Role of Serum Soluble CD163 in the Diagnosis, Risk of Bleeding, and Prognosis of Gastro-Esophageal Varices in Cirrhotic Patients

Establishment and validation of a nomogram for predicting esophagogastric variceal bleeding in patients with liver cirrhosis

BACKGROUND

Patients with decompensated liver cirrhosis suffering from esophagogastric variceal bleeding (EGVB) face high mortality.

AIM

To investigate the risk factors for EGVB in patients with liver cirrhosis and establish a diagnostic nomogram.

METHODS

Patients with liver cirrhosis who met the inclusion criteria were randomly divided into training and validation cohorts in a 6:4 ratio in this retrospective research. Univariate analysis, least absolute shrinkage and selection operator regression, and multivariate analysis were employed to establish the nomogram model. Calibration curve, the area under the receiver operating characteristic curve (AUC), and decision curve analysis (DCA) were applied to assess the discrimination, accuracy, and clinical practicability of the nomogram, respectively.

RESULTS

A total of 1115 patients were enrolled in this study. The nomogram was established based on white blood cells (P < 0.001), hemoglobin (P < 0.001), fibrinogen (P < 0.001), total bilirubin (P = 0.007), activated partial thromboplastin time (P = 0.002), total bile acid (P = 0.012), and ascites (P = 0.006). The calibration curve indicated that the actual observation results were in good agreement with the prediction results of the model. The AUC values of the diagnostic model were 0.861 and 0.859 in the training and validation cohorts, respectively, which were higher than that of the aspartate aminotransferase-to-platelet ratio index, fibrosis index based on 4 factors, and aspartate aminotransferase-to-alanine aminotransferase ratio. Additionally, DCA indicated that the net benefit value of the model was higher than that of the other models.

CONCLUSION

This research constructed and validated a nomogram with perfect performance for predicting EGVB events in patients with liver cirrhosis, which could help clinicians with timely diagnosis, individualized treatment, and follow-up.

Development and validation of a nomogram for esophagogastric variceal bleeding in liver cirrhosis: A cohort study in 1099 cases

OBJECTIVES

Esophagogastric variceal bleeding (EVB) is a catastrophic complication of decompensated liver cirrhosis. We aimed to establish a nomogram based on noninvasive clinical and imaging variables to predict the risk of EVB.

METHODS

The cut-off value of each variable was determined through univariate regression analysis. The least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses were used to determine the risk factors and establish predictive models. The nomogram was established and validated using the calibration discrimination across different groups.

RESULTS

Six indicators, including platelet count, hemoglobin, albumin to globulin ratio, fasting blood glucose, serum chloride, and computed tomography portal vein diameter (CTPD), were found to be related to the risk of EVB. Two models, with or without CTPD, were established and compared. Model 1 with CTPD had better discrimination than model 2 with C-index of 0.893 (95% confidence interval [CI] 0.872-0.915) and 0.862 (95% CI 0.837-0.887) in the primary cohort, respectively (Z = 2.027, P = 0.043). While the C-index of the two models in the validation cohort was 0.878 (95% CI 0.838-0.919) and 0.810 (95% CI 0.757-0.863). Moreover, the clinical decision analysis curve and clinical impact curve showed that these models might confer a significant net benefit on patients and provide a reference threshold for clinicians.

CONCLUSION

A nomogram using routine clinical indicators was established to predict the risk of EVB in patients with liver cirrhosis, which was verified in an independent cohort and demonstrated a great consistency.

Small varices in chronic liver diseases

PURPOSE OF REVIEW

Gastroesophageal varices are common complications of chronic liver diseases (CLDs) and portal hypertension. Small varices have the risk of progressing to larger varices, causing bleeding or even death. Thus, early detection and appropriate management of small varices are necessary. The purpose of this review is to summarize the advance in the recent 5years about diagnosing and managing the small varices in CLDs.

RECENT FINDINGS

The diagnosing methods of small varices in recent studies include improved endoscopic examinations, such as capsule endoscopy, and many noninvasive methods, including blood tests, ultrasound, computed tomography and magnetic resonance. For the management of small varices, though it is controversial, prevention using nonselective beta-blockers is still an essential part.

SUMMARY

In this review, we summarize the classification of varices, the invasive and noninvasive diagnostic methods, their performances, and the emerging progression in the management of small varices in the recent 5 years. We hope that this review provides relevant information to understand better and appropriately manage small varices.

Soluble CD163 for Prediction of High-Risk Esophageal Varices and Variceal Hemorrhage in Patients with Liver Cirrhosis

INTRODUCTION

Activation of hepatic macrophages in liver disease is pathogenically related to portal hypertension (PH). Soluble CD163 (sCD163) is shed in blood by activated macrophages and may predict PH progression noninvasively. This study was designed to investigate the relation of serum sCD163 to the grade and bleeding risk of esophageal varices (EV) and its role for prediction of variceal hemorrhage (VH).

METHODS

The study included cirrhotic patients divided into 3 groups: patients who presented with acute upper gastrointestinal bleeding (UGIB) proved to originate from EV on endoscopy, patients without any history of UGIB but who revealed EV on surveillance endoscopy, and patients without endoscopic evidence of varices. Variceal grade and risk signs and bleeding stigmata were noted simultaneously with measurement of serum sCD163 concentration.

RESULTS

Serum sCD163 concentration showed a significant increase in cirrhotic patients compared to healthy subjects (p < 0.001) with a stepwise increase among the group without varices, nonbleeder group, and bleeder group sequentially. Serum sCD163 levels correlated positively with the variceal grade and risk signs in both the bleeder and nonbleeder groups (p = 0.002, p < 0.001 and p = 0.004, p < 0.001, respectively). Serum sCD163 at a cutoff value of 3.6 mg/L performed significantly for prediction of EV presence (AUC = 0.888). Serum sCD163 at a cutoff value >4 mg/L significantly predicted large-size and high-risk EV (AUC = 0.910 and AUC = 0.939, respectively) and the index bleed risk (AUC = 0.977). Serum sCD163 at a cutoff value >4.05 mg/L modestly discriminated bleeding EV from those that had never bled (AUC = 0.811).

CONCLUSIONS

Serum sCD163 levels accurately predicted high-grade and high-risk EV and could help plan for primary prophylaxis. However, it modestly identified VH occurrence, and endoscopy would be required to make a definitive diagnosis.

Noninvasive Detection of Clinically Significant Portal Hypertension in Compensated Advanced Chronic Liver Disease

Patients with compensated advanced chronic liver disease have different prognoses depending on the presence of portal hypertension. Current non-invasive diagnostic methods allow identification of clinically significant portal hypertension. Portosystemic collaterals on imaging or liver stiffness of more than 20 to 25 kPa by using transient elastography identifies patients with clinically significant portal hypertension. Patients with liver stiffness of less than 20 kPa and platelet count of greater than 150 g/L can avoid endoscopy. This rule could be expanded using spleen stiffness. Methods to risk stratify for portal hypertension in compensated advanced chronic liver disease and successfully treated chronic hepatitis C and B are subject of research.

Emerging non-invasive approaches for diagnosis and monitoring of portal hypertension

Clinically significant portal hypertension is associated with an increased risk of developing gastro-oesophageal varices and hepatic decompensation. Hepatic venous pressure gradient measurement and oesophagogastroduodenoscopy are the gold-standard methods for assessing clinically significant portal hypertension (hepatic venous pressure gradient ≥10 mm Hg) and gastro-oesophageal varices, respectively. However, invasiveness, cost, and feasibility limit their widespread use, especially if repeated and serial evaluations are required to assess the efficacy of pharmacotherapy. Although new techniques for non-invasive portal pressure measurement have been pursued for many decades, only recently have new tools been assessed and validated for larger clinical application. This Review focuses on the recent advances in non-invasive approaches for the diagnosis and serial monitoring of portal hypertension and varices for clinical practice.