Indocyanine green clearance test combined with MELD score in predicting the short-term prognosis of patients with acute liver failure

BACKGROUND: Acute liver failure(ALF) is an acute severe deterioration of liver function with high mortality. Early and accurate prognostic assessment of patients with ALF is critically important. Although the model for end-stage liver disease(MELD) scores and King’s College Hospital(KCH) criteria are well-accepted as predictive tools, their accuracy is unsatisfactory.The indocyanine green(ICG) clearance test(ICGR15, ICG retention rate at the 15 minutes) is a sensitive indicator of liver function. In this study, we investigated the efficacy of the ICGR15 for the short-term prognosis in patients with ALF. We compared the predictive value of ICGR15 with the MELD scores and KCH criteria.METHODS: Sixty-nine patients who had been diagnosed with ALF were recruited retrospectively. ICGR15 had been performed by ICG pulse spectrophotometry and relevant clinical and laboratory indices were analyzed within 24 hours of diagnosis.In addition, the MELD scores and KCH criteria were calculated.RESULTS: The three-month mortality of all patients was 47.83%.Age, serum total bilirubin and creatinine concentrations,international normalized ratio for prothrombin time, ICGR15,MELD scores and KCH criteria differed significantly between surviving and deceased patients. A positive correlation was observed between ICGR15 and MELD scores(r=0.328, P=0.006).The ICGR15-MELD model, Logit(P)=0.096×ICGR15+0.174 ×MELD score–9.346, was constructed by logistic regression analysis. The area under the receiver operating characteristic curve was 0.855. When set the cut-off point to-0.4684, the sensitivity was 87.90% and specificity, 72.20%. The area under the receiver operating characteristic curve of the ICGR15-MELD model(0.855) was significantly higher than that of the ICGR15(0.793), MELD scores(0.776) and KCH criteria(0.659).Based on this cut-off value, the patients were divided into two groups. The mortality was 74.36% in the first group(ICGR15-MELD≥-0.4686) and 13.33% in the second group(ICGR15-MELD<-0.4686), with a significant difference between the two groups(χ2=25.307, P=0.000).CONCLUSION: The ICGR15-MELD model is superior to the ICGR15, MELD scores, and KCH criteria in predicting the shortterm prognosis of patients with ALF.

Indocyanine green retention is a potential prognostic indicator after splenectomy and pericardial devascularization for cirrhotic patients

BACKGROUND：Splenectomy and pericardial devascularization（SPD）is an effective treatment of upper gastrointestinal bleeding and hypersplenism in cirrhotic patients with portal hypertension.Indocyanine green retention at 15 minutes（ICGR15）was reported to offer better sensitivity and specificity than the Child-Pugh classification in hepatectomy,but few reports describe ICGR15 in SPD.The present study was to evaluate the prognostic value of ICGR15 for cirrhotic patients with portal hypertension who underwent SPD.METHODS：From January 2012 to January 2015,43 patients with portal hypertension and hypersplenism caused by liver cirrhosis were admitted in our center and received SPD.The ICGR15,Child-Pugh classification,model for end-stage liver disease（MELD）score,and perioperative characteristics were analyzed retrospectively.RESULTS：Preoperative liver function assessment revealed that 34 patients were Child-Pugh class A with ICGR15 of13.6%-43.0%and MELD score of 7-20;8 patients were class B with ICGR15 of 22.8%-40.7%and MELD score of 7-17;1patient was class C with ICGR15 of 39.7%and MELD score of 22.The optimal ICGR15 threshold for liver function compensation was 31.2%,which offered a sensitivity of 68.4%and a specificity of 70.8%.Univariate analysis showed preoperative ICGR15,MELD score,surgical procedure,intraoperative blood loss,and autologous blood transfusion were significantly different between postoperative liver function compensated and decompensated groups.Multivariate regression analysis revealed that ICGR15 was an independent risk factor of postoperative liver function recovery（P=0.020）.CONCLUSIONS：ICGR15 has outperformed the Child-Pugh classification for assessing liver function in cirrhotic patients with portal hypertension.ICGR15 may be a suitable prognostic indicator for cirrhotic patients after SPD.

A new scoring system for assessment of liver function after successful hepatectomy in patients with hepatocellular carcinoma

BACKGROUND:Whether a major liver resection is safe has been judged mainly from the patient’s hepatic reserve.However,a safe limit for liver resection does not exist yet.This study aimed to construct a new scoring system as a guide to determine a safe limit for liver resection and avoid liver dysfunction after hepatectomy.METHODS:Eighty-six patients with hepatocellular carcinoma who had undergone hepatectomy in West China Hospital from March 2007 to June 2010 were reviewed.The patients were classified according to the levels of total bilirubin after hepatectomy and the parameters in the perioperative period were compared.Receiver operating characteristic (ROC) analysis was made to assess the liver function compensatory (LFC) value to predict liver dysfunction of the patients after hepatectomy.LFC value is defined as the preoperative KICG value×22.487+standard remnant liver volume (SRLV)×0.020.RESULTS:Patients were classified into group Ⅰ (normal group,n=69) and group Ⅱ (with total bilirubin >85.5 μmol/L for 7 days after hepatectomy,n=17) based on the levels of total bilirubin after hepatectomy.Group II was further divided into two subgroups:recovered subgroup (n=14) and fatal subgroup (n=3).There were no significant differences in preoperative data or intraoperative findings except the indocyanine green test parameters (KICG and ICG R15) and SRLV.ROC analysis showed that the sensitivity and specificity of an LFC value ≤13.01 were 94.1% and 82.6% respectively for predicting liver dysfunction of the patients after hepatectomy.CONCLUSIONS:The LFC value appears to be a good predictor of postoperative liver dysfunction in patients who undergo hepatectomy for HCC.An expected LFC value of 13.01 seems to be a safe limit for liver resection.

Low preoperative platelet counts predict a high mortality after partial hepatectomy in patients with hepatocellular carcinoma

AIM： To assess the validity of our selection criteria for hepatectomy procedures based on indocyanine green disappearance rate （KICG）, and to unveil the factors affecting posthepatectomy mortality in patients with hepatocellular carcinoma （HCC）. METHODS： A retrospective analysis of 198 consecutive patients with HCC who underwent partial hepatectomies in the past 14 years was conducted. The selection criteria for hepatectomy procedures during the study period were KICG≥0.12 for hemihepatectomy, KICG≥0.10 for bisegmentectomy, KCG≥0.08 for monosegmentectomy, and KICG≥ 0.06 for nonanatomic hepatectomy. The hepatectomies were categorized into three types： major hepatectomy （hemihepatectomy or a more extensive procedure）, bisegmentectomy, and limited hepatectomy. Univariate （Fishers exact test） and multivariate （the logistic regression model） analyses were used. RESULTS： Postoperative mortality was 5% after major hepatectomy, 3% after bisegmentectomy, and 3% after limited hepatectomy. The bhree percentages were comparable （P = 0.876）. The platelet count of ≤ 10× 10^4/μL was the strongest independent factor for postoperative mortality on univariate （P = 0.001） and multivariate （risk ratio, 12.5; P= 0.029） analyses. No patient with a platelet count of 〉7.3× 10^4/μL died of postoperative morbidity, whereas 25% （6/24 patients） of patients with a platelet count of ≤7.3×10^4/μL died （P〈0.001）. CONCLUSION： The selection criteria for hepatectomy procedures based on KICG are generally considered valid, because of the acceptable morbidity and mortality with these criteria. The preoperative platelet count independently affects morbidity and mortality after hepatectomy, suggesting that a combination of KICG and platelet count would further reduce postoperative mortality.

Clinical value of predictive models based on liver stiffness measurement in predicting liver reserve function of compensated chronic liver disease

BACKGROUND Assessment of liver reserve function(LRF)is essential for predicting the prognosis of patients with chronic liver disease(CLD)and determines the extent of liver resection in patients with hepatocellular carcinoma.AIM To establish noninvasive models for LRF assessment based on liver stiffness measurement(LSM)and to evaluate their clinical performance.METHODS A total of 360 patients with compensated CLD were retrospectively analyzed as the training cohort.The new predictive models were established through logistic regression analysis and were validated internally in a prospective cohort(132 patients).RESULTS Our study defined indocyanine green retention rate at 15 min(ICGR15)≥10%as mildly impaired LRF and ICGR15≥20%as severely impaired LRF.We constructed predictive models of LRF,named the mLPaM and sLPaM,which involved only LSM,prothrombin time international normalized ratio to albumin ratio(PTAR),age and model for end-stage liver disease(MELD).The area under the curve of the mLPaM model(0.855,0.872,respectively)and sLPaM model(0.869,0.876,respectively)were higher than that of the methods for MELD,albumin bilirubin grade and PTAR in the two cohorts,and their sensitivity and negative predictive value were the highest among these methods in the training cohort.In addition,the new models showed good sensitivity and accuracy for the diagnosis of LRF impairment in the validation cohort.CONCLUSION The new models had a good predictive performance for LRF and could replace the indocyanine green(ICG)clearance test,especially in patients who are unable to undergo ICG testing.

Non-invasive tests for the prediction of post-hepatectomy liver failure in the elderly

Post-hepatectomy liver failure(PHLF)is associated with great morbidity and mortality after resection of hepatocellular carcinoma.Previous studies have underlined that advanced age could be a potential factor influencing post-operative complications and long-term survival.In the past,candidates for resection were based on the Child-Pugh classification,the predictive value of which was rather low.The selection of patients undergoing resection in Western countries is based on the assessment of portal hypertension(PH),which is clinically assessed by measurement of the hepatic venous pressure gradient,an invasive and costly process.Thus,there have been several attempts to identify the best non-invasive test(NIT)to accurately predict PHLF.Most biochemical NITs for the prediction of PHLF are focused on evaluation of underlying liver cirrhosis and PH.Amongst them,FIB-4,which also includes the patient's age,seems to have more robust supporting results.In Europe and the USA.,the most tested and reliable NIT for predicting PHLF is the evaluation of liver stiffness measurement,which is also influenced by age.Imaging parameters are promising tools which are used only in specialized centers however,and when available.Liver volume parameters,as well as contrast-enhanced data,demonstrate good accuracy in predicting PHLF.In this scenario,the evaluation of sarcopenia and bone mineral density through contextual imaging allows the delineation of PHLF in at-risk elderly patients.Further studies focused on parameters for the evaluation of PHLF in elderly patients are needed.

Predictive factors for hepatocellular carcinoma recurrence after curative treatments

Hepatocellular carcinoma(HCC)is the fifth most common neoplasm worldwide.Recurrence of HCC after resection or loco-regional therapies represents an important clinical issue as it affects up to 70%of patients.This can be divided into early or late,if it occurs within or after 24 months after treatment,respectively.While the predictive factors for early recurrence are mainly related to tumour biology(local invasion and intrahepatic metastases),late recurrences are mainly related to de novo tumour formation.Thus,it is important to recognize these factors prior to any treatment in each patient,in order to optimize the treatment strategy and follow-up after treatment.The aim of this review is to summarize the current evidence available regarding predictive factors for the recurrence of HCC,according to the different therapeutic strategies available.In particular,we will discuss the role of new ultrasound-based techniques and biological features,such as tumor-related and circulating biomarkers,in predicting HCC recurrence.Recent advances in imaging-related parameters in computed-tomography scans and magnetic resonance imaging will also be discussed.