Survival outcomes of right-lobe living donor liver transplantation for patients with high Model for End-stage Liver Disease scores

BACKGROUND: Controversy exists over whether living donor liver transplantation (LDLT) should be offered to patients with high Model for End-stage Liver Disease (MELD) scores. This study tried to determine whether a high MELD score would result in inferior outcomes of right-lobe LDLT. METHODS: Among 411 consecutive patients who received right-lobe LDLT at our center, 143 were included in this study. The patients were divided into two groups according to their MELD scores: a high-score group (MELD score ≥25; n=75) and a low-score group (MELD score 【25; n=68). Their demographic data and perioperative conditions were compared. Univariable and multivariable analyses were performed to identify risk factors affecting patient survival. RESULTS: In the high-score group, more patients required preoperative intensive care unit admission (49.3% vs 2.9%; P【0.001), mechanical ventilation (21.3% vs 0%; P【0.001), or hemodialysis (13.3% vs 0%; P=0.005); the waiting time before LDLT was shorter (4 vs 66 days; P【0.001); more blood was transfused during operation (7 vs 2 units; P【0.001); patients stayed longer in the intensive care unit (6 vs 3 days; P【0.001) and hospital (21 vs 15 days; P=0.015) after transplantation;more patients developed early postoperative complications (69.3% vs 50.0%; P=0.018); and values of postoperative peak blood parameters were higher. However, the two groups had comparable hospital mortality. Graft survival and patient overall survival at one year (94.7% vs 95.6%; 95.9% vs 96.9%), three years (91.9% vs 92.6%; 93.2% vs 95.3%), and five years (90.2% vs 90.2%; 93.2% vs 95.3%) were also similar between the groups. CONCLUSIONS: Although the high-score group had signifi-cantly more early postoperative complications, the two groups had comparable hospital mortality and similar satisfactory rates of graft survival and patient overall survival. Therefore, a high MELD score should not be a contraindication to right-lobe LDLT if donor risk and recipient benefit are taken into full account.

Indocyanine green clearance test and model for end-stage liver disease score of patients with liver cirrhosis

BACKGROUND: The indocyanine green (ICG) clearance test (clearance rate (K) and retention rate at 15 minutes (R(15))) is a sensitive indicator to evaluate liver function. The model for end-stage liver disease (MELD) score has emerged as a useful tool for estimating the mortality of patients awaiting liver transplantation and has recently been validated on patients with liver diseases of various etiologies and severity. In this study, we investigated the correlation between the ICG clearance test and MELD score of patients with liver cirrhosis. METHODS: From June 2007 to March 2008, 52 patients with liver cirrhosis admitted to our center were classified into Child-Pugh class A (8 patients), B (14) and C (30). The ICG clearance test (K value and R(15)) was performed by ICG pulse spectrophotometry (DDG-3300K), and the MELD scores of patients were calculated. RESULTS: As the Child-Pugh classification of liver function gradually deteriorated, the K value decreased, while R(15) and MELD score increased. There were significant statistical differences in K value, R(15) and MELD score in patients with different Child-Pugh classifications. Significant correlations were found between the parameters of the ICG clearance test (K value and R(15)) and MELD score. A negative correlation was observed between K value and MELD score (r=-0.892, P < 0.05), while a positive correlation was observed between R(15) and MELD score (r=0.804, P < 0.05). CONCLUSIONS: The ICG clearance test and MELD score are good parameters for evaluating liver function. Moreover, K value and R(15) have significant correlations with MELD score, especially the K value, which may be a convenient and appropriate indicator to evaluate liver function of patients with liver cirrhosis.

Relationship between model for end-stage liver disease score and left ventricular function in patients with end-stage liver disease

BACKGROUND:Decreased cardiac contractility has been observed in cirrhosis,suggesting a latent cardiomyopathy in these patients.This study was designed to evaluate left ventricular structure and function in patients with end-stage liver disease by the model for end-stage liver disease(MELD) scoring system. METHODS:We recruited 82 patients(72 male,10 female; mean age 50.3±8.9 years)with end-stage liver disease who underwent orthotopic liver transplantation between January 2002 and May 2008.Seventy-eight patients had cirrhosis and 4 had primary liver cancer.Patients were categorized into three groups on the basis of MELD score:≤9(27 patients, 33%);10-19(40,49%);and≥20(15,18%).The relationship between MELD score and cardiac structure and function was determined.Preoperative assessments of blood biochemistry, blood coagulation,serum virology,echocardiography and electrocardiography were performed. RESULTS:MELD score was positively correlated with enlarged left atrial diameter,increased interventricular septum thickness(IVST),increased aortic flow,corrected QT interval (QTc)extension and cardiac output(P=0.033,0.002,0.000, 0.000 and 0.009,respectively).International normalized ratio also had a correlation with the above parameters and enlarged left ventricular end-diastolic diameter(P=0.043,0.010,0.000, 0.001,0.016 and 0.008,respectively).Serum creatinine was positively correlated with IVST(r=0.257,P=0.020),but negatively correlated with early maximal ventricular filling velocity/late diastolic or atrial velocity ratio(r=-0.300, P=0.006).A difference of QTc>440 ms among the three groups was statistically significant(χ2=9.791,P=0.007).CONCLUSIONS:Abnormalities in cardiac structure and function are common in patients with end-stage liver disease. MELD score is a practically useful approach for the assessment of cardiac function in such patients.

Comparative study of indocyanine green-R15,Child-Pugh score,and model for end-stage liver disease score for prediction of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

BACKGROUND Hepatic encephalopathy(HE)remains an enormous challenge in patients who undergo transjugular intrahepatic portosystemic shunt(TIPS)implantation.The preoperative indocyanine green retention rate at 15 min(ICG-R15),as one of the liver function assessment tools,has been developed as a prognostic indicator in patients undergoing surgery,but there are limited data on its role in TIPS.AIM To determine whether the ICG-R15 can be used for prediction of post-TIPS HE in decompensated cirrhosis patients with portal hypertension(PHT)and compare the clinical value of ICG-R15,Child-Pugh score(CPS),and model for end-stage liver disease(MELD)score in predicting post-TIPS HE with PHT.METHODS This retrospective study included 195 patients with PHT who underwent elective TIPS at Beijing Shijitan Hospital from January 2018 to June 2019.All patients underwent the ICG-R15 test,CPS evaluation,and MELD scoring 1 wk before TIPS.According to whether they developed HE or not,the patients were divided into two groups:HE group and non-HE group.The prediction of one-year post-TIPS HE by ICG-R15,CPS and MELD score was evaluated by the areas under the receiver operating characteristic curves(AUCs).RESULTS A total of 195 patients with portal hypertension were included and 23%(45/195)of the patients developed post-TIPS HE.The ICG-R15 was identified as an independent predictor of post-TIPS HE.The AUCs for the ICG-R15,CPS,and MELD score for predicting post-TIPS HE were 0.664(95%confidence interval[CI]:0.557-0.743,P=0.0046),0.596(95%CI:0.508-0.679,P=0.087),and 0.641(95%CI:0.554-0.721,P=0.021),respectively.The non-parametric approach(Delong-Delong&Clarke-Pearson)showed that there was statistical significance in pairwise comparison between AUCs of ICG-R15 and MELD score(P=0.0229).CONCLUSION The ICG-R15 has appreciated clinical value for predicting the occurrence of post-TIPS HE and is a choice for evaluating the prognosis of patients undergoing TIPS.

Modified model for end-stage liver disease improves shortterm prognosis of hepatitis B virus-related acute-on-chronic liver failure

AIM To investigate whether the short-term prognosis of hepatitis B virus(HBV)-related acute-on-chronic liver failure(ACLF) could be improved by using a modified model for end-stage liver disease(MELD) including serum lactate.METHODS This clinical study was conducted at the First Affiliated Hospital, Fujian Medicine University, China. From 2009 to 2015, 236 patients diagnosed with HBV-related ACLF at our center were recruited for this 3-month followup study. Demographic data and serum lactate levels were collected from the patients. The MELD scores with or without serum lactate levels from survival and nonsurvival groups were recorded and compared.RESULTS Two hundred and thirty-six patients with HBV-ACLF were divided into two groups: survival group(S) andnon-survival group(NS). Compared with the NS group, the patients in survival the S group had a significantly lower level of serum lactate(3.11 ± 1.98 vs 4.67 ± 2.43, t = 5.43, P < 0.001) and MELD score(23.33 ± 5.42 vs 30.37 ± 6.58, t = 9.01, P = 0.023). Furthermore, serum lactate level was positively correlated with MELD score(r = 0.315, P < 0.001). Therefore, a modified MELD including serum lactate was developed by logistic regression analysis(0.314 × lactate + 0.172 × MELD-5.923). In predicting 3-month mortality using the MELD-LAC model, the patients from the S group had significantly lower baseline scores(-0.930 ± 1.34) when compared with those from the NS group(0.771 ± 1.32, t = 9.735, P < 0.001). The area under the receiver operating characteristic curve(AUROC) was 0.859 calculated by using the MELD-LAC model, which was significantly higher than that calculated by using the lactate level(0.790) or MELD alone(0.818). When the cutoff value was set at-0.4741, the sensitivity, specificity, positive predictive value and negative predictive value for predicting short-term mortality were 91.5%, 80.10%, 94.34% and 74.62%, respectively. When the MELD-LAC scores at baseline level were set at-0.5561 and 0.6879, the corresponding mortality rates within three months were 75% and 90%, respectively.CONCLUSION The short-term prognosis of HBV-related ACLF was improved by using a modified MELD including serum lactate from the present 6-year clinical study.

End-stage liver disease score and future liver remnant volume predict post-hepatectomy liver failure in hepatocellular carcinoma

BACKGROUND Hepatocellular carcinoma(HCC)is the world’s sixth most common malignant tumor and the third cause of cancer death.Although great progress has been made in hepatectomy,it is still associated with a certain degree of risk of posthepatectomy liver failure(PHLF),which extends the length of hospital stay and remains the leading cause of postoperative death.Studies have shown that assessment of hepatic functional reserve before hepatectomy is beneficial for reducing the incidence of PHLF.AIM To assess the value of model for end-stage liver disease(MELD)score combined with standardized future liver remnant(sFLR)volume in predicting PHLF in patients undergoing hepatectomy for HCC.METHODS This study was attended by 238 patients with HCC who underwent hepatectomy between January 2015 and January 2018.Discrimination of sFLR volume,MELD score,and sFLR/MELD ratio to predict PHLF was evaluated according to the area under the receiver operating characteristic curve.RESULTS The patients were divided into two groups according to whether PHLF occurred after hepatectomy.The incidence of PHLF was 8.4%in our research.The incidence of PHLF increased with the decrease in sFLR volume and the increase in MELD score.Both sFLR volume and MELD score were considered independent predictive factors for PHLF.Moreover,the cut-off value of the sFLR/MELD score to predict PHLF was 0.078(P<0.001).This suggests that an sFLR/MELD≥0.078 indicates a higher incidence of PHLF than an sFLR/MELD<0.078.CONCLUSION MELD combined with sFLR is a reliable and effective PHLF predictor,which is superior to MELD score or sFLR volume alone.

Application of a biochemical and clinical model to predict individual survival in patients with end-stage liver disease

AIM:To investigate the capability of a biochemical and clinical model,BioCliM,in predicting the survival of cirrhotic patients.METHODS:We prospectively evaluated the survival of 172 cirrhotic patients.The model was constructed using clinical(ascites,encephalopathy and variceal bleeding) and biochemical(serum creatinine and serum total bilirubin) variables that were selected from a Cox proportional hazards model.It was applied to estimate 12-,52-and 104-wk survival.The model's calibration using the Hosmer-Lemeshow statistic was computed at 104 wk in a validation dataset.Finally,the model's validity was tested among an independent set of 85 patients who were stratified into 2 risk groups(low risk≤8 and high risk>8).RESULTS:In the validation cohort,all measures of fi t,discrimination and calibration were improved when the biochemical and clinical model was used.The proposed model had better predictive values(c-statistic:0.90,0.91,0.91) than the Model for End-stage Liver Disease(MELD) and Child-Pugh(CP) scores for 12-,52-and 104-wk mortality,respectively.In addition,the Hosmer-Lemeshow(H-L) statistic revealed that the biochemical and clinical model(H-L,4.69) is better calibrated than MELD(H-L,17.06) and CP(H-L,14.23).There were no significant differences between the observed and expected survival curves in the stratified risk groups(low risk,P=0.61;high risk,P=0.77).CONCLUSION:Our data suggest that the proposed model is able to accurately predict survival in cirrhotic patients.

Living donor liver transplantation for high model for endstage liver disease score:What have we learned?

AIM: To assess the impact of model for end-stage liver disease(MELD) score on patient survival and morbidity post living donor liver transplantation(LDLT). METHODS: A retrospective study was performed on 80 adult patients who had LDLT from 2011-2013. Nine patients were excluded and 71 patients were divided into two groups; Group 1 included 38 patients with a MELD score < 20, and Group 2 included 33 patients with a MELD score > 20. Comparison between both groups was done regarding operative time, intra-operative blood requirement, intensive care unit(ICU) and hospital stay, infection, and patient survival.RESULTS: Eleven patients died(15.5%); 3/38(7.9%)patients in Group 1 and 8/33(24.2%) in Group 2 with significant difference(P = 0.02). Mean operative time, duration of hospital stay, and ICU stay were similar in both groups. Mean volume of blood transfusion and cell saver re-transfusion were 8 ± 4 units and 1668 ± 202 m L, respectively, in Group 1 in comparison to 10 ± 6 units and 1910 ± 679 m L, respectively, in Group 2 with no significant difference(P = 0.09 and 0.167, respectively). The rates of infection and systemic complications(renal, respiratory, cardiovascular and neurological complications) were similar in both groups. CONCLUSION: A MELD score > 20 may predict mortality after LDLT.

Outcomes of liver transplantation for end-stage biliary disease: A comparative study with end-stage liver disease

AIM: To evaluate the outcomes of patients with endstage biliary disease(ESBD) who underwent liver transplantation, to define the concept of ESBD, the criteria for patient selection and the optimal operation for decision-making.METHODS: Between June 2002 and June 2014, 43 patients with ESBD from two Chinese organ transplantation centres were evaluated for liver transplantation. The causes of liver disease were primary biliary cirrhosis(n = 8), cholelithiasis(n = 8), congenital biliary atresia(n = 2), graft-related cholangiopathy(n = 18), Caroli's disease(n = 2), iatrogenic bile duct injury(n = 2), primary sclerosing cholangitis(n = 1), intrahepatic bile duct paucity(n = 1) and Alagille's syndrome(n = 1). The patients with ESBD were compared with an end-stage liver disease(ESLD) case control group during the same period, and the potential prognostic values of multiple demographic and clinical variables were assessed. The examined variables included recipient age, sex, pre-transplant clinical status, pre-transplant laboratory values, operation condition and postoperative complications, as well as patient and allograft survival rates. Survival analysis was performed using Kaplan-Meier curves, and the rates were compared using log-rank tests. All variables identified by univariate analysis with P values < 0.100 were subjected to multivariate analysis. A Cox proportional hazard regression model was used to determine the effect of the study variables on outcomes in the study group.RESULTS: Patients in the ESBD group had lower model for end-stage liver disease(MELD)/paediatric end-stage liver disease(PELD) scores and a higher frequency of previous abdominal surgery compared to patients in the ESLD group(19.2 ± 6.6 vs 22.0 ± 6.5, P = 0.023 and 1.8 ± 1.3 vs 0.1 ± 0.2, P = 0.000). Moreover, theoperation time and the time spent in intensive care were significantly higher in the ESBD group than in the ESLD group(527.4 ± 98.8 vs 443.0 ± 101.0, P = 0.000, and 12.74 ± 6.6 vs 10.0 ± 7.5, P = 0.000). The patient survival rate in the ESBD group was not significantly different from that of the ESBD group at 1, 3 and 5 years(ESBD: 90.7%, 88.4%, 79.4% vs ESLD: 84.9%, 80.92%, 79.0%, χ2 = 0.194, P = 0.660). The graftsurvival rates were also similar between the two groups at 1, 3 and 5 years(ESBD: 90.7%, 85.2%, 72.7% vs ESLD: 84.9%, 81.0%, 77.5%, χ2 = 0.003, P = 0.958). Univariate analysis identified MELD/PELD score(HR = 1.213, 95%CI: 1.081-1.362, P = 0.001) and bleeding volume(HR = 0.103, 95%CI: 0.020-0.538, P = 0.007) as significant factors affecting the outcomes of patients in the ESBD group. However, multivariate analysis revealed that MELD/PELD score(HR = 1.132, 95%CI: 1.005-1.275, P = 0.041) was the only negative factor that was associated with short survival time.CONCLUSION: MELD/PELD criteria do not adequately measure the clinical characteristics and staging of ESBD. The allocation system based on MELD/PELD criteria should be re-evaluated for patients with ESBD.

Individual immunosuppressive protocol after liver transplantation in benign end-stage liver disease:a single-center experience of 645 cases

Objective To analyze individual immunosuppressive protocol ( IP) after liver transplantation ( LT) in benign end - stage liver disease. Methods The clinical data of 645 patients with benign end - stage liver disease undergoing LT in our institute from April 2002 to Aug 2010 were analyzed retrospectively. 146 cases from Apr.

Fecal cytolysin does not predict disease severity in acutely decompensated cirrhosis and acute-on-chronic liver failure

Background:Cirrhosis with acute decompensation(AD)and acute-on-chronic liver failure(ACLF)are characterized by high morbidity and mortality.Cytolysin,a toxin from Enterococcus faecalis(E.faecalis),is associated with mortality in alcohol-associated hepatitis(AH).It is unclear whether cytolysin also contributes to disease severity in AD and ACLF.Methods:We studied the role of fecal cytolysin in 78 cirrhotic patients with AD/ACLF.Bacterial DNA from fecal samples was extracted and real-time quantitative polymerase chain reaction(PCR)was performed.The association between fecal cytolysin and liver disease severity in cirrhosis with AD or ACLF was analyzed.Results:Fecal cytolysin and E.faecalis abundance did not predict chronic liver failure(CLIF-C)AD and ACLF scores.Presence of fecal cytolysin was not associated with other liver disease markers,including Fibrosis-4(FIB-4)index,‘Age,serum Bilirubin,INR,and serum Creatinine(ABIC)’score,Child-Pugh score,model for end-stage liver disease(MELD)nor MELD-Na scores in AD or ACLF patients.Conclusions:Fecal cytolysin does not predict disease severity in AD and ACLF patients.The predictive value of fecal cytolysin positivity for mortality appears to be restricted to AH.

Predicting utility of a model for end stage liver disease in alcoholic liver disease

瞄准：作为短术语(30 d 和 90 d ) 的预言者为结束阶段肝疾病验证 Maddrey 判别式函数分数和模型的统计实用程序在有含酒精的肝炎并且到的病人的死亡与含酒精的肝炎在临床的特征和病人的实验室变量之中估计预示的因素。方法：有含酒精的肝炎的诊断的 34 个病人承认从 2000 ～ 2005 的雅典的大学医院在当前的回顾的学习被估计，统计分析被进行到 Hippokration。结果：30-d 和 90-d 死亡率在 5.9% 点被报导(2/34 ) 并且 14.7%(5/34 ) 分别地。重要关联为结束阶段肝疾病为模型被表明( P30 = 0.094 ， P90 = 0.046 )并且 Maddrey 判别式功能分数( P30 = 0.033 ， P90 = 0.038 )与 30-d 和 90-d 死亡而一个重要协会也为丙氨酸 aminotransferase 被建立( P = 0.057 )，血纤维蛋白降级产品( P = 0.048 )并且C反应的蛋白质( P = 0.067 )与 90-d 死亡。为 30-d 死亡，在曲线下面的区域是 0.969 (95%CI：0.902-1.036， P = 0.028 ) 为为结束阶段肝疾病 20 和 0.984 的模型(95%CI：0.942-1.027， P = 0.023 ) 为 Maddrey 判别式功能分数与最佳割掉 30.5 的点(敏感 1，特性 0.937 ) 并且 108.68 (敏感 1，特性 0.969 ) 分别地。因此，为 90-d 死亡，在曲线下面的区域是 0.762 (95%CI：0.559-0.965， P = 0.065 ) 为为结束阶段肝疾病 20 和 0.752 的模型(95%CI：0.465-1.038， P = 0.076 ) 为 Maddrey 判别式功能分数与最佳割掉 19 的点(敏感 0.6，特性 0.6 ) 并且 92 (敏感 0.6，特性 0.946 ) 分别地。为不同分数范畴的观察 Kaplan Meier 幸存率与木头等级测试和更高的分数相比价值与更低的幸存被相关。结论：为结束阶段肝疾病和 Maddrey 判别式功能分数的模型的相等被当前的学习暗示，由阴谋的接收装置起作用的曲线和估计的幸存率验证了。90-d 死亡的独立预言者也被验证了的 C 反应的蛋白质，血纤维蛋白降级产品和丙氨酸 aminotransferase 的一个统计上重要的实用程序。

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.

Characteristics of alcoholic liver disease and predictive factors for mortality of patients with alcoholic cirrhosis

BACKGROUND:Alcoholic liver disease is one of the major chronic liver diseases worldwide.The aim of the study was to describe the clinical characteristics of alcoholic liver disease and to compare the predictive values of biochemical parameters,complications,Child-Turcotte-Pugh score,model for end-stage liver disease(MELD)score and discriminant function score for the mortality of in-hospital or 3-month after discharge of patients with alcoholic cirrhosis(AC).METHODS:A retrospective record review and statistical analysis were performed on 205 consecutive patients with the discharge diagnosis of alcoholic liver disease.Three models were used to predict the mortality of patients with AC.The number of variceal hemorrhage,infection,hepatic encephalopathy and hepatocellular carcinoma was analyzed as"numbers of complications".Model 1 consisted of creatinine,white blood cell count,international normalized ratio and"numbers of complications".Model 2 consisted of MELD score.Model 3included"numbers of complications"and MELD score.RESULTS:The risk of developing AC was significant for patients with alcohol consumption of higher than 80 g/d(OR=2.807,P【0.050)and drinking duration of longer than 10 years(OR=3.429,P【0.028).The area under curve for predicting inhospital mortality of models 1,2 and 3 was 0.950,0.886 and 0.911(all P【0.001),respectively.The area under curve for predicting the 3-month mortality of models 1,2 and 3 was 0.867,0.878 and0.893(all P【0.001),respectively.CONCLUSIONS:There is a dose-dependent relationship between alcohol consumption and the risk of developing AC.MELD score has a better predictive value than Child-TurcottePugh or discriminant function score for patients with AC,and model 1 or 3 is better than model 2.

外周血NLR、AFP联合MELD评分系统对HBV-ACLF患者近期预后的评估价值

目的探究外周血中性粒细胞和淋巴细胞的比值(NLR)、甲胎蛋白(AFP)+终末期肝病模型(MELD)评分系统在判断乙型肝炎病毒相关慢加急(亚急)性肝衰竭(HBV-ACLF)患者近期预后方面的意义,以指导有关疾病研究和相关治疗干预工作的开展。方法选择2018年1月至2018年12月被福建医科大学孟超肝胆医院所接收HBV-ACLF患者115例并实施回归性分析,按预后近期3个月内的病情转归将患者分为好转组与无效/恶化组,然后做如下分析:①应用Logistic回归分析HBVACLF患者的性别、年龄以及入院24 h的血常规指标、肝功能指标、甲胎蛋白、C反应蛋白、降钙素原、血肌酐、血氨、钠、病史及并发症与近期预后的相关性。②用ROC曲线评价和预后明显相关指标监测HBV-ACLF患者近期预后的临床价值。结果恶化/无效组的NLR水平与MELD评分均高于好转组,而好转组的AFP值高于恶化/无效组(P<0.05)。通过ROC曲线分析表明,NLR、AFP+MEL对HBV-ACLF患者近期预后具有最高的预后准确度价值,其曲线包围的图形有最大的面积为0.880,NLR、AFP+MELD评分系统评估患者治疗无效/恶化组的敏感度、特异度、阳性预测及阴性预测的数值分别为90.00%、75.38%、73.77%及90.74%。结论NLR、AFP+MELD评分在HBV-ACLF患者3个月的预后评估方面具有更高预测效力,可引导HBV-ACLF临床治疗工作的开展。

Prognostic Value of Model for End-Stage Liver Disease Incorporating with Serum Sodium Score for Development of Acute Kidney Injury after Liver Transplantation

Background： Contribution of model for end-stage liver disease incorporating with serum sodium （MELD-Na） score in predicting acute kidney injury （AKI） after orthotopic liver transplantation （OLT） is yet to be identified. This study assessed the prognostic value ot MELD-Na score for the development of AKl following OLT. Methods： Preoperative and surgery-related variables of 321 adult end-stage liver disease patients who underwent OLT in Fuzhou General Hospital were collected. PostoperativeAKI was defined and staged in accordance with the clinical practice guidelines developed by Kidney Disease： Improving Global Outcomes. Univariate and multivariate analysis was performed to determine the risk factors fnr AKI following OLT. The discriminating power of MELD/MELD-Na score on AKI outcome was evaluated by receiver operating characteristic （ROC） curve. Spearman＇s correlation analysis was used for identifying the correlated relationship between MELD/MELD-Na score and the severity levels of AKI. Results： The prevalence of AKI following OLT was in 206 out of 321 patients （64.2%）. Three risk lhctors for AKI post-OLT were presented, preoperative calculated MELD score （odds ratio [OR] = 1.048, P = 0.021）, intraoperative volume of red cell suspension transfusion （OR = 1.001, P 0.002）, and preoperative liver cirrhosis （OR = 2.015, P = 0.012）. Two areas under ROC curve （AUCs） of MELD/MELD-Na score predicting AKI were 0.688 and 0.672, respectively; the difference between two AUCs was not significant （Z= 1.952, P = 0.051）. The Spearman＇s correlation coefficients between MELD/MELD-Na score and the severity levels of AKI were 0.406 and 0.385 （P 0.001, 0.001）, respectively. Conclusions： We demonstrated that preoperative MELD score, intraoperative volume of red cell suspension transfusion and preoperative liver cirrhosis were risk factors for AKI following OLT. Furthermore, we preliminarily validated that MELD score seemed to have a stronger power discriminating AKI post-OLT than that of novel MELD-Na score.

Change in model for end-stage liver disease score at two weeks,as an indicator of mortality or liver transplantation at 60 days in acute-on-chronic liver failure

Background:Acute-on-chronic liver failure(ACLF)is characterised by a sudden deterioration of underlying chronic liver disease,resulting in increased rates of mortality and liver transplantation.Early prognostication can benefit optimal allocation of resources.Methods:ACLF was defined as per the disease criteria of the Asian Pacific Association for the Study of the Liver.Inpatient discharge summaries from between January 2001 and April 2013 were reviewed.The primary outcome was mortality or liver transplantation within 60 days from onset of ACLF.Absolute‘model for end-stage liver disease’(MELD)score and change in MELD at Weeks 1,2 and 4 were reviewed in order to identify the earliest point for prediction of mortality or liver transplantation.Results:Clinical data were collected on 53 subjects who fulfilled the inclusion and exclusion criteria.At 60 days from presentation,20 patients(37.7%)died and 4(7.5%)underwent liver transplantation.Increased MELD of-2 after 2 weeks was 75.0%sensitive and 75.9%specific for predicting mortality or liver transplantation.If the MELD score did not increase at 2 weeks,predictive chance of survival was 93.8%over the next 60 days.MELD change at 1 week showed poor sensitivity and specificity.Change at 4 weeks was too late for intervention.Conclusion:Change in MELD score at 2 weeks provides an early opportunity for prognostication in ACLF.A MELD score that does not deteriorate by Week 2 would predict 93.8%chance of survival for the next 60 days.This finding warrants further validation in larger cohort studies.

血管性血友病因子水平联合MELD评分体系对肝硬化短期预后的预测价值

目的探讨血浆血管性血友病因子(vWF)水平与肝硬化严重程度的关系及其联合终末期肝病模型(MELD)评分体系对肝硬化患者短期预后的预测价值。方法随机收集2017年9月至2022年3月于上海交通大学医学院附属瑞金医院感染科住院的肝硬化患者共234例。检测所有患者的血浆vWF:Ag水平,收集相关临床数据。分析血浆vWF:Ag水平与MELD和MELD-Na评分的相关性,评估血浆vWF:Ag水平对肝硬化患者未来1个月和3个月发生死亡/肝移植的预测作用,构建vWF:Ag联合MELD改良评分,以期提高诊断价值。结果血浆vWF:Ag水平与MELD和MELD-Na评分均呈正相关,随两者的升高而升高(r=0.576和r=0.579,P均<0.01)。分别有16.7%(29/174)和24.8%(38/153)的患者在其后1个月和3个月时发生死亡/肝移植。各时间点死亡/肝移植组患者的血浆vWF:Ag水平均显著高于非死亡/肝移植组(1个月非死亡/肝移植组vs死亡/肝移植组:(224.4±42.7)%vs(260.7±34.5)%,P<0.01;3个月非死亡/肝移植组vs死亡/肝移植组:(219.0±40.3)%vs(262.5±34.2)%,P<0.01)。多因素分析结果显示,血浆vWF:Ag水平是3个月死亡/肝移植的独立预测因素(OR=1.026,95%CI:1.006~1.046,P<0.01),其诊断的ROC曲线下面积(AUC)为0.795,略低于MELD评分的0.835和MELD-Na评分的0.851。构建vWF:Ag联合MELD-Na改良评分可将诊断的AUC提高至0.881。结论肝硬化患者的血浆vWF:Ag水平随肝病的严重程度而升高。血浆vWF:Ag水平是3个月死亡/肝移植的独立预测因素,vWF:Ag联合MELD-Na改良评分可进一步提高其诊断价值。

Sarcopenia in the prognosis of cirrhosis: Going beyond the MELD score

Estimating the prognosis of patients with cirrhosis remains challenging, because the natural history of cirrhosis varies according to the cause, presence of portal hypertension, liver synthetic function, and the reversibility of underlying disease. Conventional prognostic scoring systems, including the Child-Turcotte-Pugh score or model for endstage liver diseases are widely used; however, revised models have been introduced to improve prognostic performance. Although sarcopenia is one of the most common complications related to survival of patients with cirrhosis, the newly proposed prognostic models lack a nutritional status evaluation of patients. This is reflected by the lack of an optimal index for sarcopenia in terms of objectivity, reproducibility, practicality, and prognostic performance, and of a consensus definition for sarcopenia in patients with cirrhosis in whom ascites and edema may interfere with body composition analysis. Quantifying skeletal muscle mass using cross-sectional abdominal imaging is a promising tool for assessing sarcopenia. As radiological imaging provides direct visualization of body composition, it is useful to evaluate sarcopenia in patients with cirrhosis whose body mass index, anthropometric measurements, or biochemical markers are inaccurate on a nutritional assessment. Sarcopenia defined by cross-sectional imaging-based muscular assessment is prevalent and predicts mortality in patients with cirrhosis. Sarcopenia alone or in combination with conventional prognostic systems shows promise for a cirrhosis prognosis. Including an objective assessment of sarcopenia with conventional scores to optimize the outcome prediction for patients with cirrhosis needs further research.

Prognostic models for acute liver failure

BACKGROUND: Acute liver failure (ALF) remains a dramatic and unpredictable disease with high morbidity and mortality. Early and accurate prognostic assessment of patients with ALF is critically important for optimum clinical pathway. DATA SOURCES: Five English-language medical databases, MEDLINE, Science Direct, OVID, Springer Link and Wiley Interscience were searched for articles on 'acute liver failure', 'prognosis', and related topics. RESULTS: Multi-variable prognostic models including the King's College Hospital criteria and the model for end-stage liver disease score have been widely used in determination of the prognosis of ALF, but the results are far from satisfactory. Other prognostic indicators including serum Gc-globulin, arterial blood lactate, serum phosphate, arterial blood ammonia, and serum alpha-fetoprotein are promising but await further assessement. CONCLUSIONS: A reliable prognostic model to be developed in the future should not only have predictive value for poor outcome but also help to predict the survival of patients without a liver transplantation. Further studies are necessary to assess the prognostic accuracy of any new models. (Hepatobiliary Pancreat Dis Int 2010; 9: 122-128)