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.

A good prognostic predictor for liver transplantation recipients with benign end-stage liver cirrhosis

BACKGROUND： Post-transplant model for predicting mortality（PMPM, calculated as-5.359＋1.988×ln（serum creatinine [mg/d L]）＋1.089×ln（total bilirubin [mg/d L]）） score has been proved to be a simple and accurate model for predicting the prognosis after liver transplantation（LT） in a single center study. Here we aim to verify this model in a large cohort of patients.METHODS： A total of 2727 patients undergoing LT with endstage liver cirrhosis from January 2003 to December 2010 were included in this retrospective study. Data were collected from the China Liver Transplant Registry（CLTR）. PMPM score was calculated at 24-h and 7-d following LT. According to the PMPM score at 24-h, all patients were divided into the low-risk group（PMPM score ≤-1.4, n=2509） and the high-risk group（PMPM score 〉-1.4, n=218）. The area under receiver operator characteristic curve（AUROC） was calculated for evaluating the prognostic accuracy.RESULTS： The 1-, 3-, and 5-year patient survival rates in the low-risk group were significantly higher than those in the high-risk group（90.23%, 88.01%, and 86.03% vs 63.16%, 59.62%, and 56.43%, respectively, P〈0.001）. In the high-risk group, 131 patients had a decreased PMPM score（≤-1.4） at 7-d, and their cumulative survival rate was significantly higher than the other 87 patients with sustained high PMPM score（〉-1.4）（P〈0.001）. For predicting 3-month mortality, PMPM score showed a much higher AUROC than post-transplant MELD score（P〈0.05）.CONCLUSION： PMPM score is a simple and effective tool to predict short-term mortality after liver transplantation in patients with benign liver diseases, and an indicator for prompt salvaging treatment as well.

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.

Corrected QT interval in cirrhosis:A systematic review and metaanalysis

BACKGROUND Corrected QT(QTc)interval is prolonged in patients with liver cirrhosis and has been proposed to correlate with the severity of the disease.However,the effects of sex,age,severity,and etiology of cirrhosis on QTc have not been elucidated.At the same time,the role of treatment,acute illness,and liver transplantation(Tx)remains largely unknown.AIM To determine the mean QTc in patients with cirrhosis,assess whether QTc is prolonged in patients with cirrhosis,and investigate whether QTc is affected by factors such as sex,age,severity,etiology,treatment,acute illness,and liver Tx.METHODS In the present systematic review and meta-analysis,the searching protocol“{[QTc]OR[QT interval]OR[QT-interval]OR[Q-T syndrome]}AND{[cirrhosis]OR[Child-Pugh]OR[MELD]}”was applied in PubMed,EMBASE,and Google Scholar databases to identify studies that reported QTc in patients with cirrhosis and published after 1998.Seventy-three studies were considered eligible.Data concerning first author,year of publication,type of study,method used,sample size,mean age,female ratio,alcoholic etiology of cirrhosis ratio,Child-Pugh A/B/C ratio,mean model for end-stage liver disease(MELD)score,treatment withβ-blockers,episode of acute gastrointestinal bleeding,formula for QT correction,mean pulse rate,QTc in patients with cirrhosis and controls,and QTc according to etiology of cirrhosis,sex,Child-Pugh stage,MELD score,and liver Tx status(pre-Tx/post-Tx)were retrieved.The Newcastle-Ottawa quality assessment scale appraised the quality of the eligible studies.Effect estimates,expressed as proportions or standardized mean differences,were combined using the randomeffects,generic inverse variance method of DerSimonian and Laird.Subgroup,sensitivity analysis,and meta-regressions were applied to assess heterogeneity.RESULTS QTc combined mean in patients with cirrhosis was 444.8 ms[95%confidence interval(CI):440.4-449.2;P<0.001 when compared with the upper normal limit of 440 ms],presenting high heterogeneity(I2=97.5%;95%CI:97.2%-97.8%);both Egger’s and Begg’s tests showed non-significance.QTc was elongated in patients with cirrhosis compared with controls(P<0.001).QTc was longer in patients with Child-Pugh C cirrhosis when compared with Child-Pugh B and A(P<0.001);Child-Pugh B patients presented longer QTc when compared with Child-Pugh A patients(P=0.003).The MELD score was higher in patients with cirrhosis with QTc>440 ms when compared with QTc≤440 ms(P<0.001).No correlation of QTc with age(P=0.693),sex(P=0.753),or etiology(P=0.418)was detected.β-blockers shortened QTc(P<0.001).QTc was prolonged during acute gastrointestinal bleeding(P=0.020).Tx tended to improve QTc(P<0.001).No other sources of QTc heterogeneity were revealed.CONCLUSION QTc is prolonged in cirrhosis independently of sex,age,and etiology but is correlated with severity and affected byβ-blockers and acute gastrointestinal bleeding.QTc is improved after liver Tx.

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.

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.

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.

Development and validation of a new prognostic model for patients with acute-on-chronic liver failure in intensive care unit

BACKGROUND Cirrhotic patients with acute-on-chronic liver failure(ACLF)in the intensive care unit(ICU)have a poor but variable prognoses.Accurate prognosis evaluation can guide the rational management of patients with ACLF.However,existing prognostic scores for ACLF in the ICU environment lack sufficient accuracy.AIM To develop a new prognostic model for patients with ACLF in ICU.METHODS Data from 938 ACLF patients in the Medical Information Mart for Intensive Care(MIMIC)database were used to develop a new prognostic model(MIMIC ACLF)for ACLF.Discrimination,calibration and clinical utility of MIMIC ACLF were assessed by area under receiver operating characteristic curve(AUROC),calibration curve and decision curve analysis(DCA),respectively.MIMIC ACLF was then externally validated in a multiple-center cohort,the Electronic Intensive Care Collaborative Research Database and a single-center cohort from the Second Hospital of Hebei Medical University in China.RESULTS The MIMIC ACLF score was determined using nine variables:ln(age)×2.2+ln(white blood cell count)×0.22-ln(mean arterial pressure)×2.7+respiratory failure×0.6+renal failure×0.51+cerebral failure×0.31+ln(total bilirubin)×0.44+ln(internationalized normal ratio)×0.59+ln(serum potassium)×0.59.In MIMIC cohort,the AUROC(0.81/0.79)for MIMIC ACLF for 28/90-day ACLF mortality were significantly greater than those of Chronic Liver Failure Consortium ACLF(0.76/0.74),Model for End-stage Liver Disease(MELD;0.73/0.71)and MELD-Na(0.72/0.70)(all P<0.001).The consistency between actual and predicted 28/90-day survival rates of patients according to MIMIC ACLF score was excellent and superior to that of existing scores.The net benefit of MIMIC ACLF was greater than that achieved using existing scores within the 50%threshold probability.The superior predictive accuracy and clinical utility of MIMIC ACLF were validated in the external cohorts.CONCLUSION We developed and validated a new prognostic model with satisfactory accuracy for cirrhotic patients with ACLF hospitalized in the ICU.The model-based risk stratification and online calculator might facilitate the rational management of patients with ACLF.

Combined MELD and blood lipid level in evaluating the prognosis of decompensated cirrhosis

AIM: To evaluate the prognostic value of the combined model for end-stage liver disease (MELD) and blood lipid level in patients with decompensated cirrhosis. METHODS: A total of 198 patients with decompensated cirrhosis were enrolled into the study. The values of triglyceride (TG), cholesterol (TC), high density lipoproteins (HDL) and low density lipoprotein (LDL) of each patient on the fi rst day of admission were retrieved from the medical records, and MELD was calculated. All the patients were followed up for 1 year. The relationship between the change of blood lipid level and the value of MELD score was studied by analysis of variance. The prognostic factors were screened by multivariate Cox proportional hazard model. Draw Kaplan-Meier survival curves were drawn. RESULTS: Forty-f ive patients died within 3 mo and 83 patients died within 1 year. The levels of TG, TC, HDL and LDL of the death group were all lower than those of the survivors. The serum TG, TC, HDL and LDL levels were lowered with the increase of the MELD score. Multivariate Cox proportional hazard model showed that MELD ≥18 and TC ≤2.8 mmol/L were independent risk factors for prognosis of decompensated cirrhosis. Survival analysis showed that MELD ≥18 combined with TC ≤ 2.8 mmol/L can clearly discriminate between the patients who would survive and die in 1 year. CONCLUSION: MELD ≥18 and TC ≤2.8 mmol/L are two important indexes to predict the prognosis of patients with decompensated cirrhosis. Their combination can effectively predict the long-term prognosis of patients with decompensated cirrhosis.

Autologous mobilized peripheral blood CD34^+ cell infusion in non-viral decompensated liver cirrhosis

AIM: To study the effect of mobilized peripheral blood autologous CD34 positive(CD34+) cell infusion in patients with non-viral decompensated cirrhosis.METHODS: Cirrhotic patients of non-viral etiology were divided into 2 groups based on their willingness to be listed for deceased donor liver transplant(DDLT)(control, n = 23) or to receive autologous CD34+ cell infusion through the hepatic artery(study group, n= 22). Patients in the study group were admitted to hospital and received granulocyte colony stimulating factor injections 520 μg/d for 3 consecutive days to mobilize CD34+ cells from the bone marrow. On day 4,leukapheresis was done and CD34+ cells were isolated using CliniMAC magnetic cell sorter. The isolated CD34+ cells were infused into the hepatic artery under radiological guidance. The patients were discharged within 48 h. The control group received standard of care treatment for liver cirrhosis and were worked up for DDLT as per protocol of the institute. Both groups were followed up every week for 4 wk and then every month for 3 mo.RESULTS: In the control and the study group, the cause of cirrhosis was cryptogenic in 18(78.2%) and16(72.72%) and alcohol related in 5(21.7%) and6(27.27%), respectively. The mean day 3 cell count(cells/μL) was 27.00 ± 20.43 with a viability of 81.84± 11.99%. and purity of 80%-90%. Primary end point analysis revealed that at 4 wk, the mean serum albumin in the study group increased significantly(2.83± 0.36 vs 2.43 ± 0.42, P = 0.001) when compared with controls. This improvement in albumin was,however, not sustained at 3 mo. However, at the end of3 mo there was a statistically significant improvement in serum creatinine in the study group(0.96 ± 0.33 vs 1.42 ± 0.70, P = 0.01) which translated into a significant improvement in the Model for End-Stage Liver Disease score(15.75 ± 5.13 vs 19.94 ± 6.68,P = 0.04). On statistical analysis of secondary end points, the transplant free survival at the end of 1 mo and 3 mo did not show any significant difference(P =0.60) when compared to the control group. There was no improvement in aspartate transaminase, alanine transaminase, and bilirubin at any point in the study population. There was no mortality benefit in the study group. The procedure was safe with no procedural or treatment related complications.CONCLUSION: Autologous CD 34+ cell infusion is safe and effectively improves liver function in the short term and may serve as a bridge to liver transplantation.

Liver cirrhosis-effect on QT interval and cardiac autonomic nervous system activity

AIM To examine the impact of liver cirrhosis on QT interval and cardiac autonomic neuropathy(CAN). METHODS A total of 51 patients with cirrhosis and 51 controls were examined. Standard 12-lead electrocardiogram recordings were obtained and QT as well as corrected QT interval(QTc) and their dispersions(dQT, dQTc) were measured and calculated using a computer-based program. The diagnosis of CAN was based upon the battery of the tests proposed by Ewing and Clarke and the consensus statements of the American Diabetes Association. CAN was diagnosed when two out of the four classical Ewing tests were abnormal. RESULTS QT, QTc and their dispersions were significantly longer(P < 0.01) in patients with cirrhosis than in controls. No significant differences in QT interval were found among the subgroups according to the etiology of cirrhosis. Multivariate regression analysis after controlling for age, gender and duration of cirrhosis demonstrated significant association between QT and presence of diabetes mellitus [standardized regression coefficient(beta) = 0.45, P = 0.02] and treatment with diuretics(beta = 0.55, P = 0.03), but not with the Child-Pugh score(P = 0.54). Prevalence of CAN was common(54.9%) among patients with cirrhosis and its severity was associated with the Child-Pugh score(r = 0.33, P = 0.02). Moreover, patients with decompensated cirrhosis had more severe CAN that those with compensated cirrhosis(P = 0.03). No significant association was found between severity of CAN and QT interval duration.CONCLUSION Patients with cirrhosis have QT prolongation. Treatment with diuretics is associated with longer QT. CAN is common in patients with cirrhosis and its severity is associated with severity of the disease.

Assessment of hemostatic profile in patients with mild to advanced liver cirrhosis

BACKGROUND Hemostasis of patients suffering from liver cirrhosis is challenging due to both,pro-and anticoagulatory disorders leading to hemostatic alterations with distinct abnormalities of coagulation.Pathological changes in conventional coagulation analysis and platelet count are common manifestations of decreased liver synthesis of coagulation factors and reduced platelet count in these patients.However,conventional coagulation analysis and platelet count do not reflect invivo coagulation status or platelet function.The purpose of this present observational study was therefore to assess the haemostatic profile including plasmatic coagulation using thrombelastometry and impedance aggregometry for platelet function in patients suffering from liver cirrhosis.AIM To assess the hemostatic profile of cirrhotic patients according to model for endstage liver disease(MELD)score.METHODS Our study included both in-and outpatients suffering from liver cirrhosis attending the out-and inpatient care of the department of hepatology.Demographic and biochemical data as well as medical history including cause of liver cirrhosis,end stage kidney failure and medication with anticoagulants were recorded.To assess the hemostatic profile,platelet function was analyzed by multiple electrode aggregometry(MEA)using Multiplate^■(ADP-,ASPI-and TRAP-test)and thrombelastometry using ROTEM^■(EXTEM,INTEM,FIBTEM).Data were compared using Mann-Whitney U-or χ^2-test.Spearman correlation was performed to analyze the association between MELD Score and results of thrombelastometry and MEA.RESULTS A total of 68 patients attending the out-and inpatient care suffering from liver cirrhosis were screened.Of these,50 patients were included and assigned to groups according to MELD score 6 to 11(n=25)or≥17(n=25).Baseline patient characteristics revealed significant differences for MELD score(8 vs 22,P<0.0001)and underlying laboratory parameters(international normalized ratio,bilirubine,creatinine)as well as fibrinogen level(275 mg/dL vs 209 mg/dL,P=0.006)and aPTT(30 s vs 35 s,P=0.047).MEA showed a moderately impaired platelet function(medians:AUCADP=43U,AUCASPI=71U,AUCTRAP=92U)but no significant differences between both groups.Thrombelastometry using ROTEM?(EXTEM,INTEM,FIBTEM)revealed values within normal range in both groups.No significant correlation was observed between MELD score and results of MEA/thrombelastometry.CONCLUSION Our data demonstrate a partially impaired hemostatic profile in liver cirrhosis patients unrelated to MELD score.An individual assessment of a potential coagulopathy should therefore be considered.

Predictors of fifty days in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis

AIM: To determine the predictors of 50 d in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis(SBP).METHODS: Two hundred and eighteen patients admitted to an intensive care unit in a tertiary care hospital between June 2013 and June 2014 with the diagnosis of SBP(during hospitalization) and cirrhosis were retrospectively analysed. SBP was diagnosed by abdominal paracentesis in the presence of polymorphonuclear cell count ≥ 250 cells/mm3 in the peritoneal fluid. Student's t test, multivariate logistic regression, cox proportional hazard ratio(HR), receiver operating characteristics(ROC) curves and Kaplan-Meier survival analysis were utilized for statistical analysis. Predictive abilities of several variables identified by multivariate analysis were compared using the area under ROC curve. P < 0.05 were considered statistical significant. RESULTS: The 50 d in-hospital mortality rate attributable to SBP is 43.11%(n = 94). Median survival duration for those who died was 9 d. In univariate analysis acute kidney injury(AKI), hepatic encephalopathy, septic shock, serum bilirubin, international normalized ratio, aspartate transaminase, and model for end-stage liver disease- sodium(MELD-Na) were significantly associated with in- hospital mortality in patients with SBP(P ≤ 0.001). Multivariate coxproportional regression analysis showed AKI(HR = 2.16, 95%CI: 1.36-3.42, P = 0.001) septic shock(HR = 1.73, 95%CI: 1.05-2.83, P = 0.029) MELD-Na(HR = 1.06, 95%CI: 1.02-1.09, P ≤ 0.001) was significantly associated with 50 d in-hospital mortality. The prognostic accuracy for AKI, MELD-Na and septic shock was 77%, 74% and 71% respectively associated with 50 d inhospital mortality in SBP patients.CONCLUSION: AKI, MELD-Na and septic shock were predictors of 50 d in-hospital mortality in decompensated cirrhosis patients with SBP.

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.

Phase 1 human trial of autologous bone marrow-hematopoietic stem cell transplantation in patients with decompensated cirrhosis

AIM: To evaluate safety and feasibility of autologous bone marrow-enriched CD34+ hematopoietic stem cell Tx through the hepatic artery in patients with decompensated cirrhosis.METHODS: Four patients with decompensated cirrhosis were included. Approximately 200 mL of the bone marrow of the patients was aspirated, and CD34+ stem cells were selected. Between 3 to 10 million CD34+ cells were isolated. The cells were slowly infused through the hepatic artery of the patients.RESULTS: Patient 1 showed marginal improvement in serum albumin and no significant changes in other test results. In patient 2 prothrombin time was decreased; however, her total bilirubin, serum creatinine, and Model of End-Stage Liver Disease (MELD) score worsened at the end of follow up. In patient 3 there was improvement in serum albumin, porthrombin time (PT), and MELD score. Patient 4 developed radiocontrast nephropathy after the procedure, and progressed to type 1 hepatorenal syndrome and died of liver failure a few days later. Because of the major side effects seen in the last patient, the trial was prematurely stopped.CONCLUSION: Infusion of CD34+ stem cells through the hepatic artery is not safe in decompensated cirrhosis. Radiocontrast nephropathy and hepatorenal syndrome could be major side effects. However, this study doesnot preclude infusion of CD34+ stem cells through other routes.

Tongue thickness in health vs cirrhosis of the liver:Prospective observational study

BACKGROUNDMalnutrition affects 40%-90% of patients with cirrhosis of the liver. L3 skeletalmuscle index (L3SMI) is presently accepted as the most objective and quantitativemeasure available for sarcopenia, a surrogate marker of malnutrition. L3SMIapplication is, however, limited by non-availability of computed tomographyscanning in remote areas, cost, need for extensive training, and the risk ofexposure to radiation. Therefore, an alternative dependable measure with wideravailability is needed. Malnutrition causes sarcopenia not only in skeletal musclesbut also in other muscular structures such as the psoas muscle, diaphragm andtongue. We therefore hypothesised that the tongue, being easily accessible forinspection and for measurement of thickness using ultrasonography, may be usedto document sarcopenia.AIMTo measure and compare tongue thickness in healthy individuals and in patientswith cirrhosis of the liver and to study its correlation with conventionalprognostic scores for patients with cirrhosis of the liver.METHODSTongue thickness was measured using ultrasonography. One hundred twentysubjects of either gender aged 18 to 65 years were studied, with 30 subjects in eachgroup. The tongue thickness was compared between groups based on “ChildTurcotte Pugh” (CTP) scores. The correlations between measured tonguethickness and “Model for end stage liver disease” (MELD) score and between age and measured tongue thickness were also assessed.RESULTSMean tongue thickness (mean ± SD) in patients with CTP class A, B and C was4.39 ± 0.39 cm, 4.19 ± 0.53 cm, and 3.87 ± 0.42, respectively, and was 4.33 ± 0.49 cmin normal healthy individuals. Significant differences were seen in tonguethickness between patients with CTP class C and those with CTP class A and B (P< 0.05). Patients with CTP class C also had a significantly reduced tonguethickness than normal individuals (P < 0.05). However, no significant differencewas seen in tongue thickness between patients with CTP class A and B andnormal individuals. A statistically significant, negative correlation was foundbetween MELD score and tongue thickness (r = -0.331) (P < 0.001). No correlationwas observed between L3SMI and MELD score (r = 0.074, P = 0.424). L3SMI(mean ± SD) in healthy subjects was 39.66 ± 6.8 and was 38.26 ± 8.88 in patientswith CTP class C, and the difference was not significant. No significant correlationwas found between age of the patients and tongue thickness. Intra-classcorrelation coefficient was used to determine the reliability of the tonguethickness measurements. The intra-class correlation coefficient was 0.984 (95%CI:0.979-0.989) and was indicative of good reliability.CONCLUSIONTongue thickness measured by ultrasonography, correlates significantly with theseverity of liver disease, as assessed by CTP and MELD scores. The patients with aCTP score ≥ 10 have significantly reduced tongue thickness as compared tonormal individuals and those with less severe liver disease and CTP scores of 5-9.No significant difference in tongue thickness was found between healthyindividuals and CTP class A and B patients.

Dynamic changes in liver function after transjugular intrahepatic portosystemic shunt in patients with cirrhosis

Purpose:To evaluate the dynamic changes in liver function after transjugular intrahepatic portosystemic shunt(TIPS)creation in patients with cirrhosis and to explore its association with clinical outcomes.Methods:This retrospective study included patients who underwent TIPS between August 2016 and December2020.Liver function was primarily evaluated using the model for end-stage liver disease(MELD)score,which was analyzed at baseline,1 week,1 month,3 months,6 months,and 12 months using one-way repeated measures ANOVA.The Kaplan-Meier method,log-rank test,and multivariate analysis were used as appropriate.Results:In total,235 patients were included in this study.The MELD score was significantly higher at 1 week(11.8±3.1 vs 13.5±3.5,p<0.05)and 1 month(11.8±3.1 vs 13.2±4.6,p<0.05)than the baseline level and recovered at 3 months(11.8±3.1 vs 11.9±3.9,p>0.05).At 12 months,the MELD score was higher than the baseline level(11.8±3.1 vs 12.4±3.2,p<0.05).Patients with a recovery of the MELD score(n=151)at 3 months had a lower probability of overt and severe HE(log-rank p=0.015 and p=0.027,respectively)than those without recovery(n=84).Logistic regression analysis revealed that albumin(odds ratio[OR],0.926;95%confidence interval[CI],0.863–0.992;p=0.029)and platelet count(OR,0.993;95%CI,0.987–0.999;p=0.033)were independent predictive factors for non-recovery of the MELD score at 3 months.Conclusions:Liver function after TIPS creation showed a trend of deterioration at first,followed by recovery.Recovery of liver function at three months was associated with reduced overt and severe HE.

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)

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.

MELD score can predict early mortality in patients with rebleeding after band ligation for variceal bleeding

AIM:To investigate the outcomes,as well as risk factors for 6-wk mortality,in patients with early rebleeding after endoscopic variceal band ligation (EVL) for esophageal variceal hemorrhage (EVH).METHODS:Among 817 EVL procedures performed for EVH between January 2007 and December 2008,128 patients with early rebleeding,defined as rebleeding within 6 wk after EVL,were enrolled for analysis.RESULT:The rate of early rebleeding after EVL for acute EVH was 15.6% (128/817).The 5-d,6-wk,3-mo,and 6-mo mortality rates were 7.8%,38.3%,55.5%,and 58.6%,respectively,in these early rebleeding patients.The use of beta-blockers,occurrence of hypovolemic shock,and higher model for end-stage liver disease (MELD) score at the time of rebleeding were independent predictors for 6-wk mortality.A cut-off value of 21.5 for the MELD score was found with an area under ROC curve of 0.862 (P < 0.001).The sensitivity,specificity,positive predictive value,and negative predictive value were 77.6%,81%,71.7%,and 85.3%,respectively.As for the 6-mo survival rate,patients with a MELD score ≥ 21.5 had a significantly lower survival rate than patients with a MELD score < 21.5 (P < 0.001).CONCLUSION:This study demonstrated that the MELD score is an easy and powerful predictor for 6-wk mortality and outcomes of patients with early rebleeding after EVL for EVH.