Accuracy of MELD scores in predicting mortality in decompensated cirrhosis from variceal bleeding, hepatorenal syndrome, alcoholic hepatitis, or acute liver failure as well as mortality after non-transplant surgery or TIPS

Acute kidney injury is independently associated with death in patients with cirrhosis

BACKGROUND AND AIMS

Current creatine-based criteria for defining acute kidney injury (AKI) are validated in general hospitalised patients but their application to cirrhotics (who are younger and have reduced muscle mass) is less certain. We aimed to evaluate current definitions of AKI (acute kidney injury network (AKIN) criteria) in a population of cirrhotic patients and correlate this with outcomes.

METHODS

We prospectively identified patients with AKI and clinical, radiological or histological evidence of cirrhosis. We compared them with a control group with evidence of cirrhosis and no AKI.

RESULTS

162 cirrhotic patients were studied with a mean age of 56.8±14 years. They were predominantly male (65.4%) with alcoholic liver disease (78.4%). 110 patients had AKI: 44 stage 1, 32 stage 2 and 34 stage 3. They were well matched in age, sex and liver disease severity with 52 cirrhotics without AKI. AKI was associated with increased mortality (31.8% vs 3.8%, p<0.001). Mortality increased with each AKI stage; 3.8% in cirrhotics without AKI, 13.5% stage 1, 37.8% stage 2 and 43.2% stage 3 (p<0.001 for trend). Worsening liver disease (Child-Pugh class) correlated with increased mortality: 3.1% class A, 23.6% class B and 32.8% class C (p=0.006 for trend). AKI was associated with increased length of stay: median 6.0 days (IQR 4.0-8.75) versus 16.0 days (IQR 6.0-27.5), p<0.001. Multivariate analysis identified AKI and Child-Pugh classes B and C as independent factors associated with mortality.

CONCLUSIONS

The utility of AKIN criteria is maintained in cirrhotic patients. Decompensated liver disease and AKI appear to be independent variables predicting death in cirrhotics.

Hospital mortality over time in patients with specific complications of cirrhosis

Hospital mortality secondary to cirrhosis is high.

AIM

To evaluate hospital mortality in patients admitted for specific complications of cirrhosis over time.

MATERIAL AND METHODS

Registry-data from Administrative Inpatient Dataset of acute care hospitals were collected at discharge from 2003 to 2010. Inclusion criteria were as follows: hospital admissions where one of the diagnoses was cirrhosis and the reason for admission was a specific complication of cirrhosis (ascites, encephalopathy, hepatorenal syndrome and haemorrhage from varices, bacterial spontaneous peritonitis). Analysis of variance was used for comparisons of quantitative variables and Chi-square for qualitative variables. Logistic regression was performed to identify the risk factors associated with hospital mortality; the Hosmer and Lemeshow test was applied to evaluate calibration and the ROC curve for discrimination respectively.

RESULTS

A total of 12,671 hospital admissions were analysed; 67.7% were men. Mean hospitalization stay was 10.9 (SD 9.2) days and the most frequent causes were encephalopathy (44.2%) and ascites (30.9%). Global hospital mortality was 11.6%. Logistic regression showed that once all factors had been adjusted, hepatorenal syndrome conveyed the highest risk for death (49.2%; OR = 8.1(95%CI:6.6-9.9). Risk of death was also increased by associated comorbidities and older age. Hospital mortality in the period 2006-2010 was 27% inferior to the period 2003-2005. The area under the ROC curve (AUROC) was 0.77 (95%CI 0.76-0.78).

CONCLUSIONS

Hospital mortality as a result of specific complications of cirrhosis is high, but has been declining in recent years.

New advances in the use of serum prealbumin as an index of liver function

Serum prealbumin, mainly synthesized in the liver, can be used to assess the function of liver protein synthesis, reserve and nutritional status with many advantages such as convenience, accuracy and fewer interference factors; however, it is clinically used often as an independent factor, and there is little systematic, relevant and prospective research on it. Although serum prealbumin test has been used for a long time, many clinicians do not attach great importance to the characteristics of changes in serum prealbumin. In this paper, we will review new characteristics of biochemistry structure and function of serum prealbumin, and relevance between serum prealbumin and serum albumin, cholesterol, cholinesterase, total bile acids, prothrombin time, Child-Turcotte-Pugh, and model of end-stage liver stage.

Macrophage activation is a prognostic parameter for variceal bleeding and overall survival in patients with liver cirrhosis

BACKGROUND & AIMS

Soluble CD163 (sCD163) is shed in the blood circulation by activated macrophages, correlates strongly with the hepatic venous pressure gradient (HVPG) and is thereby a good indicator of portal hypertension. It is unknown whether sCD163 correlates with the risk of variceal bleeding and overall survival (OS) in patients with liver cirrhosis. We performed a prospective study to investigate if sCD163 serum levels correlate with the risk of variceal bleeding and OS in cirrhotic patients.

METHODS

Patients with liver cirrhosis were prospectively enrolled and followed until death or last contact. At the day of inclusion in the study, blood samples were taken and sCD163 serum levels were assessed by ELISA (enzyme-linked immunosorbent assay). The time until the end points death and variceal bleeding was assessed and the risks of death or variceal bleeding were calculated with uni- and multivariate Cox regression analyses.

RESULTS

High sCD163 levels (>4100 ng/L) were associated with death independently of the MELD (model of end stage liver disease) score, CRP (C-reactive protein), age and gender. Furthermore, high sCD163 levels were associated with gastrointestinal bleeding independently of the variceal stage and red spots.

CONCLUSIONS

The sCD163 serum level is a new independent non-invasive risk factor for death and variceal bleeding in cirrhotic patients.

Clinical applications of the Model for End-Stage Liver Disease (MELD) in hepatic medicine

The Model for End-Stage Liver Disease (MELD) score incorporates serum bilirubin, creatinine, and the international normalized ratio (INR) into a formula that provides a continuous variable that is a very accurate predictor of 90-day mortality in patients with cirrhosis. It is currently utilized in the United States to prioritize deceased donor organ allocation for patients listed for liver transplantation. The MELD score is superior to other prognostic models in patients with end-stage liver disease, such as the Child-Turcotte-Pugh score, since it uses only objective criteria, and its implementation in 2002 led to a sharp reduction in the number of people waiting for liver transplant and reduced mortality on the waiting list without affecting posttransplant survival. Although mainly adopted for use in patients waiting for liver transplant, the MELD score has also proved to be an effective predictor of outcome in other situations, such as patients with cirrhosis going for surgery and patients with fulminant hepatic failure or alcoholic hepatitis. Several variations of the original MELD score, involving the addition of serum sodium or looking at the change in MELD over time, have been examined, and these may slightly improve its accuracy. The MELD score does have limitations in situations where the INR or creatinine may be elevated due to reasons other than liver disease, and its implementation for organ allocation purposes does not take into consideration several conditions that benefit from liver transplantation. The application of the MELD score in prioritizing patients for liver transplantation has been successful, but further studies and legislation are required to ensure a fair and equitable system.

Association of AKI with mortality and complications in hospitalized patients with cirrhosis

Acute kidney injury (AKI) is a common and devastating complication in patients with cirrhosis. However, the definitions of AKI employed in studies involving patients with cirrhosis have not been standardized, lack sensitivity, and are often limited to narrow clinical settings. We conducted a multicenter, prospective observational cohort study of patients with cirrhosis and AKI, drawn from multiple hospital wards, utilizing the modern acute kidney injury network (AKIN) definition and assessed the association between AKI severity and progression with in-hospital mortality. Of the 192 patients who were enrolled and included in the study, 85 (44%) progressed to a higher AKIN stage after initially fulfilling AKI criteria. Patients achieved a peak severity of AKIN stage 1, 26%, stage 2, 24%, and stage 3, 49%. The incidence of mortality, general medical events (bacteremia, pneumonia, urinary tract infection), and cirrhosis-specific complications (ascites, encephalopathy, spontaneous bacterial peritonitis) increased with severity of AKI. Progression was significantly more common and peak AKI stage higher in nonsurvivors than survivors (P < 0.0001). After adjusting for baseline renal function, demographics, and critical hospital- and cirrhosis-associated variables, progression of AKI was independently associated with mortality (adjusted odds ratio = 3.8, 95% confidence interval 1.3-11.1).

CONCLUSION

AKI, as defined by AKIN criteria, in patients with cirrhosis is frequently progressive and severe and is independently associated with mortality in a stage-dependent fashion. Methods for earlier diagnosis of AKI and its progression may result in improved outcomes by facilitating targeted and timely treatment of AKI.

Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation

PURPOSE

To compare the performance of various liver disease scoring systems in predicting early mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

In this single-institution retrospective study, eight scoring systems were used to grade liver disease in 211 patients (male-to-female ratio = 131:80; mean age, 54 y) before TIPS creation from 1999-2011. Scoring systems included bilirubin level, Child-Pugh (CP) score, Model for End-Stage Liver Disease (MELD) and Model for End-Stage Liver Disease sodium (MELD-Na) score, Emory score, prognostic index (PI), Acute Physiology and Chronic Health Evaluation (APACHE) 2 score, and Bonn TIPS early mortality (BOTEM) score. Medical record review was used to identify 30-day and 90-day clinical outcomes. The relationship of scoring parameters with mortality outcomes was assessed with multivariate analysis, and the relative ability of systems to predict mortality after TIPS creation was evaluated by comparing area under receiver operating characteristic (AUROC) curves.

RESULTS

TIPS were successfully created for variceal hemorrhage (n = 121), ascites (n = 72), hepatic hydrothorax (n = 15), and portal vein thrombosis (n = 3). All scoring systems had a significant association with 30-day and 90-day mortality (P<.050 in each case) on multivariate analysis. Based on 30-day and 90-day AUROC, MELD (0.878, 0.816) and MELD-Na (0.863, 0.823) scores had the best capability to predict early mortality compared with bilirubin (0.786, 0.749), CP (0.822, 0.771), Emory (0.786, 0.681), PI (0.854, 0.760), APACHE 2 (0.836, 0.735), and BOTEM (0.798, 0.698), with statistical superiority over bilirubin, Emory, and BOTEM scores.

CONCLUSIONS

Several liver disease scoring systems have prognostic value for early mortality after TIPS creation. MELD and MELD-Na scores most effectively predict survival after TIPS creation.

Predictors of a variceal source among patients presenting with upper gastrointestinal bleeding

BACKGROUND

Patients with upper gastrointestinal bleeding (UGIB) require an early, tailored approach best guided by knowledge of the bleeding lesion, especially a variceal versus a nonvariceal source.

OBJECTIVE

To identify, by investigating a large national registry, variables that would be predictive of a variceal origin of UGIB using clinical parameters before endoscopic evaluation.

METHODS

A retrospective study was conducted in 21 Canadian hospitals during the period from January 2004 until the end of May 2005. Consecutive charts for hospitalized patients with a primary or secondary discharge diagnosis of UGIB were reviewed. Data regarding demographics, including historical, physical examination, initial laboratory investigations, endoscopic and pharmacological therapies administered, as well as clinical outcomes, were collected. Multivariable logistic regression modelling was performed to identify clinical predictors of a variceal source of bleeding.

RESULTS

The patient population included 2020 patients (mean [± SD] age 66.3±16.4 years; 38.4% female). Overall, 215 (10.6%) were found to be bleeding from upper gastrointestinal varices. Among 26 patient characteristics, variables predicting a variceal source of bleeding included history of liver disease (OR 6.36 [95% CI 3.59 to 11.3]), excessive alcohol use (OR 2.28 [95% CI 1.37 to 3.77]), hematemesis (OR 2.65 [95% CI 1.61 to 4.36]), hematochezia (OR 3.02 [95% CI 1.46 to 6.22]) and stigmata of chronic liver disease (OR 2.49 [95% CI 1.46 to 4.25]). Patients treated with antithrombotic therapy were more likely to experience other causes of hemorrhage (OR 0.44 [95% CI 0.35 to 0.78]).

CONCLUSION

Presenting historical and physical examination data, and initial laboratory tests carry significant predictive ability in discriminating variceal versus nonvariceal sources of bleeding.

QT interval prolongation in liver cirrhosis: innocent bystander or serious threat?

The ECG QT interval measures the length of ventricular systole. Its prolongation is essentially caused by a delayed repolarization phase, and is associated with an increased risk of ventricular arrhythmias and sudden death in several congenital and acquired conditions. Abnormalities in cardiac electrophysiology are well documented in patients with liver cirrhosis, and the prolonged QT interval has emerged as the electrophysiological hallmark of cirrhotic cardiomyopathy. This article will focus on: first, the epidemiology of QT interval prolongation in cirrhosis; second, the potential molecular mechanisms responsible for the pathogenesis of this electrophysiological abnormality and the putative role of circulating cardiotoxins; third, its prognostic meaning; and fourth, its clinical relevance, in terms of the association between the presence of a long QT interval and the occurrence of ventricular arrhythmias in cirrhotic patients treated with drugs known to increase the QT length or exposed to stressful conditions, such as liver transplantation, gastrointestinal bleeding and shock.

Cost of a quality-adjusted life year in liver transplantation: the influence of the indication and the model for end-stage liver disease score

Cost issues in liver transplantation (LT) have received increasing attention, but the cost-utility is rarely calculated. We compared costs per quality-adjusted life year (QALY) from the time of placement on the LT waiting list to 1 year after transplantation for 252 LT patients and to 5 years after transplantation for 81 patients. We performed separate calculations for chronic liver disease (CLD), acute liver failure (ALF), and different Model for End-Stage Liver Disease (MELD) scores. For the estimation of QALYs, the health-related quality of life was measured with the 15D instrument. The median costs and QALYs after LT were €141,768 and 0.895 for 1 year and €177,618 and 3.960 for 5 years, respectively. The costs of the first year were 80% of the 5-year costs. The main cost during years 2 to 5 was immunosuppression drugs (59% of the annual costs). The cost/QALY ratio improved from €158,400/QALY at 1 year to €44,854/QALY at 5 years, and the ratio was more beneficial for CLD patients (€42,500/QALY) versus ALF patients (€63,957/QALY) and for patients with low MELD scores versus patients with high MELD scores. Although patients with CLD and MELD scores > 25 demonstrated markedly higher 5-year costs (€228,434) than patients with MELD scores < 15 (€169,541), the cost/QALY difference was less pronounced (€59,894/QALY and €41,769/QALY, respectively). The cost/QALY ratio for LT appears favorable, but it is dependent on the assessed time period and the severity of the liver disease.

In-hospital mortality among a cohort of cirrhotic patients admitted to a tertiary hospital

BACKGROUND/AIM

To determine the mortality rate in a cohort of hospitalized patients with cirrhosis and examine their resuscitation status at admission.

MATERIALS AND METHODS

A retrospective chart review was conducted of patients with cirrhosis who were admitted to a tertiary care hospital in Riyadh, Saudi Arabia, from January 1, 2009, to December 31, 2009.

RESULTS

We reviewed 226 cirrhotic patients during the study period. The hospital mortality rate was 35%. A univariate analysis revealed that worse outcomes were seen in patients with advanced age or who had worse child-turcotte-pugh (CPT) scores, worse model for end-stage liver disease (MELD) scores, low albumin and high serum creatinine. Using a multivariate analysis, we found that advanced age (P=0.004) and high MELD (P=0.001) scores were independent risk factors for the mortality of cirrhotic patients. The end-of-life decision were made in 34% of cirrhotic patients, and the majority of deceased patients were "no resuscitation" status (90% vs. 4%, P<0.001).

CONCLUSIONS

The relatively high mortality in cirrhotic patients admitted for care in a tertiary hospital, Saudi Arabia was comparable to that reported in the literature. Furthermore, end-of-life discussions should be addressed early in the hospitalization of cirrhotic patients.