1
|
Sathar SA, Vargheese J. CHIBA score: a novel model for predicting 3-month mortality in a cohort of Decompensated Liver Disease (DCLD). EGYPTIAN LIVER JOURNAL 2023. [DOI: 10.1186/s43066-023-00243-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Abstract
Background
Decompensated liver disease (DCLD) has high mortality, and its prediction is important to prognosticate and prioritize patients for liver transplantation. MELD, MELD variants, and CTP were widely tested for mortality prediction with few drawbacks. The aim of the study is to propose a new prognostic model for DCLD which is better than the existing scores.
Materials and methods
Retrospective study with 321 DCLD patients were enrolled. Patient relatives were telephonically contacted regarding date of death, and mortality at 3 months was assessed. Logistic regression was done, coefficient of beta of independent variables were found out, and a new CHIBA score was proposed.
CHIBA score = creatinine × 0.6 + HE × 0.4+ INR × 0.8 + bilirubin × 0.125 + ascites × 1.2) where C stands for creatinine, H for hepatic encephalopathy, I for INR, B for bilirubin, and A for ascites.
Results
CHIBA score has AUROC of 0.793 (at a cutoff of > 5.5, it has a sensitivity of 66% and specificity of 76%) compared to MELD-Na of 0.735 (cutoff > 25, sensitivity 65%, and specificity 72%); MELD of 0.727 (cutoff > 17 sensitivity of 80.37% and specificity of 55.14%); I-MELD of 0.72; MESO index of 0.72; and UKELD of 0.686. For validation, 214 patients were selected, and AUROC of CHIBA score in the validation cohort was 0.77. At a cutoff of > 5.5, it has a sensitivity of 60% and specificity of 77%.
Conclusion
CHIBA score is superior to MELD and MELD variants in predicting 3-month mortality, and it is validated in an external cohort. It can be calculated at bedside as it is a simple score with no logarithmic variables in it.
Collapse
|
2
|
Miño Bernal JF, López Morales E, Sandino NJ, Molano Franco D. Cirrosis hepática o falla hepática crónica agudizada: definición y clasificación. REPERTORIO DE MEDICINA Y CIRUGÍA 2022. [DOI: 10.31260/repertmedcir.01217372.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La cirrosis se considera el estadio crónico e irreversible de la lesión hepática. Su etiología es diversa y abarca causas como las infecciones víricas, tóxicos como el alcohol, medicamentos, patologías autoinmunes y otras. La descompensación de la cirrosis hepática es consecuencia de cambios fisiopatológicos que se dan con el tiempo como ascitis, peritonitis bacteriana espontánea, hemorragia del tubo digestivo, síndrome hepatorrenal, encefalopatía hepática o hipertensión portopulmonar, mientras que la falla hepática crónica agudizada debe considerarse como una entidad que debe diferenciarse de la anterior, ya que es una falla multiorgánica de curso rápido, por lo regular en pacientes hospitalizados en unidad de cuidado intensivo, a menudo secundaria a desencadenantes como estados de choque. El clínico debe identificarlas para su abordaje y evaluación. El método actual adecuado para estadificar esta entidad es el puntaje CLIFF SOFA, que evalúa la mortalidad a 28 y 90 días, permitiendo intervenciones adecuadas en cada caso.
Collapse
|
3
|
Benson AB, D'Angelica MI, Abbott DE, Anaya DA, Anders R, Are C, Bachini M, Borad M, Brown D, Burgoyne A, Chahal P, Chang DT, Cloyd J, Covey AM, Glazer ES, Goyal L, Hawkins WG, Iyer R, Jacob R, Kelley RK, Kim R, Levine M, Palta M, Park JO, Raman S, Reddy S, Sahai V, Schefter T, Singh G, Stein S, Vauthey JN, Venook AP, Yopp A, McMillian NR, Hochstetler C, Darlow SD. Hepatobiliary Cancers, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:541-565. [PMID: 34030131 DOI: 10.6004/jnccn.2021.0022] [Citation(s) in RCA: 439] [Impact Index Per Article: 146.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The NCCN Guidelines for Hepatobiliary Cancers focus on the screening, diagnosis, staging, treatment, and management of hepatocellular carcinoma (HCC), gallbladder cancer, and cancer of the bile ducts (intrahepatic and extrahepatic cholangiocarcinoma). Due to the multiple modalities that can be used to treat the disease and the complications that can arise from comorbid liver dysfunction, a multidisciplinary evaluation is essential for determining an optimal treatment strategy. A multidisciplinary team should include hepatologists, diagnostic radiologists, interventional radiologists, surgeons, medical oncologists, and pathologists with hepatobiliary cancer expertise. In addition to surgery, transplant, and intra-arterial therapies, there have been great advances in the systemic treatment of HCC. Until recently, sorafenib was the only systemic therapy option for patients with advanced HCC. In 2020, the combination of atezolizumab and bevacizumab became the first regimen to show superior survival to sorafenib, gaining it FDA approval as a new frontline standard regimen for unresectable or metastatic HCC. This article discusses the NCCN Guidelines recommendations for HCC.
Collapse
Affiliation(s)
- Al B Benson
- 1Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Robert Anders
- 5The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | - Prabhleen Chahal
- 11Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Jordan Cloyd
- 13The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Evan S Glazer
- 14St. Jude Children's Research HospitalThe University of Tennessee Health Science Center
| | | | - William G Hawkins
- 16Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - R Kate Kelley
- 19UCSF Helen Diller Family Comprehensive Cancer Center
| | - Robin Kim
- 20Huntsman Cancer Institute at the University of Utah
| | - Matthew Levine
- 21Abramson Cancer Center at the University of Pennsylvania
| | | | - James O Park
- 23Fred Hutchinson Cancer Research CenterSeattle Cancer Care Alliance
| | | | | | | | | | | | | | | | - Alan P Venook
- 19UCSF Helen Diller Family Comprehensive Cancer Center
| | - Adam Yopp
- 31UT Southwestern Simmons Comprehensive Cancer Center; and
| | | | | | | |
Collapse
|
4
|
Kong L, Lv T, Jiang L, Yang J, Yang J. Outcomes of hemi- versus whole liver transplantation in patients from mainland china with high model for end-stage liver disease scores: a matched analysis. BMC Surg 2020; 20:290. [PMID: 33218334 PMCID: PMC7677100 DOI: 10.1186/s12893-020-00965-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 11/15/2020] [Indexed: 02/08/2023] Open
Abstract
Background Adult hemiliver transplantation (AHLT) is an important approach given the current shortage of donor livers. However, the suitability of AHLT versus adult whole liver transplantation (AWLT) for recipients with high Model for End-Stage Liver Disease (MELD) scores remains controversial. Methods We divided patients undergoing AHLT and AWLT into subgroups according to their MELD scores (≥ 30: AHLT, n = 35; AWLT, n = 88; and < 30: AHLT, n = 323; AWLT, n = 323). Patients were matched by demographic data and perioperative conditions according to propensity scores. A cut-off value of 30 for MELD scores was determined by comparing the overall survival data of 735 cases of nontumor liver transplantation. Results Among patients with an MELD score ≥ 30 and < 30, AHLT was found to be associated with increased warm ischemia time, operative time, hospitalization time, and intraoperative blood loss compared with AWLT (P < 0.05). In the MELD ≥ 30 group, although the 5-year survival rate was significantly higher for AWLT than for AHLT (P = 0.037), there was no significant difference between AWLT and AHLT in the MELD < 30 group (P = 0.832); however, we did not observe a significant increase in specific complications following AHLT among patients with a high MELD score (≥ 30). Among these patients, the incidence of complications classified as Clavien-Dindo grade III or above was significantly higher in patients undergoing AHLT than in those undergoing AWLT (25.7% vs. 11.4%, P = 0.047). For the MELD < 30 group, there was no significant difference in the incidence of complications classified as Clavien-Dindo grade III or above for patients undergoing AHLT or AWLT. Conclusion In patients with an MELD score < 30, AHLT can achieve rates of mortality and overall survival comparable to AWLT. In those with an MELD score ≥ 30, the prognosis and incidence of complications classified as Clavien-Dindo III or above are significantly worse for AHLT than for AWLT; therefore, we may need to be more cautious regarding the conclusion that patients with a high MELD score can safely undergo AHLT.
Collapse
Affiliation(s)
- LingXiang Kong
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Tao Lv
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Li Jiang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jian Yang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jiayin Yang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| |
Collapse
|
5
|
Meena RK, G. S, P. K, Mohamed I, Masiwal P, Ramadoss K. Constipation and upper gastrointestinal bleed: Leading precipitating factors of hepatic encephalopathy in Indian cirrhotic patients. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2018. [DOI: 10.1016/j.injms.2018.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
6
|
Abstract
There is a strong imperative to develop valid and accurate prognostic modeling for acute liver failure (ALF). Despite the numerous clinical models that have been proposed thus far and the use of some such models, that is, King's College Criteria and Model for End-Stage Liver Disease, in clinical practice to aid decision-making, there is a significant need for improvement for determining patients' clinical course, survival, and requirement for liver transplantation. Future prognostic models shall need a stronger statistical foundation and accountability for time and variability in the clinical course of ALF and be applied for pretransplant and posttransplant outcomes.
Collapse
|
7
|
Kramer L, Gendo A, Madl C, Mullen K, Kaminski-Russ K, Sunder-Plassmann G, Schaffer A, Bauer E, Roth E, Ferenci P. A Controlled Study of Sorbent Suspension Dialysis in Chronic Liver Disease and Hepatic Encephalopathy. Int J Artif Organs 2018. [DOI: 10.1177/039139880102400707] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To investigate the role of extracorporeal detoxification in cirrhotic patients with advanced hepatic encephalopathy not responding to medical treatment, 20 patients were randomized to receive six hours of additional sorbent dialysis or ongoing standardized medical treatment. Following treatment, the clinical stage of encephalopathy remained unchanged in both groups. Abnormal sensory evoked potentials improved following sorbent dialysis (N70 latency, 128 ms before versus 110 ms after treatment, P<0,05; cervico-cranial transmission, 7.7 ms versus 6.8 ms, P<0.01) indicating improvement in important aspects of cerebral function. In contrast, brain function remained unchanged following medical treatment (N70 latency, 114 ms versus 113 ms; cervico-cranial transmission, 7.7 ms versus 7.2 ms, P=NS, respectively). Serum benzodiazepine levels decreased significantly after sorbent dialysis but not after medical treatment. Biocompatibility of sorbent dialysis was limited and clinical complications occurred in a proportion of patients. In conclusion, a six-hour treatment with sorbent suspension dialysis did not ameliorate the clinical stage of HE but improved neurophysiologic function in cirrhotic patients who had not responded to conventional medical treatment.
Collapse
Affiliation(s)
- L. Kramer
- Department of Medicine IV, University of Vienna Medical School, Vienna - Austria
| | - A. Gendo
- Department of Medicine IV, University of Vienna Medical School, Vienna - Austria
| | - C. Madl
- Department of Medicine IV, University of Vienna Medical School, Vienna - Austria
| | - K.D. Mullen
- Department of Internal Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH - USA
| | - K. Kaminski-Russ
- Department of Internal Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH - USA
| | - G. Sunder-Plassmann
- Department of Medicine III, University of Vienna Medical School, Vienna - Austria
| | - A. Schaffer
- Department of Medicine IV, University of Vienna Medical School, Vienna - Austria
| | - E. Bauer
- Department of Medicine IV, University of Vienna Medical School, Vienna - Austria
| | - E. Roth
- Department of Surgery, University of Vienna Medical School, Vienna - Austria
| | - P. Ferenci
- Department of Medicine IV, University of Vienna Medical School, Vienna - Austria
| |
Collapse
|
8
|
Huang GQ, Xie YY, Zhu PW, Wang XD, Lin Z, Wang Y, Ye JP, Wang YM, Chen YX, Jin XZ, Van Poucke S, Chen YP, Zheng MH. Stratified alpha-fetoprotein pattern accurately predicts mortality in patients with acute-on-chronic hepatitis B liver failure. Expert Rev Gastroenterol Hepatol 2018; 12:295-302. [PMID: 29300103 DOI: 10.1080/17474124.2018.1424540] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Alpha-fetoprotein (AFP) has been shown to predict the prognosis of liver disease in several studies. This study aimed to evaluate the prognostic value of stratified AFP in patients with acute-on-chronic hepatitis B liver failure (ACHBLF). METHODS A total of 192 patients were included and AFP were categorized into quartiles. The prognostic value was determined for overall survival (OS) and assessed by Kaplan-Meier analysis. Univariate and multivariate Cox proportional hazard regression analyses studied the association of all independent parameters with disease prognosis. RESULTS The optimal cut-off points of AFP were: (Q1) 252.3-4800.0 ng/ml, (Q2) 76.0-252.2 ng/ml, (Q3) 18.6-75.9 ng/ml, and (Q4) 0.7-18.5 ng/ml. Based on the Kaplan-Meier analysis of the OS, each AFP quartile revealed a progressively worse OS and apparent separation (log-rank P = 0.006). The second-highest quartiles of AFP (Q2) always demonstrated an extremely favorable short-term survival. Combining the lowest AFP quartiles with a serum sodium < 131mmol/L or an INR ≥ 3.3 showed a poor outcome (90-days survival of 25.0% and 11.9% respectively). CONCLUSIONS Stratified AFP could strengthen the predictive power for short-term survival of patients with ACHBLF. Combining AFP quartiles with low serum sodium and high INR may better predict poor outcome in ACHBLF patients.
Collapse
Affiliation(s)
- Gui-Qian Huang
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,b Department of Neurology , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Yao-Yao Xie
- c Department of Clinical Laboratory , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Pei-Wu Zhu
- c Department of Clinical Laboratory , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Xiao-Dong Wang
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,d Institute of Hepatology , Wenzhou Medical University , Wenzhou , China
| | - Zhuo Lin
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,d Institute of Hepatology , Wenzhou Medical University , Wenzhou , China
| | - Yan Wang
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Jiang-Pin Ye
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Yu-Min Wang
- c Department of Clinical Laboratory , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Ying-Xiao Chen
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Xiao-Zhi Jin
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Sven Van Poucke
- e Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy , Ziekenhuis Oost-Limburg , Genk , Belgium
| | - Yong-Ping Chen
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,d Institute of Hepatology , Wenzhou Medical University , Wenzhou , China
| | - Ming-Hua Zheng
- a Department of Hepatology, Liver Research Center , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,d Institute of Hepatology , Wenzhou Medical University , Wenzhou , China
| |
Collapse
|
9
|
Al-Freah MAB, Moran C, Foxton MR, Agarwal K, Wendon JA, Heaton ND, Heneghan MA. Impact of comorbidity on waiting list and post-transplant outcomes in patients undergoing liver retransplantation. World J Hepatol 2017; 9:884-895. [PMID: 28804571 PMCID: PMC5534363 DOI: 10.4254/wjh.v9.i20.884] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 04/20/2017] [Accepted: 05/31/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the impact of Charlson comorbidity index (CCI) on waiting list (WL) and post liver retransplantation (LRT) survival.
METHODS Comparative study of all adult patients assessed for primary liver transplant (PLT) (n = 1090) and patients assessed for LRT (n = 150), 2000-2007 at our centre. Demographic, clinical and laboratory variables were recorded.
RESULTS Median age for all patients was 53 years and 66% were men. Median model for end stage liver disease (MELD) score was 15. Median follow-up was 7-years. For retransplant patients, 84 (56%) had ≥ 1 comorbidity. The most common comorbidity was renal impairment in 66 (44.3%). WL mortality was higher in patients with ≥ 1 comorbidity (76% vs 53%, P = 0.044). CCI (OR = 2.688, 95%CI: 1.222-5.912, P = 0.014) was independently associated with WL mortality. Patients with MELD score ≥ 18 had inferior WL survival (Log-Rank 6.469, P = 0.011). On multivariate analysis, CCI (OR = 2.823, 95%CI: 1.563-5101, P = 0.001), MELD score ≥ 18 (OR 2.506, 95%CI: 1.044-6.018, P = 0.04), and requirement for organ support prior to LRT (P < 0.05) were associated with reduced post-LRT survival. Donor/graft parameters were not associated with survival (P = NS). Post-LRT mortality progressively increased according to the number of transplanted grafts (Log-Rank 18.455, P < 0.001). Post-LRT patient survival at 1-, 3- and 5-years were significantly inferior to those of PLT at 88% vs 73%, P < 0.001, 81% vs 71%, P = 0.018 and 69% vs 55%, P = 0.006, respectively.
CONCLUSION Comorbidity increases WL and post-LRT mortality. Patients with MELD ≥ 18 have increased WL mortality. Patients with comorbidity or MELD ≥ 18 may benefit from earlier LRT. LRT for ≥ 3 grafts may not represent appropriate use of donated grafts.
Collapse
|
10
|
White N, Reid F, Harris A, Harries P, Stone P. A Systematic Review of Predictions of Survival in Palliative Care: How Accurate Are Clinicians and Who Are the Experts? PLoS One 2016; 11:e0161407. [PMID: 27560380 PMCID: PMC4999179 DOI: 10.1371/journal.pone.0161407] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/04/2016] [Indexed: 11/18/2022] Open
Abstract
Background Prognostic accuracy in palliative care is valued by patients, carers, and healthcare professionals. Previous reviews suggest clinicians are inaccurate at survival estimates, but have only reported the accuracy of estimates on patients with a cancer diagnosis. Objectives To examine the accuracy of clinicians’ estimates of survival and to determine if any clinical profession is better at doing so than another. Data Sources MEDLINE, Embase, CINAHL, and the Cochrane Database of Systematic Reviews and Trials. All databases were searched from the start of the database up to June 2015. Reference lists of eligible articles were also checked. Eligibility Criteria Inclusion criteria: patients over 18, palliative population and setting, quantifiable estimate based on real patients, full publication written in English. Exclusion criteria: if the estimate was following an intervention, such as surgery, or the patient was artificially ventilated or in intensive care. Study Appraisal and Synthesis Methods A quality assessment was completed with the QUIPS tool. Data on the reported accuracy of estimates and information about the clinicians were extracted. Studies were grouped by type of estimate: categorical (the clinician had a predetermined list of outcomes to choose from), continuous (open-ended estimate), or probabilistic (likelihood of surviving a particular time frame). Results 4,642 records were identified; 42 studies fully met the review criteria. Wide variation was shown with categorical estimates (range 23% to 78%) and continuous estimates ranged between an underestimate of 86 days to an overestimate of 93 days. The four papers which used probabilistic estimates tended to show greater accuracy (c-statistics of 0.74–0.78). Information available about the clinicians providing the estimates was limited. Overall, there was no clear “expert” subgroup of clinicians identified. Limitations High heterogeneity limited the analyses possible and prevented an overall accuracy being reported. Data were extracted using a standardised tool, by one reviewer, which could have introduced bias. Devising search terms for prognostic studies is challenging. Every attempt was made to devise search terms that were sufficiently sensitive to detect all prognostic studies; however, it remains possible that some studies were not identified. Conclusion Studies of prognostic accuracy in palliative care are heterogeneous, but the evidence suggests that clinicians’ predictions are frequently inaccurate. No sub-group of clinicians was consistently shown to be more accurate than any other. Implications of Key Findings Further research is needed to understand how clinical predictions are formulated and how their accuracy can be improved.
Collapse
Affiliation(s)
- Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom
- * E-mail:
| | - Fiona Reid
- Department of Primary Care & Public Health Sciences, King’s College London, London, United Kingdom
| | - Adam Harris
- Department of Experimental Psychology, University College London, London, United Kingdom
| | - Priscilla Harries
- Department of Clinical Sciences, Brunel University London, London, United Kingdom
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom
| |
Collapse
|
11
|
Sustained low-efficiency dialysis with regional citrate anticoagulation in medical intensive care unit patients with liver failure: A prospective study. J Crit Care 2015; 30:1096-100. [PMID: 26254678 DOI: 10.1016/j.jcrc.2015.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 05/19/2015] [Accepted: 06/06/2015] [Indexed: 11/22/2022]
Abstract
PURPOSE Patients with liver failure requiring dialysis are at increased risk for citrate accumulation during sustained low-efficiency dialysis (SLED). The aim of this study was to evaluate the feasibilty of citrate SLED in critical ill patients with liver failure and investigate predictive parameters regarding citrate accumulation. MATERIALS AND METHODS This is a prospective study in 24 medical intensive care unit patients with liver failure and a total of 43 SLED runs (maximum of 3 runs per patient) using citrate anticoagulation. Liver function was characterized before SLED using not only laboratory parameters but also determination of the plasma disappearance rate of indocyanine green. In addition, blood gas parameters as well total calcium and citrate in serum were measured at baseline and defined time points during SLED. RESULTS Accumulation of citrate could be observed in all SLED runs, which were nearly normalized until the end of SLED and 24 hours after SLED, respectively. However, the critical threshold of total calcium/ionized calcium on ratio of greater than 2.5 was exceeded in only 1 patient. Equalization of initial metabolic acidosis was possible without major disturbances of acid base and electrolyte status. Liver function parameters showed poor predicitve capabilities regarding citrate accumulation. CONCLUSIONS Despite substantial accumulation of citrate in serum, SLED is save and feasible in patients with liver failure using a citrate anticoagulation. Careful monitoring of electrolytes and acid base status is mandatory to ensure patient safety.
Collapse
|
12
|
Xiao K, Guo C, Su L, Yan P, Li X, Xie L. Prognostic value of different scoring models in patients with multiple organ dysfunction syndrome associated with acute COPD exacerbation. J Thorac Dis 2015; 7:329-36. [PMID: 25922710 DOI: 10.3978/j.issn.2072-1439.2014.11.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 10/14/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Chronic obstructive pulmonary disease (COPD) represents an increasing healthcare concern as a leading cause of morbidity and mortality worldwide. Our objective was to predict the outcome of COPD patients associated with multiple organ dysfunction syndrome (MODS) by scoring models. METHODS A retrospective study was performed on severe COPD patients within 24 hours of the onset of MODS. The Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Multiple Organ Dysfunction Score (MODS), Simplified Acute Physiology Score II (SAPS II), and Sepsis-related Organ Failure Assessment (SOFA) scores were calculated for patients. RESULTS A total of 153 elderly patients were recruited. Compared to 30-day survivors, the number of failing organs and all of the scoring models were significantly higher in 30-day non-survivors. The SOFA showed the highest sensitivity and area under the curve (AUC) for predicting the prognosis of patients with MODS induced by acute exacerbation of COPD. The results of logistic regression indicated that factors that were correlated with the prognosis of COPD included the exacerbation history, SOFA score, number of failing organs, and duration of ICU stay. The value of exacerbation frequency for predicting the outcome of COPD was excellent (AUC: 0.892), with a sensitivity of 0.851 and a specificity of 0.797. CONCLUSIONS The SOFA score, determined at the onset of MODS in elderly patients with COPD, was a reliable predictor of the prognosis. The exacerbation frequency, number of failing organs, and the SOFA score were risk factors of a poor prognosis, and the exacerbation frequency could also effectively predict the outcome of COPD.
Collapse
Affiliation(s)
- Kun Xiao
- 1 Department of Respiratory Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China ; 2 Department of Cardiology, Fuwai Hospital CAMS & PUMC, Beijing 100037, China ; 3 Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100032, China ; 4 Department of Internal Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Chao Guo
- 1 Department of Respiratory Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China ; 2 Department of Cardiology, Fuwai Hospital CAMS & PUMC, Beijing 100037, China ; 3 Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100032, China ; 4 Department of Internal Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Longxiang Su
- 1 Department of Respiratory Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China ; 2 Department of Cardiology, Fuwai Hospital CAMS & PUMC, Beijing 100037, China ; 3 Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100032, China ; 4 Department of Internal Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Peng Yan
- 1 Department of Respiratory Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China ; 2 Department of Cardiology, Fuwai Hospital CAMS & PUMC, Beijing 100037, China ; 3 Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100032, China ; 4 Department of Internal Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Xin Li
- 1 Department of Respiratory Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China ; 2 Department of Cardiology, Fuwai Hospital CAMS & PUMC, Beijing 100037, China ; 3 Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100032, China ; 4 Department of Internal Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Lixin Xie
- 1 Department of Respiratory Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China ; 2 Department of Cardiology, Fuwai Hospital CAMS & PUMC, Beijing 100037, China ; 3 Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100032, China ; 4 Department of Internal Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| |
Collapse
|
13
|
|
14
|
Abstract
The decision to perform liver transplantation for a particular patient is never the decision of one single individual, although a single individual could preclude transplant as an option if the opportunity for referral is missed. Every physician treating patients with cirrhosis, including primary care physicians and primary gastroenterologists, should watch for the essential turning points at which a patient may become eligible for a transplant referral. Timing of referral could be assessed according to either the type of liver disease or non–disease-specific measures of disease severity. Although the MELD score is an easily accessible and convenient tool it is not as well known as CTP classification, and many cirrhotic patients under long-term management may not be being allocated a MELD score regularly calculated by their primary physicians. Because a slow progression in MELD score may occur without a change in symptoms, reaching the MELD score acceptable for transplant referral may go unrecognized. As generalists face the rising prevalence of NAFLD and the rising prevalence of cirrhosis and HCC from HCV, there will be an increasing need for education in the management of liver disease. It will be necessary for specialists and health care systems to better inform primary care physicians about the recommendations on criteria for transplant referral and the critical windows of opportunity within which they can act. Although there is a recognized knowledge gap that needs to be addressed, once a patient is in medical care, inadequate physician knowledge should never be the cause for late timing or missing the opportunity for referral.
Collapse
Affiliation(s)
- Rena K Fox
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco School of Medicine, 1545 Divisadero Street, Suite 307, San Francisco, CA 94143-0320, USA.
| |
Collapse
|
15
|
Xie YD, Feng B, Gao Y, Wei L. Characteristics of alcoholic liver disease and predictive factors for mortality of patients with alcoholic cirrhosis. Hepatobiliary Pancreat Dis Int 2013; 12:594-601. [PMID: 24322744 DOI: 10.1016/s1499-3872(13)60094-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Alcoholic liver disease is one of the major chronic liver diseases worldwide. The aim of the study was to describe the clinical characteristics of alcoholic liver disease and to compare the predictive values of biochemical parameters, complications, Child-Turcotte-Pugh score, model for end-stage liver disease (MELD) score and discriminant function score for the mortality of in-hospital or 3-month after discharge of patients with alcoholic cirrhosis (AC). METHODS A retrospective record review and statistical analysis were performed on 205 consecutive patients with the discharge diagnosis of alcoholic liver disease. Three models were used to predict the mortality of patients with AC. The number of variceal hemorrhage, infection, hepatic encephalopathy and hepatocellular carcinoma was analyzed as "numbers of complications". Model 1 consisted of creatinine, white blood cell count, international normalized ratio and "numbers of complications". Model 2 consisted of MELD score. Model 3 included "numbers of complications" and MELD score. RESULTS The risk of developing AC was significant for patients with alcohol consumption of higher than 80 g/d (OR=2.807, P<0.050) and drinking duration of longer than 10 years (OR=3.429, P<0.028). The area under curve for predicting in-hospital mortality of models 1, 2 and 3 was 0.950, 0.886 and 0.911 (all P<0.001), respectively. The area under curve for predicting the 3-month mortality of models 1, 2 and 3 was 0.867, 0.878 and 0.893 (all P<0.001), respectively. CONCLUSIONS There is a dose-dependent relationship between alcohol consumption and the risk of developing AC. MELD score has a better predictive value than Child-Turcotte-Pugh or discriminant function score for patients with AC, and model 1 or 3 is better than model 2.
Collapse
Affiliation(s)
- Yan-Di Xie
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Disease, Beijing 100044, China.
| | | | | | | |
Collapse
|
16
|
Morimoto N, Okada K, Okita Y. The model for end-stage liver disease (MELD) predicts early and late outcomes of cardiovascular operations in patients with liver cirrhosis. Ann Thorac Surg 2013; 96:1672-8. [PMID: 23987897 DOI: 10.1016/j.athoracsur.2013.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 05/25/2013] [Accepted: 06/03/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to evaluate the severity of cirrhosis as a predictor of early and late outcomes after cardiovascular operations. METHODS We retrospectively reviewed patients who underwent cardiovascular operations in our institute between October 1999 and April 2009. The severity of liver cirrhosis was assessed using the Child-Pugh classification and the Model for End-stage Liver Disease (MELD) score. RESULTS Liver cirrhosis was identified in 32 consecutive patients. Averages of Child-Pugh and MELD scores were 7.2 ± 1.9 and 11.5 ± 5.1, respectively: 14 patients were classified as Child-Pugh class A, 14 as class B, and 4 as class C. The MELD score was less than 10 (category 1) in 10 patients, between 10 and 14.9 (category 2) in 14, and 15 or higher (category 3) in 8. The hospital mortality rate was 16% (5 of 32). Hospital mortality increased significantly as the MELD score category increased: category 1, 0%; category 2, 7%; and category 3, 50% (p = 0.005). There was no significant association between hospital mortality and Child-Pugh classification: class A, 7%; class B, 21%; and class C, 0% (p = 0.60). Overall survival was 72% ± 8% at 5 years and 47% ± 13% at 10 years. The survival rate decreased significantly as the MELD score category increased (p = 0.004). No relationship was found between the Child-Pugh classification and long-term survival. CONCLUSIONS Our results suggest that the MELD score is useful to predict hospital death and long-term survival after cardiac operations for patients with liver cirrhosis.
Collapse
Affiliation(s)
- Naoto Morimoto
- Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.
| | | | | |
Collapse
|
17
|
Bertot LC, Gomez EV, Almeida LA, Soler EA, Perez LB. Model for End-Stage Liver Disease and liver cirrhosis-related complications. Hepatol Int 2013. [PMID: 26201769 DOI: 10.1007/s12072-012-9403-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The Model for End-Stage Liver Disease (MELD) score has gained wide acceptance for predicting survival in patients undergoing liver transplantation. The strength of this score remains in the mathematical formula derived from a multivariate Cox regression analysis; it is a continuous scale and lacks a ceiling or a floor effect with a wide range of discrimination. It is based on objective, reproducible, and readily available laboratory data and the wide range of samples which have been validated. Liver cirrhosis complications such as ascites, encephalopathy, spontaneous bacterial peritonitis and variceal bleeding were not considered in the MELD score underestimating their direct association with the severity of liver disease. In this regard, several recent studies have shown that clinical manifestations secondary to portal hypertension are good prognostic markers in cirrhotic patients and may add additional useful prognostic information to the current MELD. We review the feasibility of MELD score as a prognostic predictor in patients with liver cirrhosis-related complications.
Collapse
Affiliation(s)
| | - Eduardo Vilar Gomez
- Department of Hepatology, National Institute of Gastroenterology, Havana, Cuba
| | | | - Enrique Arus Soler
- Department of Hepatology, National Institute of Gastroenterology, Havana, Cuba
| | - Luis Blanco Perez
- Department of Hepatology, National Institute of Gastroenterology, Havana, Cuba
| |
Collapse
|
18
|
Abstract
The Model for End-Stage Liver Disease (MELD) score incorporates serum bilirubin, creatinine, and the international normalized ratio (INR) into a formula that provides a continuous variable that is a very accurate predictor of 90-day mortality in patients with cirrhosis. It is currently utilized in the United States to prioritize deceased donor organ allocation for patients listed for liver transplantation. The MELD score is superior to other prognostic models in patients with end-stage liver disease, such as the Child-Turcotte-Pugh score, since it uses only objective criteria, and its implementation in 2002 led to a sharp reduction in the number of people waiting for liver transplant and reduced mortality on the waiting list without affecting posttransplant survival. Although mainly adopted for use in patients waiting for liver transplant, the MELD score has also proved to be an effective predictor of outcome in other situations, such as patients with cirrhosis going for surgery and patients with fulminant hepatic failure or alcoholic hepatitis. Several variations of the original MELD score, involving the addition of serum sodium or looking at the change in MELD over time, have been examined, and these may slightly improve its accuracy. The MELD score does have limitations in situations where the INR or creatinine may be elevated due to reasons other than liver disease, and its implementation for organ allocation purposes does not take into consideration several conditions that benefit from liver transplantation. The application of the MELD score in prioritizing patients for liver transplantation has been successful, but further studies and legislation are required to ensure a fair and equitable system.
Collapse
Affiliation(s)
- Tsang Lau
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, USA
| | - Jawad Ahmad
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, USA
| |
Collapse
|
19
|
Abstract
INTRODUCTION Mortality rates of intensive care patients are quite high. The aim of this study was to determine the availability of thyroid function tests and predictive scoring systems on the outcome of cirrhotic patients admitted to the intensive care unit. METHODS A total of 106 patients were included in the final analysis, of which 32 were men (30.2%) and 74 were women (69.8%). Predictors of mortality that were investigated include acute physiology and chronic health evaluation (APACHE II), model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP) and sequential organ failure assessment (SOFA) scores and thyroid function tests including free triiodo-L-thryronin (fT3), free tetraiodothyronine/thyroxine (fT4) and thyroid-stimulating hormone/thyrotropin (TSH) levels. RESULTS High APACHE II, MELD, CTP and SOFA score and suppression of fT3 were all found to be associated with higher mortality in our intensive care patients who have cirrhosis (P < 0.001). Suppression of fT3 was also found to be reciprocally correlated with high APACHE II, MELD, CTP and SOFA scores (P < 0.001). fT4 had also reciprocal correlation with APACHE II, MELD, CTP and mortality. There is no correlation between TSH levels and predictive scores or mortality. CONCLUSIONS Calculation of APACHE II, MELD, CTP and SOFA scores and measurement of fT3 and fT4 levels may all be useful as predictors of mortality in intensive care patients who have cirrhosis.
Collapse
|
20
|
Schultheiß C, Saugel B, Phillip V, Thies P, Noe S, Mayr U, Haller B, Einwächter H, Schmid RM, Huber W. Continuous venovenous hemodialysis with regional citrate anticoagulation in patients with liver failure: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R162. [PMID: 22913794 PMCID: PMC3580752 DOI: 10.1186/cc11485] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 08/22/2012] [Indexed: 01/24/2023]
Abstract
Introduction Liver failure patients might be at risk for citrate accumulation during continuous venovenous hemodialysis (CVVHD) with regional citrate anticoagulation. The aim of this study was to investigate the predictive capability of baseline liver function parameters regarding citrate accumulation, expressed as an increase in the calcium total/calcium ionized (Catot/Caion) ratio ≥2.5, and to describe the feasibility of citrate CVVHD in liver failure patients. Methods We conducted a prospective observational study in medical ICU patients treated in a German university hospital. We performed 43 CVVHD runs using citrate for regional anticoagulation in 28 critically ill patients with decompensated liver cirrhosis or acute liver failure (maximum of two CVVHD runs per patient). Liver function was characterized before CVVHD using laboratory parameters, calculation of Child-Pugh and Model of End-stage Liver Disease scores, and determination of the plasma disappearance rate of indocyanine green. In addition to blood gas analysis, we measured total calcium and citrate in serum at baseline and after definitive time points for each CVVHD run. Results Accumulation of citrate in serum correlated with an increase in the Catot/Caion ratio. Although the critical upper threshold of Catot/Caion ratio ≥2.5 was exceeded 10 times in seven different CVVHD runs, equalization of initial metabolic acidosis was possible without major disturbances of acid-base and electrolyte status. Standard laboratory liver function parameters showed poor predictive capabilities regarding citrate accumulation in terms of an elevated Catot/Caion ratio ≥2.5. In contrast, serum lactate ≥3.4 mmol/l and prothrombin time ≤26% predicted an increase in the Catot/Caion ratio ≥2.5 with high sensitivity (86% for both lactate and prothrombin time) and specificity (86% for lactate, 92% for prothrombin time). Conclusions Despite substantial accumulation of citrate in serum, CVVHD with regional citrate anticoagulation seems feasible in patients with severely impaired liver function. Citrate accumulation in serum is reflected by an increase in the Catot/Caion ratio. To identify patients at risk for citrate accumulation in terms of a Catot/Caion ratio ≥2.5, baseline serum lactate (threshold ≥3.4 mmol/l) and prothrombin time (threshold ≤26%) may be useful for risk prediction in daily clinical practice. Careful monitoring of electrolytes and acid-base status is mandatory to ensure patient safety.
Collapse
|
21
|
Tas A, Akbal E, Beyazit Y, Kocak E. Serum lactate level predict mortality in elderly patients with cirrhosis. Wien Klin Wochenschr 2012; 124:520-5. [PMID: 22810366 DOI: 10.1007/s00508-012-0208-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 06/25/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cirrhotic patients admitted to the intensive care unit (ICU) usually have multi-organ failure. Multiple organ failure entails a very poor outcome in all intensive care patients. Cirrhotic patients show high morbidity and mortality rates compared with other critically ill patients. Severity scores have been developed for cirrhotic patients admitted to ICU. The main aim of this study was to determine whether lactate level gives any predictive value for mortality in cirrhotic elderly patients admitted to the ICU. METHODS In all the patients enrolled, a diagnosis of cirrhosis was confirmed either histologically or by resorting to clinical, laboratory, and ultrasonographic findings. During this period, patients with cirrhosis were admitted to the ICU with varying indications. Child-Turcotte-Pugh (CTP), Model for End-stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores and lactate were compared between deceased and discharged patients. RESULTS A total of 90 consenting patients were enrolled in this study. The mean age of all the patients was 69 ± 5.919. We detected etiological factors for cirrhosis as HBV, HCV, alcohol, and cryptogenic cirrhosis. Hepatorenal syndrome and spontaneous bacterial peritonitis were significantly higher in patients who died than in those who were discharged from the ICU (p values were 0.01 and 0.028, respectively). Lactate level, CTP, APACHE II, MELD and SOFA scores were significantly higher in patients who died than in those who were discharged from the ICU (p values were 0.002, < 0.001, < 0.001, and < 0.001, respectively). CONCLUSIONS Many factors may be useful as a predictor of mortality in ICU in elderly patients with cirrhosis. In terms of prognostic value, the lactate level and APACHE II score are the two best predictive factors in cirrhotic elderly patients admitted to the ICU.
Collapse
Affiliation(s)
- Adnan Tas
- Department of Gastroenterology, Osmaniye Public Hospital, Raufbey Mahallesi, Osmaniye, Turkey.
| | | | | | | |
Collapse
|
22
|
Risk factors for kidney impairment and differential impact of liver transplantation on renal function. Transplant Proc 2011; 43:609-11. [PMID: 21440776 DOI: 10.1016/j.transproceed.2011.01.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a common problem in long-term survivors after liver transplantation (LT). It is important to identify and correct risk factors that negatively affect kidney function. The purpose of this study was to delineate the risk factors associated with progressive kidney dysfunction after OLT. METHODS We analyzed 50 recipients (10 female, 40 male) of overall age of 44±13 year who were all ≥18 years old and underwent first LT between 1999 and 2005. Patient-related risk factors were evaluated for renal failure at 3 and 5 years after transplantation. We evaluated parameters of demographic data, laboratory values, daily proteinuria, and renal resistive index (RRI) by Doppler ultrasonography. CKD was defined as a sustained decrease in estimated glomerular filtration rate (eGFR). Patients were divided into 3 groups according to the change in eGFR from the baseline value: group 1, stable eGFR (no change from baseline); group 2, <50% decreased eGFR; and group 3, ≥50% decrease from baseline. eGFR was calculated by using Modification of Diet in Renal Disease (MDRD) formula. RESULTS At 3 years after LT, GFR negatively correlated with initial Child-Pugh score (r=-0.42; P<.01); microalbuminuria (r=-0.28; P<.01), and RRI (r=-0.36; P<.01). After 5 years, GFR negatively correlated with initial gamma glutamyl transferase (r=-0.21; P<.05), PT (r=-0.29; P<.05), and RRI (r=-0.32; P<.01). Pretransplantation direct bilirubin levels were significantly correlated with GFR decrease at 3 years (P=.05). At 5 years of follow-up, smoking (P<.05), baseline alanine aminotransferase (P=.03) and serum triglyceride (P<.01) levels significantly correlated with eGFR decrease. Pretransplantation serum creatinine levels were stratified into normal versus high groups. Patients with increased basal serum creatinine levels displayed shorter survivals than those with normal creatinine levels, namely, median values of 21±3.9 months versus 14±2.4 months, log rank test: P<.05). CONCLUSION Renal function after liver transplantation show sustained impairment in certain patients. In the short term the main risk factors for renal detoriation were severity of liver disease before LT, microalbuminuria, and renal perfusion. In the long term, smoking and dyslipidemia were the main predictors of CKD. Patients with high basal serum creatinine values were at increased risk of mortality.
Collapse
|
23
|
Hoang MH, Houng SJ, Jun HJ, Lee JH, Choi JW, Kim SH, Kim YR, Lee SJ. Barley intake induces bile acid excretion by reduced expression of intestinal ASBT and NPC1L1 in C57BL/6J mice. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2011; 59:6798-6805. [PMID: 21591702 DOI: 10.1021/jf200681n] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
To investigate the hypocholesterolemic mechanism of barley in vivo, six-week-old C57BL/6J mice were fed a high-fat diet (HFD) or high-fat diet containing barley (HFD-B) for seven weeks. Total and LDL cholesterol concentrations were significantly reduced in the HFD-B group while fecal cholesterol and bile acid was increased. Real-time PCR and immunoblot analysis revealed the induction of FXR expression, which in turn suppressed the expression of ASBT and NPC1L1 in the HFD-B group compared with the controls. In the liver, the expression of HMG-CoA reductase was significantly reduced while LDL receptor expression was unaltered in the HFD-B group compared with the controls. Our data suggest that the hypocholesterolemic effects of barley are primarily the result of reduced dietary cholesterol uptake and bile acid resorption. Reduced expression of intestinal ASBT and NPC1L1 may play a key role in the regulation of dietary cholesterol and bile acid metabolism in mice consuming a diet containing barley.
Collapse
Affiliation(s)
- Minh-Hien Hoang
- Division of Food Bioscience and Technology, College of Life Sciences and Biotechnology, Korea University, Seoul 136-713, South Korea
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Short-term and long-term vital outcomes of cirrhotic patients admitted to an intensive care unit. Eur J Gastroenterol Hepatol 2010; 22:1474-80. [PMID: 21389797 DOI: 10.1097/meg.0b013e32834059cd] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate short-term and long-term vital outcomes of cirrhotic patients admitted to a general ICU, to evaluate the prognostic value of severity scores and to identify risk factors associated with death. METHODS Observational retrospective single-center epidemiological study. All cirrhotic patients admitted to the ICU were eligible for the study. Clinical data, general ICU severity scores, and liver-specific severity scores were recorded. The mortality rate was analyzed during the stay in ICU, at day 28 and month 6 after admission. Risk factors for death were identified by univariate and multivariate analyses. RESULTS During the study period, 86 cirrhotic patients were admitted to the ICU. The in-ICU, day-28 and month-6 mortality rates were 37, 48, and 60%, respectively. In the multivariate analysis, mechanical ventilation, the prothrombin time, and the plasma albumin level on admission were associated with the in-ICU mortality, whereas only the plasma albumin level was associated with the 6-month mortality [odds ratio 0.80; 95% confidence interval (0.70-0.92)]. The Sequential Organ Failure Assessment score was more predictive than liver-specific scores for mortality in the ICU, but not at day 28 or month 6. CONCLUSION ICU admission should not be ruled out for patients with complicated cirrhosis. Although common in cirrhotic patients, low plasma albumin level was the only factor independently associated with short-term and long-term mortalities.
Collapse
|
25
|
Wei Y, Li J, Zhang L, Zheng D, Shi B, Cong Y. Assessment of validity of INR system for patients with liver disease associated with viral hepatitis. J Thromb Thrombolysis 2010; 30:84-9. [PMID: 19915802 DOI: 10.1007/s11239-009-0423-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
International Normalized Ratio (INR), which standardizes prothrombin time (PT) during oral anticoagulation, has been extended to standardize PT in liver diseases and is included in all prognostic models of survival, the classification of CHILD-Pugh or Meld. However, the mechanisms of PT prolongation in liver diseases differ from those involved in oral anticoagulation. Our aim was to assess the validity of the INR system for patients with liver disease associated with viral hepatitis. We prospectively collected blood samples from 61 patients with liver disease associated with viral hepatitis; control patients were on warfarin (n = 20). PTs were measured on a STA-R coagulometer with six thromboplastin reagents, and INRs were calculated using instrument-specific ISIs. Simultaneously, we selected 15 pairs of patients in the study population and in the control population such that INR values for each patient pair are almost equal. For these 15 pairs of patients, we performed factor assays and measured the coagulant activities of factors II, V, VI, and X and fibrinogen. Analysis of results for the control population confirms the validity of the INR system for patients on oral anticoagulants in that there was no significant difference between the reported INRs for the six different thromboplastin reagents. Conversely, for the study population, there was a significant difference between the INR results using the different reagents. Results for fibrinogen and factors V, VII, and X showed significant differences between the two groups; however, control and patient results for factor II were not statistically different. The INR system is not valid for comparison of patients with liver disease associated with viral hepatitis because different reagents do not yield the same INR for the same sample.
Collapse
Affiliation(s)
- YuXiang Wei
- Graduate School of the Chinese PLA General Hospital, Beijing, People's Republic of China
| | | | | | | | | | | |
Collapse
|
26
|
Serum sodium, renal function, and survival of patients with end-stage liver disease. J Hepatol 2010; 52:523-8. [PMID: 20185195 PMCID: PMC4546826 DOI: 10.1016/j.jhep.2010.01.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 09/15/2009] [Accepted: 10/22/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Serum creatinine, a component of the model for end-stage liver disease (MELD), is an important prognostic indicator in patients with end-stage liver disease (ESLD). In addition, serum sodium has recently been recognized as an important predictor of mortality in patients with ESLD. We investigate the role of serum creatinine and sodium, and glomerular filtration rate (GFR) as determinants of survival in patients with ESLD. METHODS A prospective database was utilized to identify all adults listed for primary liver transplantation (LTx) at the Mayo Clinic, Rochester, between 1990 and 1999. GFR was measured by iothalamate clearance. RESULTS Among 837 patients listed for LTx, 660 had complete data including measured GFR. There was a significant association between GFR and survival after adjustment for MELD, with a linear rise in the risk of death as GFR decreased between 60 and 20ml/min/1.73m(2). Multivariable models showed that GFR is superior to creatinine in predicting mortality - a model consisting of total bilirubin (hazard ratio (HR)=2.17, p<0.01), INR (HR=3.26, p<0.01) and GFR (HR=0.42, p<0.01) was superior to MELD (chi-square 65.6 vs. 59.4, c-statistic 0.792 vs. 0.780). Serum sodium did not contribute to survival prediction when accurately measured GFR data were available. CONCLUSIONS Serum concentrations of creatinine and sodium in patients with end-stage liver disease reflect a reduction in renal function, the underlying event that decreases survival.
Collapse
|
27
|
Lv XH, Liu HB, Wang Y, Wang BY, Song M, Sun MJ. Validation of model for end-stage liver disease score to serum sodium ratio index as a prognostic predictor in patients with cirrhosis. J Gastroenterol Hepatol 2009; 24:1547-53. [PMID: 19686416 DOI: 10.1111/j.1440-1746.2009.05913.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM To evaluate the prognostic ability of model for end-stage liver disease (MELD) to serum sodium (SNa) ratio (MESO) index and to compare the predictive accuracy of the MESO index with the MELD score and the modified Child-Turcotte-Pugh (CTP) score for short-term survival in cirrhotic patients. METHODS A total of 256 patients with cirrhosis were retrospectively evaluated. The predictive accuracy of the MESO index, MELD score and modified CTP score were compared by the area under the receiver-operator characteristic curve (AUC). RESULTS Using 1-month and 3-month mortality as the end-point, overall, MESO and MELD were significantly better than the CTP score in predicting the risk of mortality at 1 month (AUC, 0.866,0.819 vs 0.722, P < 0.01) and 3 months (AUC, 0.875,0.820 vs 0.721, P < 0.01). In the low MELD group, the AUC of MESO index (0.758, 0.759) and CTP score (0.754, 0.732) were higher than that of the MELD score (0.608, 0.611) at 1 month and 3 months, respectively (P < 0.01). However, in the high MELD group, the AUC of MESO index (0.762, 0.779) and MELD (0.737, 0.773) were higher than that of the CTP score (0.710, 0.752) at 1 month and 3 months, respectively, although there were no significant differences (P > 0.05). With appropriate cut-offs for the MESO index, the mortality rate of patients in high MESO was higher (57.1% at 1 month and 69.2% at 3 months) than that of the low MESO (5.5% at 1 month and 7.9% at 3 months) (P < 0.01). CONCLUSIONS The MESO index, which adds SNa to MELD, is a useful prognostic marker and is found to be superior to the MELD score and modified CTP score for short-term prognostication of patients with cirrhosis.
Collapse
Affiliation(s)
- Xiao-Hui Lv
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, Liaoning Province, China.
| | | | | | | | | | | |
Collapse
|
28
|
Gomez EV, Bertot LC, Oramas BG, Soler EA, Navarro RL, Elias JD, Jiménez OV, Vazquez MDRA. Application of a biochemical and clinical model to predict individual survival in patients with end-stage liver disease. World J Gastroenterol 2009; 15:2768-77. [PMID: 19522028 PMCID: PMC2695893 DOI: 10.3748/wjg.15.2768] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the capability of a biochemical and clinical model, BioCliM, in predicting the survival of cirrhotic patients.
METHODS: We prospectively evaluated the survival of 172 cirrhotic patients. The model was constructed using clinical (ascites, encephalopathy and variceal bleeding) and biochemical (serum creatinine and serum total bilirubin) variables that were selected from a Cox proportional hazards model. It was applied to estimate 12-, 52- and 104-wk survival. The model’s calibration using the Hosmer-Lemeshow statistic was computed at 104 wk in a validation dataset. Finally, the model’s validity was tested among an independent set of 85 patients who were stratified into 2 risk groups (low risk ≤ 8 and high risk > 8).
RESULTS: In the validation cohort, all measures of fit, discrimination and calibration were improved when the biochemical and clinical model was used. The proposed model had better predictive values (c-statistic: 0.90, 0.91, 0.91) than the Model for End-stage Liver Disease (MELD) and Child-Pugh (CP) scores for 12-, 52- and 104-wk mortality, respectively. In addition, the Hosmer-Lemeshow (H-L) statistic revealed that the biochemical and clinical model (H-L, 4.69) is better calibrated than MELD (H-L, 17.06) and CP (H-L, 14.23). There were no significant differences between the observed and expected survival curves in the stratified risk groups (low risk, P = 0.61; high risk, P = 0.77).
CONCLUSION: Our data suggest that the proposed model is able to accurately predict survival in cirrhotic patients.
Collapse
|
29
|
Benson AB, Abrams TA, Ben-Josef E, Bloomston PM, Botha JF, Clary BM, Covey A, Curley SA, D'Angelica MI, Davila R, Ensminger WD, Gibbs JF, Laheru D, Malafa MP, Marrero J, Meranze SG, Mulvihill SJ, Park JO, Posey JA, Sachdev J, Salem R, Sigurdson ER, Sofocleous C, Vauthey JN, Venook AP, Goff LW, Yen Y, Zhu AX. NCCN clinical practice guidelines in oncology: hepatobiliary cancers. J Natl Compr Canc Netw 2009; 7:350-91. [PMID: 19406039 PMCID: PMC4461147 DOI: 10.6004/jnccn.2009.0027] [Citation(s) in RCA: 411] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Al B Benson
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Comparison of modes of prothrombin time reporting in patients with advanced liver disease associated with viral hepatitis. J Thromb Thrombolysis 2009; 29:81-6. [DOI: 10.1007/s11239-009-0330-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Accepted: 03/12/2009] [Indexed: 01/26/2023]
|
31
|
Choi PC, Kim HJ, Choi WH, Park DI, Park JH, Cho YK, Sohn CI, Jeon WK, Kim BI. Model for end-stage liver disease, model for end-stage liver disease-sodium and Child-Turcotte-Pugh scores over time for the prediction of complications of liver cirrhosis. Liver Int 2009; 29:221-6. [PMID: 18544124 DOI: 10.1111/j.1478-3231.2008.01803.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND/AIMS There has been no report concerning the predictive capability of each scoring system in determining the development of complications of liver cirrhosis such as variceal bleeding and/or hepatic encephalopathy. METHODS We retrospectively studied 128 patients with liver cirrhosis [92 males; mean (standard deviation) 54.2 (11.2) years] admitted to our institution from March 2004 to April 2006. Seventy-three patients (57.0%, group 1) were admitted because of complications of cirrhosis and 55 patients (43.0%, group 2) were admitted for causes unrelated to complications of cirrhosis. We calculated values for model for end-stage liver disease (MELD), MELD-sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) scores on admission and at 3 and 6 months before admission. Each delta score was defined as the difference in the scores of 3 and 6 months before admission. RESULTS The relative risk for complications in the patients with DeltaMELD/3 months >/=1.35, DeltaMELD-Na/3 months >/=1.35 and DeltaCTP/3 months >/=1 was 2.05 [95% confidence intervals (CI) 1.47-2.85, P<0.01], 2.04 (95% CI 1.45-2.88, P<0.01) and 1.98 (95% CI 1.39-2.81, P<0.01) respectively. The area under the receiver-operating characteristic curves of DeltaMELD/3 months, DeltaMELD-Na/3 months and DeltaCTP/3 months for the occurrence of cirrhotic complications were 0.691, 0.694 and 0.722 respectively. A higher DeltaMELD/3 months (>/=1.35), DeltaMELD-Na/3 months (>/=1.35) and DeltaCTP/3 months (>/=1) was associated with decreased survival. CONCLUSIONS Delta model for end-stage liver disease/3 months, DeltaMELD-Na/3 months and DeltaCTP/3 months were clinically useful parameters for predicting the occurrence of cirrhotic complications.
Collapse
Affiliation(s)
- Pil Cho Choi
- Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Inequities of the Model for End-Stage Liver Disease: an examination of current components and future additions. Curr Opin Organ Transplant 2008; 13:227-33. [PMID: 18685308 DOI: 10.1097/mot.0b013e3282ff84c7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to examine the limitations of the Model for End-Stage Liver Disease (MELD) components and summarize data on promising new predictor variables. RECENT FINDINGS Promising modifications to MELD have been aimed at identifying more accurate measurements of the current MELD components and at improving survival prediction in earlier stages of cirrhosis. Incorporation of new measurements of cholestasis, coagulopathy and renal dysfunction should improve accuracy and reliability of MELD in predicting mortality in end stage liver disease. Direct bilirubin may be a more specific surrogate marker of liver disease than total bilirubin and further investigation of its use in liver mortality risk models in warranted. The recently developed liver-specific international normalized ratio may mitigate thromboplastin-related variation in international normalized ratio measurements. The incorporation of more accurate assessments of renal function into MELD should improve prognostic accuracy and would avert systematic biases associated with serum creatinine. Hepatic venous pressure gradient and serum sodium are promising predictors of liver-related mortality that may warrant further consideration. SUMMARY Modification to MELD, particularly if intended for use in liver transplant allocation, should be based upon objective, reliable, reproducible and readily available predictors; and be able to withstand rigorous model development and validation.
Collapse
|
33
|
Xu X, Ling Q, Wu J, Chen J, Gao F, Feng XN, Zheng SS. A novel prognostic model based on serum levels of total bilirubin and creatinine early after liver transplantation. Liver Int 2007; 27:816-24. [PMID: 17617125 DOI: 10.1111/j.1478-3231.2007.01494.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND/AIM We aim to evaluate the impact of early renal dysfunction (ERD), early allograft dysfunction (EAD) on post-transplant mortality, and further explore a simple and accurate model to predict prognosis. PATIENTS A total of 161 adult patients who underwent liver transplantation for benign end-stage liver diseases were enrolled in the retrospective study. Another 38 patients were used for model validation. RESULTS Poor patient survival was associated with ERD or EAD. A post-transplant model for predicting mortality (PMPM) based on serum levels of total bilirubin and creatinine at 24-h post-transplantation was then established according to multivariate logistic regression. At 3 months, 6 months and 1 year, the area under receiver operating characteristic curves (AUC) of PMPM score at 24-h post-transplantation (0.876, 0.878 and 0.849, respectively) were significantly higher than those of pre-transplant model for end-stage liver diseases (MELD) score (0.673, 0.674 and 0.618, respectively) or the post-transplant MELD score at 24-h post-transplantation (0.787, 0.787 and 0.781, respectively) (P<0.05). Patients with PMPM score <or=-1.4 (low-risk group, n=114) achieved better survival than those with PMPM score >-1.4 (high-risk group, n=47) (P<0.001). The patients in the high-risk group showed a relatively good outcome if their PMPM scores decreased to <or=-1.4 at post-transplant day 7. The subsequent validation study showed that PMPM functioned with a predictive accuracy of 100%. CONCLUSION The PMPM score could effectively predict short- and medium-term mortality in liver transplant recipients.
Collapse
Affiliation(s)
- Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | | | | | | | | | | |
Collapse
|
34
|
Cholongitas E, Marelli L, Kerry A, Goodier DW, Nair D, Thomas M, Patch D, Burroughs AK. Female liver transplant recipients with the same GFR as male recipients have lower MELD scores--a systematic bias. Am J Transplant 2007; 7:685-92. [PMID: 17217437 DOI: 10.1111/j.1600-6143.2007.01666.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Women have lower glomerular filtration (GFR) than men for the same serum creatinine (Cr) value, not accounted for in model for end-stage liver disease (MELD). We compare male/female Cr, GFR (using MDRD formula) and respective MELD scores in 403 Cr measurements using standard (sCr), O'Leary modified (mCr) and Compensated (cCr) Jaffe and Enzymatic (eCr) in 158 liver disease patients, mCr in 208 liver transplantation (LT) candidates, and EDTA-Cr(51)-GFR in 38 other candidates for LT; considering each female as male, a 'corrected' Cr was derived. MELD scores were calculated for measured and "corrected" Cr in females. Median Cr and GFR in females were lower than males (p < 0.05). Both MDRD and EDTA-Cr(51) GFR were lower in females than males, despite lower Cr values. In females, each MELD score was lower than the corresponding MELD-corrected Cr (p < 0.001) with > or =three-point difference in liver disease patients: 25%[sCr]; 23%[mCr]; 11%[eCr]; and 14%[cCr]. In 65% of female LT candidates, two- or three-point difference was found. Females with liver disease have lower GFR than males for the same Cr value; correcting Cr increases MELD score by two or three points in 65% of female LT candidates. MELD score adjustment in females would ensure equal LT priority by gender.
Collapse
Affiliation(s)
- E Cholongitas
- Liver Transplantation and Hepatobiliary Medicine Unit, Royal Free Hospital, London NW3 2QG, UK
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Fassi-Fehri H, Zakaria Y, Marechal JM, Marcotte G, Colombel M, Martin X, Badet L. Néphrectomie élargie gauche chez deux patients atteints d’hypertension portale porteurs d’un shunt veineux spléno-rénal. Prog Urol 2007; 17:101-4. [PMID: 17373247 DOI: 10.1016/s1166-7087(07)92235-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The authors report two cases of hepatic cirrhosis complicated by portal hypertension with splenorenal venous shunt presenting with left renal tumour that was treated by left radical nephrectomy with preservation of the shunt.
Collapse
Affiliation(s)
- Hakim Fassi-Fehri
- Service d'Urologie et de la Transplantation, Hôpital Edouard Herriot, Lyon, France.
| | | | | | | | | | | | | |
Collapse
|
36
|
Marelli L, Stigliano R, Triantos C, Senzolo M, Cholongitas E, Davies N, Tibballs J, Meyer T, Patch DW, Burroughs AK. Transarterial therapy for hepatocellular carcinoma: which technique is more effective? A systematic review of cohort and randomized studies. Cardiovasc Intervent Radiol 2007; 30:6-25. [PMID: 17103105 DOI: 10.1007/s00270-006-0062-3] [Citation(s) in RCA: 590] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, or whether embolization (TAE) alone gives the same survival advantage, is not known. PURPOSE To evaluate whether specific patient characteristics and/or radiological transarterial techniques result in better outcomes. METHOD A PubMed search was carried out for cohort and randomized trials (n = 175) testing transarterial therapies; meta-analysis was performed where appropriate. RESULTS Anticancer drugs were used as sole agent in 75% of cases (double 15% and triple 6%): doxorubicin (36%), cisplatin (31%), epirubicin (12%), mitoxantrone (8%), mitomycin (8%), and SMANCS (5%). Embolizing agents used were: gelatin sponge particles (71%), polyvinyl alcohol (PVA) particles (8%), degradable starch microspheres (DSM) (4%), and embospheres (4%). Sessions per patient were 2.5 +/- 1.5 (interval: 2 months). Objective response was 40 +/- 20%; survival rates at 1, 2, 3, and 5 years were: 62 +/- 20%, 42 +/- 17%, 30 +/- 15%, and 19 +/- 16%, respectively, and survival time was 18 +/- 9.5 months. The post-TACE complications were: acute liver failure, 7.5% (range 0-49%); acute renal failure, 1.8% (0-13%); encephalopathy, 1.8% (0-16%); ascites, 8.3% (0-52%); upper gastrointestinal bleeding; 3% (0-22%); and hepatic or splenic abscess, 1.3% (0-2.5%). Treatment-related mortality was 2.4% (0-9.5%), mainly due to acute liver failure. Our meta-analysis of nine randomized controlled trials (RCTs) confirmed that TACE improves survival; but a meta-analysis of TACE versus TAE alone (3 RCTs, 412 patients) demonstrated no survival difference. CONCLUSIONS No chemotherapeutic agent appears better than any other. There is no evidence for benefit with lipiodol. Gelatin sponge is the most used embolic agent, but PVA particles may be better. TAE appears as effective as TACE. New strategies to reduce the risk of post-TACE complications are required.
Collapse
Affiliation(s)
- Laura Marelli
- Liver Transplantation and Hepatobiliary Medicine Unit, Royal Free Hospital, Pond Street, NW3 2QG, London, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Ham J, Gish RG, Mullen K. Model for end-stage liver disease (MELD) exception for hepatic encephalopathy. Liver Transpl 2006; 12:S102-4. [PMID: 17123294 DOI: 10.1002/lt.20968] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- John Ham
- Oregan Health Sciences University, Portland, OR, USA
| | | | | |
Collapse
|
38
|
Laleman W, Wilmer A, Evenepoel P, Elst IV, Zeegers M, Zaman Z, Verslype C, Fevery J, Nevens F. Effect of the molecular adsorbent recirculating system and Prometheus devices on systemic haemodynamics and vasoactive agents in patients with acute-on-chronic alcoholic liver failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R108. [PMID: 16859530 PMCID: PMC1751025 DOI: 10.1186/cc4985] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Revised: 06/29/2006] [Accepted: 07/10/2006] [Indexed: 02/06/2023]
Abstract
Introduction Patients with acute-on-chronic liver failure show an aggravated hyperdynamic circulation. We evaluated, in a controlled manner, potential changes in systemic haemodynamics induced by the molecular adsorbent recirculating system (MARS) and the Prometheus system liver detoxification devices in a group of patients with acute-on-chronic liver failure. Methods Eighteen patients (51.2 ± 2.3 years old; Child–Pugh score, 12.5 ± 0.2; Maddrey score, 63.1 ± 5.0; hepatic venous pressure gradient, 17.6 ± 0.9 mmHg) with biopsy-proven alcoholic cirrhosis and superimposed alcoholic hepatitis were either treated with standard medical therapy (SMT) combined with MARS (n = 6) or Prometheus (n = 6) or were treated with SMT alone (n = 6) on three consecutive days (6 hours/session). Liver tests, systemic haemodynamics and vasoactive substances were determined before and after each session. Results Groups were comparable for baseline haemodynamics and levels of vasoactive substances. Both MARS and Prometheus decreased serum bilirubin levels (P < 0.005 versus SMT), the Prometheus device being more effective than MARS (P = 0.002). Only MARS showed significant improvement in the mean arterial pressure (Δchange, +9 ± 2.4 mmHg versus -0.3 ± 2.4 mmHg with Prometheus and -5.2 ± 2.1 mmHg with SMT, P < 0.05) and in the systemic vascular resistance index (Δchange, +131.5 ± 46.2 dyne.s/cm5/m2 versus -92.8 ± 85.2 dyne.s/cm5/m2with Prometheus and -30.7 ± 32.5 dyne.s/cm5/m2 with SMT; P < 0.05), while the cardiac index and central filling remained constant. This circulatory improvement in the MARS group was paralleled by a decrease in plasma renin activity (P < 0.05), aldosterone (P < 0.03), norepinephrine (P < 0.05), vasopressin (P = 0.005) and nitrate/nitrite levels (P < 0.02). Conclusion The MARS device, and not the Prometheus device, significantly attenuates the hyperdynamic circulation in acute-on-chronic liver failure, presumably by a difference in removal rate of certain vasoactive substances. These findings suggest conspicuous conceptual differences among the albumin dialysis devices.
Collapse
Affiliation(s)
- Wim Laleman
- Department of Hepatology, University Hospital Gasthuisberg, KU Leuven, Belgium
| | - Alexander Wilmer
- Department of Medical Intensive Care, University Hospital Gasthuisberg, KU Leuven, Belgium
| | - Pieter Evenepoel
- Department of Nephrology, University Hospital Gasthuisberg, KU Leuven, Belgium
| | - Ingrid Vander Elst
- Department of Hepatology, University Hospital Gasthuisberg, KU Leuven, Belgium
| | - Marcel Zeegers
- Department of Hepatology, University Hospital Gasthuisberg, KU Leuven, Belgium
| | - Zahur Zaman
- Department of Laboratory Medicine, University Hospital Gasthuisberg, KU Leuven, Belgium
| | - Chris Verslype
- Department of Hepatology, University Hospital Gasthuisberg, KU Leuven, Belgium
| | - Johan Fevery
- Department of Hepatology, University Hospital Gasthuisberg, KU Leuven, Belgium
| | - Frederik Nevens
- Department of Hepatology, University Hospital Gasthuisberg, KU Leuven, Belgium
| |
Collapse
|
39
|
Laleman W, Wilmer A, Evenepoel P, Elst IV, Zeegers M, Zaman Z, Verslype C, Fevery J, Nevens F. Effect of the molecular adsorbent recirculating system and Prometheus devices on systemic haemodynamics and vasoactive agents in patients with acute-on-chronic alcoholic liver failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006. [PMID: 16859530 PMCID: PMC4092483 DOI: 10.1186/cc4455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Wim Laleman
- Department of Hepatology, University Hospital Gasthuisberg, KU Leuven, Belgium.
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Evenepoel P, Laleman W, Wilmer A, Claes K, Kuypers D, Bammens B, Nevens F, Vanrenterghem Y. Prometheus versus molecular adsorbents recirculating system: comparison of efficiency in two different liver detoxification devices. Artif Organs 2006; 30:276-84. [PMID: 16643386 DOI: 10.1111/j.1525-1594.2006.00215.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Albumin dialysis by the molecular adsorbents recirculating system (MARS) and by fractionated plasma separation, adsorption, and dialysis (Prometheus[PROM]) represent novel nonbiological liver support systems specifically designed to remove albumin-bound substances. Preliminary evidence suggests a favorable impact of MARS on the course and outcome of liver failure. This study aimed at comparing the detoxification capacity of both devices. For this purpose, we performed a retrospective analysis on data prospectively collected in patients with acute-on-chronic liver failure treated with either the MARS (n = 9) or the PROM (n = 9) device on 2-5 consecutive days. Each treatment was performed for at least 5 h at identical blood and dialysate flows. Blood clearances were calculated during the first treatment session for urea nitrogen, creatinine, total bilirubin, and bile acids from paired arterial and venous line samples after 1, 4, and 6 h of treatment. Reduction ratios for all single-treatment sessions, and the overall treatment phase, were calculated from pretreatment and post-treatment values. For all markers but bile acids, the single-treatment as well as the overall treatment phase reduction ratios obtained with PROM were significantly higher compared with those obtained with MARS. PROM led at all time points to higher clearances for all evaluated solutes. Blood clearances of protein-bound substances declined over time with MARS, but not with PROM. In conclusion, a significant decline in the serum level of water-soluble and protein-bound toxins was achieved with both devices. PROM produces higher blood clearances for most toxins, which results in higher delivered treatment doses compared with a matching treatment with MARS.
Collapse
Affiliation(s)
- Pieter Evenepoel
- Department of Medicine, Division of Nephrology, University Hospital Leuven, Leuven, Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Dangleben DA, Jazaeri O, Wasser T, Cipolle M, Pasquale M. Impact of cirrhosis on outcomes in trauma. J Am Coll Surg 2006; 203:908-13. [PMID: 17116560 DOI: 10.1016/j.jamcollsurg.2006.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Revised: 07/27/2006] [Accepted: 08/01/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality. STUDY DESIGN The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test. RESULTS Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS. CONCLUSIONS The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.
Collapse
Affiliation(s)
- Dale A Dangleben
- Department of Surgery, Lehigh Valley Hospital, Allentown, PA 18105-1556, USA
| | | | | | | | | |
Collapse
|
42
|
Ranes JL, Gordon SM, Chen P, Fatica C, Hammel J, Gonzales JP, Arroliga AC. Predictors of long-term mortality in patients with ventilator-associated pneumonia. Am J Med 2006; 119:897.e13-9. [PMID: 17000224 DOI: 10.1016/j.amjmed.2005.12.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2005] [Revised: 12/09/2005] [Accepted: 12/12/2005] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the long-term outcome of ventilator-associated pneumonia (VAP) and identify factors associated with increased mortality. METHODS We retrospectively studied 671 patients with VAP admitted to an intensive care unit between 1994 and 2000. We determined long-term and out-of-hospital mortality for these patients. RESULTS The in-hospital mortality was 42.3%; 19.8% of patients had concomitant bacteremia, the mortality was 59.7% versus 38.0% for those without bacteremia (P <.001). The factors associated with increased hospital mortality by univariable analysis were: diagnosis on admission, the need of vasopressors during the stay in the intensive care unit, not undergoing a tracheostomy, the absence of fever, the presence of concomitant bacteremia, and renal failure or the need for dialysis. Patients transferred from an outside hospital and patients with normal serum bicarbonate, serum total bilirubin <2 mg/dL, and platelets >120x4> 10(3)/microL had a lower in-hospital mortality. All of these factors except bilirubin level, platelet count, transfer from outside hospital, and serum bicarbonate remained significant on multivariable analysis. The estimated mortality at 1, 3 and 5 years is 25.9% (95% confidence interval [CI], 20.2-30.1%), 33.6% (95% CI, 27.4-39.2%) and 44.7% (95% CI, 38.1-50.6%), respectively. CONCLUSIONS VAP is associated with a high rate of hospital and long-term mortality. The presence of bacteremia is associated with a high mortality. The 5-year estimated mortality of the survivors is less than 50%.
Collapse
Affiliation(s)
- Justin L Ranes
- Department of Pulmonary, Allergy and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | | | | | | | | | |
Collapse
|
43
|
Cholongitas E, Senzolo M, Patch D, Shaw S, Hui C, Burroughs AK. Review article: scoring systems for assessing prognosis in critically ill adult cirrhotics. Aliment Pharmacol Ther 2006; 24:453-64. [PMID: 16886911 DOI: 10.1111/j.1365-2036.2006.02998.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cirrhotic patients admitted to intensive care units (ICU) still have poor outcomes. Some current ICU prognostic models [Acute Physiology and Chronic Health Evaluation (APACHE), Organ System Failure (OSF) and Sequential Organ Failure Assessment (SOFA)] were used to stratify cirrhotics into risk categories, but few cirrhotics were included in the original model development. Liver-specific scores [Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD)] could be useful in this setting. AIM To evaluate whether ICU prognostic models perform better compared with liver-disease specific ones in cirrhotics admitted to ICU. METHODS We performed a structured literature review identifying clinical studies focusing on prognosis and risk factors for mortality in adult cirrhotics admitted to ICU. RESULTS We found 21 studies (five solely dealing with gastrointestinal bleeding) published during the last 20 years (54-420 patients in each). APACHE II and III, SOFA and OSF had better discrimination for correctly predicting death compared with the CTP score. The MELD score was evaluated only in one study and had good predictive accuracy [receiver operator characteristic (ROC) curve: 0.81). Organ dysfunction models (OSF, SOFA) were superior compared with APACHE II and III (ROC curve: range 0.83-0.94 vs. 0.66-0.88 respectively). Cardiovascular, liver and renal system dysfunction were more frequently independently associated with mortality. CONCLUSIONS General-ICU models had better performance in cirrhotic populations compared with CTP score; OSF and SOFA had the best predictive ability. Further prospective and validation studies are needed.
Collapse
Affiliation(s)
- E Cholongitas
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, UK
| | | | | | | | | | | |
Collapse
|
44
|
Graziadei I. Liver transplantation organ allocation between Child and MELD. Wien Med Wochenschr 2006; 156:410-5. [PMID: 16937044 DOI: 10.1007/s10354-006-0317-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 04/05/2006] [Indexed: 12/14/2022]
Abstract
Liver transplantation (LT) has been established as the most effective therapy for acute and chronic liver diseases over the last few decades due to its excellent long-term results. At the beginning of the LT era, donor organs were allocated based on waiting time. However, as the number of LT candidates consistently increased, a specific allocation system became necessary to prioritize the large number of patients waiting for a limited pool of organs. The LT candidates were categorized into different urgency levels based on their hospital status, degree of liver disease as measured by the Child-Turcotte-Pugh score, and accompanying complications of liver disease, such as ascites, variceal bleeding or hepatocellular carcinoma. The majority of European countries, including Austria, still rely on this organ allocation system. In the United States, however, a new allocation system based on the risk of death without transplantation, assessed by the Model for End-stage Liver Disease (MELD), was initiated in February 2002. Recent reports have shown that the introduction of the MELD system led to a reduction in waiting list mortality, but also that the MELD score has several limitations that call for further refinements. In the transplant community there are reasonable doubts that MELD is actually superior to the Child-Turcotte Pugh score. Therefore, the optimal liver organ allocation system is yet to be defined.
Collapse
Affiliation(s)
- Ivo Graziadei
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria.
| |
Collapse
|
45
|
Cholongitas E, Papatheodoridis GV, Vangeli M, Terreni N, Patch D, Burroughs AK. Systematic review: The model for end-stage liver disease--should it replace Child-Pugh's classification for assessing prognosis in cirrhosis? Aliment Pharmacol Ther 2005; 22:1079-89. [PMID: 16305721 DOI: 10.1111/j.1365-2036.2005.02691.x] [Citation(s) in RCA: 276] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prognosis in cirrhotic patients has had a resurgence of interest because of liver transplantation and new therapies for complications of end-stage cirrhosis. The model for end-stage liver disease score is now used for allocation in liver transplantation waiting lists, replacing Child-Turcotte-Pugh score. However, there is debate as whether it is better in other settings of cirrhosis. AIM To review studies comparing the accuracy of model for end-stage liver disease score vs. Child-Turcotte-Pugh score in non-transplant settings. RESULTS Transjugular intrahepatic portosystemic shunt studies (with 1360 cirrhotics) only one of five, showed model for end-stage liver disease to be superior to Child-Turcotte-Pugh to predict 3-month mortality, but not for 12-month mortality. Prognosis of cirrhosis studies (with 2569 patients) none of four showed significant differences between the two scores for either short- or long-term prognosis whereas no differences for variceal bleeding studies (with 411 cirrhotics). Modified Child-Turcotte-Pugh score, by adding creatinine, performed similarly to model for end-stage liver disease score. Hepatic encephalopathy and hyponatraemia (as an index of ascites), both components of Child-Turcotte-Pugh score, add to the prognostic performance of model for end-stage liver disease score. CONCLUSIONS Based on current literature, model for end-stage liver disease score does not perform better than Child-Turcotte-Pugh score in non-transplant settings. Modified Child-Turcotte-Pugh and model for end-stage liver disease scores need further evaluation.
Collapse
Affiliation(s)
- E Cholongitas
- Liver Transplantation and Hepatobiliary Medicine Unit, Royal Free Hospital, London, UK.
| | | | | | | | | | | |
Collapse
|
46
|
Tseng PL, Lu SN, Tung HD, Wang JH, Changchien CS, Lee CM. Determinants of early mortality and benefits of lamivudine therapy in patients with hepatitis B virus-related decompensated liver cirrhosis. J Viral Hepat 2005; 12:386-92. [PMID: 15985009 DOI: 10.1111/j.1365-2893.2005.00608.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic hepatitis B infection (HBV) is a major health problem worldwide. The prognosis is grave for patients with HBV-related decompensated liver cirrhosis (LC). We evaluated the effectiveness and the determinants of early mortality of lamivudine treatment in patients with HBV-related decompensated LC. Thirty patients with HBV-related decompensated LC and active viral replication were treated with lamivudine 100 mg daily for a median duration of 9 months. Among these patients, five patients died within 3 months. Two patients were lost to follow-up at week 8 and 9. One patient was treated for <6 months. Twenty-two patients were treated over 6 months. Univariate analysis revealed that the total bilirubin (P = 0.008), prothrombin time (P = 0.004), Child-Turcotte-Pugh score (P = 0.005), the model of efd-stage liver disease score (P = 0.004) and stage III hepatic encephalopathy (P = 0.001) were predictive factors of early mortality. Multivariate analysis revealed that the independent factor associated with early mortality was stage III encephalopathy. Among 22 patients, liver function improved markedly after lamivudine therapy. Of the nine hepatitis B e antigen (HBeAg)-positive patients, three had HBeAg seroconversion. Two patients had YMDD mutant and virological breakthrough at 41 and 46 weeks. One of the two had hepatocellular carcinoma and died of hepatic failure at week 125; the other received adefovir and is doing well. Lamivudine appeared to have benefits in viral suppression and significant improvement in liver function in patients with HBV-related decompensated LC. As noted in prior studies, poor baseline liver function is associated with a poor prognosis in Asian patients with decompensated HBV cirrhosis treated with lamivudine.
Collapse
Affiliation(s)
- Po-Lin Tseng
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | | | | | | | | | | |
Collapse
|
47
|
Huo TI, Wu JC, Lin HC, Lee FY, Hou MC, Lee PC, Chang FY, Lee SD. Evaluation of the increase in model for end-stage liver disease (DeltaMELD) score over time as a prognostic predictor in patients with advanced cirrhosis: risk factor analysis and comparison with initial MELD and Child-Turcotte-Pugh score. J Hepatol 2005; 42:826-32. [PMID: 15885353 DOI: 10.1016/j.jhep.2005.01.019] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2004] [Revised: 11/24/2004] [Accepted: 01/15/2005] [Indexed: 12/28/2022]
Abstract
BACKGROUND/AIMS The model for end-stage liver disease (MELD) has been used to prioritize cirrhotic patients awaiting liver transplantation. The change in MELD score over time (DeltaMELD) may have additional prognostic value. We investigated the ability of DeltaMELD to predict the outcome of advanced cirrhosis and prospectively assessed the factors associated with increasing DeltaMELD. METHODS Risk factors were determined in 58 prospectively followed-up patients. The predictive power of DeltaMELD, initial MELD and Child-Turcotte-Pugh (CTP) score was compared by using c-statistic in 351 patients. RESULTS Ascites (P=0.020) and hepatic encephalopathy (P=0.023) were significantly associated with increasing MELD score at 3 months. The area under receiver operating characteristic (ROC) curve for DeltaMELD/month was 0.779 compared with 0.718 for MELD (P=0.130) and 0.528 for CTP score (P<0.001) at 6 months; the area was 0.822, 0.744 and 0.528, respectively (P=0.018 and <0.001, respectively) at 12 months. DeltaMELD/month >2.5 was the only significant prognostic predictor at 6 (odds ratio: 9.8, P<0.001) and 12 months (odds ratio: 16.3, P<0.001) in multivariate logistic analysis. CONCLUSIONS Increasing MELD score is associated with the onset of ascites and encephalopathy. DeltaMELD is superior to initial MELD and CTP scores to predict intermediate term outcome in patients with advanced cirrhosis.
Collapse
Affiliation(s)
- Teh-Ia Huo
- National Yang-Ming University School of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Papatheodoridis GV, Cholongitas E, Dimitriadou E, Touloumi G, Sevastianos V, Archimandritis AJ. MELD vs Child-Pugh and creatinine-modified Child-Pugh score for predicting survival in patients with decompensated cirrhosis. World J Gastroenterol 2005; 11:3099-104. [PMID: 15918197 PMCID: PMC4305847 DOI: 10.3748/wjg.v11.i20.3099] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Model of End-stage Liver Disease (MELD) score has recently gained wide acceptance over the old Child-Pugh score in predicting survival in patients with decompensated cirrhosis, although it is more sophisticated. We compared the predictive values of MELD, Child-Pugh and creatinine-modified Child-Pugh scores in decompensated cirrhosis.
METHODS: A cohort of 102 patients with decompensated cirrhosis followed-up for a median of 6 mo was studied. Two types of modified Child-Pugh scores estimated by adding 0-4 points to the original score using creatinine levels as a sixth categorical variable were evaluated.
RESULTS: The areas under the receiver operating charac-teristic curves did not differ significantly among the four scores, but none had excellent diagnostic accuracy (areas: 0.71-0.79). Child-Pugh score appeared to be the worst, while the accuracy of MELD was almost identical with that of modified Child-Pugh in predicting short-term and slightly better in predicting medium-term survival. In Cox regression analysis, all four scores were significantly associated with survival, while MELD and creatinine-modified Child-Pugh scores had better predictive values (c-statistics: 0.73 and 0.69-0.70) than Child-Pugh score (c-statistics: 0.65). Adjustment for gamma-glutamate transpeptidase levels increased the predictive values of all systems (c-statistics: 0.77-0.81). Analysis of the expected and observed survival curves in patients subgroups according to their prognosis showed that all models fit the data reasonably well with MELD probably discriminating better the subgroups with worse prognosis.
CONCLUSION: MELD compared to the old Child-Pugh and particularly to creatinine-modified Child-Pugh scores does not appear to offer a clear advantage in predicting survival in patients with decompensated cirrhosis in daily clinical practice.
Collapse
Affiliation(s)
- George V Papatheodoridis
- 2nd Department of Internal Medicine, National University of Medical School, Hippokration General Hospital, 114 Vas. Sophias Ave., 115 27 Athens, Greece.
| | | | | | | | | | | |
Collapse
|
49
|
Li Y, Hou MJ, Ma J, Tang ZH, Zhu HL, Ling WH. Dietary fatty acids regulate cholesterol induction of liver CYP7α1 expression and bile acid production. Lipids 2005; 40:455-62. [PMID: 16094854 DOI: 10.1007/s11745-005-1404-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In the present study we investigated the effects of dietary fats containing predominantly PUFA, monounsaturated FA (MUFA), or saturated FA (SFA) on lipid profile and liver cholesterol 7alpha-hydroxylase (CYP7alpha1) mRNA expression and bile acid production in C57BL/6J mice. The animals (n = 75) were randomly divided into five groups and fed a basic chow diet (AIN-93G) (BC diet), a chow diet with 1 g/100 g of cholesterol (Chol diet), a chow diet with 1 g/100 g of cholesterol and 14 g/100 g of safflower oil (Chol + PUFA diet), a chow diet with 1 g/100 g of cholesterol and olive oil (Chol + MUFA diet), or a chow diet with 1 g/100 g of cholesterol and myristic acid (Chol + SFA diet) for 6 wk. The results showed that the Chol + SFA diet decreased CYP7alpha1 gene expression and bile acid pool size, resulting in increased blood and liver cholesterol levels. Addition of PUFA and MUFA to a 1% cholesterol diet increased the bile acid pool production or bile acid excretion and simultaneously decreased liver cholesterol accumulation despite decreased CYP7alpha1 mRNA expression. The results indicate that the decreased bile acid pool size induced by the SFA diet is related to inhibition of the liver CYP7alpha1 gene expression, but an increased bile acid pool size and improved cholesterol homeostasis are disassociated from the liver CYP7alpha1 gene expression.
Collapse
Affiliation(s)
- Yan Li
- Department of Clinical Nutrition, Sun Yat-sen University Northern Campus, Guangzhou, 510080, People's Republic of China
| | | | | | | | | | | |
Collapse
|
50
|
Gildea TR, Cook WC, Nelson DR, Aggarwal A, Carey W, Younossi ZM, Arroliga AC. Predictors of Long-term Mortality in Patients With Cirrhosis of the Liver Admitted to a Medical ICU. Chest 2004. [DOI: 10.1016/s0012-3692(15)31377-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
|