Liver stiffness and 30-day mortality in a cohort of patients admitted to hospital

Prognostic value of liver stiffness in patients hospitalized for acute decompensated heart failure: a meta-analysis

PURPOSE

Heart failure (HF) is a major health problem affecting millions of people worldwide. In the latest years, many efforts have been made to identify predictors of poor prognosis in these patients. The aim of this systematic review and meta-analysis was to enlighten the correlation between liver stiffness (LS), assessed by Shear Wave Elastography techniques, and HF, particularly focusing on the prognostic value of LS on cardiovascular outcomes.

METHODS

We searched the PUBMED databases (up to May 1st, 2023) for studies that enlightened the correlation between LS and cardiovascular outcomes in patients hospitalized for acute decompensated heart failure (ADHF). We performed a meta-analysis to estimate the efficacy of LS in predicting the prognosis of patients with ADHF.

RESULTS

We analyzed data from 7 studies, comprising 677 patients, that assessed the prognostic value of LS in predicting cardiovascular outcomes in patients hospitalized for ADHF. The pooled analysis showed that increased liver stiffness was associated with higher risk of adverse cardiac events (hazard ratio 1.07 [1.03, 1.12], 95% CI).

CONCLUSION

Increased LS is associated with poor prognosis in patients hospitalized for HF and might help effectively identify those patients at high risk for worse outcomes.

Transient elastography (FibroScan) in critical care: Applications and limitations

FibroScan^® is a non-invasive device that assesses the ‘hardness’ (or stiffness) of the liver via the technique of transient elastography. Because fibrous tissue is harder than normal liver, the degree of hepatic fibrosis can be inferred from the liver hardness. This technique is increasingly being employed to diagnose liver fibrosis, even in critically ill patients. It is now being used not only for diagnosis and staging of liver cirrhosis, but also for outcome prognostication. However, the presence of several confounding factors, especially in critically ill patients, may make interpretation of these results unreliable. Through this review we aim to describe the indications and pitfalls of employing FibroScan in patients admitted to intensive care units.

Liver stiffness as measured by transient elastography is a predictor of outcomes in patients with chronic heart failure with reduced, mid-range, and recovered left-ventricular ejection fraction

Background

Transient elastography is a noninvasive method for assessing liver stiffness (LS), which can reflect right-sided filling pressure associated with passive liver congestion in patients with HF.

Methods

A prospective, single-center observational study in which LS was measured in consecutive ambulatory patients with heart failure with reduced, mid-range, and recovered left ventricular ejection fraction, between March 2018 and June 2019. Mean follow up was 219 ± 86 days. The primary endpoint was time to first event, which was defined as a composite of cardiovascular death or HF hospitalization.

Results

Eighty-five patients were included in the final analysis. Mean age was 62 ± 10 and 68% were male. Mean ejection fraction and median NT-proBNP were, respectively, 38.7 ± 14.3% and 1140 pg/mL (interquartile range 224.3-2810.3). The median LS for the entire population was 6.3 (2.5-41.2) kPa. LS correlated with NT-proBNP (r = 0.46; p < 0.0001), total bilirubin (r = 0.47; p < 0.001), direct bilirubin (r = 0.43; p = 0.0001), gama-glutamyl-transpeptidase (r = 0.54; p < 0.0001), and alkaline phosphatase (r = 0.39; p = 0.0004). A Receiver Operating Characteristic (ROC) curve was performed and a cut point of 5.9 kPa showed sensitivity of 80% and specificity of 64.1% with area under the curve of 0.73. Using Cox proportional hazard model (independent variables: LS as a continuous variable, age, gender, NT-proBNP, LVEF, and creatinine), only LS was independently associated with the primary endpoint (hazard ratio 1.05, 95% confidence interval 1.01-1.09; for each increment of one unit of LS).

Conclusion

LS correlates with biomarkers of myocardial stretch and several liver function tests and is an independent predictor of outcomes in ambulatory patients with HF.

Prospective Comparison of Transient Elastography Using Two Different Devices: Performance of FibroScan and FibroTouch

Purpose

Transient elastography (TE) using FibroScan (FS) has been established to non-invasively assess liver fibrosis and steatosis. The aim of this study was to compare the recently introduced FibroTouch (FT) device with the established FS with respect to liver stiffness and CAP.

Patients and Methods

Thirty-nine patients with and without liver disease were included. All patients were measured three times with FS (FibroScan 530 compact, Echosens, France) and FT (FibroTouch-FT100, Wuxi Hisky Med, China). For FS, M and XL probe were used according to the manufacturer’s specifications. For steatosis, CAP and the comparable FT equivalent UAP (ultrasound attenuation parameter) was determined. Finally, FT and FS were explored in liver tissue-mimicking phantoms.

Results

LS between FS and FT correlated well with r=0.91. Root-mean-square (RMS) of the coefficient of variation for LS was better in FS (11.1% vs 27.4%). Bland-Altman analysis showed a 3.1 kPa mean overestimation of LS by FT. In addition, UAP strongly and linearly depended on the BMI following UAP=3.02 × BMI+186. In phantoms, a similar relation was found with UAP (phantom)= 3.78 × BMI + 146 suggesting that UAP is directly calculated from entered BMI instead of assessing shear-wave attenuation. Consequently, RMS-CV was lower for FT (6.0% vs 9.7%). However, if using different BMI, CV-RMS for FT increased to 12.7%. LS of a patient with manifest liver cirrhosis and ascites was 38.8 kPa using the FS-XL probe but almost normal with FT (7.2 kPa).

Conclusion

Although LS by FT shows good correlation with LS-FS, it has larger variation, continuously overestimates LS and completely fails in ascites. Moreover, FT-UAP seems to be a misleading parameter for steatosis assessment because it is at least in part calculated from mandatory entered patient data. In conclusion, novel LS cut-off values need to be defined for LS-FT and usage of UAP is not recommended.

Predictive models of mortality and hospital readmission of patients with decompensated liver cirrhosis

INTRODUCTION

Complications of cirrhosis are one the major causes of hospital admission associated with high morbimortality rates and social and economic charges. The aims of this study were to evaluate hospital readmission and mortality rates and predictive factors for hospital readmission and mortality.

METHODS

Patients with decompensated cirrhosis admitted to our institution between 2008-2014 were retrospectively analyzed.

RESULTS

Included 427 admissions from 177 patients with cirrhosis with mean age of 59.0 ± 12.3 years. The major cause was alcoholic-related liver disease and the median duration of admission was 9.0 days (IQR 6.0-14.0). During the follow-up period,there were 250 readmissions from 95 patients, with a median of 58 (IQR27-134) days for readmission, representing 58.5% of the total number of admissions.The 180-day mortality rate was 35.0%. In the multivariate analysis, ascites, smoking and MELD Na were associated with 180-day mortality. Creatinine, albumin, esophageal variceal bleeding, previous variceal banding, lactulose, rifaximin and proton pump inhibitors use were independently associated with need of readmission. Based on regression analysis, two models were calculated to predict 180-day mortality (AUROC 0.74 (0.682-0.794)) and need for readmission(AUROC 0.821 (0.781-0.861)), p < 0.001.

CONCLUSION

The readmission rate and mortality of cirrhotic patients are still very high and it is a priority to determine preventable risk factors to improve patient outcome. Two models were created to predict 180-day mortality(AUROC 0.74) and need for readmission(AUROC 0.821), that could guide the management of the patients at the time of admission.

Non-invasive diagnosis and biomarkers in alcohol-related liver disease

Even though alcohol-related liver disease (ALD) is a major cause of severe liver disease worldwide, most patients with ALD are diagnosed at the decompensation stage. Liver biopsy is still considered the gold standard for establishing a definite diagnosis and assessing the fibrosis stage of ALD, but it is an invasive procedure, associated with significant morbidity. During the last decade, non-invasive tests have been developed to estimate the severity of liver fibrosis and steatosis. Measurement of liver stiffness by transient elastography has become the most commonly used non-invasive parameter to evaluate fibrosis. In ALD, transient elastography has been demonstrated to have an excellent performance to detect advanced fibrosis and cirrhosis. However, aspartate aminotransferase levels must be considered when interpreting liver stiffness cut-offs. Non-invasive biological tests have also been evaluated to assess liver fibrosis in ALD. The commercially available Enhanced Liver Fibrosis test and FibroTest have comparable performance for the diagnosis of advanced fibrosis in ALD, with studies suggesting that they are better than other biological tests (i.e. FIB-4 and APRI). Although ultrasound is still accepted as an initial screen for fatty liver diagnosis, new methods have recently been developed to detect steatosis. Magnetic resonance spectroscopy and magnetic resonance imaging techniques are highly accurate and reproducible, with superior sensitivities and specificities for detecting histological steatosis than ultrasound. However, low availability and high cost limit the use of magnetic resonance techniques in routine clinical practice. More recently, controlled attenuation parameter was developed as a novel tool to non-invasively assess liver steatosis; performed in combination with transient elastography, it was suggested to be superior to regular ultrasound for detecting steatosis and was shown to have acceptable diagnostic accuracy. New serum biomarkers are under investigation to non-invasively diagnose more severe forms of ALD and to predict prognosis of patients.

Does pressure cause liver cirrhosis? The sinusoidal pressure hypothesis

Independent of their etiology, all chronic liver diseases ultimately lead to liver cirrhosis, which is a major health problem worldwide. The underlying molecular mechanisms are still poorly understood and no efficient treatment strategies are available. This paper introduces the sinusoidal pressure hypothesis (SPH), which identifies an elevated sinusoidal pressure (SP) as cause of fibrosis. SPH has been mainly derived from recent studies on liver stiffness. So far, pressure changes have been exclusively seen as a consequence of cirrhosis. According to the SPH, however, an elevated SP is the major upstream event that initiates fibrosis via biomechanic signaling by stretching of perisinusoidal cells such as hepatic stellate cells or fibroblasts (SPH part I: initiation). Fibrosis progression is determined by the degree and time of elevated SP. The SPH predicts that the degree of extracellular matrix eventually matches SP with critical thresholds > 12 mmHg and > 4 wk. Elevated arterial flow and final arterialization of the cirrhotic liver represents the self-perpetuating key event exposing the low-pressure-organ to pathologically high pressures (SPH part II: perpetuation). It also defines the “point of no return” where fibrosis progression becomes irreversible. The SPH is able to explain the macroscopic changes of cirrhotic livers and the uniform fibrotic response to various etiologies. It also opens up new views on the role of fat and disease mechanisms in other organs. The novel concept will hopefully stimulate the search for new treatment strategies.

Microfibrillar-Associated Protein 4: A Potential Biomarker for Screening for Liver Fibrosis in a Mixed Patient Cohort

Background and Aims

A method for assessment of liver fibrosis and cirrhosis without the need for a liver biopsy is desirable. Microfibrillar-associated protein 4 (MFAP4) is a suggested biomarker for identification of high-risk patients with severe fibrosis stages. This study aimed to examine associations between plasma MFAP4 (pMFAP4) and transient elastography or chronic hepatitis C virus infection in drug users and in a mixed patient cohort with increased risk of liver disease. Moreover, the study aimed to identify comorbidities that significantly influence pMFAP4.

Methods

pMFAP4 was measured in samples from 351 drug users attending treatment centres and from 248 acutely hospitalized medical patients with mixed diagnoses. Linear and logistic multivariate regression analyses were performed and nonparametric receiver operating characteristic-curves for cirrhosis were used to estimate cut-off points for pMFAP4. Univariate and subgroup analyses were performed using non-parametric methods.

Results

pMFAP4 increased significantly with liver fibrosis score. pMFAP4 was significantly associated with chronic viral infection in the drug users and with transient elastography in both cohorts. In the mixed patient cohort, pMFAP4 was significantly increased among patients with a previous diagnosis of liver disease or congestive heart failure compared to patients with other diagnoses.

Conclusions

pMFAP4 has the potential to be used as an outreach-screening tool for liver fibrosis in drug users and in mixed medical patients. pMFAP4 level is positively associated with transient elastography, but additional studies are warranted to validate the possible use of pMFAP4 in larger cohorts and in combination with transient elastography.

Novel method of evaluating liver stiffness using transient elastography to evaluate perioperative status in severe heart failure

BACKGROUND

The aim of the present study was to assess the efficacy of a non-invasive method, transient elastography (FibroScan), in measuring liver stiffness (LS), and whether LS can be used as a marker of cardiac - and hence perioperative - status.

METHODS AND RESULTS

Perioperative LS was prospectively measured using a FibroScan in 30 patients (21 male; 42.2 ± 13.3 years old) who underwent left ventricular assist device (LVAD) implantation. LS was checked pre- and postoperatively, then analyzed in regard to perioperative status. Preoperative LS was 13.3 ± 13.0 kPa (normal, <5.5 kPa), and was abnormal in 77% of patients. Four required bilateral VAD. LS in patients with bilateral VAD tended to be higher than in LVAD patients (25.1 ± 22.7 vs. 11.5 ± 10.5 kPa, P=0.051). No patient with LS ≤ 7.0 kPa required a right VAD. The incidence of major adverse events was lower in patients with LS ≤ 12.5 kPa (25% vs. 80%, P<0.05). There were also no mortalities among patients with LS ≤ 12.5 kPa.

CONCLUSIONS

LS was correlated with preoperative severity in patients with severe heart failure and reflected liver congestion, and may be useful to predict the requirement of right VAD, as well as postoperative complications in patients with LVAD implantation. This novel modality may be a useful non-invasive assessment method for management of severe heart failure.

Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis

BACKGROUND & AIMS

Liver stiffness measurement (LSM), using elastography, can independently predict outcomes of patients with chronic liver diseases (CLDs). However, there is much variation in reporting and consistency of findings. We performed a systematic review and meta-analysis to evaluate the association between LSM and outcomes of patients with CLDs.

METHODS

We performed a systematic review of the literature, through February 2013, for studies that followed up patients with CLDs prospectively for at least 6 months and reported the association between baseline LSM and subsequent development of decompensated cirrhosis or hepatocellular carcinoma (HCC), as well as mortality. Summary relative risk (RR) estimates per unit of LSM and 95% confidence intervals (CIs) were estimated using the random effects model.

RESULTS

Our final analysis included 17 studies, reporting on 7058 patients with CLDs. Baseline LSM was associated significantly with risk of hepatic decompensation (6 studies; RR, 1.07; 95% CI, 1.03-1.11), HCC (9 studies; RR, 1.11; 95% CI, 1.05-1.18), death (5 studies; RR, 1.22; 95% CI, 1.05-1.43), or a composite of these outcomes (7 studies; RR, 1.32; 95% CI, 1.16-1.51). We observed considerable heterogeneity among studies-primarily in the magnitude of effect, rather than the direction of effect. This heterogeneity could not be explained by variations in study locations, etiologies and stages of CLD, techniques to measure liver stiffness, adjustment for covariates, or method of imputing relationship in the meta-analysis.

CONCLUSIONS

Based on a meta-analysis of cohort studies, the degree of liver stiffness is associated with risk of decompensated cirrhosis, HCC, and death in patients with CLDs. LSM therefore might be used in risk stratification.

Liver stiffness predicts liver-related complications and mortality in HIV patients with chronic hepatitis C on antiretroviral therapy

BACKGROUND

Liver disease is currently one of the leading causes of death in HIV individuals. Hepatic fibrosis largely mediates this effect and infection with hepatitis C virus (HCV) is the most common cause. Few studies have examined so far the predictive value of liver fibrosis staging on mortality and liver decompensation in HIV/HCV-coinfected patients.

METHODS

A prospective programme of liver fibrosis assessment using transient elastometry has been ongoing at our institution since 2004. Data from all HIV/HCV-coinfected patients who underwent a transient elastometry examination and have at least 18 months of follow-up were selected for the current analysis.

RESULTS

A total of 545 HIV/HCV-coinfected patients were examined (mean age 41 years, 71% men, 81% IDUs, mean BMI 23.3 kg/m2, HBsAg+ 4.2%, alcohol abuse 8.4%, mean CD4 cell count 519 cells/μl). The mean follow-up was 70.9 ± 15.7 months. During follow-up, 12 patients (2.2%) died, four of them due to hepatic complications. Liver-related events (ascites, encephalopathy, oesophageal varices or hepatocellular carcinoma) appeared in 53 patients (10%). In the multivariate analysis, baseline liver stiffness was the strongest predictor of liver-related complications [odds ratio (OR) 1.12, 95% confidence interval (CI) 1.08-1.16, P < 0.0001] and of all-cause mortality (OR 1.09, 95% CI 1.01-1.19, P = 0.02). The achievement of sustained virological response following peginterferon/ribavirin therapy during the study period was protective against the development of liver-related events (OR 0.02, 95% CI 0-0.23, P = 0.01).

CONCLUSION

Liver fibrosis staging, as measured by transient elastometry, predicts liver-related complications and all-cause mortality in HIV/HCV-coinfected patients on antiretroviral therapy.

Liver Hemangioma Might Lead to overestimation of Liver Fibrosis by Fibroscan; A Missed Issue in Two Cases

BACKGROUND

The assessment of liver fibrosis is an important way for prediction of liver disease progression and patient's prognosis. Liver stiffness measurement (LSM) is strongly associated with stage of liver diseases. overestimation of liver fibrosis in heart failure has been reported. We would like to introduce a new leading cause of liver fibrosis overestimation by presentation of two cases.

CASE PRESENTATION

one case with right lobe hemangioma has an overestimation of liver fibrosis. The result completely changed when Fibroscan was performed in patient's left lobe. Interestingly, another case with left lobe hemangioma had overestimation of fibrosis in her left lobe but, right lob Fibroscan was normal.

CONCLUSION

We found that liver hemangioma may leads to overestimation of liver stiffness and the correct inspection of liver echogenicity before any interpretation of high liver stiffness is recommended. We suggest that patient with higher level of Fibroscan score repeat it in other sides of the liver. Also, they should be evaluated by sonography for ruling out of possible confounders such as hepatic hemangioma.

Liver Hemangioma Might Lead to overestimation of Liver Fibrosis by Fibroscan; A Missed Issue in Two Cases

BACKGROUND

The assessment of liver fibrosis is an important way for prediction of liver disease progression and patient's prognosis. Liver stiffness measurement (LSM) is strongly associated with stage of liver diseases. overestimation of liver fibrosis in heart failure has been reported. We would like to introduce a new leading cause of liver fibrosis overestimation by presentation of two cases.

CASE PRESENTATION

one case with right lobe hemangioma has an overestimation of liver fibrosis. The result completely changed when Fibroscan was performed in patient's left lobe. Interestingly, another case with left lobe hemangioma had overestimation of fibrosis in her left lobe but, right lob Fibroscan was normal.

CONCLUSION

We found that liver hemangioma may leads to overestimation of liver stiffness and the correct inspection of liver echogenicity before any interpretation of high liver stiffness is recommended. We suggest that patient with higher level of Fibroscan score repeat it in other sides of the liver. Also, they should be evaluated by sonography for ruling out of possible confounders such as hepatic hemangioma.

Impact of heart failure and changes to volume status on liver stiffness: non-invasive assessment using transient elastography

AIM

The impact of cardiac dysfunction on the liver is known as cardiac hepatopathy. In certain instances this can result in significant hepatic fibrosis or cirrhosis. The validity of non-invasive tools to assess hepatic fibrosis, such as FibroScan(®) which measures liver stiffness (LSM), has not been established in this setting. We examined the impact of cardiac dysfunction on LSM using FibroScan(®) and the influence of volume changes on LSM.

METHODS AND RESULTS

A prospective, cross-sectional study examined the use of FibroScan(®) in subjects with left-sided heart failure (LHF, n = 32), right-sided heart failure (RHF, n = 9), and acute decompensated heart failure (ADHF, n = 8). The impact of volume changes upon LSM was further examined in the ADHF group (pre- and post-diuresis) and in a haemodialysis group (HD, n = 12), pre- and post-ultrafiltration on dialysis. Compared with healthy controls [n = 55, LSM = median 4.4 (25th percentile 3.6, 75th percentile 5.1) kPa], LSM was increased in all the cardiac dysfunction subgroups [LHF, 4.7 (4.0, 8.7) kPa, P = 0.04; RHF, 9.7 (5.0, 10.8) kPa, P < 0.001; ADHF, 11.2 (6.7, 14.3) kPa, P < 0.001]. Alteration in volume status via diuresis did not change the baseline LSM in ADHF [11.2 (6.7, 14.3) to 9.5 (7.3, 21.6) kPa, P > 0.05] with mean diuresis 5051 ± 1585 mL, or ultrafiltration in HD [6.0 (3.6, 5.1) vs. 5.7 (4.8, 7.0) kPa, P > 0.05] with mean diuresis 1962 ± 233 mL.

CONCLUSION

Our findings support the concept of increased LSM in the cardiac failure population. LSM was not altered to a statistically significant level with acute volume changes.

Endo-hepatology: a new paradigm

Recent advances in hepatology have included a new and effective treatment of viral hepatitis, with an increased need for the assessment of liver function and histology. At the same time, there have been a growing number of endoscopic procedures that are pertinent to patients with liver disease. It would be ideal if the assessment and treatment of liver disease and portal hypertension could be performed and assimilated by the liver/gastrointestinal specialist. The authors like to consider this area of integration or overlap of endoscopic procedures within the practice of hepatology as endo-hepatology.