Prognostic models including the Child-Pugh, MELD and Mayo risk scores--where are we and where should we go?

Important predictor of mortality in patients with end-stage liver disease

Prognosis is an essential part of the baseline assessment of any disease. For predicting prognosis of end-stage liver disease, many prognostic models were proposed. Child-Pugh score has been the reference for assessing the prognosis of cirrhosis for about three decades in end-stage liver disease. Despite of several limitations, recent large systematic review showed that Child-Pugh score was still robust predictors and it's components (bilirubin, albumin and prothrombin time) were followed by Child-Pugh score. Recently, Model for end-stage liver disease (MELD) score emerged as a "modern" alternative to Child-Pugh score. The MELD score has been an important role to accurately predict the severity of liver disease and effectively assess the risk of mortality. Due to several weakness of MELD score, new modified MELD scores (MELD-Na, Delta MELD) have been developed and validated. This review summarizes the current knowledge about the prognostic factors in end-stage liver disease, focusing on the role of Child-Pugh and MELD score.

Relationship between severity of liver dysfunction and the relative ratio of liver to aortic enhancement (RE) on MRI using hepatocyte-specific contrast

PURPOSE

To evaluate differences in liver enhancement among patients with low and high morbidity risks and to determine the relationship between severity of liver dysfunction and the relative ratio of liver to aortic enhancement (RE) on MRI using hepatocyte-specific contrast.

MATERIALS AND METHODS

A total of 126 patients underwent magnetic resonance imaging (MRI) and blood serum testing including serology, bilirubin, international normalized ratio, and creatinine tests. Radiologists analyzed a region of interest in the liver and aorta on precontrast and 10- and 20-minute delayed hepatobiliary phase MR images. Liver enhancement after 10 (LE10min ) and 20 minutes (LE20min ) were compared between the low- and high-risk groups by independent t-test. Regression analysis was used to assess the relationship between the Model for Endstage Liver Disease (MELD) score and RE.

RESULTS

All 126 patients were classified into either the low-risk group (MELD <8; n = 85) or high-risk group (MELD ≥8; n = 41). The mean LE10min and LE20min were significantly higher in the low-risk group (471.61; 95% confidence interval [CI]: 449.79-493.43 and 510.69; 95% CI: 486.51-534.87, respectively) than in the high-risk group (401.6776; 95% CI: 364.75-438.61 and 413.81; 95% CI: 370.91-456.70). There was a moderate inverse correlation between MELD score and the relative ratio of liver enhancement (RLE) (r = -0.5442; 95% CI: -0.6480 to -0.4207; P<0.01), but a high positive correlation between MELD score and RE (r = 0.7470; 95% CI: 0.6665-0.8102; P < 0.01).

CONCLUSION

Although liver enhancement was significantly greater in low-risk patients compared to high-risk patients, RE may be a better predictor of liver function than RLE.

Therapeutic efficacy of fuzheng-huayu tablet based traditional chinese medicine syndrome differentiation on hepatitis-B-caused cirrhosis: a multicenter double-blind randomized controlled trail

Aim. To evaluate and predict the therapeutic efficacy of Fuzheng-Huayu tablet (FZHY) based traditional Chinese Medicine (TCM) syndrome differentiation or TCM symptoms on chronic hepatitis B caused cirrhosis (HBC). Methods. The trial was designed according to CONSORT statement. It was a multi-center, double-blind, randomized, placebo-controlled trail. Several clinical parameters, Child-Pugh classification and TCM symptoms were detected and evaluated. The FZHY efficacy was predicted by an established Bayes forecasting method following the Bayes classification model. Results. The levels of HA and TCM syndrome score in FZHY group were significantly decreased (P < 0.05) compared to placebo group, respectively. The efficacy of FZHY on TCM syndrome score in HBC patients with some TCM syndromes was better. In TCM syndrome score evaluation, there were 53 effective and 22 invalid in FZHY group. TCM symptoms predicted FZHY efficacy on HBC were close to Child-Pugh score prediction. Conclusion. FZHY decreases the levels of HA and TCM syndrome scores, improves the life quality of HBC patients. Moreover, there were different therapeutic efficacies among different TCM syndromes, indicating that accurate TCM syndrome differentiation might guide the better TCM treatment. Furthermore, the FZHY efficacy was able to predict by Bayes forecasting method through the alteration of TCM symptoms.

Value of baseline platelet count for prediction of complications in primary biliary cirrhosis patients treated with ursodeoxycholic acid

BACKGROUND

Decreased platelet count has been observed in various liver diseases, but its significance in primary biliary cirrhosis (PBC) remains unknown. The present study aimed to evaluate the predictive value of the platelet count at diagnosis for PBC-related complications in patients newly diagnosed with PBC and treated with ursodeoxycholic acid (UDCA).

METHODS

Ninety-six PBC patients without complications treated with UDCA immediately after diagnosis were retrospectively reviewed. All hematologic and chemical parameters, Mayo risk score and PBC-related complications including upper gastrointestinal hemorrhage, presence of ascites, serum bilirubin concentration > 102.6 μmol/L and onset of hepatic encephalopathy were extracted. The associations between these parameters at diagnosis and complications were determined and the prognostic value of the platelet count was evaluated by receiver operating characteristics (ROC) analysis, Kaplan-Meier method and Cox proportional hazard model with the hazard ratio (HR) and 95% confidence interval (CI) calculated.

RESULTS

Patients with PBC-related complications had significantly decreased platelet count and serum bilirubin concentration, prolonged prothrombin time, and increased Mayo risk score compared to those without complications. A platelet count of ≤ 132.5 × 10(9)/L was associated with the occurrence of complications, with an area under the ROC curve of 0.74 (95% CI: 0.64-0.85). The association remained even after adjustment for Mayo risk score (HR: 2.85; 95% CI: 1.46-5.54; p < 0.01), as shown in the Cox proportional hazard model.

CONCLUSIONS

Decreased platelet count is a predictive factor for PBC-related complications. A cut-off value of ≤ 132.5 × 10(9)/L is recommended for the baseline platelet count to predict complications in patients newly diagnosed with PBC and treated with UDCA.

Nutritional assessments for ordinary medical care in patients with chronic liver disease

AIM

  In patients with chronic liver disease who are at risk of malnutrition, simple and useful assessments for nutritional status should be established for ordinary medical care. The prognostic nutritional index (PNI) and controlling nutritional status (CONUT) are simple assessments constructed of only two or three laboratory data. We aimed to describe the potential of PNI and CONUT as a nutritional assessment tool in patients with chronic liver disease.

METHODS

  We enrolled 165 patients, aged 18-85 years, with chronic liver disease. These patients were nutritionally assessed by PNI or CONUT, demonstrating the association with the severity of chronic liver disease or anthropometric values.

RESULTS

  The value of PNI or CONUT was significantly associated with the severity of chronic liver disease (P < 0.001, respectively). In addition, the value of CONUT was significantly associated with all the anthropometric values such as body mass index (BMI, P < 0.05), mid-arm circumference (AC, P < 0.001), mid-arm muscle circumference (AMC, P < 0.001), and triceps skinfold thickness (TSF, P < 0.001), whereas the value of PNI was significantly associated with the values of AC (P < 0.01), AMC (P < 0.05) and TSF (P < 0.05). Approximately 80% of cirrhotic patients were assessed by PNI or CONUT to have obvious malnutrition.

CONCLUSION

  PNI and CONUT are potential tools for nutritional assessment in patients with chronic liver disease, especially for ordinary medical care, because of their simplicity.

Polymorphisms of the CD14 genes are associated with susceptibility to alcoholic liver disease in Greek patients

BACKGROUND

The incidence and severity of alcoholic liver disease (ALD) in chronic drinkers has been found to correlate with some environmental factors and especially with the dose of alcohol consumption, but it is obvious that other parameters clearly contribute to individual alcohol susceptibility. Chronic ethanol exposure leads to continuous endotoxin-mediated Toll-like receptor-4 (TLR-4) and CD14 activation and subsequent cytokine release resulting in chronic inflammation with continued hepatocellular damage. Therefore, genetic studies of polymorphism in TLR-4 and CD14 genes seem to be appropriate in determining genetic susceptibility to ALD. Our aim is to evaluate in a series of Greek drinkers, the possible association of polymorphisms in the TLR-4 and CD14 genes with ALD.

METHODS

In 96 patients with ALD polymorphism of TLR-4 and CD14 genes were studied compared with 104 patients with cirrhosis of other etiology, 100 healthy subjects, and 50 patients with a history of alcohol abuse but without liver disease.

RESULTS

No association between ALD and the presence of the Asp299Gly and Thr399Ile polymorphisms in the TLR-4 gene could be documented in our patients. Regarding the CD14 -159 (C/T) genotypes, TT genotype and T allele were found to be overrepresented in alcoholic patients compared with patients with nonalcohol-induced liver disease and healthy controls. On the other side, when compared patients with ALD and patients with alcohol abuse and no liver disease, TT genotype was found to be significantly less frequent. There is no statistically significant association with the presence of the T allele and the severity of ALD, suggesting that CD14 polymorphism does not influence disease severity in advanced stages of the disease.

CONCLUSIONS

In our series in Greek patients with alcohol abuse and alcoholic cirrhosis, a significant negative association with the CD14 endotoxin receptor gene polymorphism (TT genotype) but not with the TLR-4 gene polymorphism was documented.

The Charlson comorbidity index as a predictor of outcomes in liver transplantation: single-center experience

Several comorbidity indices, such as the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score, have been used to optimize available organ resources and adjust priorities in diagnosis and allocation of grafts for patients who are candidates for liver transplantation. There have also been various attempts to create instruments to accurately predict outcomes after liver transplantation, but none has proved to be truly applicable, with the exception of the Charlson comorbidity index (CCI). We retrospectively reviewed data of 221 liver recipients, including living-related liver transplantation and multiple organ transplantation performed between January 2006 and September 2009. Survival analysis revealed a significant association of the CCI with decreased posttransplantation patient survival (P = .003). Furthermore, Kaplan-Meier plots and log-rank test showed a significant association between graft survival and the score (P = .039). Our data suggest that the CCI is a simple tool for the evaluation of comorbidity and that increased preoperative patient comorbidity increases the risk of graft loss and patient death after liver transplantation. The CCI should be considered an important tool for improving patient care because of its potential applications for patient management.

Clinicopathologic characteristics and long-term prognosis of scirrhous hepatocellular carcinoma

BACKGROUND

Clinicopathologic features and long-term outcomes in patients with scirrhous hepatocellular carcinoma (S-HCC) are not fully defined.

METHODS

We compared data of 37 patients with S-HCC and 604 with usual HCC (U-HCC) undergoing surgery.

RESULTS

The S-HCC group showed less HBV infection (78.4 vs. 92.0%, P = 0.02), low serum AFP level (2320 ± 6356 vs. 3297 ± 18690 ng/ml, P < 0.0001), less delayed washout during CT (72.7 vs. 90.7%, P = 0.004), and low usefulness of clinical diagnostic criteria (32.4 vs. 57.5%, P = 0.003), compared to the U-HCC group. More portal vein invasion (18.9 vs. 4.1%, P = 0.03) and less liver cirrhosis (35.1 vs. 65.1%, P = 0.001) and fibrous capsule (40.5 vs. 81.6%, P < 0.001) were noted in the S-HCC group than the U-HCC group. Long-term survival rates were similar between the S-HCC and U-HCC groups, even with subgroup analysis according to Child-Pugh score and modified UICC stage.

CONCLUSION

The S-HCC group showed distinct patient and tumor characteristics but similar long-term outcome.

Interleukin-10 genotype correlated to deficiency syndrome in hepatitis B cirrhosis

Traditional Chinese medicine (TCM) syndrome is an important basis for TCM diagnosis and treatment. As Child-Pugh classification as well as compensation and decompensation phase in liver cirrhosis, it is also an underlying clinical classification. In this paper, we investigated the correlation between single nucleotide polymorphisms (SNPs) of Interleukin-10 (IL-10) and TCM syndromes in patients with hepatitis B cirrhosis (HBC). Samples were obtained from 343 HBC patients in China. Three SNPs of IL-10 (-592A/C, -819C/T, and -1082A/G) were detected with polymerase chain-reaction-ligase detection reaction (PCR-LDR). The result showed the SNP-819C/T was significantly correlated with Deficiency syndrome (P = 0.031), but none of the 3 loci showed correlation either with Child-Pugh classification and phase in HBC patients. The logistic regression analysis showed that the Excess syndrome was associated with dizzy and spider nevus, and the Deficiency syndrome was associated with dry eyes, aversion to cold, IL-10-819C/T loci, and IL-10-1082A/G loci. The odds ratio (OR) value at IL-10-819C/T was 4.022. The research results suggested that IL-10-819C/T locus (TC plus CC genotype) is probably a risk factor in the occurrence of Deficiency syndrome in HBC patients.

Prognostic factors and survival analysis of antimitochondrial antibody-positive primary biliary cirrhosis in Chinese patients

BACKGROUND AND AIMS

Primary biliary cirrhosis (PBC) is a relatively uncommon liver disease, and information on the prognosis and survival of PBC patients in mainland China is lacking. We therefore conducted a retrospective study to investigate the prognostic factors and survival in Chinese PBC patients.

METHODS

Between October 2001 and May 2009, patients registered at Beijing You'an Hospital with abnormal liver function and serum positivity for antimitochondrial antibody (AMA) and/or AMA-M2 (n = 391) were screened. Patients diagnosed with PBC were identified, and their medical data were reviewed and analyzed for mortality predictors.

RESULTS

A total of 147 PBC patients were identified (mean age: 54 years, range: 28-81), of whom 126 (85.7%) were women. At the time of diagnosis, 119 patients (81.0%) were symptomatic, 28(19.0%) had hepatic decompensation, and no patients were asymptomatic. During a median follow-up period of 48 months (range: 2-312), 36 patients (24.5%) died or underwent liver transplantation, and 65 patients (44.2%) developed hepatic decompensation. The overall 5-year survival rate was 79%. Multivariate analysis indicated that Mayo risk score ≥6.11(P = 0.008), and serum IgG ≥ 17.20 g/l (P = 0.016) were associated with mortality.

CONCLUSIONS

Most Chinese PBC patients in this study were symptomatic at diagnosis and had significant mortality. Mayo risk score, and serum IgG were independent prognostic factors for survival.

Strategies for resection using portal vein embolization: hepatocellular carcinoma and hilar cholangiocarcinoma

Preoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications of major hepatectomy for hepatocellular carcinoma (HCC) or hilar cholangiocarcinoma (CCA). In patients with HCC who are candidates for extended hepatectomy and in patients with HCC and well-compensated cirrhosis who are being considered for major hepatectomy, FLR volumetry is routinely performed, and PVE is employed in selected cases to optimize the volume and function of the FLR prior to surgery. Similarly, in patients with hilar CCA who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLR volumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for these diseases and oncological outcomes similar to those in patients who undergo resection without PVE. Specific indications for PVE are being clarified. FLR volumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE (a dynamic test of liver regeneration) complements analysis of the pre-PVE FLR volume (a static test). Together, FLR degree of hypertrophy and FLR volume are the best predictors of outcome after major hepatectomy in an individual patient, regardless of the degree of underlying liver disease. This article synthesizes the literature on the approach to patients with HCC and CCA who are candidates for major hepatectomy. The rationale and indications for FLR volumetry and PVE and outcomes following PVE and major hepatectomy for HCC and CCA are discussed.

Association of preoperative parameters with postoperative mortality and long-term survival after liver transplantation

BACKGROUND

The ability of Child-Turcotte-Pugh (CTP) or Model for End-Stage Liver Disease (MELD) scores to predict recipient survival after liver transplantation is controversial. This analysis aims to identify preoperative parameters that might be associated with early postoperative mortality and long-term survival after liver transplantation.

METHODS

We studied a total of 15 parameters, using both univariate and multivariate models, among adults who underwent primary liver transplantation.

RESULTS

A total of 458 primary adult liver transplants were performed. Fifty-seven (12.44%) patients died during the first 3 postoperative months and composed the early mortality group. The remaining 401 patients composed the long-term patient survival group. The parameters that were identified through univariate analysis to be associated with early postoperative mortality were CTP score, MELD score, bilirubin, creatinine, international normalized ratio and warm ischemia time (WIT). In all multivariate models, WIT retained its statistical significance. The 10-year long-term survival was 65%. The parameters that were identified to be independent predictors of long-term survival were the recipient's sex (improved survival in women, p = 0.005), diagnosis of hepatocellular cancer (p=0.015) and recipient's age (p=0.024).

CONCLUSION

Either CTP or MELD score, in conjunction with WIT, might have a role in predicting early postoperative mortality after liver transplantation, whereas the recipient's sex and the absence of hepatocellular cancer are associated with improved long-term survival.

Time-dependent predictive accuracy in the presence of competing risks

Competing risks arise naturally in time-to-event studies. In this article, we propose time-dependent accuracy measures for a marker when we have censored survival times and competing risks. Time-dependent versions of sensitivity or true positive (TP) fraction naturally correspond to consideration of either cumulative (or prevalent) cases that accrue over a fixed time period, or alternatively to incident cases that are observed among event-free subjects at any select time. Time-dependent (dynamic) specificity (1-false positive (FP)) can be based on the marker distribution among event-free subjects. We extend these definitions to incorporate cause of failure for competing risks outcomes. The proposed estimation for cause-specific cumulative TP/dynamic FP is based on the nearest neighbor estimation of bivariate distribution function of the marker and the event time. On the other hand, incident TP/dynamic FP can be estimated using a possibly nonproportional hazards Cox model for the cause-specific hazards and riskset reweighting of the marker distribution. The proposed methods extend the time-dependent predictive accuracy measures of Heagerty, Lumley, and Pepe (2000, Biometrics 56, 337-344) and Heagerty and Zheng (2005, Biometrics 61, 92-105).

A 35-year follow-up of a large cohort of patients with primary biliary cirrhosis seen at a single centre

BACKGROUND

The natural history of primary biliary cirrhosis (PBC) is still debated.

AIMS

To evaluate: (i) long-term survival in a large cohort of PBC patients observed prospectively at a single centre and (ii) mortality in relation to baseline characteristics and ursodeoxycholic acid (UDCA) treatment.

METHODS

We considered all consecutive patients between 1973 and 2007 (327 subjects; 310 females, 17 males).

RESULTS

The mean follow-up was 9.1±7.7 years. The patients' age at diagnosis for representative periods (1973-1980, 1981-1990, 1991-2000, 2001-2007) increased progressively from 47.7±1.5 to 53.2±1.2, to 65.2±2.1 and then 63.6±2.9 years. The proportion of asymptomatic patients at diagnosis increased from 30 to 48% in the last decade, while associated symptoms of extrahepatic autoimmunity remained unchanged. Eighty patients (24.4%) died, 74 of them because of liver failure (12 patients developed hepatocellular carcinoma); nine patients underwent liver transplantation. From 1988 onwards, all patients were treated with UDCA (n=288). The mean age at death for the sample as a whole was 67.2±1.3 years. The survival probability at 20 years was 82% for patients with histological stages I-II at entry, 64% for those with stage III and 42% for those with stage IV (P=0.0007). Mortality was significantly reduced in patients treated with UDCA (P=0.012), whereas it was independently associated with oesophageal varices (P=0.015). Patients treated with UDCA had a better prognosis than those untreated, irrespective of the histological stage. Early treated subjects with a good response to UDCA have an 85% chance of survival at 20 years.

CONCLUSIONS

The clinical presentation of PBC has been changing over the years. Its early detection and early treatment improve the related survival rates.

Could metabolic liver function tests predict mortality on waiting list for liver transplantation? A study on 560 patients

BACKGROUND

Allocation of graft in liver transplantation (LT) depends mainly on Model for End Stage Liver Disease (MELD) score. We studied the prognostic ability of three metabolic liver function tests in 560 cirrhotic patients listed for transplantation, in comparison with MELD and Child-Turcotte-Pugh (CTP) scores.

METHODS

Indocyanine green retention rate (ICG), aminopyrine breath test (ABT), and galactose elimination capacity were performed at the time of listing in addition to standard biological parameters. Seventy-three patients died on waiting list, 438 were transplanted, and 73 died after LT. Cox regression analysis and receiver operating characteristic curves with c-statistics were calculated after stratification according to CTP and MELD score.

RESULTS

For the mortality before transplantation, c-statistics showed that ICG and ABT had a slightly better prognostic ability (0.73 and 0.68, respectively) than MELD score (0.66), and similar to CTP score (0.70). ABT's prognostic ability remained significant once the MELD score (below and above 20) had already been taken into account. Only ICG had a prognostic ability to predict the survival after LT, even after stratification according to MELD and CTP score.

CONCLUSIONS

Our results strongly support that ABT and ICG may be useful in the ranking of the patients in LT list, adding prognosis information in association with MELD score.

Prioritization for liver transplantation

There are three possible policies for prioritization for liver transplantation: medical urgency, utility and transplant benefit. The first is based on the severity of cirrhosis, using Child-Turcotte-Pugh score and, more recently, the Model for End-stage Liver Disease (MELD) score, or variants of MELD, for allocation. Although prospectively developed and validated, the MELD score has several limitations, including interlaboratory variations for measurement of serum creatinine and international normalized ratio of prothrombin time, and a systematic adverse female gender bias. Adjustments to the original MELD equation and new scoring systems have been proposed to overcome these limitations; incorporation of serum sodium improves its predictive accuracy. The MELD score poorly predicts outcomes after liver transplantation due to the absence of donor factors incorporated into the scoring system. Several utility models are based on donor and recipient characteristics. Combined poor recipient and donor characteristics lead to very poor outcomes, which in a utility system would be considered unacceptable. Finally, transplant benefit models rank patients according to the net survival benefit that they would derive from transplantation. However, complex statistical models are required, and unmeasured characteristics may unduly affect the models. Well-designed prospective studies and simulation models are necessary to establish the optimal allocation system in liver transplantation.

Autologous CD34+ and CD133+ stem cells transplantation in patients with end stage liver disease

AIM: To assess the utility of an autologous CD34⁺ and CD133⁺ stem cells infusion as a possible therapeutic modality in patients with end-stage liver diseases.

METHODS: One hundred and forty patients with end-stage liver diseases were randomized into two groups. Group 1, comprising 90 patients, received granulocyte colony stimulating factor for five days followed by autologous CD34⁺ and CD133⁺ stem cell infusion in the portal vein. Group 2, comprising 50 patients, received regular liver treatment only and served as a control group.

RESULTS: Near normalization of liver enzymes and improvement in synthetic function were observed in 54.5% of the group 1 patients; 13.6% of the patients showed stable states in the infused group. None of the patients in the control group showed improvement. No adverse effects were noted.

CONCLUSION: Our data showed that a CD34⁺ and CD133⁺ stem cells infusion can be used as supportive treatment for end-stage liver disease with satisfactory tolerability.

Predictive parameters after molecular absorbent recirculating system treatment integrated with model for end stage liver disease model in patients with acute-on-chronic liver failure

AIM

The aim of study was to highlight parameters that in association with Model for End-stage Liver Disease (MELD) provide predictive criteria for long-term survival after treatment with the Molecular Adsorbent Recirculating System (MARS). Two homogenous groups were studied: one treated with standard medical therapy (SMT) and the other, with MARS.

MATERIALS AND METHODS

Twenty acute-on-chronic liver failure patients on the waiting list for liver transplantation and affected by alcoholic cirrhosis with similar MELD scores (20-29) were evaluated for 7 days from inclusion and for 6-month survival. Ten patients (seven males and three females) were treated with MARS. Their mean age was 48.5 years (range = 35-61). The number of MARS applications was six for 6 consecutive days, and the length of the applications was 8 hours. Ten other patients (seven males and three females) were treated with SMT, including prophylaxis against bacterial infections and judicious use of diuretics. The precipitating factors were also treated appropriately. The mean age of the patients was 51 years (range = 37-64). All the variables that were significant upon univariate analysis were enrolled in a receiver operating characteristic analysis, with the intention to detect predictive parameters for patient death at 6 months. We considered a significant area under curve (AUC) value to be greater than 0.5.

RESULTS

Among 11 patients who died within 6 months there were in the MARS group and eight in the SMT group: the 3- and 6-month patient survival rates were 90% and 70% versus 30% and 20% in the two groups, respectively. Nine measures resulted in an AUC > 0.5: DeltaMELD; interleukin (IL)-8; IL-6; tumor necrosis factor- alpha, MELD score; creatinine, bilirubin international normalized ratio (INR) and cardiac index. DeltaMELD and postoperative IL-8 concentrations showed better results (AUC = 0.899), followed by postoperative creatinine (AUC = 0.879), postoperative cardiac index (AUC = 0.833), and postoperative INR (AUC = 0.818). Postoperative creatinine showed the best sensitivity (100%), while IL-8, the best specificity (88.9%).

CONCLUSION

A combination of biochemical and clinical variables probably represent the best way to predict the survival of patients, allowing physicians to select the best therapies for each patient.

Circulating vascular endothelial growth factor and nitric oxide in patients with liver cirrhosis: A possible association with liver function impairment

Hemodynamic disorders of liver cirrhosis complicated with portal hypertension are associated with an increased angiogenesis in animal model of portal hypertension and cirrhosis which were linked to increased expression of vascular endothelial growth factor (VEGF) and nitric oxide (NO). The aim of study was to evaluate the serum concentration of VEGF and total nitric oxide (NO) in liver cirrhosis and the possible association with the degree of liver insufficiency. VEGF and NO were measured in serum of 64 patients with liver cirrhosis by ELISA and spectrophotometry respectively. The significant increase of serum VEGF was observed in liver cirrhosis compared to healthy individuals as well as serum NO (106.1 ± 66.7 vs. 41.5 ± 6 pg/mL, P < 0.05; 113.5 ± 65.8 vs. 20.8 ± 3.8 μmol/l, P< 0.001, respectively). Serum VEGF and NO showed significant associations with biochemical indices of liver function and with Child-pugh score where they were increased respectively to the degree of liver insufficiency. A significant association of raised serum NO in early stage of portal hypertension reflect its benefit in early expect of portal hypertension but, high serum VEGF in late stage may reflect its prognostic value in liver cirrhosis.

Limitations of the MELD score in predicting mortality or need for removal from waiting list in patients awaiting liver transplantation

Background

Decompensated cirrhosis is associated with a poor prognosis and liver transplantation provides the only curative treatment option with excellent long-term results. The relative shortage of organ donors renders the allocation algorithms of organs essential. The optimal strategy based on scoring systems and/or waiting time is still under debate.

Methods

Data sets of 268 consecutive patients listed for single-organ liver transplantation for nonfulminant liver disease between 2003 and 2005 were included into the study. The Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores of all patients at the time of listing were used for calculation. The predictive ability not only for mortality on the waiting list but also for the need for withdrawal from the waiting list was calculated for both scores. The Mann-Whitney-U Test was used for the univariate analysis and the AUC-Model for discrimination of the scores.

Results

In the univariate analysis comparing patients who are still on the waiting list and patients who died or were removed from the waiting list due to poor conditions, the serum albumin, bilirubin INR, and CTP and MELD scores as well as the presence of ascites and encephalopathy were significantly different between the groups (p < 0.05), whereas serum creatinine and urea showed no difference.

Comparing the predictive abilities of CTP and MELD scores, the best discrimination between patients still alive on the waiting list and patients who died on or were removed from the waiting list was achieved at a CTP score of ≥9 and a MELD score of ≥14.4. The sensitivity and specificity to identify mortality or severe deterioration for CTP was 69.0% and 70.5%, respectively; for MELD, it was 62.1% and 72.7%, respectively. This result was supported by the AUC analysis showing a strong trend for superiority of CTP over MELD scores (AUROC 0.73 and 0.68, resp.; p = 0.091).

Conclusion

The long term prediction of mortality or removal from waiting list in patients awaiting liver transplantation might be better assessed by the CTP score than the MELD score. This might have implications for the development of new improved scoring systems.

Validation of model for end-stage liver disease score to serum sodium ratio index as a prognostic predictor in patients with cirrhosis

AIM

To evaluate the prognostic ability of model for end-stage liver disease (MELD) to serum sodium (SNa) ratio (MESO) index and to compare the predictive accuracy of the MESO index with the MELD score and the modified Child-Turcotte-Pugh (CTP) score for short-term survival in cirrhotic patients.

METHODS

A total of 256 patients with cirrhosis were retrospectively evaluated. The predictive accuracy of the MESO index, MELD score and modified CTP score were compared by the area under the receiver-operator characteristic curve (AUC).

RESULTS

Using 1-month and 3-month mortality as the end-point, overall, MESO and MELD were significantly better than the CTP score in predicting the risk of mortality at 1 month (AUC, 0.866,0.819 vs 0.722, P < 0.01) and 3 months (AUC, 0.875,0.820 vs 0.721, P < 0.01). In the low MELD group, the AUC of MESO index (0.758, 0.759) and CTP score (0.754, 0.732) were higher than that of the MELD score (0.608, 0.611) at 1 month and 3 months, respectively (P < 0.01). However, in the high MELD group, the AUC of MESO index (0.762, 0.779) and MELD (0.737, 0.773) were higher than that of the CTP score (0.710, 0.752) at 1 month and 3 months, respectively, although there were no significant differences (P > 0.05). With appropriate cut-offs for the MESO index, the mortality rate of patients in high MESO was higher (57.1% at 1 month and 69.2% at 3 months) than that of the low MESO (5.5% at 1 month and 7.9% at 3 months) (P < 0.01).

CONCLUSIONS

The MESO index, which adds SNa to MELD, is a useful prognostic marker and is found to be superior to the MELD score and modified CTP score for short-term prognostication of patients with cirrhosis.

The galactose elimination capacity and mortality in 781 Danish patients with newly-diagnosed liver cirrhosis: a cohort study

Background

Despite its biologic plausibility, the association between liver function and mortality of patients with chronic liver disease is not well supported by data. Therefore, we examined whether the galactose elimination capacity (GEC), a physiological measure of the total metabolic capacity of the liver, was associated with mortality in a large cohort of patients with newly-diagnosed cirrhosis.

Methods

By combining data from a GEC database with data from healthcare registries we identified cirrhosis patients with a GEC test at the time of cirrhosis diagnosis in 1992–2005. We divided the patients into 10 equal-sized groups according to GEC and calculated all-cause mortality as well as cirrhosis-related and not cirrhosis-related mortality for each group. Cox regression was used to adjust the association between GEC and all-cause mortality for confounding by age, gender and comorbidity, measured by the Charlson comorbidity index.

Results

We included 781 patients, and 454 (58%) of them died during 2,617 years of follow-up. Among the 75% of patients with a decreased GEC (<1.75 mmol/min), GEC was a strong predictor of 30-day, 1-year, and 5-year mortality, and this could not be explained by confounding (crude hazard ratio for a 0.5 mmol/min GEC increase = 0.74, 95% CI 0.59–0.92; adjusted hazard ratio = 0.64, 95% CI 0.51–0.81). Further analyses showed that the association between GEC and mortality was identical for patients with alcoholic or non-alcoholic cirrhosis etiology, that it also existed among patients with comorbidity, and that GEC was only a predictor of cirrhosis-related mortality. Among the 25% of patients with a GEC in the normal range (≥ 1.75 mmol/min), GEC was only weakly associated with mortality (crude hazard ratio = 0.79, 95% CI 0.59–1.05; adjusted hazard ratio = 0.80, 95% CI 0.60–1.08).

Conclusion

Among patients with newly-diagnosed cirrhosis and a decreased GEC, the GEC was a strong predictor of short- and long-term all-cause and cirrhosis-related mortality. These findings support the expectation that loss of liver function increases mortality.

Impact of tips preliver transplantation for the outcome posttransplantation

The effects of transjugular intrahepatic portocaval shunt (TIPS) on the survival of grafts and patients after liver transplantation (LTx) have only been documented in small series and with only a comparative description with non-TIPS recipients. We evaluated 61 TIPS patients who had a subsequent LTx and compared these with 591 patients transplanted with cirrhosis without TIPS. Pretransplant characteristics were similar between groups. Graft survival at 1, 3 and 5 years post-LTx was 85.2%, 77% and 72.1% (TIPS) and 75.3%, 69.8% and 66.1% (controls). Patient survival at the same points was 91.7%, 85% and 81.7%, respectively (TIPS) and 85.4%, 80.3% and 76.2% (controls). Cox regression showed the absence of TIPS pre-LTx, transfusion of >5 units of blood during LTx, intensive care unit (ICU) stay post-LTx >3 days and earlier period of transplant to be significantly associated with a worse patient and graft survival at 1 year. Migration of the TIPS stent occurred in 28% of cases, increasing the time on bypass during LTx, but was not related to graft or patient survival. TIPS may improve portal supply to the graft and reduce collateral flow, improving function. This may account for the improved adjusted graft and patient survival by Cox regression at 12 months. Long-term survival was not affected.

Can the MELD Score Predict Perioperative Morbidity for Patients with Liver Cirrhosis Undergoing Laparoscopic Cholecystectomy?

The Model for End Stage Liver Disease (MELD) score is a mortality predictor in patients awaiting liver transplantation. We evaluated the MELD score's ability to predict morbidity for patients with cirrhosis undergoing laparoscopic cholecystectomy. From March 1991 to February 2004, data of all patients undergoing laparoscopic cholecystectomy were prospectively collected. Data of patients with liver cirrhosis were reviewed. The MELD and Child scores were correlated with outcome variables. Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) exhibited liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range, 28 to 92 years). The mortality rate was 6.3 per cent, morbidity rate 18 per cent, and conversion rate 11 per cent. Laboratory values on 55 patients were available to calculate MELD scores. The mean MELD score was 11 (range, 6 to 23). There was no significant variation in MELD scores with gender ( P = 0.61) or cirrhosis etiology, alcoholic and nonalcoholic ( P = 0.52). MELD and Child's score correlated well ( P < 0.001); however, the risk of complication was not related to the MELD ( P = 0.94) or Child-Pugh-Turcotte score ( P = 0.26). Morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy remains high. The MELD score is useful for transplant risk stratification for but requires further investigation regarding morbidity prediction for laparoscopic cholecystectomy.

Prognostic value of 13C-phenylalanine breath test on predicting survival in patients with chronic liver failure

AIM: To evaluate the prognostic value of percentage of ¹³C-phenylalanine oxidation (¹³C-PheOx) obtained by ¹³C-phenylalanine breath test (¹³C-PheBT) on the survival of patients with chronic liver failure.

METHODS: The hepatic function was determined by standard liver blood tests and the percentage of ¹³C-PheOx in 118 chronic liver failure patients. The follow-up period was of 64 mo. Survival analysis was performed by the Kaplan-Meier method and variables that were significant (P < 0.10) in univariate analysis and subsequently introduced in a multivariate analysis according to the hazard model proposed by Cox.

RESULTS: Forty-one patients died due to progressive liver failure during the follow-up period. The probability of survival at 12, 24, 36, 48 and 64 mo was 0.88, 0.78, 0.66, 0.57 and 0.19, respectively. Multivariate analysis demonstrated that Child-Pugh classes, age, creatinine and the percentage of ¹³C-PheOx (HR 0.338, 95% CI: 0.150-0.762, P = 0.009) were independent predictors of survival. When Child-Pugh classes were replaced by all the parameters of the score, only albumin, bilirubin, creatinine, age and the percentage of ¹³C-PheOx (HR 0.449, 95% CI: 0.206-0.979, P = 0.034) were found to be independent predictors of survival.

CONCLUSION: Percentage of ¹³C-PheOx obtained by ¹³C-PheBT is a strong predictor of survival in patients with chronic liver disease.

Natural history and clinical impact of cryoglobulins in chronic hepatitis C: 10-year prospective study of 343 patients

BACKGROUND & AIMS

Serum cryoglobulins (CGs) are present in patients with chronic hepatitis C virus (HCV) infection, but their long-term clinical importance has not been established. We assessed the development rates, morbidity, and influence on the evolutionary course of hepatitis C of CG.

METHODS

A cohort of 343 HCV-RNA seropositive outpatients (173 men; age, 58 y; 82 with cirrhosis; 61 treated with interferon) with persistently increased aminotransferase levels and histologically defined liver disease was investigated. Patients initially were investigated for the presence, amount, and type of CG and prospectively followed up with clinical and laboratory examinations every 6 months.

RESULTS

At enrollment, CGs were found in 163 (47%) patients at a mean level of 173 +/- 142 mg/L; 80% were type III, and associated to female sex (61% vs 40%, P = .0002) and cirrhosis (29% vs 19%, P = .04). Over the course of 17-130 months (median, 116 mo), de novo CG developed in 25 patients (2.3% per year), including 5 with cryoglobulinemic syndrome (.3% per year). The 10-year rates of progression to cirrhosis and of liver and extrahepatic complications were similar in CG (+) and CG (-) patients (32% vs 34%; 23% vs 16%; 5% vs 3%). The 10-year survival rates were lower for cirrhotic than for noncirrhotic patients (57% vs 91%, P < .00001), independently of CGs.

CONCLUSIONS

CGs are common in patients with chronic HCV infection, mainly are type III, and do not influence the clinical course of hepatitis C during the first decades, except for the few rare cases of cryoglobulinemic syndrome.

Different methods of creatinine measurement significantly affect MELD scores

Bilirubin (Bil) interferes with creatinine (Cr) measurement. Different laboratory methods are used to overcome this problem. Model for end-stage liver disease (MELD) scoring incorporates Cr and is used to prioritize patients for liver transplantation. Thus, MELD scores may vary with different Cr measurements influencing patients' priority. Our aim was to evaluate 4 different Cr assays (O'Leary modified Jaffe [mJCr], compensated [rate blanked] kinetic Jaffe [cJCr], enzymatic [ECr], and standard kinetic Jaffe [JCr]) in patients with abnormal liver function tests and assess changes in MELD score. A total of 403 consecutive samples from 158 patients' Cr assays were evaluated.. Bland-Altman plots and MELD scores were also evaluated for each assay. Agreement was found to be poor among all Cr assays. Increased variability in Cr occurred with increasing Bil concentrations: Bil <100 micromol/L <or=3-point MELD variation - 3-point difference in 2%; Bil >or=400micromol/L <or=7-point MELD variation - >or=3-point difference in 78%. When MELD was >or=25 (mJCr as reference; mean, 30.5 points), MELD variation was greatest: mean, 28 (MELD cJCr), 27.5 (MELD ECr), and 28.4 (MELD JCr) (P < 0.001). In conclusion, there is poor agreement among different assays for Cr. As Bil concentration rises, there is greater variability in each creatinine measurements and thus greater variability in MELD scores that, this affect prioritization for liver transplantation.

Human serum fetuin A/alpha2HS-glycoprotein level is associated with long-term survival in patients with alcoholic liver cirrhosis, comparison with the Child-Pugh and MELD scores

Background

Serum concentration of fetuin A/α2HS-glycoprotein (AHSG) is a good indicator of liver cell function and 1-month mortality in patients with alcoholic liver cirrhosis and liver cancer. We intended to determine whether decreased serum AHSG levels are associated with long-term mortality and whether the follow-up of serum AHSG levels can add to the predictive value of the Child-Pugh (CP) and MELD scores.

Methods

We determined serum AHSG concentrations in 89 patients by radial immunodiffusion. Samples were taken at the time of enrolment and in the 1^st, 3^rd, 6^th, and the 12^th month thereafter.

Results

Forty-one patients died during the 1-year follow-up period, 37 of them had liver failure. Data of these patients were analysed further. Deceased patients had lower baseline AHSG levels than the 52 patients who survived (293 ± 77 vs. 490 ± 106 μg/ml, mean ± SD, p < 0.001). Of all laboratory parameters serum AHSG level, CP and MELD scores showed the greatest difference between deceased and survived patients. The cutoff AHSG level 365 μg/ml could differentiate between deceased and survived patients (AUC: 0.937 ± 0.025, p < 0.001, sensitivity: 0.865, specificity: 0.942) better than the MELD score of 20 (AUC: 0.739 ± 0.052, p < 0.001, sensitivity: 0.595, specificity: 0.729). Initial AHSG concentrations < 365 μg/ml were associated with high mortality rate (91.4%, relative risk: 9.874, 95% C.I.: 4.258–22.898, p < 0.001) compared to those with ≥ 365 μg/ml (9.3%). Fourteen out of these 37 fatalities occurred during the first month of observation. During months 1–12 low AHSG concentration proved to be a strong indicator of mortality (relative risk: 9.257, 95% C.I.: 3.945–21.724, p < 0.001). Multiple logistic regression analysis indicated that decrease of serum AHSG concentration was independent of all variables that differed between survived and deceased patients during univariate analysis. Multivariate analysis showed that correlation of low serum AHSG levels with mortality was stronger than that with CP and MELD scores. Patients with AHSG < 365 μg/ml had significantly shortened survival both in groups with MELD < 20 and MELD ≥ 20 (p < 0.0001 and p = 0.0014, respectively).

Conclusion

Serum AHSG concentration is a reliable and sensitive indicator of 1-year mortality in patients with alcoholic liver cirrhosis that compares well to the predictive value of CP score and may further improve that of MELD score.

Female liver transplant recipients with the same GFR as male recipients have lower MELD scores--a systematic bias

Women have lower glomerular filtration (GFR) than men for the same serum creatinine (Cr) value, not accounted for in model for end-stage liver disease (MELD). We compare male/female Cr, GFR (using MDRD formula) and respective MELD scores in 403 Cr measurements using standard (sCr), O'Leary modified (mCr) and Compensated (cCr) Jaffe and Enzymatic (eCr) in 158 liver disease patients, mCr in 208 liver transplantation (LT) candidates, and EDTA-Cr(51)-GFR in 38 other candidates for LT; considering each female as male, a 'corrected' Cr was derived. MELD scores were calculated for measured and "corrected" Cr in females. Median Cr and GFR in females were lower than males (p < 0.05). Both MDRD and EDTA-Cr(51) GFR were lower in females than males, despite lower Cr values. In females, each MELD score was lower than the corresponding MELD-corrected Cr (p < 0.001) with > or =three-point difference in liver disease patients: 25%[sCr]; 23%[mCr]; 11%[eCr]; and 14%[cCr]. In 65% of female LT candidates, two- or three-point difference was found. Females with liver disease have lower GFR than males for the same Cr value; correcting Cr increases MELD score by two or three points in 65% of female LT candidates. MELD score adjustment in females would ensure equal LT priority by gender.

Conventional predictors of survival poorly predict and significantly underpredict survival after H-graft portacaval shunts

OBJECTIVE

This study was undertaken to evaluate the ability to predict survival after 8 mm prosthetic H-graft portacaval shunts (HGPCS).

METHODS

Since 1988, 170 patients have been prospectively followed after HGPCS. Using preshunt data, predictors of survival after shunting [MELD Score, Emory Score, Child Pugh Score, Discriminant Function (DF), and Child Class] were determined and related to actual survival.

RESULTS

Child Class was: (a) 10%, (b) 28%, and (c) 62%. Actual 5- and 10-year survival by Child Class was: (a) 67% and 33%, (b) 49% and 16%, (c) 29% and 7%. Survival correlated with all predictors of survival (p < 0.01 for each). Actual survival was better than predicted by MELD (p < 0.001). By Multiple Variable Regression Analysis--Computed Model, explained variation in survival was greatest for Child Class (18%), followed by MELD (14%), with DF, Emory Score, and Child Pugh Score not significantly contributing.

CONCLUSIONS

After HGPCS, actual survival is better than predicted by MELD. Child Class explains only a minor variation in survival, although it better explains survival than MELD, Emory Score, Child Pugh Score, or DF. Conventional predictors of survival poorly and underpredict survival after HGPCS and should be used with caution.

Model for End-Stage Liver Disease Score-Based Allocation of Donors for Liver Transplantation: A Spanish Multicenter Experience

BACKGROUND

Prioritizing the liver transplant waiting list (WL) is subject to great variability. We present the experience of four transplant centers in Andalusia (Southern Spain) with a new consensus model of WL management based on the Model for End-Stage Liver Disease (MELD) score.

METHODS

The initial criteria for local prioritizing were: a) cirrhosis with MELD score > or =24, and b) all hepatocellular carcinoma (HCC) admitted to the WL. Fourteen months later new criteria were established: a) cirrhosis with MELD score > or =18, and b) uninodular HCC between 3-5 cm or multinodular HCC (2-3 nodules <3 cm). Access to regional priority was scheduled after three months for patients with cirrhosis or six months for patients with HCC. We analyzed the WL mortality rate, posttransplant survival rate, and overall survival rate over three 14-month periods: A (before implementation of priority criteria), B (initial criteria), and C (current criteria).

RESULTS

Priority was given to 36% of recipients in period B and 47% in period C. The WL mortality rate (including removals from WL) was 12.9%, 12.9%, and 10.7% in periods A, B, and C, respectively. One-year graft survival was 79.7%, 72.6%, and 81.2% in the same periods. The overall one-year survival rate for new cases on the WL was 74.9% in period A, 68.6% in period B, and 82.2% in period C.

CONCLUSIONS

The allocation system and WL management with the current criteria resulted in lower waiting list mortality without reducing posttransplant survival, leading to better survival for all patients listed.

Modeling Perioperative Risk: Can Numbers Speak Louder Than Words?

Perioperative care is one of the most complex segments of medicine, because it imposes unique and unprecedented stress on the patient and requires the participation of multiple medical specialists. For this reason, the concept of risk management is ideally suited for application in the perioperative period. The authors believe that risk stratification systems applied to perioperative management should address the three dimensions of patient condition, surgical risk and invasiveness, and anesthetic complexity. They have proposed a system that integrates these factors to document and communicate the relevant elements affecting the "shape" of preoperative patients. Admittedly far short of the ideal formula, we hope this nonetheless prompts efforts to establish more uniform means of assessment and communication and provides a foundation for this endeavor. The old adage can be modified: "if your patient rates more than two ASPIRIN, call me before the morning (of surgery)."

Liver transplantation organ allocation between Child and MELD

Liver transplantation (LT) has been established as the most effective therapy for acute and chronic liver diseases over the last few decades due to its excellent long-term results. At the beginning of the LT era, donor organs were allocated based on waiting time. However, as the number of LT candidates consistently increased, a specific allocation system became necessary to prioritize the large number of patients waiting for a limited pool of organs. The LT candidates were categorized into different urgency levels based on their hospital status, degree of liver disease as measured by the Child-Turcotte-Pugh score, and accompanying complications of liver disease, such as ascites, variceal bleeding or hepatocellular carcinoma. The majority of European countries, including Austria, still rely on this organ allocation system. In the United States, however, a new allocation system based on the risk of death without transplantation, assessed by the Model for End-stage Liver Disease (MELD), was initiated in February 2002. Recent reports have shown that the introduction of the MELD system led to a reduction in waiting list mortality, but also that the MELD score has several limitations that call for further refinements. In the transplant community there are reasonable doubts that MELD is actually superior to the Child-Turcotte Pugh score. Therefore, the optimal liver organ allocation system is yet to be defined.

A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation

The Model for End-Stage Liver Disease (MELD) score is now used for allocation in liver transplantation (LT) waiting lists, replacing the Child-Turcotte-Pugh (CTP) score. However, there is debate as whether it is superior to CTP score to predict mortality in patients with cirrhosis on the LT waiting list and after LT. We reviewed studies comparing the accuracy of MELD vs. CTP score in transplantation settings. We found that in studies of the LT waiting list (12,532 patients with cirrhosis), only 4 of 11 showed MELD to be superior to CTP in predicting short-term (3-month) mortality. In addition, 2 of 3 studies (n = 1,679) evaluating the changes in MELD score (DeltaMELD) showed that DeltaMELD had better prediction for mortality than the baseline MELD score. The impact of MELD on post-LT mortality was assessed in 15 studies (20,456 patients); only 6 (9,522 patients) evaluated the discriminative ability of MELD score using the concordance (c) statistic (the MELD score had always a c-statistic < 0.70). In 11 studies (19,311 patients), high MELD score indicated poor post-LT mortality for cutoff values of 24-40 points. In re-LT patients, 2 of 4 studies evaluated the discriminative ability of MELD score on post-LT mortality. Finally, several studies have shown that the predictive ability of MELD score increases by adding clinical variables (hepatic encephalopathy, ascites) or laboratory (sodium) parameters. On the basis of the current literature, MELD score does not perform better than the CTP score for patients with cirrhosis on the waiting list and cannot predict post-LT mortality.

The natural history of compensated cirrhosis due to hepatitis C virus: A 17-year cohort study of 214 patients

Large databases of consecutive patients followed for sufficiently long periods are needed to establish the rates, chronology, and hierarchy of complications of cirrhosis as well as the importance of other potential causes of liver disease. In accordance with this goal, a cohort of patients with compensated cirrhosis due to hepatitis C virus (HCV) was followed for 17 years. Two hundred and fourteen HCV RNA-seropositive patients with Child-Pugh class A cirrhosis who had no previous clinical decompensation were prospectively recruited and followed up with periodic clinical and abdominal ultrasound examinations. During 114 months (range 1-199), hepatocellular carcinoma (HCC) developed in 68 (32%), ascites in 50 (23%), jaundice in 36 (17%), upper gastrointestinal bleeding in 13 (6%), and encephalopathy in 2 (1%), with annual incidence rates of 3.9%, 2.9%, 2.0%, 0.7%, and 0.1%, respectively. Clinical status remained unchanged in 154 (72%) and progressed to Child-Pugh class B in 45 (21%) and class C in 15 (7%). HCC was the main cause of death (44%) and the first complication to develop in 58 (27%) patients, followed by ascites in 29 (14%), jaundice in 20 (9%), and upper gastrointestinal bleeding in 3 (1%). The annual mortality rate was 4.0% per year and was higher in patients with other potential causes of liver disease than in those without them (5.7% vs. 3.6%; P = .04). In conclusion, hepatitis C-related cirrhosis is a slowly progressive disease that may be accelerated by other potential causes of liver disease. HCC was the first complication to develop and the dominant cause for increased mortality.

Prediction model of hepatocarcinogenesis for patients with hepatitis C virus-related cirrhosis. Validation with internal and external cohorts

BACKGROUND/AIMS

To estimate hepatocarcinogenesis rates in patients with hepatitis C virus (HCV)-related cirrhosis, an accurate prediction table was created.

METHODS

A total of 183 patients between 1974 and 1990 were assessed for carcinogenesis rate and risk factors. Predicted carcinogenesis rates were validated using a cohort from the same hospital between 1991 and 2003 (n=302) and an external cohort from Tokyo National Hospital between 1975 and 2002 (n=205).

RESULTS

The carcinogenesis rates in the primary cohort were 28.9% at the 5th year and 54.0% at the 10th year. A proportional hazard model identified alpha-fetoprotein (>or=20 ng/ml, hazard ratio 2.30, 95% confidence interval 1.55-3.42), age (>or=55 years, 2.02, 95% CI 1.32-3.08), gender (male, 1.58, 95% CI 1.05-2.38), and platelet count (<100,000 counts/mm3, 1.54, 95% CI 1.04-2.28) as independently associated with carcinogenesis. When carcinogenesis rates were simulated in 16 conditions according to four binary variables, the 5th- and 10th-year rates varied from 9 to 64%, and 21-93%, respectively. Actual carcinogenesis rates in the internal and external validation cohorts were similar to those of the simulated curves.

CONCLUSIONS

Simulated carcinogenesis rates were applicable to patients with HCV-related cirrhosis. Since, hepatocarcinogenesis rates markedly varied among patients depending on background features, we should consider stratifying them for cancer screening and cancer prevention programs.

Association between portal endotoxemia and Child-Pugh classification in complex pathogens-induced hepatic cirrhosis in rats

AIM: To evaluate the association between the Child-Pugh classification and portal endotoxe-mia during the course of rat liver cirrhosis induced by carbon tetrachloride (CCl₄) plus ethanol and cholesterol.

METHODS: Liver cirrhosis model was induced in 20 Wistar rats using CCl₄ plus ethanol and cholesterol, while 6 rats were treated as controls. At 6 and 10 wk, serum samples were collected from portal vein for the detection of prothrombin time, albumin, bilirubin and endotoxin level, and the ascites and brain wave were also tested. The liver function was evaluated by Child-Pugh scoring system and the relationship between Child-Pugh classification and portal endotoxemia was assessed.

RESULTS: Spearman rank correlation analysis showed that Child-Pugh grading was correlated with albumin level and prothrombin time (r = -0.695, P < 0.05; r = 0.649, P < 0.05), but not with bilirubin level (P > 0.05). The level of endotoxin in portal vein was elevated with prolonging of cirrhosis time, and it was significantly higher at 6 or 10 wk than that in the controls (1983.7 ± 586.4, 2600.7 ± 343.8 mEU/L vs 925.1 ± 527.7 mEU/L, both P < 0.01). Endotoxin level was correlated with cirrhosis time (r = 0.624, P < 0.01) and Child-Pugh classification (r = 0.680, P < 0.01).

CONCLUSION: Portal endotoxemia is significantly correlated with Child-Pugh classification, indicating that intestinal endotoxemia plays an important role during the course of complex pathogens-induced cirrhosis in rats.

Systematic review: The model for end-stage liver disease--should it replace Child-Pugh's classification for assessing prognosis in cirrhosis?

BACKGROUND

Prognosis in cirrhotic patients has had a resurgence of interest because of liver transplantation and new therapies for complications of end-stage cirrhosis. The model for end-stage liver disease score is now used for allocation in liver transplantation waiting lists, replacing Child-Turcotte-Pugh score. However, there is debate as whether it is better in other settings of cirrhosis.

AIM

To review studies comparing the accuracy of model for end-stage liver disease score vs. Child-Turcotte-Pugh score in non-transplant settings.

RESULTS

Transjugular intrahepatic portosystemic shunt studies (with 1360 cirrhotics) only one of five, showed model for end-stage liver disease to be superior to Child-Turcotte-Pugh to predict 3-month mortality, but not for 12-month mortality. Prognosis of cirrhosis studies (with 2569 patients) none of four showed significant differences between the two scores for either short- or long-term prognosis whereas no differences for variceal bleeding studies (with 411 cirrhotics). Modified Child-Turcotte-Pugh score, by adding creatinine, performed similarly to model for end-stage liver disease score. Hepatic encephalopathy and hyponatraemia (as an index of ascites), both components of Child-Turcotte-Pugh score, add to the prognostic performance of model for end-stage liver disease score.

CONCLUSIONS

Based on current literature, model for end-stage liver disease score does not perform better than Child-Turcotte-Pugh score in non-transplant settings. Modified Child-Turcotte-Pugh and model for end-stage liver disease scores need further evaluation.

Longitudinal modifications of the MELD score have prognostic meaning in patients with liver cirrhosis

BACKGROUND

The Model for End-Stage Liver Disease (MELD) score is an important and well established tool for assessing prognosis in patients with liver cirrhosis. It has been suggested that the longitudinal evaluation of the MELD score may reflect the progression of liver failure more reliably and therefore be more useful in prognostic assessment.

AIM

To assess the prognostic meaning of MELD score modifications in a cohort of cirrhotic patients in whom clinical and biochemical workup was carried out at least twice during a minimum interval of 30 days.

METHODS

Forty-six cirrhotic patients were longitudinally evaluated for a median follow-up of 365 days. After initial assessment, all the patients had at least one clinical and biochemical reevaluation during follow-up, which was performed no less than 1 month after initial evaluation. MELD was calculated at entry and at second evaluation. DeltaMELD was calculated as MELD at second evaluation minus MELD at entry. DeltaMELD/time was calculated as DeltaMELD divided by time elapsed between initial assessment and second evaluation expressed in months.

RESULTS

During follow-up, 13 patients died (28%). The median interval between clinical evaluations was 120 days. MELD scores at entry (13 +/- 4 vs 16 +/- 6, P = 0.0516) and DeltaMELD (0 +/- 4 vs 4 +/- 2, P = 0.0028) were significantly different between patients who died and those who survived during the 1-year follow-up. All the patients who died during follow-up showed an increase of at least 1 unit in DeltaMELD/time (sensitivity = 100%), and all the patients who survived showed a decrease of more than 1 unit in DeltaMELD/time (specificity = 100%).

CONCLUSIONS

Longitudinal evaluation of the MELD score provides important prognostic information that seems to complete the prognostic definition provided by "static" MELD. Prospective studies in larger series are needed to validate the prognostic use of MELD modifications over time.