A model to predict survival in patients with end-stage liver disease

Anti-factor Xa and activated partial thromboplastin time strategies for unfractionated heparin dosing after HeartMate 3 left ventricular assist device implantation

BACKGROUND

No clear guidelines exist for perioperative anticoagulation management after durable left ventricular assist device insertion. In this study, we sought to compare outcomes between anti-factor Xa (FXa) and activated partial thromboplastin time (aPTT) in monitoring unfractionated heparin (UFH) dosing after HeartMate 3 (HM3) insertion.

METHODS

This is a single-center retrospective review of patients who received UFH after HM3 insertion between 01/2020-12/2022. Post-operative UFH dose was titrated by aPTT goal 45-60 sec (n = 53) or FXa goal 0.1-0.2 U/mL (n = 59). Baseline differences between cohorts were balanced by inverse probability treatment weighting.

RESULTS

At baseline, unadjusted FXa patients were more likely to be white (47.5% vs. 35.8%, p < 0.001), INTERMACS 1-2 (69.5% vs. 47.2%, p = 0.013), have history of coronary artery disease (66.1% vs. 43.4%, p = 0.026), and lower eGFR (54.1 vs. 63.7 mL/min/1.73 m2, p = 0.029) compared to the aPTT group. After adjusting for several bleeding/thrombosis risk factors, 97.5% of FXa and 91.0% of aPTT patients reached therapeutic levels with comparable UFH duration and maximum dose. Moreover, in-hospital mortality (2.5% vs. 3.1%, p = 0.842), major bleeding events (4.2% vs. 9.2%, p = 0.360), and thromboembolic events (21.8% vs. 10.1%, p = 0.151) remained without significant differences between FXa and aPTT cohorts. There was a high degree of variability in FXa (r2 = 0.20) and aPTT (r2 = 0.22) values for any given UFH dose.

CONCLUSIONS

No differences in frequency of bleeding or thromboembolic events were observed in this study between FXa versus aPTT cohorts after HM3 implantation. More longitudinal studies are warranted to determine whether or not one assay is superior to the other.

Prognostic value of the modified Model for End-Stage Liver Disease score in patients treated with cardiac resynchronization therapy

Background

Hepatorenal dysfunction is prevalent among individuals with heart failure (HF).

OBJECTIVE

This study investigated prognostic value of the modified Model for End-Stage Liver Disease (Model for End-Stage Liver Disease excluding international normalized ratio [MELD-XI] scores and Model for End-Stage Liver Disease with albumin replacing international normalized ratio [MELD-Albumin]) score in patients undergoing cardiac resynchronization therapy (CRT).

Methods

We retrospectively evaluated 365 patients (mean age 58.7 ± 11.1 years; 64.9% men) undergoing CRT implantation between 2007 and 2019. Patients were divided into 4 groups based on the modified MELD score quartiles before CRT. The primary endpoint was the combination of all-cause mortality and HF hospitalization, whereas the secondary endpoint was CRT response at 6 months.

Results

During mean follow-up of 3.3 years (interquartile range 1.9-5.2 years), 168 patients reached the primary endpoint. Logistic regression revealed the MELD-Albumin score was independently associated with CRT response, even after adjusting for covariates (odds ratio 1.10; 95% confidence interval [CI] 1.02-1.19; P = .013). Kaplan-Meier analysis revealed that patients with a higher MELD-XI and MELD-Albumin score had a greater risk of adverse outcomes (log-rank test: P < .001). A Cox proportional hazards analysis showed that the modified MELD score remained significantly associated with adverse outcomes after adjusting for clinical and echocardiographic factors (MELD-XI: hazard ratio 1.06, 95% CI 1.02-1.11, P = .006; MELD-Albumin: hazard ratio 1.10, 95% CI 1.05-1.16, P < .001). Furthermore, receiver-operating characteristic analysis indicated that the MELD-Albumin score provided a stronger prognostic value for long-term adverse outcomes in patients undergoing CRT than the MELD-XI score (MELD-Albumin: area under the curve 0.692, 95% CI 0.644-0.742; MELD-XI: area under the curve 0.659, 95% CI 0.608-0.715; P = .008).

Conclusion

The MELD-Albumin score may be useful for stratifying patients at risk for CRT response and adverse outcomes in those undergoing CRT for HF.

Clinical Outcomes of Percutaneous Transhepatic Biliary Drainage in Pediatric Patients following Liver Transplantation

Purpose

Cholestatic complications remain a primary cause of post-liver transplantation (LTX) morbidity in pediatric patients. Standard biliary access by endoscopic retrograde cholangioscopy may not be feasible due to modified biliary drainage. Percutaneous transhepatic biliary drainage (PTCD) may be performed alternatively. However, systematic data concerning safety and efficacy of PTCD in these patients are scarce.

Methods

In this retrospective study, procedural and safety characteristics of PTCD in pediatric patients following LTX were analyzed. We compared laboratory indicators of inflammation, cholestasis, and graft function before and at 6 and 12 months after the first PTCD insertion. Efficacy was analyzed by percentage of patients without cholangitis, need for surgical biliary re-intervention and re-transplantation during a follow-up period of 60 months.

Results

Over a decade, PTCD was attempted in a total of 15 patients, with technical success (93.3%) in 14 patients. Periprocedural complications, including bleeding (7.1%) and cholangitis (21.4%) were observed in patients. During follow-up, both MELD-score (baseline: 13 [8-15] vs. 12 months: 8 [7-8], p<0.001) and parameters of cholestasis (GGT: baseline: 286 [47-458] U/L vs. 12 months: 105 [26-147] U/L, p=0.024) decreased. Prior to PTCD, cholangitis (64.3%) and cholangiosepsis (21.4%) were common complications. In contrast, following PTCD, cholangitis occurred in only one patient (7.1%). Five patients (35.7%) needed surgical biliary re-intervention and two (14.3%) required re-transplantation.

Conclusion

PTCD in pediatric patients following LTX had an acceptable safety profile, demonstrating a biochemical improvement of both cholestasis and graft function and may prevent cholestatic complications, thus reducing the need for surgical re-intervention and re-transplantation.

Serial Procalcitonin Measurements for Determining Bacterial Infection and Mortality in Cirrhotic Patients With Systemic Inflammatory Response Syndrome

INTRODUCTION

The utility of serial procalcitonin (PCT) measurements in cirrhotic patients with systemic inflammatory response syndrome (SIRS) is not well understood. The aim of this study was to assess the effectiveness of serial PCT measurements for diagnosing bacterial infections and predicting 30-day mortality in this population.

METHODS

We prospectively studied 120 cirrhotic patients with SIRS, 64.2% of whom had bacterial infections. Serial PCT levels were measured within the first 72 hours of admission.

RESULTS

Patients with bacterial infections had significantly higher PCT levels at admission, 24 hours, and 72 hours compared with those without infections. PCT values >0.5 ng/mL within 72 hours demonstrated high sensitivity (81.8-87.5%) but moderate specificity (27.9-44.2%) for diagnosing bacterial infections. Serial PCT monitoring, including the 72-hr/baseline ratio and changes in PCT over 72 hours, provided insights into the evolution of bacterial infections and short-term mortality. Patients with a PCT 72-hour/baseline ratio >0.8 had higher 30-day mortality than those with a ratio <0.5 (50.0% vs 25.6%; odds ratio 3.91, 95% CI 1.40-10.97). Patients whose PCT levels decreased by >50% had lower 30-day mortality than those with increasing levels (23.3% vs 46.7%; odds ratio 0.25, 95% CI 0.08-0.74). Patients with Model for End-Stage Liver Disease scores >15 and bacterial infections who experienced a PCT decrease of <50% had higher 30-day mortality than those with greater reductions (57.7% vs 25.0%, P = 0.021).

DISCUSSION

Serial PCT measurements within 72 hours of admission are useful for determining bacterial infections and mortality in cirrhotic patients with SIRS. PCT monitoring may optimize antibiotic use and enhance early risk stratification, potentially improving patient outcomes.

Definition, diagnosis and epidemiology of acute-on-chronic liver failure

This narrative review addresses the definition of acute-on-chronic liver failure, a condition associated with high short-term mortality in patients with chronic liver disease and/or cirrhosis. We provide two major points of view: the East and the West perspective. Both definitions vary regarding the underlying patient population and organ failure(s) definition. Nevertheless, all the definitions have their clinical utility: from the core concept of having the "liver" as a conditio sine qua non, the syndrome cannot exist (Asian Pacific Association for the Study of the Liver); a data-driven, robust definition (European Association for the Study of the Liver); a bedside tool that can quickly identify patients at high risk of dying (North American Consortium for the Study of End-stage Liver Disease [NACSELD]). In each section, we provide the overall definitions, the criteria of organ failure(s), and some epidemiological data illustrating how these apply in each area of the world.

Noninvasive assessment of hepatic decompensation

Noninvasive tests (NITs) are used in all aspects of liver disease management. Their most prominent break-through since the millennium has been in advancing early detection of liver fibrosis, but their use is not limited to this. In contrast to the symptom-driven assessment of decompensation in patients with cirrhosis, NITs provide not only opportunities for earlier diagnoses but also accurate prognostication, targeted treatment decisions, and a means of monitoring disease. NITs can inform disease management and decision-making based on validated cutoffs and standardized interpretations as a valuable supplement to clinical acumen. The Baveno VI and VII consensus meetings resulted in tangible improvements to pathways of care for patients with compensated and decompensated advanced chronic liver disease, including the combination of platelet count and transient elastography to diagnose clinically significant portal hypertension. Furthermore, circulating NITs will play increasingly important roles in assessing the response to interventions against ascites, variceal bleeding, HE, acute kidney injury, and infections. However, due to NITs' wide availability, there is a risk of inaccurate use, leading to a waste of resources and flawed decisions. In this review, we describe the uses and pitfalls of NITs for hepatic decompensation, from risk stratification in primary care to treatment decisions in outpatient clinics, as well as for the in-hospital management of patients with acute-on-chronic liver failure. We summarize which NITs to use when, for what indications, and how to maximize the potential of NITs for improved patient management.

Effectiveness of liver transplant mortality scales in a Mexican population

BACKGROUND

Liver transplantation is the treatment of choice in patients with chronic liver disease and acute liver failure of any etiology. Scales such as the Survival Outcome Following Transplantation (SOFT) score and the Balance of Risk (BAR) score can be used to predict survival. In this study, we compared these scales in the Mexican population.

METHODS

A cross-sectional analytical study was carried out in a Mexican third-level transplant center. The MELD, SOFT, and BAR scales were adopted. The ROC curves of the three predictive scores were constructed, and the areas under the curve were obtained and compared. A bivariate analysis and Cox regression were performed. Finally, a survival analysis was performed using Kaplan-Meier curves.

RESULTS

We analyzed 123 liver transplant (LT) recipients. The bivariate analysis and Cox regression indicated that portal thrombosis, with an HR of 3.36 (IC 1.069-10.59, p = 0.038), and the number of red blood cells transfused, with an HR of 1.084 (CI 1.039-1.130, p < 0.000), were significantly associated with mortality. The receiver height was a protective factor, with an HR of 0.001 (CI 0.000-0.761, p = 0.041). Regarding the Pearson correlation analysis, the BAR scale had a coefficient of 0.199 (p = 0.032) for transfusion, while the SOFT scale's correlation coefficients for cold ischemia and transfusion were 0.236 (p = 0.011) and 0.274 (p = 0.003), respectively, all indicating weak correlations. The areas under the curve (AUCs) of MELD, SOFT, and BAR in predicting 3-month mortality were 0.495 (P = 0.94), 0.608 (p = 0.129), and 0.502 (p = 0.97), respectively. Finally, in the survival analysis using Kaplan-Meier curves, an estimated mean survival period of 71.52 months was obtained, with a survival rate of 89.3 % at 30 days and 81.1 % at five years.

CONCLUSION

In this study, it was found that all three scales were deficient in discriminating among the outcomes obtained in the Mexican population.

Exploring the Viability of Matching Marginal Donors With Low Renal Function Recipients in Liver Transplantation

BACKGROUND

Renal function varies among liver transplantation (LT) candidates with the same Model for End-Stage Liver Disease (MELD)3.0 score. The impact of marginal grafts on post-LT renal function and prognosis varies based on the pre-LT renal function. We explored the effects of matching recipients with low renal function to marginal donors on graft survival (GS) and post-LT kidney function.

METHODS

We analyzed data from the Scientific Registry of Transplant Recipients (SRTR), categorizing pre-LT renal function by estimated glomerular filtration rate (eGFR) into low (<30 mL/min/1.73 m2) and high (≥30 mL/min/1.73 m2). Marginal donors were defined by criteria including donation after cardiac death, age ≥ 65, severe macrosteatosis (≥30%), or body mass index ≥ 40 kg/m2. The primary outcome was to compare 3-year post-LT GS between patients with low and high pre-LT renal function. Additionally, we examined post-LT eGFR 1-3 months post-LT.

RESULTS

Of 13 279 LT recipients, 12 851 had high pre-LT eGFR and 428 had low pre-LT eGFR. Kaplan-Meier survival analysis showed that recipients with low pre-LT eGFR had significantly lower 3-year GS compared to those with high eGFR (p < 0.01). Recipients of organs from marginal donors also exhibited a significant reduction in 3-year GS (p < 0.01). This adverse effect persisted within the same MELD3.0 category. Additionally, lower pre-LT eGFR was associated with an increased risk of post-LT kidney function deterioration, especially among those receiving grafts from marginal donors. Multivariable logistic regression identified recipient age > 65 as a significant risk factor for post-LT kidney function decline (OR 3.34 [1.05-10.7]; p = 0.03).

DISCUSSION

GS was notably worse in recipients with low pre-LT eGFR, particularly when matched with marginal donors. A recipient age > 65 is a risk indicator for post-LT kidney function deterioration with marginal donors, underscoring the importance of careful donor-recipient matching, especially with compromised pre-LT kidney function.

Smoking and outcomes in candidates for liver transplantation: Analysis of the Pulmonary Vascular Complications of Liver Disease 2 (PVCLD2)

Patients with chronic liver disease commonly have abnormal lung function; however, the impact of smoking on outcomes in these patients is unknown. We hypothesized current or past smoking would be associated with worse survival in patients with advanced liver disease. The Pulmonary Vascular Complications in Liver Disease Study 2 (PVCLD2) was a prospective cohort of patients with advanced liver disease undergoing evaluation for liver transplantation (LT). Patients were classified by self-report as a "non-smoker," "past smoker," or "current smoker." We used Cox proportional hazards models and Fine-Gray models with LT as a competing risk. Models were adjusted for age, sex, body mass index, race, family income, liver disease etiology, and Model for End-Stage Liver Disease-Sodium score. Of the 410 patients included, most (65%) were male and the mean age at enrollment was 56.5 years. One hundred sixty (39%) patients were nonsmokers, 183 (45%) were past smokers, and 67 (16%) were current smokers. In total, 151 (37%) patients received an LT, and 88 (20%) patients died. When compared to nonsmokers, current smokers had a 2.17-fold increase in risk of death overall (95% CI: 1.12-4.18, p = 0.02). There was a 7% increase in overall risk of death for every 5 pack-years increase (95% CI: 1.01-1.13, p = 0.02). With LT as a competing risk, the subdistributional HR of current smokers versus nonsmokers for death was 2.45 (95% CI: 1.31-4.60, p = 0.005). In this model, past smokers displayed a nonsignificant increase in the risk of death compared to nonsmokers (subdistributional HR: 1.58, 95% CI: 0.91-2.72, p = 0.10). Patients with advanced liver disease undergoing evaluation for LT who smoke have an increased risk of death. Smoking cessation could lead to improved overall survival with or without LT.

Optimizing the tapering scheme of corticosteroid treatment for acute onset of autoimmune hepatitis

BACKGROUND

Uncertainties persist regarding the optimal management of acute onset of autoimmune hepatitis, including the use of corticosteroids. This study aimed to compare the effectiveness and safety of rapid versus slow corticosteroid tapering in acute onset of AIH.

METHODS

A multicenter study involving patients with acute AIH was conducted. We defined acute AIH as an acute presentation (<30 days) with AIH and exhibiting no evidence of pre-existing liver diseases. Initially, corticosteroid treatment and overall outcomes were reported. Subsequently, the role of corticosteroid tapering rate in modifying outcomes across subgroups was investigated. For patients with an initial corticosteroid dose of 20 mg/day or higher, we further classified patients into rapid tapering group (duration until dose of prednisone <20 mg/day <3 weeks) and slow tapering group (duration until dose of prednisone <20 mg/day ≥3 weeks). Adverse events were defined as any of the following events, progression (e.g., acute icteric AIH progression to AS-AIH or AIH-ALF, AS-AIH progression to AIH-ALF, non-cirrhotic progression to cirrhosis, compensated cirrhosis progression to decompensation), LT, and liver-related death.

RESULTS

This retrospective cohort study enrolled 237 patients, with 109 presenting acute icteric AIH, 97 with acute-severe AIH (AS-AIH), and 31 with AIH-acute liver failure (ALF). Among patients with acute icteric AIH, slow tapering significantly improved adverse outcome-free survival compared to rapid tapering (99 % vs. 71 %, P < 0.0001). Similarly, in AS-AIH patients, slow tapering resulted in notably higher adverse outcome-free survival rates compared to rapid tapering (92 % vs. 54 %, P < 0.001). Slow tapering independently predicted fewer adverse events (OR 0.144; 95 % CI 0.037-0.562; P = 0.005). However, in AIH-acute liver failure (ALF) patients, tapering rate did not significantly affect adverse outcome-free survival (38 % vs. 50 %, P = 0.590). Overall, there were no significant differences in osteoporosis or infection occurrence between tapering groups in the entire acute AIH cohort.

CONCLUSION

A slow corticosteroid tapering reduced adverse outcomes in acute exacerbation of AIH patients, particularly in acute icteric AIH and AS-AIH.

Prognostic factors for mortality in patients with acute-on-chronic liver failure

OBJECTIVE

The aim is to explore significant prognostic factors for 90-day mortality in patients with acute-on-chronic liver failure (ACLF) and assist clinicians in the early identification of critically ill ACLF patients.

METHODS

A retrospective analysis was conducted on 288 ACLF patients, who were classified into survivors (n = 187) and nonsurvivors (n = 101) based on 90-day outcomes. Multivariate stepwise logistic regression analyses were employed to identify significant prognostic factors and construct a novel prognostic model, the AHUCTPI. The model's performance was assessed and the internal validation was performed. Additionally, the influence of dynamic changes in laboratory markers on 90-day mortality was examined.

RESULTS

Independent risk factors for 90-day mortality included age ≥45 years, presence of hepatic encephalopathy (HE), and upper gastrointestinal bleeding (UGB) during hospitalization, imaging-confirmed cirrhosis at admission, elevated baseline total bilirubin (TBIL), reduced baseline platelet-to-neutrophil ratio (PNR), and elevated baseline international normalized ratio (INR) (P < 0.05 for all). The AHUCTPI model's formula is as follows: Logit (p) = -10.019 + 1.808 × age (1 if ≥45 years, 0 if <45 years) + 1.048 × HE (1 if present, 0 if absent) + 1.721 × UGB (1 if present, 0 if absent) + 1.362 × cirrhosis (1 if present, 0 if absent) + 0.008 × TBIL (μmol/L) - 0.039 × PNR + 1.963 × INR. The AUHCTPI model demonstrated superior predictive accuracy compared with the MELD (Model for End-Stage Liver Disease) score, with the area under the receiver operating characteristic curve values of 0.914 and 0.739, respectively, and calibration curves closely approximating the ideal curve.

CONCLUSION

ACLF is a complex, dynamic syndrome. Age, HE, and UGB during hospitalization, imaging-diagnosed cirrhosis at admission, baseline TBIL, PNR, and INR were significant predictors for 90-day mortality in ACLF patients, and the AHUCTPI model provides excellent calibration and discrimination. Dynamic monitoring of laboratory trends enhances prognostic accuracy and supports timely clinical decision-making.

Dose determination of VV116 in COVID-19 patients with severe liver dysfunction: a case report

VV116 is an oral antiviral drug against SARS-CoV-2, known for its favorable efficacy and safety profile. But its application in patients with severe liver dysfunction has not been evaluated. Here, we report a case in which a patient with aplastic anemia and liver impairment (recovery phase of acute liver failure) was infected with SARS-CoV-2. Based on clinical trials and pharmacokinetic analysis about VV116, we initiated a reduced dose of 300 mg every 12 h on day 1, 200 mg every 12 h on days 2-5 for antiviral therapy. Finally, the patient's viral load rapidly dropped to an undetected level, and no drug-related adverse effects were observed.

Association between lactate-to-albumin ratio and all-cause mortality in critically ill cirrhotic patients with sepsis: a retrospective analysis of the MIMIC-IV database

BACKGROUND

The impact of lactate-to-albumin ratio (LAR) on mortality of critically ill cirrhotic patients with sepsis is scant.

METHODS

Critically ill cirrhotic patients with sepsis were obtained from the MIMIC-IV database (v3.0). Cox regression models alone and in combination with restricted cubic splines, generalized additive models and smoothed curve fitting were used to investigate the relationship between LAR and all-cause mortality.

RESULTS

A total of 1864 patients were included. The 30-day, 90-day, and 180-day all-cause mortality rates were 38.0%, 46.3%, and 49.5%, respectively. Higher LAR were significantly and nonlinearly associated with higher risks of 30-day, 90-day, and 180-day all-cause mortality (all adjusted HR = 1.17, P < 0.001). L-shaped associations between LAR and 30-day, 90-day, and 180-day all-cause mortality were observed, with an inflection point of 1.05 (P for log-likelihood ratio < 0.01). Compared with patients with LAR < 1.05, patients with LAR ≥ 1.05 had higher risks of 30-day, 90-day, and 180-day all-cause mortality (adjusted HR (95% CI): 1.48 (1.27-1.72), 1.44 (1.25-1.66), and 1.38 (1.21-1.57), respectively). No potential modifiers were found in the relationship between LAR and mortality.

CONCLUSIONS

LAR was positively and nonlinearly associated with all-cause mortality in critically ill cirrhotic patients with sepsis. Thus, it could be used as a prognostic biomarker.

The prognostic nutritional index is an effective prognostic and nutritional status indicator for cirrhosis

BACKGROUND AND AIM

Malnutrition is an important clinical feature of cirrhotic patients and is closely associated with prognosis. The prognostic nutritional index (PNI) is a measure of nutritional status. This study was conducted to clarify whether the PNI is related to the severity and prognosis of cirrhosis.

METHODS

In this study, we retrospectively analysed the clinical data of patients who were hospitalized with a primary diagnosis of liver cirrhosis from January 2020 to December 2023 at Tianmen Hospital affiliated with Wuhan University of Science and Technology. Cox regression was used to analyse the independent risk factors for prognosis in patients with decompensated cirrhosis, and the predictive value of the PNI for assessing cirrhosis severity and prognosis was analysed via receiver operating characteristic (ROC) curves.

RESULTS

A total of 513 patients with cirrhosis were included in the study. The patients were divided according to disease severity into compensated (28) and decompensated (485) groups, where the decompensated group consisted of the ascites-only group (63), the complications group (381), and the death group (41). The PNI [hazard ratio (HR) = 0.925, 95% confidence interval (CI): 0.858-0.997, P = 0.041] and platelet count (HR = 1.006, 95% CI: 1.002-1.01, P = 0.002) were found to be independent factors influencing poor prognosis in patients with decompensated cirrhosis. The PNI has predictive value for mortality in decompensated cirrhosis patients. Moreover, a significant disparity was observed in the PNI between the compensated and decompensated groups, and the PNI in the compensated group [47.03(42.85,51.50)] was markedly greater than that in the decompensated group [34.15(30.05,37.93)]. As the severity of the disease increased, the PNI progressively decreased in the ascites-only group [36.40 (32.15, 40.80)], the complication group [34.05 (30.08, 37.80)], and the death group [30.15 (27.05, 35.58)].The ROC curves revealed that the PNI had a high predictive value for decompensated cirrhosis [area under the curve (AUC) = 0.897] and the highest predictive value for mortality outcome (AUC = 0.943). This research also demonstrated that the PNI is strongly correlated with the occurrence and number of complications.

CONCLUSION

The prognostic nutritional index is a good indicator of the severity and prognosis of cirrhotic disease and warrants clinical promotion.

A high rate of mortality in liver cirrhosis patients after emergency abdominal surgery

PURPOSE

In the elective setting, there are high mortality rates for patients with liver cirrhosis after surgery. Few studies focus on emergency surgery. This study investigates mortality and morbidity of patients with cirrhosis undergoing emergency abdominal surgery.

METHODS

In a database established at two Copenhagen University Hospitals (Herlev and North Zealand), including all patients operated in an emergency setting (n = 1116), including all patients with known cirrhosis at time of surgery. Postoperative complications, and mortality rates were evaluated by a matched case-control method, matching cases and controls according to surgical procedure, age, sex and American Society of Anaesthesiologists-class (ASA). Medical and surgical complications were classified according to the Clavien-Dindo classification.

RESULTS

In the study, 24 patients with cirrhosis and 48 matched controls were evaluated. The 30-day mortality was 37.5% for patients with cirrhosis and 12.5% for controls (OR 4.2, 95% CI [1.28, 13.80], p = 0.014) and 90-day mortality was 62.5% for patients with cirrhosis compared to 18.8% for controls (OR 7.22, 95% CI [2.41, 21.68], p < 0.001). For patients with cirrhosis 58.3% had surgical complications compared to 31.3% for the controls (p = 0.027). The reoperation rate was 45.8% in the cirrhosis group and 22.9% in the control group (p = 0.047). The days-alive-out-of-hospital at 90-days (DAOH-90) was 9 days in the cirrhosis group and 78 days in the control group (p < 0.001).

CONCLUSION

This retrospective study shows that patients with cirrhosis have significantly higher mortality rates after emergency surgery, more surgical complications and reoperations, and reduced DAOH-90.

A novel risk-predicted nomogram for acute kidney injury progression in decompensated cirrhosis: a double-center study in Vietnam

OBJECTIVES

Acute kidney injury (AKI) is commonly encountered in patients hospitalized for decompensated cirrhosis and is associated with prolonged hospital stays, increased treatment burden, and even mortality. The present study aimed to determine the prevalence of and develop a predictive nomogram for AKI in patients with decompensated cirrhosis.

METHODS

This cross-sectional, double-center study involved 544 patients hospitalized with decompensated cirrhosis. Acute kidney injury was diagnosed using American Gastroenterological Association's guidelines with one more criterion: an increase in serum creatinine ≥ 0.3 mg/dL within 48 h or an increase in serum creatinine ≥ 50% compared to baseline serum creatinine or when the urine output is reduced below 0.5 mL/kg/h for > 6 h. We used the Bayesian model averaging method find the optimal model for predicting AKI. A predictive nomogram was also developed to enable risk prediction.

RESULTS

The overall AKI prevalence was 26.7% (95% Confidence interval [CI] 25.7-27.7). The optimal model for predicting AKI included diuretic therapy (odds ratio [OR]: 5.55; 95%CI 3.31-9.33), infection (OR: 2.06; 95%CI 1.31-3.22), ascites (OR: 3.20; 95%CT: 1.67-6.13), Child-Pugh group C (OR: 2.91; 95%CI 1.84-4.62), serum potassium (OR per 1 mmol/L increase: 1.62; 95%CI 1.25-2.1) and serum chloride (OR per 1 mmol/L decrease: 1.03; 95%CI 1.01-1.06). The area under the receiver operating characteristic curve was 0.8, with a 95%CI ranging from 0.75 to 0.84.

CONCLUSIONS

Acute kidney injury was relatively common among patients hospitalized for decompensated cirrhosis. A novel nomogram-including diuretic therapy, infection, ascites, Child-Pugh group C, serum potassium and, serum chloride, was helpful for the selective screening of AKI in patients with decompensated cirrhosis.

Interprofessional Therapeutic Drug Monitoring of Piperacillin/Tazobactam Enhances Care for Patients with Acute-on-Chronic Liver Failure in the ICU: A Retrospective Observational Pilot Study

Background: Acute-on-chronic liver failure (ACLF) is a severe, rapidly progressing syndrome in patients with liver cirrhosis, often triggered by bacterial infections. Piperacillin/Tazobactam is a key antibiotic in this setting, and therapeutic drug monitoring (TDM) helps optimize its dosing. This study evaluates the impact of an interprofessional TDM strategy for Piperacillin/Tazobactam in ACLF patients in the ICU. Methods: This retrospective ICU study evaluated an interprofessional TDM approach for optimizing Piperacillin/Tazobactam dosing in critically ill ACLF patients. The team, consisting of physicians, clinical pharmacists, and staff nurses, engaged in shared decision making, collaboratively interpreting TDM results and adjusting the dosing accordingly. This study included 26 patients with ACLF who underwent initial TDM and 7 who received follow-up TDM. Piperacillin/Tazobactam dosing was modified based on TDM recommendations, with serum concentrations measured weekly. Adherence to and the implementation of interprofessional dosing recommendations were systematically analyzed to assess the impact of this approach. Results: The initial TDM showed that 30.8% of patients had Piperacillin/Tazobactam levels within the target range, while 53.8% were above and 15.4% below. The interprofessional team recommended dose reductions in seven patients, increases in three, and no change in eleven, with five requiring antibiotic modifications. At the first follow-up TDM, 20.0% reached target levels, while 80.0% remained above, with no subtherapeutic cases. The team recommended one further dose reduction and maintained dosing in four patients. All recommendations were fully implemented, demonstrating strong adherence to the collaborative protocol. Conclusions: The interprofessional TDM strategy optimized Piperacillin/Tazobactam dosing in ACLF patients with full adherence to the recommendations. This collaborative approach improves outcomes and supports global efforts to curb antibiotic resistance.

Cirrhosis and Faecal microbiota Transplantation (ChiFT) protocol: a Danish multicentre, randomised, placebo-controlled trial in patients with decompensated liver cirrhosis

INTRODUCTION

Liver cirrhosis is a progressive disease with high mortality. Gut microbiota derangement, increased gut permeability, bacterial translocation and chronic inflammation all drive disease progression. This trial aims to investigate whether faecal microbiota transplantation (FMT) may improve the disease course in patients with acute decompensation of liver cirrhosis.

METHODS AND ANALYSIS

In this Danish, multicentre, randomised, double-blinded, placebo-controlled trial, 220 patients with acute decompensation of liver cirrhosis and a Child-Pugh score≤12 will be randomised (1:1) to oral, encapsulated FMT or placebo in addition to standard of care. Before the intervention, the patients will be examined and biological samples obtained, and this is repeated at 1 and 4 weeks and 3, 6 and 12 months after the intervention. The primary outcome is the time from randomisation to new decompensation or death. Secondary endpoints include mortality, number of decompensation events during follow-up and changes in disease severity and liver function.

ETHICS AND DISSEMINATION

The Central Denmark Region Research Ethics Committee approved the trial protocol (no. 1-10-72-302-20). The results will be published in an international peer-reviewed journal, and all patients will receive a summary of the results.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov study identifier NCT04932577.

Serum sodium level is predictive for kidney injury or hyponatremia after modest-volume paracentesis (<5 L) in Asian patients with cirrhosis: A single-centered retrospective observational study

Post-paracentesis circulatory dysfunction (PPCD) is a well-known complication in patients with decompensated cirrhosis undergoing large-volume paracentesis (>5 L ascites removal). PPCD can cause acute kidney injury (AKI) and hyponatremia. Given the generally smaller body size observed in patients of Asian descent, we hypothesized that the removal of <5 L of ascitic fluid (modest-volume paracentesis; MVP) might also contribute to the development of PPCD. We investigated whether MVP could lead to AKI/hyponatremia in Thai patients with cirrhosis and identified the factor(s) associated with these outcomes. This was a retrospective, single-center study that included all consecutive patients with cirrhosis who underwent MVP at our unit between 2020 and 2021. Baseline characteristics and laboratory results obtained within 3 days prior to and 7 to 28 days following paracentesis were collected. The occurrence of AKI or hyponatremia was recorded, and the characteristics and laboratory findings of patients who developed these complications were compared with those who did not. During the study period, 73 MVPs were performed in 39 patients. Eight patients (20.5%) developed AKI/hyponatremia within 7 to 28 days of the procedure. Baseline serum sodium level was significantly lower in patients who developed AKI/hyponatremia compared to those who did not (131.0 ± 5.9 vs 135.6 ± 3.0 mEq/L, P = .004). A serum sodium cutoff value of 132 mEq/L showed a specificity and sensitivity of 0.9 and 0.63, respectively, for predicting the development of AKI/hyponatremia, with an area under the curve of 0.81. These findings highlight that PPCD resulted in AKI/hyponatremia, which was previously not anticipated, can indeed occur after paracentesis of <5 L in Thai cirrhotic patients. These results may have significant implications for clinical decision-making regarding the administration of albumin replacement therapy in Asian patients with cirrhosis who are to undergo paracentesis in future clinical practice.

Impact of acute respiratory distress syndrome on outcome in critically ill patients with liver cirrhosis

We investigated the occurrence and outcome of respiratory failure and ARDS in critically ill patients with liver cirrhosis. This is a retrospective analysis of patients with liver cirrhosis at an ICU during an 8-Year period. An assessment of acute on chronic liver failure as well as the presence and grade of ARDS within the first 72 h of admission to the ICU was performed. A total of 735 patients during the study period. Median age was 58 (50-69) years and 61% (n = 447) were male. 57% (n = 421) of the patients received mechanical ventilation (MV). Liver specific as well as ICU scores on admission were significantly higher in patients with MV. Necessity of vasopressor support (86%vs.25%, p < 0.001) and RRT (50%vs.11%, p < 0.001) was more frequent in patients with MV. The incidence of ARDS within the first 72 h of admission was 8% (n = 61). We observed a 28-day mortality or liver transplantation rate of 54% (n = 196) and 66% (n = 66%) in patients with MV and ARDS, respectively. After 90-days 63% (n = 226) with MV and 70% (n = 43) with ARDS were dead or received liver transplantation. ARDS is a prognostic factor for mortality in patients with liver cirrhosis admitted to the ICU. One out of ten critically ill cirrhotic patients develop ARDS within 72 h after admission. Although mortality rates are high initially critical care therapy should not be withheld and must be reevaluated regularly.

A new prognostic model based on serum apolipoprotein AI in patients with HBV-ACLF and acutely decompensated liver cirrhosis

BACKGROUND/AIM

To investigate the prognostic value of circulating apolipoprotein AI (apoAI) levels and develop a new prognostic model in individuals with acute-on-chronic liver failure (ACLF) and acute decompensation (AD) of liver cirrhosis caused by hepatitis B virus (HBV) infection.

METHODS

Baseline levels of serum lipids were measured, and data concerning the presence of complications were collected from 561 HBV-ACLF and AD patients. Survival analysis was conducted by log-rank test. Proportional hazards model was used to perform multivariate analysis. The dynamics of serum apoAI levels were also explored in 37 HBV-ACLF patients.

RESULTS

In the cohort, the negatively correlation was found between the Model for End-Stage Liver Disease (MELD) score and serum apoAI levels (r = -0.7946, P < 0.001). Circulating apoAI concentration was an independent risk factor for 90-day survival according to Cox multivariate analysis. A new prognostic score-integrated serum lipid profile for ACLF patients (Lip-ACLF score = 0.86×International Normalized Ratio (INR) + 0.0034×total bilirubin (TBIL) (µmol/L) + 0.99× hepatorenal syndrome (HRS) (HRS: no/1; with/2) + 0.50×hepatic encephalopathy (HE) (grade/ponint: no/1; 1-2/2; 3-4/3) - 2.97×apoAI (g/L) + 5.2) was subsequently designed for the derivation cohort. Compared to MELD score, Child-Turcotte-Pugh (CTP) score or apoAI, Lip-ACLFs was superior for the prediction of 90-day outcomes (receiver operating characteristic curve (ROC): 0.930 vs. 0.885, 0.833 or 0.856, all P < 0.01), as was the validation cohort (ROC 0.906 vs. 0.839, 0.857 or 0.837, all P < 0.05). In Kaplan‒Meier survival analysis, low apoAI levels (< 0.42 g/L) at baseline indicated poor prognosis in ACLF and AD patients. Among the 37 patients, the deceased individuals were characterised with significantly decreased serum apoAI levels during the follow-up test compared with those at baseline (P < 0.05), whereas in patients with a good prognosis, the serum apoAI levels remained stable during the follow-up.

CONCLUSION

In HBV-ACLF and AD patients, lower serum apoAI levels suggest greater disease severity and 90-day mortality risk. For predicting the short-term prognosis of these patients, the new Lip-ACLF score might serve as a potential model.

Temporal evolution of living donor liver transplantation survival-A United Network for Organ Sharing registry study

Living donor liver transplantation (LDLT) is a curative treatment for various liver diseases, reducing waitlist times and associated mortality. We aimed to assess the overall survival (OS), identify predictors for mortality, and analyze differences in risk factors over time. Adult patients undergoing LDLT were selected from the United Network for Organ Sharing database from inception (1987) to 2023. The Kaplan-Meier method was used for analysis, and multivariable Cox proportional hazard models were conducted. In total, 7257 LDLT recipients with a median age of 54 years (interquartile range [IQR]: 45-61 years), 54% male, 80% non-Hispanic White, body mass index of 26.3 kg/m2 (IQR: 23.2-30.0 kg/m2), and model for end-stage liver disease score of 15 (IQR: 11-19) were included. The median cold ischemic time was 1.6 hours (IQR: 1.0-2.3 hours) with 88% right lobe grafts. The follow-up was 4.0 years (IQR: 1.0-9.2 years). The contemporary reached median OS was 17.0 years (95% CI: 16.1, 18.1 years), with the following OS estimates: 1 year 95%; 3 years 89%; 5 years 84%; 10 years 72%; 15 years 56%; and 20 years 43%. Nine independent factors associated with mortality were identified, with an independent improved OS in the recent time era (adjusted hazards ratio: 0.53; 95% CI: 0.39, 0.71). The median center-caseload per year was 5 (IQR: 2-10), with observed center-specific improvement of OS. LDLT is a safe procedure with excellent OS. Its efficacy has improved despite an increase of risk parameters, suggesting its limits are yet to be met.

Survival benefit of liver transplantation utilizing marginal donor organ according to ABO blood type

The current liver transplantation (LT) allocation policy focuses on the MELD scores, often overlooking factors like blood type and survival benefits. Understanding blood types' impact on survival benefits is crucial for optimizing the MELD 3.0 classification. This study used the United Network for Organ Sharing national registry database (2003-2020) to identify LT characteristics per ABO blood type and to determine the optimal MELD 3.0 scores for each blood type, based on survival benefits. The study included candidates of LT aged 18 years or older listed for LT (total N=150,815; A: 56,546, AB: 5841, B: 18,500, O: 69,928). Among these, 87,409 individuals (58.0%) underwent LT (A:32,156, AB: 4,362, B: 11,786, O: 39,105). Higher transplantation rates were observed in AB and B groups, with lower median MELD 3.0 scores at transplantation (AB: 21, B: 24 vs. A/O: 26, p <0.01) and shorter waiting times (AB: 101 d, B:172 d vs. A: 211 d, O: 201 d, p <0.01). A preference for donation after cardiac death (DCD) was seen in A and O recipients. Survival benefit analysis indicated that B blood type required higher MELD 3.0 scores for transplantation than A and O (donation after brain death transplantation: ≥15 in B vs. ≥11 in A/O; DCD transplantation: ≥21 in B vs. ≥11 in A, ≥15 in O). The study suggests revising the allocation policy to consider blood type for improved post-LT survival. This calls for personalized LT policies, recommending higher MELD 3.0 thresholds, particularly for individuals with type B blood.

Isolated tricuspid regurgitation: a new entity to face. Prevalence, prognosis and treatment of isolated tricuspid regurgitation

In recent years the tricuspid is no longer considered the "forgotten valve," but nowadays, specialists focused the treatment of tricuspid regurgitation (TR) especially at the time of left heart valve (LHV) surgery, overlooking the emerging entity of isolated TR. Its incidence appears to be rising along with the higher prevalence of atrial fibrillation (AF), intracardiac devices and intravenous drug users. Hence, the aim of the present review is to summarize the available evidences in terms of natural history, clinical presentation and treatment of isolated TR. Tricuspid regurgitation is commonly classified into primary and secondary etiology. Primary or organic TR is relatively uncommon (10%) and may be due to either acquired or congenital diseases. Conversely, secondary or functional TR, caused by dilatation and flattening of the tricuspid annulus along with increase of leaflet tethering due to the remodeling of the right ventricle (RV) has become in last decade an emerging entity. Secondary TR may be due grade progression after left heart valve surgery, to previous TV surgery failure, RV remodeling or permanent AF. Primary TR causes pure volume overload on initially normal right-sided cardiac chambers. Conversely, RV enlargement is the major finding of secondary TR; RV systolic area, RV spherical index and right atrial area were identified as independent factors correlated with TV tethering height. The RV has less muscle mass than the left ventricle, and RV systolic function is therefore more load sensitive. Thus, pulmonary hypertension results in an early fall in RV ejection fraction and associated RV enlargement. An interesting entity is isolated TR related to AF, whose prevalence is estimated to be 14% in recent studies. It is known to cause dilation of the mitral and tricuspid annulus, together with changes in the dynamic mechanisms that govern the variation in area size during the cardiac cycle; as a matter of fact the relative change in TA area was significantly lower in AF (13.5%) than in sinus rhythm (SR) (33.1%). In isolated TR, medical therapy (MT) is indicated only in patients with secondary TR having also severe RV/LV dysfunction or severe pulmonary hypertension. Diuretics are the main MT in case of isolated TR in the presence of right HF in carefully selected candidates, surgery can be performed safely with good long-term survival and it should be considered early at first stages. In the treatment of isolated TR we had two diametrically opposed approaches so far, such as medical therapy, based almost exclusively on diuretics, and surgical therapy. In this scenario, trans-catheter approach is gaining momentum, including repair or replacement treatment. The former sees the use of devices for direct or indirect annuloplasty, or leaflet approximation. The second consists of orthotopic or heterotopic replacement devices (transcatheter tricuspid valve replacement devices). Evidences from randomized studies and longer follow-up will help clarify the best patient selection and treatment strategies.

Variation in intention-to-treat survival by MELD subtypes: All models created for end-stage liver disease are not equal

BACKGROUND & AIMS

Kidney dysfunction is a major determinant of prognosis in patients with decompensated cirrhosis awaiting transplantation. We hypothesized that for identical model for end-stage liver disease (MELD) scores at listing, outcomes before and after liver transplantation may vary if the predominant driver of the MELD score is serum creatinine (Cr) vs. serum bilirubin (Br) or international normalized ratio (INR).

METHODS

We evaluated all adult patients registered for liver transplantation (LT) between 2016-2020 and excluded patients receiving MELD exceptions or undergoing dual organ transplantation. Using K-Means clustering analysis, we classified each patient as MELD-Br, MELD-INR or MELD-Cr depending on the dominant variable for their MELD score. The primary outcome was intent-to-treat (ITT) survival, defined as survival within 1 year from listing with or without LT.

RESULTS

MELD scores of LT waitlist registrants were clustered into three subtypes: MELD-Br (n = 13,658), MELD-INR (n = 13,809), and MELD-Cr (n = 12,412). One-year ITT survival rates were 78% (MELD-Br), 75% (MELD-INR), and 65% (MELD-Cr), p <0.01. ITT survival was lower for each MELD subtype for females compared to males (e.g. MELD-Cr: 63% females vs. 67% males, p <0.0001). The MELD-Cr subtype had the highest MELD at listing (MELD-Cr 23.4 vs. MELD-Br 19.2 vs. MELD-INR 21.0) and the largest decline in MELD over 3 months (23% vs. 12% vs. 21%). In adjusted analyses including MELD-Na, MELD-Cr was associated with higher waitlist mortality (hazard ratio 1.339, 95% CI 1.279-1.402) and lower LT rates (hazard ratio 0.688, 95% CI 0.664-0.713) compaed to the other subtypes.

CONCLUSIONS

For equivalent listing practices, registrants with the MELD-Cr subtype have lower ITT survival. MELD subtype may serve as a more sophisticated variable for dynamic assessment of mortality risk and to guide organ allocation.

IMPACT AND IMPLICATIONS

The model for end-stage liver disease (MELD) score is an excellent predictor of waitlist mortality; however, our work highlights that the driver of a patient's MELD score matters and particularly those driven by elevated creatinine are associated with lower 1-year intent-to-treat survival. The 1-year intent-to-treat survival is also lower for women compared to men within the Cr-dominant subtype. These results are important for physicians and patients undergoing LT evaluation as creatinine may serve as a marker of prognosis and even if creatinine levels improve the prognosis remains poor, necessitating discussion about alternative pathways for transplant. Our work also highlights that the type of kidney injury matters, in that those with acute kidney injury were more likely to die or remain on the waitlist than those with chronic kidney disease within the creatinine-dominant subtype.

Larsucosterol for the Treatment of Alcohol-Associated Hepatitis

BACKGROUND

Larsucosterol is a DNA methyltransferase inhibitor in development for alcohol-associated hepatitis (AH), a disease for which there is no approved therapy.

METHODS

In this phase 2b trial, patients with severe AH were randomly assigned 1:1:1 to receive 30 mg or 90 mg of larsucosterol or placebo; a second dose was administered after 72 hours if the patient remained hospitalized. All patients received supportive care as determined by investigators. Patients in the placebo group, if prescribed, received 32 mg of methylprednisolone, while patients in the larsucosterol groups received matching placebo capsules. The primary end point was 90-day mortality or liver transplant (LT) rate. The key secondary end point was 90-day mortality. We prespecified the reporting of U.S. results separately.

RESULTS

Among 307 enrolled patients, 301 received at least one treatment dose. The difference in 90-day mortality or LT between the 30-mg or 90-mg larsucosterol and placebo groups did not reach statistical significance. Ninety-day mortality in the placebo and the 30-mg and 90-mg groups was 25 out of 103, 15 out of 102, and 17 out of 102, respectively. Among U.S. patients (76% of all enrolled patients), there were 21 deaths and 4 LTs among 77 patients in the placebo group, 8 deaths and 5 LTs among 73 patients in the 30-mg larsucosterol group, and 10 deaths and 8 LTs among 77 patients in the 90-mg larsucosterol group. In patients who were treated within less than 10 days of hospitalization (75%), mortality in the placebo group was 20 out of 79 (U.S. patients 17/57), mortality in the 30-mg larsucosterol group was 7 out of 74 (U.S. patients 4/57), and mortality in the 90-mg larsucosterol group was 13 out of 77 (U.S. patients 9/66). Most adverse events arising during treatment were attributable to hepatic disease, and there was no imbalance in adverse events that could not be ascribed to liver disease.

CONCLUSIONS

The trial did not meet the primary end point of showing a beneficial effect of larsucosterol on 90-day mortality or LT in patients with severe AH. Equipoise has been established for a further trial of larsucosterol on AH survival. (The trial was funded by the DURECT Corporation; its ClinicalTrials.gov number is NCT04563026.).

Involvement of β-catenin expression in hepatocellular carcinoma prognosis in a cohort of patients undergoing curative treatment

BACKGROUND

Hepatocellular carcinoma is a tumor of epithelial origin that arises from the action of different carcinogens on the hepatocytes and has a high worldwide incidence. The prognostic markers of this disease have not been completely established. Mutations in the gene encoding β-catenin are overexpressed in hepatocellular carcinoma. The objective of our study was to correlate the molecular expression of β-catenin in hepatocellular carcinoma with the already known prognostic markers.

METHODS

We conducted an observational and prospective cohort study on adult patients diagnosed with hepatocellular carcinoma from whom samples of nontumor and tumor liver parenchyma were taken intraoperatively to correlate the molecular expression of β-catenin in hepatocellular carcinoma with the known prognostic markers.

RESULTS

A total of 81 samples were collected, of which 48 met the inclusion criteria. The final sample was divided into patients with a diagnosis of hepatocellular carcinoma on a cirrhotic liver, corresponding to 31 patients (64.6%), and patients with a diagnosis of hepatocellular carcinoma on a noncirrhotic liver, corresponding to 17 patients (35.4%). We found that overexpression of β-catenin and the neutrophil/lymphocyte ratio are independently related to disease-free survival, and both overexpression and molecular repression of β-catenin are independently related.

CONCLUSION

Molecular overexpression of β-catenin in hepatocellular carcinoma compared with nontumor tissue is associated with worse disease-free survival, and its combination with a high neutrophil-lymphocyte ratio worsens this prognosis.

Cryptococcosis in wait-listed liver transplant candidates: Prevalence, manifestations, and risk factors

BACKGROUND

Liver cirrhosis compromises immunity against cryptococcosis, and liver transplant recipients tend to develop the disease earlier after transplantation, possibly due to unrecognized pretransplant infection. We assessed the prevalence and characteristics of cryptococcosis among liver transplant candidates and whether pre-transplant cryptococcal antigen (CrAg) can detect the disease before transplantation.

METHODS

We retrospectively included liver transplant candidates in a tertiary hospital during 2017-2022. Serum CrAg and pulmonary computed tomography were incorporated in routine transplant evaluation. Other investigations were done if indicated. Cryptococcosis was diagnosed by positive culture or CrAg. Risk factors for cryptococcosis were also assessed.

RESULTS

Of the 377 candidates with a median MELD-Na score of 18, 84.4% had hepatitis B virus (HBV) infection. Cryptococcosis was diagnosed in 10 (2.6%) candidates, by CrAg in 6, culture in 2, or both in 2. Only 3 had fever, and 3 were asymptomatic; 7 had pulmonary cryptococcosis. Of the 10 candidates with cryptococcosis, one underwent transplantation after 143-day antifungals. Of the 87 candidates undergoing liver transplantation, one (1.2%) recipient developed cryptococcosis 14 days post-transplant with negative CrAg three weeks before transplantation. HBsAg-positive chronic HBV infection with HBV DNA loads <2000 IU/mL was significantly associated with cryptococcosis (odds ratio 4.4, 95% confidence interval 1.2-16.5, p = 0.03) after the adjustment of MELD-Na score.

CONCLUSIONS

The prevalence of cryptococcosis was 2.6% among our liver transplant candidates and CrAg detected 80% of the cases. Disease presentation was mild and pulmonary disease predominated. HBsAg-positive chronic HBV infection with HBV DNA loads <2000 IU/mL was significantly associated with cryptococcosis.

Measured glomerular filtration rate predicts liver related deaths better than estimated glomerular filtration rate in advanced chronic liver disease

BACKGROUND & AIMS

Renal dysfunction is prevalent in advanced chronic liver disease (aCLD) and is associated to liver-related death (LRD). This makes a reliable evaluation of renal function (RF) a crucial aspect. RF can be estimated by formulas or measured by gold standard method. Estimated RF is not reliable in aCLD. However, there is a lack of information on the reliability of formulas in the prediction of LRD.

METHODS

We analysed a cohort of patients with aCLD in whom RF was measured by the plasma clearance of iohexol (mGFR) and estimated (eGFR) by formulas: MDRD, CKD-EPI, Royal Free Hospital (RFHC), GRAIL and Mindikoglu-eGFR. LRD was defined as death from hepatic causes. Multivariable analysis was used to evaluate association of mGFR or eGFR with LRD.

RESULTS

161 patients were evaluated, with median follow-up of 28 months, 58 died from LRD. In overall group mGFR (OR 0.99; p = 0.022) and formulas: CKD-EPI (OR 0.98; p = 0.044), GRAIL (OR 0.98; p = 0.038) was associated with LRD. In patients with normal creatinine levels (≤ 1.1 mg/dL), mGFR (OR 0.99; p = 0.031) was whereas any formula was not associated with LRD.

CONCLUSIONS

eGFR appears as an unreliable method for predicting LRDs in aCLD, especially in those with lower creatinine levels. By contrast, mGFR seems to be a superior predictor.

Robotic compared with laparoscopic cholecystectomy: A National Surgical Quality Improvement Program comparative analysis

BACKGROUND

Data demonstrating the clinical benefit of robotic cholecystectomy over the laparoscopic approach are lacking. Herein, we aim to evaluate whether robotic cholecystectomy is associated with improved surgical outcomes compared with laparoscopic cholecystectomy.

STUDY DESIGN

This is a retrospective cohort study that used the American College of Surgeons National Surgical Quality Improvement Program to compare the outcomes of patients who underwent robotic or laparoscopic cholecystectomy for benign indications in 2022.

RESULTS

Of the 59,216 patients identified, 53,746 underwent laparoscopic cholecystectomy and 5,470 robotic. Compared with the robotic cohort, the patients in the laparoscopic cholecystectomy group were older (50.4 vs 49.7 years), were of the male sex (32.7% vs 29.7%), and comprised a greater percentage of other races than White, African American, and Asian (28.6% vs 14.8%). Multivariable logistic regression revealed that robotic cholecystectomy compared with the laparoscopic approach was independently associated with a lower risk of Clavien-Dindo complications grade 3 or 4 (odds ratio, 0.82; 95% confidence interval, 0.69-0.98), a lower rate of conversion to open (odds ratio, 0.44; 95% confidence interval, 0.32-0.61), and lower odds of requiring hospitalization ≥24 hours (odds ratio, 0.76; 95% confidence interval, 0.71-0.81). There were no significant differences between the 2 approaches in terms of reoperation (odds ratio, 0.69; 95% confidence interval, 0.47-1.00) and readmission (odds ratio, 0.94; 95% confidence interval, 0.82-1.10).

CONCLUSION

Robotic cholecystectomy was independently associated with a lower risk of serious complications, lower rate conversion to open, and hospitalization ≥24 hours compared with laparoscopic cholecystectomy. These findings suggest that new technologies might enhance the safety of minimally invasive surgery.

Systematic Sex-Based Inequity in the MELD Score-Based Allocation System for Liver Transplantation in Germany

In liver allocation systems based on the Model for End-stage Liver Disease (MELD) score, sex inequities have been identified in countries with high organ donation rates. Whether similar inequities exist in regions with average to low donation rates remained unclear. We assessed the impact of sex on transplantation rates, waiting list mortality and post-transplant survival in 25,943 patients waitlisted for liver transplantation in Germany between 2003 and 2017 using competing risk analysis. Women are currently underrepresented on the waiting list (33.3%) and among transplant recipients (31.1%) compared to their proportion of severe liver disease cases (35.1%). The introduction of MELD-based allocation has worsened this disadvantage [HR before: 0.89 (0.81-0.98), after: 0.77 (0.74-0.81)]. Three key factors contribute to this disparity: Women have lower creatinine levels despite worse renal function, reducing their MELD score (median 1, 0-3). Second, exceptional MELD points are more frequently granted to men [HR 1.61 (1.54-1.69) compared to regular allocation]. Third, the small height of women has the highest impact on the probability of not being transplanted [adjusted HR 0.85 (0.81-0.9)]. Even in countries with lower organ donation rates, MELD-based allocation leads to sex inequity. Measures are needed to ensure sex-neutral liver allocation in MELD-based systems worldwide.

Clinical outcomes of COVID-19 in patients with liver cirrhosis - a propensity-matched analysis from a multicentric Brazilian cohort

BACKGROUND

Cirrhosis has been pointed out as a clinical entity that leads to worse clinical prognosis in COVID-19 patients. However, this concept is controversial in the literature. We aimed to evaluate clinical outcomes by comparing patients with cirrhosis to those without cirrhosis in a Brazilian cohort.

METHODS

Data from 20,164 COVID-19 inpatients were collected from 41 hospitals in Brazil between March to September 2020 and March 2021 to August 2022. We compared 117 patients with cirrhosis to 632 matched controls. A propensity score model was used to adjust for potential confounding variables, incorporating some predictors: age, sex at birth, number of comorbidities, hospital of admission, whether it was an in-hospital clinical manifestation of COVID-19, and admission year. Closeness was defined as being within 0.16 standard deviations of the logit of the propensity score.

RESULTS

The median age was 61 (IQR 50-70) years old, and 63.4% were men. There were no significant differences in the self-reported symptoms. Patients with cirrhosis had lower median hemoglobin levels (10.8 vs. 13.1 g/dl), lower platelets (127,000 vs. 200,000 cells/mm3), and leukocyte counts, as well as lower median C-reactive protein (63.0 vs. 76.0 p = 0.044) when compared to controls. They also had higher mortality compared to matched controls (51.3% vs. 21.7%, p < 0.001). They also had higher frequencies of admission in an intensive care unit (51.3% vs. 38.0%, p = 0.007), invasive mechanical ventilation (43.9% vs. 26.6%, p < 0.001), dialysis (17.9% vs. 11.1%, p = 0.038), septic shock (23.9% vs. 14.9%; p = 0.015) and institution of palliative care (19.7% vs. 7.4%; p < 0.001).

CONCLUSIONS

This study has shown that COVID-19 inpatients with cirrhosis had significantly higher incidence of severe outcomes, as well as higher frequency of institution of palliative care when compared to matched controls. Our findings underscore the need for these patients to receive particular attention from healthcare teams and allocated resources.

European System for Cardiac Operative Risk Evaluation II and Liver Dysfunction

Background: The importance of liver dysfunction in predicting mortality in patients undergoing cardiovascular surgery is an important topic due to the general desire to improve current risk scores such as EUROSCORE II (European System for Cardiac Operative Risk Evaluation), with EUROSCORE III being currently under development. The model for End-Stage Liver Disease (MELD) Score has already proven its utility in predicting outcomes for patients undergoing abdominal, cardiovascular or urological surgery. In the present study, we want to see its usefulness in proving the postoperative mortality in patients undergoing coronary artery bypass surgery. Methods: This was a retrospective study, and it included 185 patients, with 93 survivors being randomly chosen from a total of 589 surviving patients using age, emergency and the weight of cardiac procedures as criteria to match the 92 deceased patients during hospitalization in the postoperative period who underwent coronary artery bypass grafting (CABG) alone or CABG and other concomitant cardiovascular interventions during a 10-year period of time. We calculated for all these patients, at the time of admission, the MELD Score and EUROSCORE II, and we analyzed the predictive performance of the two scores and their constituents. Results: In the multivariable model, patients with a MELD Score ≥ 5.54 had a 2.38-fold increased risk of death (95% C.I.: 1.43-3.96, p = 0.001), while those with a EUROSCORE ≥ 10.37 had a 8.66-fold increased risk of death (95% C.I.: 3.09-24.29, p < 0.001). After combining the two scores, the conditional scenario achieved a high overall accuracy of 84.32% (p < 0.001) in predicting mortality. Conclusions: Patients with a MELD Score ≥ 5.54, had good sensitivity and a very good specificity in terms of mortality prediction, but the conditional scenario, leveraging both risk scores, i.e., the MELD Score and EUROSCORE, offers the highest utility in terms of enhancing mortality prediction regarding these patients.

Association between Clot Waveform Analysis Parameters and the Severity of Liver Cirrhosis

BACKGROUND

 Clot waveform analysis (CWA) provides a global assessment of hemostasis and may be useful for patients with cirrhosis with complex hemostatic abnormalities. This study aimed to assess the association between prothrombin time (PT-) and activated partial thromboplastin time (aPTT-) based CWA parameters and cirrhosis severity and prospectively evaluate the role of CWA in predicting mortality and acute decompensation (AD) over 1 year.

METHODS

 This prospective study included adult patients with cirrhosis between June 2021 and December 2023 at Chulalongkorn University Hospital. The PT- and aPTT-based CWA parameters were obtained using an automated coagulation analyzer.

RESULTS

 A total of 560 patients with cirrhosis were included; 165 (29.5%) and 47 (11.5%) had Child-Turcotte-Pugh (CTP) B and C cirrhosis, respectively. The PT- and aPTT-based CWA parameters, including maximum velocity (min1), maximum acceleration (min2), and maximum deceleration (max2), were significantly lower (p ≤ 0.05) in patients with decompensated cirrhosis than in those with compensated cirrhosis. Additionally, CWA values were significantly higher in patients with higher CTP and Model for End-Stage Liver Disease (MELD) scores. Multivariable analysis revealed that liver stiffness (LS) and max2 of PT-based CWA assay were independently associated with CTP B/C. In addition, min2 and max2 of PT-based CWA assay were independently associated with 1-year mortality. No significant differences in CWA parameters were observed between patients with and without portal vein thrombosis. CWA parameters were not related to AD during the 1-year follow-up.

CONCLUSION

 A hypocoagulable profile based on CWA parameters is associated with advanced-stage cirrhosis. CWA may be a useful objective marker for assessing cirrhosis severity and predicting 1-year mortality.

Predictive value of neutrophil-to-lymphocyte ratio for long-term adverse outcomes in cirrhosis patients post-transjugular intrahepatic portosystemic shunt

The neutrophil-to-lymphocyte ratio (NLR) may predict outcomes in end-stage liver disease, but its value after transjugular intrahepatic portosystemic shunt (TIPS) is unclear. This study explored the link between NLR and long-term outcomes in decompensated cirrhosis patients post-TIPS. We retrospectively analyzed 184 patients treated between January 2016 and December 2021, noting demographic data, lab results, and follow-up outcomes, including liver transplantation or death. Cox regression, adjusted for various factors, showed that NLR is an independent predictor of post-TIPS progression (HR 1.665; 95% CI 1.149-2.414; P = 0.007). Patients were divided into tertiles based on NLR. The medium tertile had a 3.51-fold increased risk of progression compared to the lowest (HR 3.510; 95% CI 1.104-11.153, P = 0.033), and the highest tertile had a 5.112-fold increase (HR 5.112; 95% CI 1.653-15.806, P = 0.005). This suggests that NLR is a valuable prognostic marker for long-term progression in these patients, highlighting the role of systemic inflammation.

Robust Predictive Performance of the SALT-M Score for Clinical Outcomes in Asian Patients With Acute-on-Chronic Liver Failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a syndrome of patients with chronic liver disease presenting with multiple organ failures. Recently, Sundaram-ACLF-LT Mortality (SALT-M) score has been developed to predict 1-year post-liver transplantation mortality. We validated the SALT-M score in a large-volume, Asian single-centre cohort.

AIMS

We validated the SALT-M score in a large-volume, Asian single-centre cohort.

METHODS

We analysed 224 patients of ACLF grade 2-3. Area under the receiver operating characteristic curve (AUROC) and concordance index (c-index) were used to assess and compare the predictability of posttransplant mortality of SALT-M and other scores. Moreover, we compared the survivals of patients with high and low SALT-M, in conjunction with MELD score and ACLF grade.

RESULTS

The AUROC for prediction of 1-year post-LT survival was higher in SALT-M (0.691) than in MELD, MELD-Na, MELD 3.0 and delta-MELD. Similarly, the c-index of the SALT-M (0.650) was higher than aforementioned MELD systems. When categorised by the cut-off of SALT-M ≥ 20 and MELD ≥ 30, patients with high SALT-M exhibited lower post-LT survival than those with low SALT-M scores regardless of high or low MELD (40.0% for high SALT-M/high MELD vs. 42.9% for high SALT-M/low MELD vs. 73.8% for low SALT-M/high MELD vs. 63.7% for low SALT-M/low MELD, p < 0.001). In patients with ACLF grade 3, SALT-M effectively stratified the posttransplant mortality (39.4% for high SALT-M vs. 63.1% for low SALT-M, p = 0.018).

CONCLUSIONS

SALT-M outperformed previous MELD systems for predicting posttransplant mortality in Asian LT cohort with severe ACLF. Transplantability for patients with severe ACLF could be determined based on SALT-M.

Development and external validation of Global Leadership Initiative on Malnutrition-dictated nomograms predicting long-term mortality in hospitalized patients with cirrhosis

OBJECTIVES

Global Leadership Initiative on Malnutrition (GLIM) criteria have gradually accounted for the mainstay evaluating nutritional status. We sought to establish GLIM-dictated nomograms with other prognostic factors influencing long-term mortality and externally validate their predictive performance in decompensated cirrhosis.

METHODS

The derivation cohort comprised 301 patients presenting with cirrhosis-associated acute insults, while the validation cohort encompassed 101 subjects from another tertiary hospital. Two nomograms were constructed to predict the 1-year all-cause mortality by integrating the GLIM criteria. The study population was stratified into low-, moderate- and high-risk mortality groups according to aforesaid proposed models.

RESULTS

Adjusting Child-Turcotte-Pugh classification (Nomo#1) or Model for End-stage Liver Disease-Sodium score (Nomo#2) separately, the GLIM criteria were independently associated with 1-year mortality in the multivariate Cox regression analysis (Nomo#1 hazard ratio (HR) = 3.139, p < 0.001; Nomo#2 HR = 3.456, p < 0.001). The C-index and time AUC for Nomo#1 and Nomo#2 performed significantly better than those of the GLIM criteria or conventional scoring systems alone. The survival rate of the low-risk group was significantly higher than those of the moderate- or high-risk groups (Nomo#1: 95% vs 65.8% vs 33.3%, p < 0.001; Nomo#2: 94.3% vs 64.5% vs 25%, p < 0.001). Furthermore, our proposed models exhibited moderate prediction accuracy and may identify malnourished patients with poor survival conditions in the external validation cohort.

CONCLUSION

GLIM criteria-defined malnutrition negatively impacted long-term mortality in the context of decompensated cirrhosis. Our established nomograms may predict survival status with sufficient discriminatory ability, alongside good consistency and clinical benefits, supporting their effectiveness in daily practice.

Histologic evidence of neutrophil extracellular traps and fibrin(ogen) deposition in liver biopsies from patients with inflammatory liver disease

Background

Liver disease is often characterized by the activation of coagulation and inflammation. Experimental studies suggest that the interaction between neutrophils and platelets with local activation of coagulation could contribute to liver injury progression, but there have been limited studies in humans.

Objectives

We studied the hemostatic components and neutrophil extracellular traps (NETs) in liver biopsies from patients with different inflammatory liver diseases.

Methods

Liver biopsies from patients with inflammatory liver disease (alcoholic steatohepatitis [ASH], autoimmune hepatitis, primary sclerosing cholangitis, metabolic-associated steatohepatitis, and allograft ischemia-reperfusion injury (IRI), each n = 20) were stained for fibrin(ogen), platelets, and NETs. The correlation of NET formation with deposition of hemostatic components and laboratory measures of disease severity was investigated.

Results

In 75% of the liver biopsies, no fibrin(ogen) was detectable, and only 20% of the biopsies showed minimal deposition. Overall, 50% of liver biopsies stained positive for NETs. Platelet deposition and NET formation were highest in IRI, where it correlated with histologic severity of injury (r = .61 [95% CI, .22-.84]; P < .01) and ASH. Platelet deposition was associated with NET formation (r = .44 [95% CI, .27-.59]; P < .001) and colocalized in the biopsies. NET formation, but not fibrin and platelet deposition, was moderately associated with the model of end-stage liver disease score (r = .29 [95% CI, .07-.49]; P < .01).

Conclusion

In contrast to experimental studies, we demonstrated minimal intrahepatic fibrin(ogen) deposition in different types of human inflammatory liver disease. Histologic evidence for intrahepatic NETs was common and most pronounced in acute ASH and IRI and was associated with platelet deposition and disease severity.

Survival benefit associated with liver transplantation for hepatocellular carcinoma based on tumor burden scores at listing

INTRODUCTION

Liver transplantation (LT) provides significant survival benefits to patients with unresectable HCC. In the United States, organ allocation policies for HCCs within the United Network for Organ Sharing criteria do not prioritize patients based on their differences in oncological characteristics. This study assessed whether transplant-associated survival benefits (TASBs) vary among patients with different tumor burden scores (TBS) measured at the time of listing.

METHODS

We analyzed data from adults applying for HCC MELD exception points between 2002 and 2019, with follow-up until December 2023, using the Scientific Registry of Transplant Recipients. TBS was determined based on the largest tumor diameter and number of HCCs. Patients were categorized into low (≤3), intermediate (3.1-5), and high (>5) TBS groups. TASB was measured as the difference in 5-year survival with and without LT.

RESULTS

This study included 36,634 LT candidates. High-TBS patients had higher waitlist dropout rates and marginally lower post-transplant survival, resulting in a significantly greater TASB. The 5-year TASB for the low, intermediate, and high TBS groups were 15.7, 22.1, and 25.0 months, respectively. The adjusted survival benefit expressed in 5-year survival differences was 21.9%, 34.5%, and 39.4% in the low, intermediate, and high TBS groups, respectively (p<0.001).

CONCLUSIONS

Higher TBS during listing correlates with greater LT benefits for patients with unresectable HCC within UNOS criteria. We conclude that organ allocation policies in the United States should prioritize patients with high TBS due to their increased risk of dropout and comparable post-transplant survival when compared to patients with less advanced tumors.

Development and validation of a machine learning-based model to predict survival in patients with cirrhosis after transjugular intrahepatic portosystemic shunt

BACKGROUND

Although numerous prognostic scores have been developed for patients with cirrhosis after Transjugular intrahepatic portosystemic shunt (TIPS) placement over years, an accurate machine learning (ML)-based model remains unavailable. The aim of this study was to develop and validate a ML-based prognostic model to predict survival in patients with cirrhosis after TIPS placement.

METHODS

In this retrospective study in China, patients diagnosed with cirrhosis after TIPS placement from 2014 to 2020 in our cohort were included to develop a ML-based model. Patients from the other two tertiary hospitals between 2016 and 2022 were as external validation cohort. The random forest (RF) model was built using 7 selected features via the least absolute shrinkage and selection operator (LASSO) regression, and subsequent 10-fold cross-validation was performed.

FINDINGS

A total of 400 patients in our cohort were included (median age and interquartile range, 59 (50, 66); 240 men). Two hundred and eighty patients made up the training set and 120 were in the testing set, and 346 patients were included in the external validation cohort. Seven attributes were selected: Na, ammonia (Amm), total bilirubin (Tb), albumin (Alb), age, creatinine (Cr), and ascites. These parameters were included in a new score named the RF model. The accuracy, precision, recall, and F1 Score of the RF model were 0.84 (95% CI: 0.76, 0.91), 0.84 (95% CI: 0.77, 0.91), 0.99 (95% CI: 0.95, 1.00), 0.91 (95% CI: 0.81, 0.10) in the testing set, and 0.88 (95% CI: 0.84, 0.91), 0.89 (95% CI: 0.85, 0.92), 0.99 (95% CI: 0.97, 1.00), 0.93 (95% CI: 0.85, 0.97) in the validation cohort, respectively. The calibration curve showed a slope of 0.875 in the testing set and a slope of 0.778 in the external validation cohort, suggesting well calibration performance. The RF model outperformed other scoring systems, such as the (Child-Turcotte-Pugh score) CTP, (model for end-stage liver disease) MELD, (sodium MELD) MELD-Na, (Freiburg index of post-TIPS survival) FIPS and (Albumin-Bilirubin) ALBI, showing the highest (area under the curve) AUC of 0.82 (95% CI: 0.72, 0.91) and 0.7 (95% CI: 0.60, 0.79) in predicting 1-year survival across the testing set and external validation cohort.

INTERPRETATION

This study developed a RF model that better predicted 1-year survival for patients with cirrhosis after TIPS placement than the other scores.

FUNDING

National Natural Science Foundation of China (grant numbers 81900552 and 82370628).

Adaptation and validation of an abbreviated version of the SIPAT integrated psychosocial risk scale in patients with liver cirrhosis candidates for liver transplantation (SIPAT-11)

INTRODUCTION

Patients with liver cirrhosis who are candidates for liver transplantation must be evaluated both clinically and socially in order to obtain the optimal outcomes and avoid futile therapeutic measures. For the evaluation of the social aspects in these patients, no validated scale in Spanish is available. The SIPAT (Stanford Integrated Psychosocial Assessment for Transplantation) scale is an instrument that measures the social, family and psychological aspects in candidates for solid organ transplantation. The objective of this study is to adapt and validate an abbreviated version of the SIPAT scale in Spanish for patients with liver cirrhosis.

MATERIAL AND METHODS

Prospective observational study carried out in the Hepatology Unit of the La Fe Unversity Hospital in Valencia, by questionnaire validation methodology. To analyze the reliability of the questionnaire, the internal consistency of all variables was calculated, for variability an exploratory factor analysis, and for stability the test-retest test was carried out.

RESULTS

96 patients who were admitted for decompensated cirrhosis to the Hepatology Unit of the La Fe Hospital in Valencia between November 1, 2017 and January 31, 2017 were selected. 84% were men, the mean age was 60.01 (SD 10.12) years. In 73.2% of those admitted, the etiology of cirrhosis was alcoholic. 14.4% had a Child's stage A, 57.7% B and 27.8% C. The internal consistency of all variables reached a Cronbach's Alpha of 0.766. In the exploratory factor analysis, 6 dimensions of the questionnaire were identified that explain 84.27% of the total variability. To see the stability of the instrument, the measurement was repeated at 2 and 6 months of follow-up, obtaining in the test-retest a kappa agreement of 0.612 and 0.565 respectively.

CONCLUSION

The SIPAT-11 questionnaire has good psychometric characteristics in cirrhotic patients who are candidates for liver transplantation. It is easy to complete and can be administered by professionals who are not specialists in the area of Mental Health.

Blood-pool SUV analysis of 99mTc-galactosyl human serum albumin (99mTc-GSA) normalized by blood volume for prediction of short-term survival in severe liver failure: preliminary report

PURPOSE

This study evaluated the usefulness of SUV analysis of 99mTc-galactosyl human serum albumin (99mTc-GSA) scintigraphy including SUV analysis of the cardiac blood pool normalized by blood volume as a predictor of short-term survival in severe liver failure.

PATIENTS AND METHODS

We enrolled 24 patients with severe liver failure who underwent 99mTc-GSA scintigraphy and were admitted to the intensive care unit. Patients were divided into survival and non-survival groups at 7, 14, and 28 days from the performance of 99mTc-GSA scintigraphy. From SPECT images we calculated SUVs of the cardiac blood pool, performing normalization for body weight, lean body weight, Japanese lean body weight, and blood volume and we calculated SUVs of the liver, normalizing by body weight, lean body weight, and Japanese lean body weight. We also calculated the uptake ratio of the heart at 15 min to that at 3 min (HH15) and the uptake ratio of the liver at 15 min to the liver plus the heart at 15 min (LHL15) from planar images of 99mTc-GSA scintigraphy.

RESULTS

There were significant differences between the 7 day survival and non-survival groups for all SUVs of the heart and the liver and HH15, for 14 day survival groups in SUVs of the heart normalized by Japanese lean body weight and blood volume, and no significant differences between 28 day survival groups for any SUVs, HH15, or LHL15. Although the difference was not significant, SUV analysis of the heart normalized by blood volume showed the highest value for the area under the receiver-operating-characteristics curve for both 7 day and 14 day survival.

CONCLUSION

SUV analysis of 99mTc-GSA including SUV analysis of cardiac blood pool normalized by blood volume is of value for prediction of short-term survival in cases with severe liver failure.

Cystatin C and the difference between cystatin C and serum creatinine: Improved metrics to predict waitlist mortality among patients with decompensated cirrhosis

Among patients with decompensated cirrhosis, serum creatinine (sCr) is biased by sex, frailty, and hepatic synthetic function, while Cystatin C (cysC) is not. We found that sCr would better associate with waitlist mortality and that the difference between cysC and sCr (cysCsCr diff ) would quantify this bias and be independently associated with outcomes. We measured cysC levels at ambulatory liver transplant visits among 525 consecutive patients seen at our center. We defined the cysCsCr diff as the difference between cysC minus sCr. We compared demographics and clinical characteristics in patients with low, intermediate, and high cysCsCr diff , divided by tertile. We used Cox regression to compare the association between sCr and cysC and waitlist mortality and demonstrate the independent association between cysCsCr diff and waitlist mortality. In Cox regression, cysC was significantly more associated with waitlist mortality than sCr ( p < 0.001). We found that as compared to those with a low cysCsCr diff , those with an intermediate or high cysCsCr diff were more likely to be female, have ascites, have higher frailty, and have higher MELD 3.0 scores ( p < 0.05 for all). Compared to those with a low cysCsCr diff , we found that those in the intermediate and high groups were more likely to die during follow-up (low: 6% vs. intermediate: 8% vs. high: 11%, p = 0.007). We found that after adjusting for the components of the MELD 3.0 score, each 1-point increase in the cysCsCr diff was associated with 1.72× (1.27-2.32) the hazard of waitlist mortality. Our study demonstrates that not only is cysC more associated with waitlist mortality than sCr, but that cysCsCr diff represents a novel independent metric associated with waitlist mortality.

Sex disparity in liver allocation within Eurotransplant

In Eurotransplant, relatively more females than males die while waiting for liver transplantation, and relatively fewer females undergo transplantation. With adult liver transplantation candidates listed between 2007 and 2019 (n = 21 170), we study whether sex disparity is inherent to the model for end-stage liver disease (MELD) scoring system, or the indirect result of a small candidate body size limiting access to transplantation. Cox proportional hazard models are used to quantify the direct effect of sex on waitlist mortality, independent of the effect of sex through MELD scores, and the direct effect of sex on the transplantation rate, independent of the effect of sex through MELD and candidate body size. Adjusted waitlist mortality hazard ratios (HRs) for female sex are insignificant (HR: 1.03, 95% CI: 0.88-1.20). We thus lack evidence that MELD systematically underestimates waitlist mortality rates for females. Transplantation rates are 25% lower for females than males in unadjusted analyses (HR: 0.74, 95% CI: 0.71-0.77), but HRs become insignificant with adjustment for mediators (HR: 0.98, 95% CI: 0.93-1.04), most importantly candidate body size. Sex disparity in Eurotransplant thus appears to be largely a consequence of lower transplantation rates for females, which are explained by sex differences in body size.

Targeted Plasma Bile Acid Metabolomic Analysis in Metabolic Dysfunction-Associated Steatohepatitis and Alcoholic Hepatitis

Background: Even though many metabolic liver diseases can now be diagnosed using blood tests and diagnostic imaging, early diagnosis remains difficult. Understanding mechanisms contributing to the progression from Metabolic Dysfunction-Associated Steatohepatitis (MASH) and Alcoholic Hepatitis (AH) to cirrhosis is critical to reduce the burden of end-stage liver disease. Monitoring individual bile acids has been proposed as a way to distinguish various liver disorders. Methods: This study explored bile acid profiles in patients with MASH and AH. Plasma samples from patients with MASH, AH, and a control group were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS) to quantify bile acid concentrations. Targeted metabolomic analysis was performed to compare bile acid levels between the hepatitis and control groups. Results: Concentrations of ursodeoxycholic acid (UDCA), chenodeoxycholic acid (CDCA), taurocholic acid (TCA), tauroursodeoxycholic acid (TUDCA), taurochenodeoxycholic acid (TCDCA), glycoursodeoxycholic acid (GUDCA), glycochenodeoxycholic acid (GCDCA), and glycocholic acid (GCA) were significantly elevated in the hepatitis group. Correlation analysis revealed strong positive relationships between the total and direct bilirubin levels and TUDCA and GCDCA. Aspartate aminotransferase (AST) showed strong positive correlations with TCDCA and GCDCA. Child-Pugh score, Fibrosis-4 index, and non-alcoholic fatty liver disease fibrosis score were positively correlated with GCA, whereas the aspartate aminotransferase-to-platelet ratio correlated with TCA, TCDCA, and GCA. The model for end-stage liver disease (MELD) score showed a strong positive correlation with GCDCA. Implications: GCDCA may serve as a predictive biomarker for liver damage, potentially enabling early diagnosis and targeted intervention in patients with MASH and AH.

The Role of Liver Stiffness Measurement and Spleen Stiffness Measurement in Predicting the Risk of Developing HCC

BACKGROUND/OBJECTIVES

Hepatocellular carcinoma (HCC) is the sixth most common cause of cancer worldwide. More than 90% of cases occur in cirrhotic patients, with the degree of fibrosis being the main risk factor for the development of HCC. Liver biopsy is the gold-standard for fibrosis assessment, but it is an invasive procedure. Liver stiffness measurement (LSM) has shown high accuracy for diagnosing liver cirrhosis, as well as for predicting decompensation and HCC development. More recently, spleen stiffness measurement (SSM) has presented excellent results for ruling in/out high-risk varices and the presence of clinical significant portal hypertension. The aim of our study was to evaluate the relationship between LSM and SSM and the risk of hepatocellular carcinoma.

METHODS

A prospective study on cirrhotic patients was performed in a tertiary center from January 2020 to May 2024. All patients were submitted to liver and spleen elastography (with a new probe of 100 Hz) by the same blinded operator and were treated in the same institution for the development of hepatocellular carcinoma.

RESULTS

We included 299 cirrhotic patients, 75.9% male, with a mean age of 61.8 years (±10.0). The median value of LSM was 25.7 kPa [4.5-75.0] and that of SSM was 44.6 kPa [7.9-100.0]. The median follow-up time was 505 days [114.0-1541.0]. During this period, 18 patients developed HCC, with a median time to HCC diagnosis after LSM and SSM of 321 days [63.0-1227.0]. LSM was the only factor associated with the development of HCC (p = 0.002) with an AUC of 0.715. On the other hand, SSM was not associated with the development of HCC.

CONCLUSIONS

We found that the risk of developing HCC is associated with liver fibrosis but not with portal hypertension (assessed using SSM).