16, 0.90); P = 0.007] correlated with MELD scores in patients diagnosed with AH. Increased levels of many biomarkers(carnitine P = 0.005, butyrobetaine P = 0.32, homocitrulline P = 0.002, leucine P = 0.027, valine P = 0.024, phenylalanine P = 0.037, tyrosine P = 0.012, acetyl-carnitine P = 0.006, propionyl-carnitine P = 0.03, butyryl-carnitine P = 0.03, trimethyl-lisine P = 0.034, pentanoyl-carnitine P = 0.03, hexanoyl-carnitine P = 0.026) were associated with increased mortality in patients with AH. CONCLUSION: Metabolomics plasma analyte levels might be used to diagnose of AH or help predict patient prognoses.