From Child-Pugh to MELD score and beyond: Taking a walk down memory lane

Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden (MELD-AFP-TBS) score to stratify prognosis after liver resection for hepatocellular carcinoma

INTRODUCTION

Morphologic criteria, such as the Barcelona Clinic Liver Cancer staging system often fail to accurately predict long-term survival among patients undergoing liver resection for hepatocellular carcinoma. We sought to develop a continuous risk score that incorporates established markers of tumor biology and liver function to improve the prediction of overall survival.

METHODS

Data from a multi-institutional database were used to identify patients who underwent curative-intent hepatectomy for hepatocellular carcinoma. A predictive score for overall survival was developed using weighted beta-coefficients from a multivariable Cox regression model.

RESULTS

Among 850 patients, 595 (70.0%) were assigned to the training cohort, and 255 (30.0%) to the test cohort. In the training cohort, multivariable analysis identified the Model of End-Stage Liver Disease (hazard ratio, 1.04; 95% confidence interval, 1.01-1.07), log-transformed alpha-fetoprotein (hazard ratio, 1.07; 95% confidence interval, 1.02-1.13), and tumor burden score (hazard ratio, 1.07; 95% confidence interval, 1.03-1.11) as independent predictors of worse overall survival. The Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score, based on the Cox model, stratified patients into low-risk (n = 466, 78.3%) with a 5-year OS of 70.5% and high-risk (n = 129, 21.7%) with a 5-year OS of 47.0% (P < .001). In the test cohort, the Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score demonstrated superior discriminative accuracy (C-index: 0.72, time-dependent area under the curve 1-year: 0.80, 3-year 0.76, 5-year 0.70) compared with the Barcelona Clinic Liver Cancer staging system (C-index: 0.53, time-dependent area under the curve 1-year: 0.61, 3-year 0.55, 5-year 0.56). An online tool was made accessible at https://jk-osu.shinyapps.io/MELD_AFP_TBS/.

CONCLUSION

The Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score provides a novel, accurate tool for prognostic stratification of patients with hepatocellular carcinoma, identifying high-risk patients who may benefit from alternative treatments to improve outcomes.

Circulating miR-485-5p as a potential diagnostic and prognostic biomarker for HCV-related hepatocellular carcinoma

Hepatitis C virus (HCV) is the predominant viral cause of hepatocellular carcinoma (HCC). Early detection and use of reliable biological markers can improve survival for HCC patients. MiR-485-5p was identified as a tumor-suppressing microribonucleic acid (miRNA) in some human cancers and was recently found to be downregulated in HCC tissues, signifying its utility as a promising biomarker. We aimed to investigate the potential role of circulating miR-485-5p as a novel diagnostic and prognostic biomarker for HCV-related HCC. This case-control study included 50 patients with HCC associated with HCV, 50 patients with HCV-related liver cirrhosis, and 50 healthy controls. History gathering, physical examination, laboratory, and imaging assessments were performed. A quantitative real-time polymerase chain reaction was used to measure miR-485-5p levels. Serum miR-485-5p values demonstrated a stepwise decline pattern from the control group to cirrhotic patients, with the HCC group exhibiting the lowest levels (p < 0.001). HCC patients with early BCLC stages had significantly lower miR-485-5p levels than those with late stages (p = 0.004). The miR-485-5p displayed a better performance in predicting HCV-related HCC with a greater area under the ROC curve (AUC) than alpha-fetoprotein (AFP) (AUC and sensitivity 0.921 and 92.0 versus 0.704 and 64.0, respectively) (p < 0.001). Also, its performance in predicting HCC prognosis surpassed that of AFP (AUC and sensitivity 0.872 and 85.19 versus 0.695 and 62.96, respectively) (p < 0.001). Circulating miR-485-5p is a promising, accurate, and noninvasive biomarker for the early detection and prediction of prognosis in patients with HCV-linked HCC.

AI Innovations in Liver Transplantation: From Big Data to Better Outcomes

Artificial intelligence (AI) has emerged as a transformative field in computational research with diverse applications in medicine, particularly in the field of liver transplantation (LT) given its ability to analyze and build upon complex and multidimensional data. This literature review investigates the application of AI in LT, focusing on its role in pre-implantation biopsy evaluation, development of recipient prognosis algorithms, imaging analysis, and decision-making support systems, with the findings revealing that AI can be applied across a variety of fields within LT, including diagnosis, organ allocation, and surgery planning. As a result, algorithms are being developed to assess steatosis in pre-implantation biopsies and predict liver graft function, with AI applications displaying great accuracy across various studies included in this review. Despite its relatively recent introduction to transplantation, AI demonstrates potential in delivering cost and time-efficient outcomes. However, these tools cannot replace the role of healthcare professionals, with their widespread adoption demanding thorough clinical testing and oversight.

Interaction between age and blood urea nitrogen to creatinine ratio on mortality in patients with severe cirrhosis: a retrospective cohort study from the MIMIC database

Background

Cirrhosis is a leading cause of global disease burden, with high mortality, particularly in critically ill patients. The blood urea nitrogen to creatinine ratio (BCR) is a straightforward biochemical indicator of renal excretory function and is linked to negative outcomes across different conditions. However, the relationship between BCR and mortality in critically ill patients with cirrhosis is unclear, The purpose of this study is to explore this question.

Methods

A retrospective cohort study was performed utilizing the MIMIC-IV database. We divided BCR into quartiles and evaluated 180-day and 365-day mortality as the primary outcomes. Kaplan-Meier survival analysis and multivariate Cox regression modeling were used to assess the link between BCR and mortality. Linear relationships were further determined using restricted cubic spline (RCS) curves, and finally, subgroup analyses were also performed.

Results

In our study of 2,816 critically ill cirrhotic patients, elevated BCR was significantly linked to higher mortality at both 180 and 365 days. The top BCR quartile showed a 45% higher risk of 180-day mortality (HR=1.45, 95% CI: 1.21-1.73) and a 38% higher risk of 365-day mortality (HR=1.38, 95% CI: 1.17-1.63) relative to the bottom quartile. RCS analysis demonstrated a notable linear correlation between BCR and mortality risk. Subgroup analyses indicated a stronger association between BCR and mortality among older patients.

Conclusion

In critically ill cirrhotic patients, elevated BCR values are strongly linked to increased mortality risk. Our research highlights BCR's potential as a prognostic marker for cirrhosis, especially in elderly patients.

Association between lactate-to-albumin ratio and all-cause mortality in cirrhosis patients: Analysis of the MIMIC-IV database

OBJECTIVE

This study evaluates the predictive value of the lactate/albumin ratio (LAR) for all-cause mortality in cirrhosis patients.

DESIGN

Retrospective observational study.

SETTING

Intensive care unit (ICU).

PATIENTS OR PARTICIPANTS

626 first-time ICU-admitted cirrhosis patients in the USA (MIMIC-IV v2.2).

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

LAR index, 28-day, and 90-day all-cause mortality.

RESULTS

Of 626 patients (60.86% male), 27.80% and 39.14% died within 28 and 90 days, respectively. Multivariate Cox analysis showed a significant association between higher LAR and mortality. Adjusted for confounders, elevated LAR increased the 28-day mortality risk [HR: 1.31 (1.21-1.42), P < 0.001]. A restricted cubic spline analysis revealed non-linear relationships between LAR and mortality. For 28-day mortality, the inflection point was 1.583: below this, HR was 2.29 (95% CI: 1.61-3.27, P < 0.001); above, HR was 1.16 (95% CI: 1.02-1.31, P = 0.021; P = 0.002). For 90-day mortality, the inflection point was 1.423: below, HR was 1.60 (95% CI: 1.04-2.47, P = 0.033); above, HR was 0.94 (95% CI: 0.75-1.16, P = 0.542; P = 0.012).

CONCLUSIONS

LAR predicts 28-day and 90-day mortality with a segmented effect. An LAR ≥1.583 signals high 28-day mortality risk, necessitating intensified monitoring and potential ICU admission. For 90-day mortality, LAR near 1.423 serves as an early warning for high-risk patients and guides interventions. Continuous LAR monitoring aids management, but prospective studies are needed to confirm clinical utility.

The role of multifocal visual evoked potential in detection of minimal hepatic encephalopathy in patients with compensated liver cirrhosis

BACKGROUND

Minimal hepatic encephalopathy (MHE) is one of the most debilitating complications of hepatic cirrhosis, and visual electrophysiology, visual evoked potential (VEP) has long been used for MHE diagnosis. This technique only produces a summed response that is greatly dominated by the macular region. Multifocal visual evoked potential (mfVEP) imaging minimizes these limitations because it allows topographic recording of the optic nerve and visual cortex. The aim of this study was to detect minimal hepatic encephalopathy among cirrhotic patients using the mfVEP in comparison to the validated psychometric hepatic encephalopathy score (PHES), paired associative learning (PAL) and the Benton visual retention test (BVRT).

METHODS

Forty-five patients with compensated hepatic cirrhosis were enrolled in our study and compared to 45 normal controls who were matched for age, sex and educational level. Both groups underwent psychological tests (PHES, PAL, BVRT) and neurophysiological tests (mfVEP).

RESULTS

1According to the validated PHES, 14 patients were found to have MHE, 15 patients were found to have abnormal mfVEP, and abnormalities in the BVRT and PAL were found in 11 and 10 patients, respectively. 2-mfVEP showed the highest sensitivity in the detection of MHE in reference to the PHES. 3- The mfVEP test and potentially the BVRT have the advantage of detecting subtle abnormalities in non-MHE cirrhotic patients, for further research and follow-up are needed.

CONCLUSION

mfVEP demonstates promising results for objective early detection of MHE, with a sensitivity of approximately 92.9%.

Role of preoperative transarterial chemoembolization (TACE) in intermediate-stage hepatocellular carcinoma (Hong Kong liver cancer stage IIB)

INTRODUCTION

Transarterial chemoembolization (TACE) has an established role in advanced HCC. The present study evaluates the role of TACE as a neoadjuvant modality in the management of intermediate HCC [Hong Kong Liver Cancer (HKLC) stage IIB].

MATERIALS AND METHODS

A retrospective analysis of HCC patients treated between January 2010 and August 2022 was performed. Patients belonging to intermediate-stage HCC (HKLC IIB) were divided into two groups, upfront surgery (UPS) and post-TACE (pTACE). Propensity score matching was done, and the primary endpoint of the study was overall survival (OS).

RESULTS

A total of 247 patients of HKLC IIB were identified during this period. Of these, 77 patients in each group were considered for analysis after propensity matching. The median follow-up was 36.4 months (0.46-144.26). In the propensity matched population (n = 154), on an intention-to-treat analysis, the median OS of the UPS group and the pTACE group was 30.06 and 39.26 months, respectively (p value = 0.77). In patients who underwent curative resection, the median OS of the UPS group was 30.68 versus 90.97 months in the pTACE group (p value = 0.006) and median DFS was 13.56 months for the UPS group versus 44.02 months in the pTACE group, respectively (p value = 0.013).

CONCLUSION

In intermediate-stage hepatocellular carcinoma (HKLC IIB), pTACE can be used to better select patients with borderline resectability. Survival was significantly improved in patients who received pTACE and were able to undergo surgical resection.

Inflammatory lipid biomarkers and transplant-free mortality risk in hepatitis B-related cirrhosis and hepatic encephalopathy

Objective

Inflammatory reactions and dyslipidemia are associated with the pathogenesis and prognosis of hepatitis B virus-related cirrhosis. We aimed to assess the predictive ability of these parameters in patients with hepatitis B virus-related cirrhosis and overt hepatic encephalopathy (HBV-related OHE).

Design

We conducted an analysis of 1,404 participants diagnosed with HBV-related OHE between January 2008 and July 2023. The prognostic significance of the neutrophil-to-high-density lipoprotein cholesterol (HDL-C) ratio (NHR), lymphocyte-to-HDL-C ratio (LHR), and monocyte-to-HDL-C ratio (MHR) was evaluated using the area under the receiver operating characteristic curve (AUC). Restrictive cubic splines (RCS) were employed to explore the relationship between NHR and 12-month transplant-free (TF) mortality. This study included a prospective test cohort of 328 patients.

Results

NHR was identified as an independent risk factor for 12-month TF mortality. The AUC for NHR (0.776) was similar to that of the model end-stage liver disease (MELD) score (AUC: 0.777). In the test cohort, NHR demonstrated AUC values comparable to MELD, with significantly higher AUCs than LHR and MHR (both p < 0.05). Based on cutoff values for NHR and MELD, patients were classified into four risk subgroups: very-low (NHR < 10 and MELD <18), low (NHR ≥ 10 and MELD <18), moderate (NHR < 10 and MELD ≥18), and high (NHR ≥ 10 and MELD ≥18). The 12-month TF mortality rates in the training cohort were 7.2, 23.5, 30.8, and 51.4%, respectively, for these subgroups, while in the test cohort, the rates were 8.7, 20.5, 30.7, and 46.0%.

Conclusion

NHR is a valuable and accessible prognostic indicator for 12-month TF mortality in patients with HBV-related OHE. Patients with both NHR ≥ 10 and MELD ≥18 are at the highest risk of mortality.

High-density lipoprotein cholesterol as a prognostic marker for 90-day transplant-free mortality in hepatitis B virus-related acute-on-chronic liver failure

Background

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is linked to dyslipidemia and inflammatory responses. This study aimed to investigate the correlation between high-density lipoprotein cholesterol (HDL-C) levels and 90-day transplant-free (TF) mortality in patients with HBV-ACLF.

Methods

A prospective cohort of 287 patients with HBV-ACLF from Beijing Ditan Hospital was enrolled between January 2016 and December 2019. The prognostic accuracy of lipid profile parameters was evaluated by the area under the receiver operating characteristic curve (AUC), and the association between HDL-C levels and mortality was assessed using a restricted cubic spline analysis. Correlations between lipid profile parameters and inflammatory factors were analyzed. Kaplan-Meier curves were used to assess 90-day TF mortality, and log-rank tests were used for comparison analysis. These results were internally validated between January 2020 and December 2023 (n=125).

Results

Patients with lower HDL-C levels exhibited higher mortality rates (adjusted hazard ratio for HDL-C < 0.13 mmol/L: 4.04, 95% confidence interval: 1.35-11.85) compared with those in the reference group (with HDL-C levels above 0.36 mmol/L). An "L-shaped" association was observed between HDL-C levels and TF mortality. The prognostic value of HDL-C (AUC at day 90: 0.732) was comparable to the model for end-stage liver disease score of 0.729. Additionally, HDL-C levels were inversely correlated with interleukin (IL)-4, IL-6, and tumor necrosis factor-α (all P<0.05). In the training cohort, the 90-day TF mortality rates were 8.3%, 15.2%, 24.0%, and 43.2% for the extremely low, low, medium, and high-risk subgroups, respectively, while in the validation cohort, they were 4.5%, 18.5%, 31.2%, and 44.7%, respectively.

Conclusions

HDL-C levels < 0.13 mmol/L were associated with increased 90-day transplant-free mortality in patients with HBV-ACLF. An inverse correlation was found between HDL-C levels and inflammatory markers.

Advancements in MELD Score and Its Impact on Hepatology

There continues to be an ongoing need for fair and equitable organ allocation. The Model for End-Stage Liver Disease (MELD) score has evolved as a calculated framework to evaluate and allocate patients for liver transplantation objectively. The original MELD score has undergone multiple modifications as it is continuously scrutinized for its accuracy in objectively representing the clinical context of patients with liver disease. Several refinements and iterations of the score have been developed, including the widely accepted MELD-Na score. In addition, the most recent updated iteration, MELD 3.0, has been created. The MELD 3.0 calculator incorporates new variables such as patient sex and serum albumin levels and assigns new weights for serum sodium, bilirubin, international normalized ratio, and creatinine levels. It is anticipated that the use of MELD 3.0 scores will reduce overall waitlist mortality and enhance access for female liver transplant candidates. However, despite the emergence of the MELD score as one of the most objective measures for fair organ allocation, various countries and healthcare systems employ alternative methods for stratification and organ allocation. This review article will highlight the origins of the MELD score, its iterations, the current MELD 3.0, and future directions for managing liver transplantation organ allocation. LAY SUMMARY: Organ donation is crucial for the management of patients unwell with liver disease, but organs must be allocated fairly and equitably. One method used for this is the Model for End-Stage Liver Disease (MELD) score, which helps objectively decide which patient is a candidate for liver transplant. Over time, the MELD score has been refined to better reflect patients' needs. For example, the latest version, MELD 3.0, now considers factors like nutrition and gender. This should ensure that more patients, especially females, are candidates and receive appropriate access to liver transplantation. However, not every country uses the MELD score. Some countries have created their own scoring systems based on local research. This review will explain where the MELD score came from, how it has changed, the current characteristics of the MELD 3.0 score, and what the future might hold for organ allocation in liver transplants.

Evaluating the positive predictive value of code-based identification of cirrhosis and its complications utilizing GPT-4

BACKGROUND AND AIMS

Diagnosis code classification is a common method for cohort identification in cirrhosis research, but it is often inaccurate and augmented by labor-intensive chart review. Natural language processing using large language models (LLMs) is a potentially more accurate method. To assess LLMs' potential for cirrhosis cohort identification, we compared code-based versus LLM-based classification with chart review as a "gold standard."

APPROACH AND RESULTS

We extracted and conducted a limited chart review of 3788 discharge summaries of cirrhosis admissions. We engineered zero-shot prompts using a Generative Pre-trained Transformer 4 to determine whether cirrhosis and its complications were active hospitalization problems. We calculated positive predictive values (PPVs) of LLM-based classification versus limited chart review and PPVs of code-based versus LLM-based classification as a "silver standard" in all 3788 summaries. Compared to gold standard chart review, code-based classification achieved PPVs of 82.2% for identifying cirrhosis, 41.7% for HE, 72.8% for ascites, 59.8% for gastrointestinal bleeding, and 48.8% for spontaneous bacterial peritonitis. Compared to the chart review, Generative Pre-trained Transformer 4 achieved 87.8%-98.8% accuracies for identifying cirrhosis and its complications. Using LLM as a silver standard, code-based classification achieved PPVs of 79.8% for identifying cirrhosis, 53.9% for HE, 55.3% for ascites, 67.6% for gastrointestinal bleeding, and 65.5% for spontaneous bacterial peritonitis.

CONCLUSIONS

LLM-based classification was highly accurate versus manual chart review in identifying cirrhosis and its complications. This allowed us to assess the performance of code-based classification at scale using LLMs as a silver standard. These results suggest LLMs could augment or replace code-based cohort classification and raise questions regarding the necessity of chart review.

Predictors of survival in autoimmune liver disease overlap syndromes

BACKGROUND

Survival in patients with autoimmune liver disease overlap syndromes (AILDOS) compared to those with single autoimmune liver disease is unclear.

AIM

To investigate the survival of patients with AILDOS and assess the accuracy of non-invasive serum models for predicting liver-related death.

METHODS

Patients with AILDOS were defined as either autoimmune hepatitis and primary biliary cholangitis overlap (AIH-PBC) or autoimmune hepatitis and primary sclerosing cholangitis overlap (AIH-PSC) and were identified from three tertiary centres for this cohort study. Liver-related death or transplantation (liver-related mortality) was determined using a population-based data linkage system. Prognostic scores for liver-related death were compared for accuracy [including liver outcome score (LOS), Hepascore, Mayo Score, model for end-stage liver disease (MELD) score and MELD incorporated with serum sodium (MELD-Na) score].

RESULTS

Twenty-two AILDOS patients were followed for a median of 3.1 years (range, 0.35-7.7). Fourteen were female, the median age was 46.7 years (range, 17.8 to 82.1) and median Hepascore was 1 (range, 0.07-1). At five years post enrolment, 57% of patients remained free from liver-related mortality (74% AIH-PBC, 27% AIH-PSC). There was no significant difference in survival between AIH-PBC and AIH-PSC. LOS was a significant predictor of liver-related mortality (P < 0.05) in patients with AIH-PBC (n = 14) but not AIH-PSC (n = 8). A LOS cut-point of 6 discriminated liver-related mortality in AIH-PBC patients (P = 0.012, log-rank test, 100% sensitivity, 77.8% specificity) (Harrell's C-statistic 0.867). The MELD score, MELD-Na score and Mayo Score were not predictive of liver-related mortality in any group.

CONCLUSION

Survival in the rare, AILDOS is unclear. The current study supports the LOS as a predictor of liver-related mortality in AIH-PBC patients. Further trials investigating predictors of survival in AILDOS are required.

Clinical characteristics and predictors of benign portal vein thrombosis in patients with liver cirrhosis: A retrospective single-center study

Portal vein thrombosis (PVT) is a common thrombotic complication of cirrhosis. It can lead to variceal bleeding and bowel ischemia and also complicate liver transplantation. Identifying the possible risk factors associated with PVT can aid in identifying patients at high risk, enabling their screening and potentially preventing PVT through the rational use of anticoagulants. This study focuses on examining the clinical characteristics of PVT in cirrhotic patients and identifying the clinical and biochemical factors that are linked to the development of PVT. Consecutive hospitalized cirrhotic patients between 2015 and 2023 were identified through the hospital's computerized medical records based on the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding system and retrospectively analyzed. 928 individuals were included in this study; 783 (84.3%) without PVT and 145 (15.7%) with benign PVT. Hepatitis B virus (HBV) was significantly more common in the PVT group (P-value = .02), while alcohol and primary sclerosing cholangitis (PSC) were less common in this group (P-value = .01 and .02, respectively). Hepatocellular carcinoma (HCC) (P-value < .01), ascites (P-value = .01), and spontaneous bacterial peritonitis (SBP) (P-value = .02) were more common in the PVT group. Patients with PVT had a higher international normalized ratio (INR) level (P-value = .042) and lower plasma albumin (P-value = .01). No differences were identified in white blood cell, hemoglobin, platelet, and bilirubin levels. However, patients with PVT had higher model for end-stage liver disease (MELD) (P-value = .01) and Child-Pugh scores (P-value = .03). This study demonstrated a higher likelihood of PVT presence in cirrhotic patients with advanced age, HBV, and HCC, along with ascites, SBP, splenomegaly, hypoalbuminemia, elevated INR, and a higher MELD score. Nevertheless, additional research endeavors are necessary to accurately ascertain and validate supplementary risk factors within a broader demographic.

Evaluation of MELD Scores and Thyroid Hormones as Prognostic Factors of Liver Cirrhosis

Background and Objectives: Hepatic cirrhosis is a disease with an increasing frequency globally, but its mechanisms of disease development are not yet completely known. The aim of this study was to evaluate the relationship between thyroid hormone levels (T3, fT4, and TSH) and survival in patients with chronic liver disease. Materials and Methods: A total of 419 patients diagnosed with liver cirrhosis were included in the study. The MELD score was computed, and TSH, T3, and fT4 were collected from each patient using the ELISA procedure. Signs and symptoms of liver failure and portal hypertension confirmed the clinical diagnosis of liver cirrhosis, and biological tests and imaging methods confirmed the diagnosis. Results: The MELD score was positively associated with TSH on admission and TSH on discharge and negatively associated with T3 at discharge. TSH levels were higher in non-survivors than in survivors. The values of T3 and fT4 present no significant changes to be considered as prognostic factors. Conclusions: Although the differences between the median TSH values of the patients who died and those who survived are not very large, the statistical significance of the data obtained demonstrates that there are changes in metabolism of the thyroid hormones during the progression of liver cirrhosis. It is possible that TSH is the one which maintains the normal balance of thyroid activity for patients with liver cirrhosis, so it can be considered as an important marker of evolution of these patients.

LINAS-Score: prognostic model for mortality assessment in patients with cirrhotic liver and infected ascites

BACKGROUND AND AIM

Patients with liver cirrhosis often face a grave threat from infected ascites (IA). However, a well-established prognostic model for this complication has not been established in routine clinical practice. Therefore, we aimed to assess mortality risk in patients with liver cirrhosis and IA.

METHODS

We conducted a retrospective study across three tertiary hospitals, enrolling 534 adult patients with cirrhotic liver and IA, comprising 465 with spontaneous bacterial peritonitis (SBP), 34 with bacterascites (BA), and 35 with secondary peritonitis (SP). To determine the attributable mortality risk linked to IA, these patients were matched with 122 patients with hydropic decompensated liver cirrhosis but without IA. Clinical, laboratory, and microbiological parameters were assessed for their relation to mortality using univariable analyses and a multivariable random forest model (RFM). Least absolute shrinkage and selection operator (Lasso) regression model was used to establish an easy-to-use mortality prediction score.

RESULTS

The in-hospital mortality risk was highest for SP (39.0%), followed by SBP (26.0%) and BA (25.0%). Besides illness severity markers, microbiological parameters, such as Candida spp., were identified as the most significant indicators for mortality. The Lasso model determined 15 parameters with corresponding scores, yielding good discriminatory power (area under the receiver operating characteristics curve = 0.89). Counting from 0 to 83, scores of 20, 40, 60, and 80 corresponded to in-hospital mortalities of 3.3%, 30.8%, 85.2%, and 98.7%, respectively.

CONCLUSION

We developed a promising mortality prediction score for IA, highlighting the importance of microbiological parameters in conjunction with illness severity for assessing patient outcomes.

Tumor burden score as a prognostic factor in patients with intermediate and locally advanced hepatocellular carcinoma undergoing liver resection: an attempt to extend resectability criteria

BACKGROUND

Surgery is currently recommended as a curative treatment option for hepatocellular carcinomas (HCC) belonging to Barcelona Clinic Liver Cancer (BCLC) stage A only. This study aims to classify various BCLC groups as per Tumor Burden Score (TBS) in an attempt to identify patients who could benefit from resection.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained database of all patients operated for HCC between January 2010 and July 2022 was performed. TBS was defined as, TBS2 = (maximum tumor diameter)2 + (number of tumors)2.

RESULTS

Two hundred and ninety-one patients who underwent resection were staged as per the latest BCLC (A = 219, B = 45, C = 27) staging. Patients were segregated into low (<7.3) and high (>7.3) TBS. With a median follow-up of 36.2 months, the median OS for stages, A and B in the low TBS group was 107.4 and 42.7 months respectively. Median OS was not reached for patients in the BCLC C stage. In patients with high TBS, the median OS for BCLC A, B and C was 42.3, 25.72, and 16.9 months respectively.

CONCLUSION

TBS is a significant factor influencing survival in patients of HCC. TBS can be used to stratify patients in BCLC B and C stages and help select patients who would benefit from surgical resection to achieve good long-term survival with acceptable morbidity.

A decade of liver transplantation in Mongolia: Economic insights and cost analysis

BACKGROUND

Mongolia introduced liver transplantation 10 years ago, becoming the 46th country globally to successfully perform this procedure. However, the cost of liver transplantation treatment remains expensive in Mongolia, a lower-middle-income country. Thus, the need to calculate the cost of liver transplants, a highly-valued treatment, forms the basis for this study.

METHODS

This study employed a retrospective research design with secondary data. The primary dataset comprised 143 cases of liver transplantation performed at the First Central Hospital of Mongolia between 2011 and 2021.

RESULTS

The average cost of a liver transplant in Mongolia is $39,589 ± 10,308, with 79.6% being direct costs and 20.4% indirect costs. Of the direct costs, 71% were attributed to drugs, medical equipment, and supplies, while 8.6% accounted for salaries. In terms of the Model of End-Stage Liver Disease (MELD) scores, treatment costs were $39,205 ± 10,786 for patients with MELD ≤ 14 points, $40,296 ± 1,517 for patients with MELD 15-20 points, $39,352 ± 8,718 for patients with MELD 21-27 points, and $39,812 ± 9,954 for patients with MELD ≤ 28 points, with no statistically significant difference (P = 0.953). However, when calculated according to the Child-Turcotte-Pugh (CTP) score classification, treatment cost for CTP-A patients was $35,970 ± 6,879, for CTP-B patients $41,951 ± 12,195, and for CTP-C patients $37,396 ± 6,701, which was statistically significant (Р=0.015).

CONCLUSION

The average cost of liver transplantation treatment in Mongolia was $39,589. Despite medical facilities' capacity to treat up to 50 patients annually, the waiting list exceeds 300 individuals, highlighting significant unmet healthcare needs.

Applicability of Child-Turcotte-Pugh Score in Anticipating Post-ERCP Adverse Events in Patients With Cirrhosis: A Systematic Review and Meta-analysis

Limited objective data exist on the comparison of post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with cirrhosis based on the severity of the disease. We evaluated the effectiveness of the Child-Turcotte-Pugh (CTP) score system in anticipating the risk of post-ERCP complications in patients with cirrhosis. The PubMed, Scopus, Embase, and Cochrane databases were searched from inception through September 2022 to identify studies comparing post-ERCP complications in patients with cirrhosis based on CTP score. Odds ratios (ORs) and their associated 95% CIs were pooled using a random-effect model to calculate effect size. The reference group for analysis was the CTP class C patient group. Seven studies comprising 821 patients who underwent 1068 ERCP procedures were included. The CTP class C patient population exhibited a higher risk of overall post-ERCP adverse events compared with those with class A or B (OR: 2.87, 95% CI: 1.77-4.65, P = 0.00 and OR: 2.02, 95% CI: 1.17-3.51, P = 0.01, respectively). Moreover, CTP class B patients had a significantly higher complication rate than CTP class A patients (OR: 1.62, 95% CI: 1.04-2.53, P = 0.03). However, no statistically significant differences were found in the occurrence of specific types of complications, including bleeding, pancreatitis, cholangitis, perforation, or mortality across the three CTP groups. We demonstrated that the CTP classification system is a reliable predictor of ERCP complications in patients with cirrhosis. Consequently, caution should be exercised when performing ERCP in patients classified as CTP class C.

Transarterial Chemoembolization Treatment Paradigms for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) accounts for 90% of liver cancer cases worldwide and is currently the most quickly increasing cause of cancer-related deaths in the United States. The 5-year survival rate for primary liver cancer is estimated to be below 20%, and HCC mortality is expected to increase by 41% by 2040. Currently, surgical resection is the first-line approach to definitive treatment of early-stage HCC. However, the majority of patients present with late-stage, unresectable disease due to the asymptomatic nature of early HCC. For patients who present with unresectable HCC, locoregional therapies such as transarterial chemoembolization (TACE) represent an alternative approach to HCC treatment. TACE is a minimally invasive, catheter-based technique that allows for targeted delivery of chemotherapy to tumor sites while occluding tumor-feeding blood vessels. In appropriately selected patients, outcomes for TACE therapy have been shown to be more favorable than supportive care or conservative management. The increasing incidence and mortality of HCC, in addition to the late-stage presentation of most HCC patients, demonstrates the need to expand the role of locoregional therapies in the treatment of HCC. TACE represents an appealing approach to HCC management, including disease control, palliation, and potentially curative-intent strategies. In this review, we will describe the current utility of TACE in the treatment of HCC, characterize the outcomes of patients treated with TACE across different HCC stages, and outline future applications of TACE in the treatment paradigm.

Pre-hospital symptom clusters and symptom network analysis in decompensated cirrhotic patients: A cross-sectional study

AIMS

To generate pre-hospital symptom networks, explore core, bridge and sentinel symptoms, identify pre-hospital symptom clusters and analyse relationship between influencing factors and symptom clusters in decompensated cirrhosis patients.

DESIGN

A cross-sectional study design using the Strengthening the Reporting of Observational Studies in Epidemiology checklist.

METHODS

Demographical, physiological, psychological and sociological characteristics and the pre-hospital symptoms of 292 decompensated cirrhotic patients were collected from October 2021 to March 2023 in China. Frequencies, percentages, means, standard deviations, independent samples t-tests, one-way analysis of variance, exploratory factor analysis, multiple stepwise regression analysis and network analysis were used for data analysis.

RESULTS

'I don't look like myself' and itching were core and bridge symptoms, while bloating and lack of energy were sentinel symptoms in decompensated cirrhotic patients. Monthly family income, anxiety, depression, social support and disease duration influenced the neuropsychological symptom cluster, with worrying as the strongest predictor symptom. Influential factors for cirrhosis-specific symptom cluster included Child-Pugh class, monthly family income, disease duration, anxiety and depression, with itching being the strongest predictor symptom. Monthly family income, disease duration and depression were influential factors for gastrointestinal symptom cluster, with loss of appetite as the strongest predictor symptom.

CONCLUSIONS

Neuropsychological, cirrhosis-specific and gastrointestinal symptom clusters were formed in decompensated cirrhotic patients. Through network analysis, direct connections between symptoms, symptom clusters and their influencing factors were revealed, thereby offering clinicians a foundation for effectively managing patients' pre-hospital symptoms.

IMPACT

Decompensated cirrhosis patients commonly have multiple symptoms, while the management of pre-hospital symptoms is often suboptimal. This study identified neuropsychological, cirrhosis-specific, gastrointestinal symptom clusters and recognized core, bridge and sentinel symptoms in these patients. It also revealed the most prominent symptoms within each cluster. This provides insight into the hierarchy of symptoms, improving symptom management in decompensated cirrhosis.

PATIENT AND PUBLIC INVOLVEMENT

There was no patient or public involvement.

A narrative review: predicting liver transplant graft survival using artificial intelligence modeling

Liver transplantation is the only treatment for patients with liver failure. As demand for liver transplantation grows, it remains a challenge to predict the short- and long-term survival of the liver graft. Recently, artificial intelligence models have been used to evaluate the short- and long-term survival of the liver transplant. To make the models more accurate, suitable liver transplantation characteristics must be used as input to train them. In this narrative review, we reviewed studies concerning liver transplantations published in the PubMed, Web of Science, and Cochrane databases between 2017 and 2022. We picked out 17 studies using our selection criteria and analyzed them, evaluating which medical characteristics were used as input for creation of artificial intelligence models. In eight studies, models estimating only short-term liver graft survival were created, while in five of the studies, models for the prediction of only long-term liver graft survival were built. In four of the studies, artificial intelligence algorithms evaluating both the short- and long-term liver graft survival were created. Medical characteristics that were used as input in reviewed studies and had the biggest impact on the accuracy of the model were the recipient's age, recipient's body mass index, creatinine levels in the recipient's serum, recipient's international normalized ratio, diabetes mellitus, and recipient's model of end-stage liver disease score. To conclude, in order to define important liver transplantation characteristics that could be used as an input for artificial intelligence algorithms when predicting liver graft survival, more models need to be created and analyzed, in order to fully support the results of this review.

Machine Learning for Short-Term Mortality in Acute Decompensation of Liver Cirrhosis: Better than MELD Score

Prediction of short-term mortality in patients with acute decompensation of liver cirrhosis could be improved. We aimed to develop and validate two machine learning (ML) models for predicting 28-day and 90-day mortality in patients hospitalized with acute decompensated liver cirrhosis. We trained two artificial neural network (ANN)-based ML models using a training sample of 165 out of 290 (56.9%) patients, and then tested their predictive performance against Model of End-stage Liver Disease-Sodium (MELD-Na) and MELD 3.0 scores using a different validation sample of 125 out of 290 (43.1%) patients. The area under the ROC curve (AUC) for predicting 28-day mortality for the ML model was 0.811 (95%CI: 0.714- 0.907; p < 0.001), while the AUC for the MELD-Na score was 0.577 (95%CI: 0.435-0.720; p = 0.226) and for MELD 3.0 was 0.600 (95%CI: 0.462-0.739; p = 0.117). The area under the ROC curve (AUC) for predicting 90-day mortality for the ML model was 0.839 (95%CI: 0.776- 0.884; p < 0.001), while the AUC for the MELD-Na score was 0.682 (95%CI: 0.575-0.790; p = 0.002) and for MELD 3.0 was 0.703 (95%CI: 0.590-0.816; p < 0.001). Our study demonstrates that ML-based models for predicting short-term mortality in patients with acute decompensation of liver cirrhosis perform significantly better than MELD-Na and MELD 3.0 scores in a validation cohort.

Clinical Outcomes and Their Determinants in Patients With Gastric Variceal Bleed Undergoing Endoscopic Cyanoacrylate Injection: An Observational Study

Background and aims

Gastric variceal bleeding (GVB), compared to esophageal varices, is rare but often massive and associated with high mortality. Endoscopic cyanoacrylate glue injection (ECGI) is the first-line treatment for GVB. Hence, we conducted this study to assess the clinical outcomes and the determinants of ECGI for gastric variceal bleeding.

Methods

This was a prospective observational study of patients with ECGI for GVB between June 2019 and February 2023. The demographic characteristics, etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate, and survival at three months were studied.

Results

A total of 135 patients underwent ECGI for GVB. Their mean (SD) age was 44.9 (13.6) years, with a male preponderance (n = 23, 68.1 %). Eighty-two patients (60.7 %) had cirrhosis. Their mean model for end-stage liver disease (MELD) score was 14.3 (7.3). Gastric varices were gastroesophageal varices (GOV)1 in 42 (31.1 %), GOV2 in 73 (54.1 %), and isolated gastric varices (IGV)1 in 20 (14.8 %) patients. Varices were large in 35 (25.9 %) and had F1 morphology in 89 (65.9 %) patients. The success rate of initial hemostasis was 98.5 %. The median sessions required were 1 (1-2), and the median volume of cyanoacrylate per session was 2 (1-2) ml. The procedure was associated with minor complications like transient abdominal pain in 11 (8.1 %) and fever in 2 (2.7 %) patients. Rebleeding was observed in 23 (17 %) patients. GOV2, F1 morphology, and a high MELD score were significantly associated with rebleeding. Five (3.7 %) patients died during the study; 2 (1.5 %) were due to failure to control bleeding.

Conclusion

In conclusion, our study demonstrated ECGI to be very safe and effective for GVB. The technical success was high and could be achieved in fewer sessions with a smaller volume of cyanoacrylate during each session.

Development and validation of a nomogram for predicting in-hospital mortality of intensive care unit patients with liver cirrhosis

BACKGROUND

Liver cirrhosis patients admitted to intensive care unit (ICU) have a high mortality rate.

AIM

To establish and validate a nomogram for predicting in-hospital mortality of ICU patients with liver cirrhosis.

METHODS

We extracted demographic, etiological, vital sign, laboratory test, comorbidity, complication, treatment, and severity score data of liver cirrhosis patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) and electronic ICU (eICU) collaborative research database (eICU-CRD). Predictor selection and model building were based on the MIMIC-IV dataset. The variables selected through least absolute shrinkage and selection operator analysis were further screened through multivariate regression analysis to obtain final predictors. The final predictors were included in the multivariate logistic regression model, which was used to construct a nomogram. Finally, we conducted external validation using the eICU-CRD. The area under the receiver operating characteristic curve (AUC), decision curve, and calibration curve were used to assess the efficacy of the models.

RESULTS

Risk factors, including the mean respiratory rate, mean systolic blood pressure, mean heart rate, white blood cells, international normalized ratio, total bilirubin, age, invasive ventilation, vasopressor use, maximum stage of acute kidney injury, and sequential organ failure assessment score, were included in the multivariate logistic regression. The model achieved AUCs of 0.864 and 0.808 in the MIMIC-IV and eICU-CRD databases, respectively. The calibration curve also confirmed the predictive ability of the model, while the decision curve confirmed its clinical value.

CONCLUSION

The nomogram has high accuracy in predicting in-hospital mortality. Improving the included predictors may help improve the prognosis of patients.

From liver to hormones: The endocrine consequences of cirrhosis

Hepatocrinology explores the intricate relationship between liver function and the endocrine system. Chronic liver diseases such as liver cirrhosis can cause endocrine disorders due to toxin accumulation and protein synthesis disruption. Despite its importance, assessing endocrine issues in cirrhotic patients is frequently neglected. This article provides a comprehensive review of the epidemiology, pathophysiology, diagnosis, and treatment of endocrine disturbances in liver cirrhosis. The review was conducted using the PubMed/Medline, EMBASE, and Scielo databases, encompassing 172 articles. Liver cirrhosis is associated with endocrine disturbances, including diabetes, hypoglycemia, sarcopenia, thyroid dysfunction, hypogonadotropic hypogonadism, bone disease, adrenal insufficiency, growth hormone dysfunction, and secondary hyperaldosteronism. The optimal tools for diagnosing diabetes and detecting hypoglycemia are the oral glucose tolerance test and continuous glucose monitoring system, respectively. Sarcopenia can be assessed through imaging and functional tests, while other endocrine disorders are evaluated using hormonal assays and imaging studies. Treatment options include metformin, glucagon-like peptide-1 analogs, sodium-glucose co-transporter-2 inhibitors, and insulin, which are effective and safe for diabetes control. Established standards are followed for managing hypoglycemia, and hormone replacement therapy is often necessary for other endocrine dysfunctions. Liver transplantation can address some of these problems.

Prognostic value of preoperative serum ferritin in hepatocellular carcinoma patients undergoing transarterial chemoembolization

The present study investigated the prognostic impact of preoperative serum ferritin (SF) levels on the survival of patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). Clinicopathological characteristics and laboratory biomarkers of 223 patients with HCC who underwent TACE were retrospectively reviewed. The Kaplan-Meier method was used to calculate the overall survival (OS), and the log-rank test was used to evaluate statistical significance. Univariate and multivariate analyses were performed using Cox proportional hazards regression to evaluate the prognostic impact of SF in these patients. The present findings identified extrahepatic metastases [hazard ratio (HR)=0.490,95%; confidence interval (CI)=0.282-0.843; P=0.010)] and vascular invasion (HR=0.373; 95% CI=0.225-0.619; P<0.0001) as independent prognostic factors for OS. However, preoperative SF levels could not independently predict OS when compared with other prognostic factors (HR=0.810; 95% CI=0.539-1.216; P=0.309). In conclusion, preoperative SF level is an unreliable biochemical predictor of survival in patients with HCC undergoing TACE.

Prognostic Factors for Mortality in Hepatocellular Carcinoma at Diagnosis: Development of a Predictive Model Using Artificial Intelligence

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for 75% of primary liver tumors. Controlling risk factors associated with its development and implementing screenings in risk populations does not seem sufficient to improve the prognosis of these patients at diagnosis. The development of a predictive prognostic model for mortality at the diagnosis of HCC is proposed.

METHODS

In this retrospective multicenter study, the analysis of data from 191 HCC patients was conducted using machine learning (ML) techniques to analyze the prognostic factors of mortality that are significant at the time of diagnosis. Clinical and analytical data of interest in patients with HCC were gathered.

RESULTS

Meeting Milan criteria, Barcelona Clinic Liver Cancer (BCLC) classification and albumin levels were the variables with the greatest impact on the prognosis of HCC patients. The ML algorithm that achieved the best results was random forest (RF).

CONCLUSIONS

The development of a predictive prognostic model at the diagnosis is a valuable tool for patients with HCC and for application in clinical practice. RF is useful and reliable in the analysis of prognostic factors in the diagnosis of HCC. The search for new prognostic factors is still necessary in patients with HCC.

Prediction of acute kidney injury in patients with liver cirrhosis using machine learning models: evidence from the MIMIC-III and MIMIC-IV

PURPOSE

To develop and validate a machine learning (ML)-based prediction model for acute kidney injury (AKI) in patients with liver cirrhosis.

METHODS

Data on liver cirrhosis patients were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) and MIMIC-IV databases in this retrospective cohort study. ML algorithms, including random forest (RF), extreme gradient boosting (XGB), light gradient boosting machine (LGBM), and gradient boosting decision tree (GBDT) were applied to construct prediction models. Predictors were screened via univariate logistic regression, and then the models were developed with all data of the included patients. A bootstrap resampling method was adopted to validate the models. The predictive abilities of our final model were compared with those of the sequential organ failure assessment score (SOFA), simplified acute physiology score II (SAPS II), Model for End-stage Liver Disease (MELD), and MELD Na.

RESULTS

This study included 950 patients, of which 429 (45.16%) had AKI. Mechanical ventilation, vasopressor, international normalized ratio (INR), bilirubin, Charlson comorbidity index (CCI), prothrombin time (PT), estimated glomerular filtration rate (EGFR), partial thromboplastin time (PTT), and heart rate served as predictors. In the derivation set, the developed RF [area under curve (AUC) = 0.747], XGB (AUC = 0.832), LGBM (AUC = 0.785), and GBDT (AUC = 0.811) models exhibited significantly greater predictive performance than the logistic regression model (AUC = 0.699) (all P < 0.05). Among the ML-based models, the XGB model had the greatest AUC. In internal validation, the predictive capacity of the XGB model (AUC = 0.833) was significantly superior to that of the logistic regression model (AUC = 0.701) (P = 0.045). Hence, the XGB model was selected as the final model for AKI prediction. In contrast to the XGB model (AUC = 0.832), the SOFA (AUC = 0.609), MELD (AUC = 0.690), MELD Na (AUC = 0.690), and SAPS II (AUC = 0.641) had significantly lower predictive abilities in the derivation set (all P < 0.001). The XGB model was internally validated to have an AUC of 0.833, which was significantly higher than the SOFA (AUC = 0.609), MELD (AUC = 0.690), MELD Na (AUC = 0.688), and SAPS II (AUC = 0.641) (all P < 0.05).

CONCLUSION

The XGB model had a better performance than the logistic regression model, SOFA, MELD, MELD Na, and SAPS II in AKI prediction for cirrhosis patients, which may help identify patients at a risk of AKI, and then provide timely interventions.

Histologic scoring of liver biopsies for the prognosis of chronic liver disease at a tertiary care hospital in South India

OBJECTIVES

The study aimed to evaluate the role of histologic scoring of liver biopsies using Ishak-modified histological activity index (HAI) and Laennec's scoring system in predicting chronic liver disease (CLD) prognosis in South India.

METHODS

A retrospective analysis of liver biopsy samples was conducted at a tertiary care hospital. The samples were scored using the Ishak-modified HAI and Laennec's scoring system for staging and grading CLD. Patient clinical data were retrieved and assessed using the Child-Pugh scoring system. Chi-squared test was used to test the association between categorical variables and the association with multiple categories was reported using Cramer's V correlation coefficient. A p-value < 0.05 was considered significant.

RESULTS

Out of 43 samples included in the study, 65.12% were male patients, with a mean age of 43.3 ± 13.9 years. Cirrhotic cases accounted for the highest proportion (65.12%, n = 28), followed by hepatitis cases (30%, n = 13). The predominant etiology was alcohol-related (44.19%, n = 19). Percutaneous liver biopsies constituted most of the samples (48.84%, n = 21), followed by transjugular (37.21%, n = 16) and ultrasonography-guided (11.63%, n = 6) biopsies. The correlation between Ishak-modified HAI stages and Child-Pugh scores was weak and insignificant (p = 0.71), while Laennec's scores showed a moderate but insignificant correlation with Child-Pugh scores (p = 0.066).

CONCLUSION

Histologic scoring of liver biopsies using the Ishak-modified HAI and Laennec's scoring system can provide valuable prognostic information for CLD. However, further research is needed to establish stronger correlations with clinical outcomes.

Portal vein thrombosis in patients with liver cirrhosis

Background/Aim. Portal vein thrombosis (PVT) in patients with liver cirrhosis (LC) has a prevalence of 0.6?26%. It is most commonly discovered incidentally as part of the evaluation of LC or in the context of acute decompensation of LC due to portal hypertension. The aim of the study was to determine the prevalence of PVT in patients with LC in relation to the severity of the disease and individual elements of portal hypertension. Methods. A total of 326 patients treated for LC decompensation were included in a retrospective study. Standard laboratory analyses, abdominal ultrasonography and/or computed tomography, and esophagogastroduodenoscopy were performed. Results. The diameter of the portal vein (PV) differed between patients without esophageal varices (12.2 mm) and those with large varices (13.6 mm), p = 0.026. PVT was identified in 6.1% of patients with LC. The patients were classified according to the Child-Pugh scoring system, which has the A, B, and C categories used to assess the severity of liver disease. PVT was present in 3.0% of patients in class C and 12.0% in class B, while none of the patients in class A had PVT (p = 0.005). PVT was present in 4.4% of patients with small varices and 16.7% with large varices (p < 0.001). There was no difference in the presence of PVT between the groups of patients with and without variceal bleeding nor between groups with different degrees of ascites. A fatal outcome occurred in 29.4% of patients, but there was no difference between patients with and without PVT. Conclusion. PVT is present in more advanced stages of LC and predominantly in patients with large esophageal varices. There was no higher prevalence of PVT observed with the occurrence of variceal bleeding or with the death outcome in patients with LC.

The Effect of Model for End-Stage Liver Disease 3.0 on Disparities between Patients with and without Hepatocellular Carcinoma in Korea

PURPOSE

The model for end-stage liver disease (MELD) 3.0 has recently been suggested for determining liver allocation. We aimed to apply MELD 3.0 to a Korean population and to discover differences between patients with and without hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This study is a retrospective study of 2203 patients diagnosed with liver cirrhosis at Severance Hospital between 2016-2022. Harrell's concordance index was used to validate the ability of MELD scores to predict 90-day survival.

RESULTS

During a mean follow-up of 12.9 months, 90-day survival was 61.9% in all patients, 50.4% in the HCC patients, and 74.8% in the non-HCC patients. Within the HCC patients, the concordance index for patients on the waitlist was 0.653 using MELD, which increased to 0.753 using MELD 3.0. Among waitlisted patients, the 90-day survival of HCC patients was worse than that of non-HCC patients with MELD scores of 31-37 only (69.7% vs. 30.0%, p=0.001). Applying MELD 3.0, the 90-day survival of HCC patients was worse than that of non-HCC patients across a wider range of MELD 3.0 scores, compared to MELD, with MELD 3.0 scores of 21-30 and 31-37 (82.0% vs. 72.5% and 72.3% vs. 24.3%, p=0.02 and p<0.001, respectively).

CONCLUSION

MELD 3.0 predicted 90-day survival of the HCC patients more accurately than original MELD score; however, the disparity between HCC and non-HCC patients increased, particularly in patients with MELD scores of 21-30. Therefore, a novel exception score is needed or the current exception score system should be modified.

Health status of patients with liver transplantation by alcohol-related disease vs another etiology: A cohort study

AIM

To study the health status of a group of patients with liver transplantation by alcohol-related disease vs another etiology before and after the transplantation.

METHOD

Longitudinal cohort study of liver transplant patients from November 2019 to July 2022. Adult patients attended in the unit of transplantation of a hospital for a first liver transplant, both elective and urgent, were included. Patients who already had a transplanted organ and those who required liver re-transplantation in the first month after the first transplant were excluded. Sociodemographic and clinical variables, MELDNa, liver frailty index, emotional-behavioral effects of transplantation, level of anxiety and depression were collected. Pearson's chi-square, Student's t, Mann-Whitney U, and Wilcoxon sign tests were used for statistical analysis.

RESULTS

The sample was n = 67 liver transplant patients with a mean age of 56.37 years, 67.2% being men and 39% due to alcohol-related liver disease. 9% of all included patients were urgent transplants. Alcohol consumption was associated with older age, a high rate of liver frailty, and a non-active work situation. Alcoholic etiology correlated with increased concern during the first six months after liver transplantation.

CONCLUSION

There are differences in the health status between liver transplant patients for alcohol-related liver disease vs other etiology. Nurses must consider the etiology of liver disease to guide care and interventions throughout the transplant process.

Prognostic assessment of liver cirrhosis and its complications: current concepts and future perspectives

Liver cirrhosis is an irreversible stage of chronic liver disease with varying clinical course. Acute decompensation of liver cirrhosis represents a watershed in prognosis and is characterized by the occurrence of clinical complications such as ascites, jaundice, hepatic encephalopathy, infections, or portal-hypertensive hemorrhages. Emergent data indicate that an acute decompensation can be subdivided into stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre-acute-on chronic liver failure (pre-ACLF) and acute-on chronic liver failure (ACLF), while the mortality risk varies greatly between the respective subgroups. ACLF is the most severe form of acutely decompensated cirrhosis and characterized by the development of organ failure(s) and a high short-term mortality. Due to the dynamic disease course of acute decompensation, it is paramount to detect patients at particular risk for severe complications those at high risk for developing ACLF as early as possible in order to initiate optimal management. This review describes new concepts and perspectives in the definition and classification of decompensated cirrhosis and provides on overview on emerging predictive scoring systems, non-invasive measurement methods and new biomarkers, which allow an early identification of patients with acute decompensation at risk.

Evaluation of the nutritional status of patients with liver cirrhosis

BACKGROUND

Progressive malnutrition coexists with liver diseases, particularly in patients with cirrhosis. Early diagnosis of malnutrition in patients with advanced stages of chronic liver disease and the implementation of appropriate nutritional treatment for malnourished patients should be an integral part of the therapeutic process.

AIM

To evaluate the nutritional status of patients with various severities of advanced liver fibrosis, using various nutritional status parameters.

METHODS

This study involved 118 patients with liver cirrhosis who were classified into three groups according to their Child-Pugh score. The nutritional status of the patients in each group was assessed using different methods. The average values obtained from the measurements were calculated for each research group. The influence of disease stage on the examined parameters of nutritional status was determined using one-way analysis of variance. To investigate the relationship between the parameters determining nutritional status and the stage of disease advancement, a correlation analysis was performed.

RESULTS

The Child-Pugh A group had the highest mean body weight (76.42 kg), highest mean body mass index (BMI) (26.72 kg/m²), and largest mean arm circumference (27.64 cm). In the Child-Pugh B group, the mean scores of all examined variables were lower than those of the Child-Pugh A group, whereas the mean body weight and BMI of the Child-Pugh C group were higher than those of the Child-Pugh B group. There was a very strong correlation between the Child-Pugh classification and subjective global assessment score; a very strong correlation between the Child-Pugh classification and arm circumference; a strong correlation between the Child-Pugh classification and body weight, albumin concentration, fat-free mass index, muscle mass index, phase angle, and BMI; and an average correlation between Child-Pugh classification and fat mass index. Notably, these indicators deteriorated with disease progression.

CONCLUSION

Advanced liver fibrosis leads to the deterioration of many nutritional status parameters. The extent of malnutrition increases with the progression of liver fibrosis. The Child-Pugh score reflects the nutritional status.

Progress on clinical prognosis assessment in liver failure

Liver failure is a group of clinical syndromes with a mortality rate of >50%. The accurate evaluation of severity in patients with liver failure has been a meaningful and hot topic in clinical research and an important guide for liver transplantation. Numerous prognosis studies have emerged in recent years with high accuracy and adequate validity. Nonetheless, different models utilize distinct parameters and have unequal efficiencies, leading to a specific value and unique application situations for each model. This review focused on the progress in recent prognostic studies including the model for end-stage liver disease, sequential organ failure assessment and its derivative models, the Chinese Group on the Study of Severe Hepatitis B Acute-on-Chronic Liver Failure, the Tongji prognostic predictor model, and other emerging prognostic models and predictors. This review aims to assist clinicians understand the framework of recent models and choose the appropriate model and treatment.

Differentiation of Spontaneous Bacterial Peritonitis from Secondary Peritonitis in Patients with Liver Cirrhosis: Retrospective Multicentre Study

Ascitic fluid infection is a serious complication of liver cirrhosis. The distinction between the more common spontaneous bacterial peritonitis (SBP) and the less common secondary peritonitis in patients with liver cirrhosis is crucial due to the varying treatment approaches. This retrospective multicentre study was conducted in three German hospitals and analysed 532 SBP episodes and 37 secondary peritonitis episodes. Overall, >30 clinical, microbiological, and laboratory parameters were evaluated to identify key differentiation criteria. Microbiological characteristics in ascites followed by severity of illness and clinicopathological parameters in ascites were the most important predictors identified by a random forest model to distinguish between SBP and secondary peritonitis. To establish a point-score model, a least absolute shrinkage and selection operator (LASSO) regression model selected the ten most promising discriminatory features. By aiming at a sensitivity of 95% either to rule out or rule in SBP episodes, two cut-off scores were defined, dividing patients with infected ascites into a low-risk (score ≥ 45) and high-risk group (score < 25) for secondary peritonitis. Overall, the discrimination of secondary peritonitis from SBP remains challenging. Our univariable analyses, random forest model, and LASSO point score may help clinicians with the crucial differentiation between SBP and secondary peritonitis.

Complement C3 Facilitates Stratification of Stages of Chronic Hepatitis B and Signifies Development of Acute-on-Chronic Liver Failure in Acute Decompensated Cirrhosis

INTRODUCTION

Patients with chronic hepatitis B (CHB) have a dynamic disease process and risk of end-stage liver disease. It is critical to unambiguously differentiate the stages of the disease and focus on therapy prior to onset of an irreversible clinical endpoint.

METHODS

We retrospectively analyzed a wide range of CHB patients at different stages. The predictive power of serum complement component 3 (C3) levels for the development of acute-on-chronic liver failure (ACLF) in patients with decompensated cirrhosis was established and validated.

RESULTS

The decrease in serum C3 levels paralleled the severity of diseases related to hepatitis B virus. Patients with decompensated cirrhosis who developed ACLF had significantly lower serum C3 levels than others on admission (0.50 vs. 0.80 g/L, P < 0.001). Data analysis also revealed that low serum C3 was a significant risk factor for developing ACLF (hazard ratio = 0.32, P < 0.01). The area under the receiver operating characteristic curve (auROC) for serum C3 levels that predicted the development of ACLF in patients with decompensated cirrhosis was 0.90, which had sensitivity and specificity of 88.2% and 88.7%, respectively. A similar result was observed in the validation set (auROC = 0.86 for predicting development of ACLF in patients with decompensated cirrhosis).

CONCLUSIONS

Serum C3 levels are valuable in assessing the severity of CHB-related stages. Low C3 levels signifies the development of ACLF in patients with decompensated cirrhosis.

Liver Function-How to Screen and to Diagnose: Insights from Personal Experiences, Controlled Clinical Studies and Future Perspectives

Acute and chronic liver disease is a relevant problem worldwide. Liver function plays a crucial role in the course of liver diseases not only in estimating prognosis but also with regard to therapeutic interventions. Within this review, we discuss and evaluate different tools from screening to diagnosis and give insights from personal experiences, controlled clinical studies and future perspectives. Finally, we offer our novel diagnostic algorithm to screen patients with presumptive acute or chronic liver disease in the daily clinical routine.

Human stem cells for decompensated cirrhosis in adults

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms of stem cell treatment in adults with decompensated cirrhosis, regardless of ethnicity, sex, types of stem cells, route of stem cell injection, and administered dose.

Albumin-bilirubin score is superior to platelet-albumin-bilirubin score and model for end-state liver disease sodium for predicting posthepatectomy liver failure

BACKGROUND

Risk stratification for patients undergoing hepatectomy can be attempted using established models. This study compares the platelet-albumin-bilirubin (PALBI) score with albumin-bilirubin (ALBI) and model for end-stage liver disease sodium (MELD-Na) for predicting posthepatectomy liver failure (PHLF) and 30-day mortality.

METHODS

The 2014-2018 NSQIP database was queried for patients who underwent elective hepatectomy. Multivariable logistic regressions assessed associations of posthepatectomy outcomes with patient and clinical characteristics. Predictive accuracy of the grading systems was evaluated using receiver operator characteristic (ROC) curves and calculating area under the curve (AUC).

RESULTS

Severe PHLF (Grade B/C) and mortality were present in 2.58% (N = 369) and 1.2% (N = 171) of patients who underwent hepatectomy (N = 13 925), respectively. ALBI Grade 2/3 had a stronger association with severe PHLF (odds ratio [OR] = 1.62, p < 0.01) and mortality (OR = 2.06, p < 0.005) than PALBI Grade 2/3 (OR = 1.14, p = 0.43 for PHLF and OR = 2.01, p < 0.005 for mortality) or MELD-Na ≥10 (OR = 1.29, p = 0.25 for PHLF and OR = 1.84, p < 0.03). ALBI had a higher AUC (0.671) than PALBI (0.625) and MELD-Na (0.627) for predicting severe PHLF. ALBI had a higher AUC (0.695) than PALBI (0.642) for predicting 30-day mortality.

CONCLUSIONS

ALBI was a more accurate predictor of severe PHLF and 30-day mortality than MELD-Na and PALBI for patients who underwent hepatectomy.

Urinary BA Indices as Prognostic Biomarkers for Complications Associated with Liver Diseases

Hepatobiliary diseases and their complications cause the accumulation of toxic bile acids (BA) in the liver, blood, and other tissues, which may exacerbate the underlying condition and lead to unfavorable prognosis. To develop and validate prognostic biomarkers for the prediction of complications of cholestatic liver disease based on urinary BA indices, liquid chromatography-tandem mass spectrometry was used to analyze urine samples from 257 patients with cholestatic liver diseases during a 7-year follow-up period. The urinary BA profile and non-BA parameters were monitored, and logistic regression models were used to predict the prognosis of hepatobiliary disease-related complications. Urinary BA indices were applied to quantify the composition, metabolism, hydrophilicity, and toxicity of the BA profile. We have developed and validated the bile-acid liver disease complication (BALDC) model based on BA indices using logistic regression model, to predict the prognosis of cholestatic liver disease complications including ascites. The mixed BA and non-BA model was the most accurate and provided higher area under the receiver operating characteristic (ROC) and smaller akaike information criterion (AIC) values compared to both non-BA and MELD (models for end stage liver disease) models. Therefore, the mixed BA and non-BA model could be used to predict the development of ascites in patients diagnosed with liver disease at early stages of intervention. This will help physicians to make a better decision when treating hepatobiliary disease-related ascites.