D-dimer level for predicting the in-hospital mortality in liver cirrhosis: A retrospective study

Top-Down Proteomics Identifies Plasma Proteoform Signatures of Liver Cirrhosis Progression

Cirrhosis, advanced liver disease, affects 2 to 5 million Americans. While most patients have compensated cirrhosis and may be fairly asymptomatic, many decompensate and experience life-threatening complications such as gastrointestinal bleeding, confusion (hepatic encephalopathy), and ascites, reducing life expectancy from 12 to less than 2 years. Among patients with compensated cirrhosis, identifying patients at high risk of decompensation is critical to optimize care and reduce morbidity and mortality. Therefore, it is important to preferentially direct them towards specialty care which cannot be provided to all patients with cirrhosis. We used discovery top-down proteomics to identify differentially expressed proteoforms (DEPs) in the plasma of patients with progressive stages of liver cirrhosis with the ultimate goal to identify candidate biomarkers of disease progression. In this pilot study, we identified 209 DEPs across three stages of cirrhosis (compensated, compensated with portal hypertension, and decompensated), of which 115 derived from proteins enriched in the liver at a transcriptional level and discriminated the three stages of cirrhosis. Enrichment analyses demonstrated DEPs are involved in several metabolic and immunological processes known to be impacted by cirrhosis progression. We have preliminarily defined the plasma proteoform signatures of cirrhosis patients, setting the stage for ongoing discovery and validation of biomarkers for early diagnosis, risk stratification, and disease monitoring.

D-dimers in advanced liver cirrhosis: Useful biomarker or not?

In clinical practice, the d-dimer levels rule out venous thromboembolism and diagnose disseminated intravascular coagulation. d-dimers increase in both physiological and pathological conditions. Liver cirrhosis, especially in the final stages, is characterized by complex coagulation and fibrinolysis factor disorders. Multiple mechanisms tried to explain the increased d-dimer levels in patients with liver cirrhosis and ascites. The d-dimer cut-off level used to rule out venous thromboembolism in cirrhosis is higher than that used to confirm the diagnosis of VTE or DIC in noncirrhotic patients. The cut-off d-dimer level used for the prognosis of thrombotic events is not standardized in advanced liver cirrhosis. Thus, it is necessary to update the clinical guidelines regarding the usefulness of d-dimer testing in advanced liver cirrhosis and the cut-off d-dimer levels, which should vary based on the detection method.

Predictive Value of the D-Dimer-to-Fibrinogen Ratio for Acute Kidney Injury after Living-Donor Liver Transplantation: A Retrospective Observational Cohort Study Using Logistic Regression and Propensity Score Matching Analyses

Background/Objectives: Liver transplantation (LT) is typically performed as a surgery to treat end-stage liver disease (ESLD). Factors influencing acute kidney injury (AKI) post-living-donor LT (LDLT) have been identified; however, the potential role of the D-dimer-to-fibrinogen ratio (DFR) in predicting AKI remains unexplored. Therefore, we analyzed the relationship between DFR levels and the occurrence of AKI following LT. Methods: We retrospectively analyzed 648 recipients after 76 were excluded based on the exclusion criteria. Multivariate logistic regression and propensity score (PS) matching analyses were performed to evaluate the association between a high DFR (>1.05) and AKI. Results: After LDLT, AKI was observed in 148 patients (22.8%). A high DFR (>1.05) was independently associated with AKI. Multivariate logistic regression analysis showed that patients with a DFR above this threshold were four times more susceptible to AKI than those with a low DFR. A high DFR was also significantly associated with AKI in the propensity score-matched patients. Conclusions: Our findings suggest that incorporating preoperative DFR assessment into the management of patients undergoing LDLT could enhance the risk stratification for postoperative AKI.

Top-Down Proteomics Identifies Plasma Proteoform Signatures of Liver Cirrhosis Progression

Cirrhosis, advanced liver disease, affects 2-5 million Americans. While most patients have compensated cirrhosis and may be fairly asymptomatic, many decompensate and experience life-threatening complications such as gastrointestinal bleeding, confusion (hepatic encephalopathy), and ascites, reducing life expectancy from 12 to less than 2 years. Among patients with compensated cirrhosis, identifying patients at high risk of decompensation is critical to optimize care and reduce morbidity and mortality. Therefore, it is important to preferentially direct them towards specialty care which cannot be provided to all patients with cirrhosis. We used discovery Top-down Proteomics (TDP) to identify differentially expressed proteoforms (DEPs) in the plasma of patients with progressive stages of liver cirrhosis with the ultimate goal to identify candidate biomarkers of disease progression. In this pilot study, we identified 209 DEPs across three stages of cirrhosis (compensated, compensated with portal hypertension, and decompensated), of which 115 derived from proteins enriched in the liver at a transcriptional level and discriminated the three stages of cirrhosis. Enrichment analyses demonstrated DEPs are involved in several metabolic and immunological processes known to be impacted by cirrhosis progression. We have preliminarily defined the plasma proteoform signatures of cirrhosis patients, setting the stage for ongoing discovery and validation of biomarkers for early diagnosis, risk stratification, and disease monitoring.

Evaluation of D-dimer and prothrombin time in alcohol related liver cirrhosis with comparison of machine learning analyses

OBJECTIVES

Liver cirrhosis (LC) can be caused by obesity, alcohol consumption, viral infection, and autoimmune disease. Early diagnosis and management of LC is important for patient quality of life. Non-invasive diagnostic methods are useful for predicting the current status and mortality risk of LC. The purpose of this study is to identify relevant diagnostic factors measured in routine laboratory test of alcohol-related liver cirrhosis (ALC) patients.

METHODS

This study analyzed data from 127 patients with ALC, including their laboratory test results and clinical information, including coagulation parameters, hematologic parameters, and biochemical parameters. These data were used to compare the performance of the prediction models from three machine learning algorithms including K-nearest neighbor (KNN), support vector machine (SVM), and random forest (RF).

RESULTS

Higher Model for End-stage Liver Disease (MELD) score were associated with prothrombin time (PT) and D-dimer. Logistic and multiple linear regression analyses revealed significant factors predicting mortality in the MELD group. Machine learning approaches were used to predict death in ALC patients using some laboratory parameters associated with mortality. The prediction model based on SVM exhibited better prediction performance than others.

CONCLUSION

PT and D-dimer were the factors that were most strongly associated with 90-day mortality, and machine learning methods can create prediction models with good predictive power.

D-dimer - a multifaceted molecule

D-dimer, a universally unique marker for fibrin degradation, is generated through the enzymatic interplay of thrombin, factor XIIIa, and plasmin. The emergence of D-dimer-containing fibrin molecules occurs in both intravascular and extravascular spaces during pivotal physiological processes like haemostasis, thrombosis, and tissue repair. Given the inherently physiological nature of fibrin formation and fibrinolysis, basal levels of D-dimer fragments are present in plasma. Beyond its role as a marker of routine physiological processes, aberrations in D-dimer levels are indicative of a spectrum of conditions, both non-pathological and pathological. The clinical utility of D-dimer has been firmly established, particularly in scenarios like venous thromboembolism (VTE), pulmonary embolism (PE), deep vein thrombosis (DVT), and disseminated intravascular coagulation (DIC). Additionally, recent applications have extended to assess the prognosis of COVID-19. While D-dimer is commonly associated with thrombotic conditions, its elevation is not confined to these conditions alone. Elevated D-dimer levels are observed across various diseases, where its significance extends beyond diagnostic indicators to prognostic implications.

Association of D-dimer level with thrombotic events, bleeding, and mortality in Japanese patients with solid tumors: a Cancer-VTE Registry subanalysis

BACKGROUND

The D-dimer test is a simple test frequently used in routine clinical screening for venous thromboembolism (VTE). The Cancer-VTE Registry was a large-scale, multicenter, prospective, observational study in Japanese patients with cancer. This study aimed to clarify the relationship between D-dimer level at cancer diagnosis (baseline) and the incidence of events during cancer treatment (1-year follow-up period).

METHODS

This was a post hoc sub-analysis of patients from the Cancer-VTE Registry whose D-dimer levels were measured at baseline. The incidence of events during the 1-year follow-up period was evaluated stratified by baseline D-dimer level. Adjusted hazard ratios for D-dimer level and events during the follow-up period were evaluated.

RESULTS

Among the total enrolled patients, baseline D-dimer level was measured in 9020 patients. The mean ± standard deviation baseline D-dimer level was 1.57 ± 3.94 µg/mL. During the follow-up period, the incidence of VTE, cerebral infarction/transient ischemic attack (TIA)/systemic embolic events (SEE), bleeding, and all-cause death increased with increasing baseline D-dimer level. The incidence of all-cause death increased with increasing D-dimer level regardless of cancer stage. The adjusted hazard ratio of all-cause death was 1.03 (95% confidence interval: 1.02-1.03) per 1.0-µg/mL increase in baseline D-dimer level.

CONCLUSIONS

Increases in D-dimer levels were associated with a higher risk of thrombotic events, such as VTE and cerebral infarction/TIA/SEE, during cancer treatment. Furthermore, higher D-dimer levels at cancer diagnosis were associated with a higher mortality rate, regardless of cancer stage.

How we manage a high D-dimer

D-dimer, a soluble fibrin degradation product that originates from plasmin-induced degradation of cross-linked fibrin, is an important biomarker of coagulation activation and secondary fibrinolysis that is routinely used to rule out venous thromboembolism (VTE), and to evaluate the risk of VTE recurrence, as well as the optimal duration of anticoagulant therapy. Besides VTE, D-dimer may be high due to physiologic conditions, including aging, pregnancy, and strenuous physical activity. In addition, several disorders have been associated with increased D-dimer levels, ranging from disseminated intravascular coagulation to infectious diseases and cancers. Thus, it is far from unusual for hematologists to have to deal with ambulatory individuals with increased D-dimer without signs or symptoms of thrombus formation. This narrative review is dedicated to the management of these cases by the hematologist.

D-dimer-to-platelet count ratio as a novel indicator for predicting prognosis in HBV-related decompensated cirrhosis

Background

Hepatitis B virus-related decompensated cirrhosis (HBV-DC) is a critical illness with a low survival rate. Timely identification of prognostic indicators is crucial for risk stratification and personalized management of patients. The present study aimed to investigate the potential of the D-dimer-to-platelet count ratio (DPR) as a prognostic indicator for HBV-DC.

Methods

A retrospective review of medical records was conducted for 164 patients diagnosed with HBV-DC. Baseline clinical and laboratory characteristics were extracted for analysis. The endpoint was 30-day mortality. Disease severity was assessed by the Model for End-stage Liver Disease (MELD) score. A multivariate logistic regression model and receiver operating characteristic curve analysis (ROC) were used to evaluate the predictive value of DPR for mortality.

Results

During the 30-day follow-up period, 30 (18.3%) patients died. Non-survivors exhibited significantly higher DPR values than survivors, and a high DPR had a strong association with increased mortality. Importantly, DPR was identified as an independent risk factor for mortality in HBV-DC patients after adjustments for confounding factors (Odds ratio = 1.017; 95% Confidence interval, 1.006-1.029; p = 0.003). The cut-off value of DPR as a predictor of mortality was>57.6 (sensitivity = 57%, specificity = 86%, p < 0.001). The area under ROC curve for DPR for 30-day mortality was 0.762, comparable to the MELD score (p = 0.100). Furthermore, the combined use of DPR and MELD score further increased the area under the ROC curve to 0.897.

Conclusion

Elevated DPR was demonstrated to have a correlation with unfavorable outcomes in HBV-DC patients, suggesting its potential utility as an effective biomarker for assessment of prognosis in these patients.

Risk factors for hepatic hydrothorax in patients with cirrhosis: a clinical retrospective study

Aims and background

Hepatic hydrothorax, which presents as an unexplained pleural effusion, is one of the important complications in patients with end-stage cirrhosis. It has a significant correlation with prognosis and mortality. The aim of this clinical study was to detect the risk factors for hepatic hydrothorax in patients with cirrhosis and to better understand potentially life-threatening complications.

Methods

Retrospectively, 978 cirrhotic patients who were hospitalized at the Shandong Public Health Clinical Center from 2013 to 2021 were involved in this study. They were divided into the observation group and the control group based on the presence of hepatic hydrothorax. The epidemiological, clinical, laboratory, and radiological characteristics of the patients were collected and analyzed. ROC curves were used to evaluate the forecasting ability of the candidate model. Furthermore, 487 cases in the experimental group were divided into left, right, and bilateral groups, and the data were analyzed.

Results

The patients in the observation group had a higher proportion of upper gastrointestinal bleeding (UGIB), a history of spleen surgery, and a higher model for end-stage liver disease (MELD) scores compared with the control group. The width of the portal vein (PVW) (P = 0.022), prothrombin activity (PTA) (P = 0.012), D-dimer (P = 0.010), immunoglobulin G (IgG) (P = 0.007), high-density lipoprotein cholesterol (HDL) (P = 0.022), and the MELD score were significantly associated with the occurrence of the hepatic hydrothorax. The AUC of the candidate model was 0.805 (P < 0.001, 95% CI = 0.758-0.851). Portal vein thrombosis was more common in bilateral pleural effusion compared with the left and right sides (P = 0.018).

Conclusion

The occurrence of hepatic hydrothorax has a close relationship with lower HDL, PTA, and higher PVW, D-dimer, IgG, and MELD scores. Portal vein thrombosis is more common in cirrhotic patients with bilateral pleural effusion compared to those with unilateral pleural effusion.

Acute kidney injury development and impact on clinical and economic outcomes in patients with cirrhosis: an observational cohort study over a 10-year period

OBJECTIVES

Acute kidney injury (AKI) is a severe complication that is associated with significant morbidity and mortality in hospitalized cirrhotic patients. Data about AKI incidence and outcomes in patients with cirrhosis is scarce in the Middle East region. This study explored the incidence and impact of AKI on clinical and economic outcomes in cirrhosis.

METHODS

This was a retrospective cohort study of cirrhosis patients admitted to an educational hospital in Jordan during the years 2012-2022. Demographics, clinical and biochemical information, and charges were retrieved from medical electronic records. Logistic regression models were conducted to evaluate predictors of AKI and mortality in cirrhosis adjusting for covariates. Hospital charges were also described.

RESULTS

A total of 380 cirrhosis patients were included with an AKI incidence of 27.9%. Male sex, elevated baseline serum creatinine, presence of spontaneous bacterial peritonitis, and higher comorbidity score were independently associated with AKI development ( P < 0.05). The hospital mortality rate was markedly higher for patients with AKI versus those without AKI (51.9% vs. 6.2%, respectively; P < 0.001). AKI was associated independently with higher odds of hospital death (OR = 5.83, P < 0.001), prolongation of the median hospital stays by 5 days ( P < 0.001), more clinical complications, and increased total hospital charges per admission by $2500.

CONCLUSION

AKI is prevalent in cirrhosis patients, and it is associated with increased mortality, hospitalization, and cost. This burden in cirrhosis emphasizes the need for early identification of patients at high risk of AKI and applying prompt and effective management approaches, aiming at improving outcomes.

Cirrhosis and COVID-19: Diffuse venous thrombosis and its clinical implication

A 60-year-old woman with Hepatitis C infection, cirrhosis, recurrent hepatic hydrothorax, and hepatocellular carcinoma was hospitalized with Coronavirus disease-2019 (COVID-19). After her initial discharge, she was re-admitted three weeks later with decompensated liver disease. Imaging revealed extensive thrombosis in the portal vein, superior mesenteric vein, splenic vein and bilateral brachial veins. Given the acute onset and extent of the thrombosis, the patient received therapeutic anticoagulation despite elevated prothrombin time/ international normalized ratio, thrombocytopenia and low fibrinogen. Cirrhotic patients with COVID-19 maybe at high risk of thrombosis, which can present with significant hepatic decompensation.

D-Dimer-to-Albumin Ratio: A Novel Indicator to Predict Poor Outcomes in Patients with HBV-Associated Decompensated Cirrhosis

BACKGROUND

The purpose of the present study was to investigate the impact of D-dimer-to-albumin ratio (DAR) on outcomes in patients with hepatitis B virus-associated decompensated cirrhosis (HBV-DeCi).

METHODS

A total of 172 HBV-DeCi patients were enrolled. Logistic regression was used to explore the association between DAR and 30-day mortality. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of DAR for predicting mortality.

RESULTS

The 30-day mortality was 19.8%. DAR was clearly higher in the nonsurvivors compared with the survivors, and increasing DAR was associated with an increasing risk of death. DAR was independently associated with mortality and its AUC for mortality was equivalent to that for Model for End-Stage Liver Disease score.

CONCLUSIONS

DAR may be a potential prognostic marker for mortality in HBV-DeCi patients.

Significance of altered anticoagulant proteins and D-dimer in cirrhotic portal vein thrombosis: relation to the degree of liver dysfunction

Aim of the study

Portal vein thrombosis (PVT) is a well-known consequence of cirrhosis. Its pathophysiology is complex, with possible downstream hepatic decompensation. This study was conducted to describe the changes of protein C (PC), protein S (PS) and D-dimer blood levels associated with PVT formation in cirrhosis and the relation to the degree of liver dysfunction.

Material and methods

This was a case-control study that included 50 cirrhotic patients who presented with acute de novo non-malignant PVT and 50 cirrhotic patients without PVT as a control group. The severity of liver disease was classified as per the Child-Turcotte-Pugh (CTP) score. Doppler ultrasonography identified acute portal vein occlusion, and dynamic contrast-enhanced computed tomography confirmed the extent and nature of PVT. Blood PC, PS and D-dimer levels were measured using enzyme-linked immunosorbent assay.

Results

PC and PS levels were significantly lower, and the D-dimer level was significantly higher, in cirrhotic patients with PVT compared to the control group. PC and PS levels were significantly decreased in patients with higher CTP score of both groups. The D-dimer level did not vary significantly with the degree of liver dysfunction in patients of either group. PC, PS and D-dimer at the cut-off points of ≤ 77 IU/dl, ≤ 63 IU/dl, and > 300 ng/ml, respectively, significantly suggested PVT occurrence.

Conclusions

Alteration of the anticoagulant proteins and D-dimer contributed to PVT formation in cirrhotic patients and could help stratify the degree of liver dysfunction. Blood level of these hemostatic proteins could be incorporated into a probability score for early diagnosis and treatment of PVT in cirrhosis.

Usefulness of the d-dimer to albumin ratio for risk assessment in patients with acute variceal bleeding at the emergency department: retrospective observational study

Background

Acute variceal bleeding (AVB) is a severe complication of portal hypertension that is caused by rupture of the esophageal or gastric varix. Scoring system for risk stratification of AVB is difficult to use because various variables must be entered, and it is difficult to apply early in the emergency department (ED). We compared and analyzed the usefulness of the D-dimer to albumin ratio (DAR) for risk stratification of AVB.

Methods

In this retrospective observational study, medical records of patients with AVB Between January 2019 and December 2020 were assessed. The primary endpoint was to evaluate whether DAR was a predictor of clinical outcomes for AVB. Receiver operating characteristic (ROC) curves were constructed using cut-off values determined by the Youden Index. Univariate and multivariate logistic regression analyses were performed to assess the factors contributing to the development of outcomes.

Results

Overall, 67 patients required intensive care. The cut-off value of DAR for patients requiring intensive care was 400. A DAR > 400 (adjusted HR: 5.636 [95% CI: 2.216–14.332]) independently predicted the need for ICU admission in these patients. Overall, 13 patients required long-term hospitalization. The cut-off value of DAR for patients requiring long-term hospitalization was 403. A DAR > 403 (adjusted HR: 9.899 [95% CI: 2.012–48.694]) independently predicted the need for long-term hospitalization. Overall, 95 patients required transfusion. The cut-off value of DAR for patients requiring transfusion was 121. A DAR > 121 (adjusted HR: 4.680 [95% CI: 1.703–12.862]) independently predicted the need for transfusion. Overall, 11 patients died during study period. The cut-off value of DAR for mortality was 450. A DAR > 450 (adjusted HR: 26.261 [95% CI: 3.054–225.827]) independently predicted mortality.

Conclusions

The DAR can be used for outcome assessment in patients with AVB with various scoring systems, but its explanatory power is not high.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00696-4.

Predictive value of elevated serum D‑dimer for short‑term prognosis in patients with HBV‑related acute‑on‑chronic liver failure

To study the predictive value of elevated serum D-dimer on short-term prognosis in patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) and the correlation between serum D-dimer level and the clinical data of these patients, a single center retrospective study was conducted to collect the clinical data and 28 and 90-day survival rates of 201 patients. Logistic regression analysis and receiver operating characteristic curves were used to determine the factors affecting short-term prognosis. A Kaplan-Meier curve was used to compare the difference in survival rate between the two groups with elevated D-dimer and normal D-dimer levels. Correlation analysis was used to determine the correlation between serum D-dimer level and the clinical data of the patients. The results showed that international normalized ratio (INR) >2.3 and age >53 years were independent risk factors affecting the 28-day survival rate of the patients (P<0.05). INR >2.3, serum total bilirubin >358.2 µmol/l, age >49 years and elevated serum D-dimer (>550 ng/ml) were independent risk factors affecting the 90-day survival rate of the patients (P<0.05). There were significant differences in the 90-day survival rate and the survival time between the patients with elevated D-dimer and normal D-dimer levels (P<0.05). Serum D-dimer level was positively associated with age, combined spontaneous peritonitis, albumin, INR and the model for end-stage liver disease sodium (MELD-Na) scores, and negatively associated with male sex, red blood cell count, and serum sodium and fibrinogen levels. It was concluded that elevated serum D-dimer (>550 ng/ml) is an independent risk factor affecting the 90-day survival rate of patients with HBV-ACLF. The 90-day survival rate and the survival time of patients with HBV-ACLF and elevated D-dimer levels are significantly lower than those with normal D-dimer levels. Overall, serum D-dimer is associated the short-term prognosis of patients with HBV-ACLF, and the detection of serum D-dimer level at admission can help predict the short-term prognosis of patients with HBV-ACLF, especially the 90-day prognosis.

Prognostic value of von-Willebrand factor in patients with liver cirrhosis and its relation to other prognostic indicators

BACKGROUND

Von-Willebrand factor (vWF) disposes certain prognostic value in patients with liver cirrhosis, but its relation to other prognostic indicators has not been fully investigated.

AIM

To analyze the relation between vWF and other prognostic indicators in cirrhotic patients and to evaluate its prognostic value for mortality.

METHODS

This analytic prospective study was carried out in a tertiary center and initially enrolled 71 patients with liver cirrhosis and portal hypertension. It analyzed the relation between vWF and the stage of the disease and several inflammatory and prognostic indicators. The prospective analysis, performed on a sample of 63 patients, evaluated the association between the selected variables [vWF, Model for End-stage Liver Disease (MELD) score, C-reactive protein (CRP), ferritin, vitamin D, activated partial thromboplastin time, thrombin time, D-dimer concentration] and the survival time as well as their predictive value in terms of 3-mo, 6-mo and 1-year mortality.

RESULTS

vWF was significantly higher in patients with higher Child-Turcotte-Pugh class (P = 0.0045), MELD group (P = 0.0057), ferritin group (P = 0.0278), and D-dimer concentration (P = 0.0232). vWF significantly correlated with D-dimer concentration, ferritin, CRP, International Normalized Ratio, and MELD, Child-Turcotte-Pugh, Sequential Organ Failure Assessment, and CLIF-consortium organ failure (CLIF-C OF) scores. vWF, MELD score, and CRP were significantly associated with death and were significant predictors of 3-mo, 6-mo, and 1-year mortality. Each vWF unit significantly increased the probability for 3-mo mortality by 1.005 times (P = 0.008), for 6-mo mortality by 1.006 times (P = 0.005), and for 1-year mortality by 1.007 times (P = 0.002). There was no significant difference between the diagnostic performance of vWF and MELD score and also between vWF and CRP regarding the 3-mo, 6-mo, and 1-year mortality.

CONCLUSION

In patients with liver cirrhosis, vWF is significantly related to other prognostic indicators and is a significant predictor of 3-mo, 6-mo, and 1-year mortality similar to MELD score and CRP.

Post-COVID-19 Liver Injury: Comprehensive Imaging With Multiparametric Ultrasound

OBJECTIVES

This study aimed to define patterns of liver injury after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection using multiparametric ultrasound (mpUS) in a variable patient population with differing severities of COVID-19.

METHODS

Ninety patients were enrolled into the study: 56 had SARS-CoV-2 3-9 months prior to enrolment; 34 served as a clinically healthy control group. All patients underwent an mpUS evaluation of the liver (elastography, dispersion and attenuation imaging). Seventy-six patients had abdominal magnetic resonance (MR) and noncontrast enhanced thoracic computed tomography (CT) scans performed at the same day. All patients were screened for biochemical markers of liver injury.

RESULTS

Liver elasticity, viscosity, and steatosis values were significantly altered in patients after COVID-19, with particularly higher fibrosis scores compared to the control group (P < .001). Increased biochemical markers of liver injury correlated with changes in mpUS (P < .05), but not with findings on CT or MR findings. Seventeen of 34 hospitalized patients had a moderate or severe course of the disease course with more pronounced changes in mpUS. Increased body mass index was found to influence liver injury and correlated with more severe forms of COVID-19 (P < .001).

CONCLUSIONS

COVID-19 can cause liver injury observable using mpUS. More severe forms of COVID-19 and patient obesity are related to increased values of liver damage observed. In comparison to MRI and CT, mpUS appears to be more sensitive to involvement of liver parenchyma. Further research is warranted to establish this promising method for evaluating post-COVID-19 liver involvement in the aftermath of the pandemic.

Prognostic value of albumin-related ratios in HBV-associated decompensated cirrhosis

Background

Identification of effective and accurate prognostic biomarkers for hepatitis B virus‐associated decompensated cirrhosis (HBV‐DeCi) is challenging. This study was designed to determine and compare the prognostic value of albumin‐related ratios (blood urea nitrogen‐to‐albumin ratio [BAR], C‐reactive protein‐to‐albumin ratio [CAR], prothrombin time‐international normalized ratio‐to‐albumin ratio [PTAR], neutrophil count‐to‐albumin ratio [NAR], and D‐dimer‐to‐albumin ratio [DAR]) in HBV‐DeCi patients.

Methods

We retrospectively recruited 161 HBV‐DeCi patients. Receiver operating characteristic curve, DeLong test, and Cox regression analyses were used to estimate and compare the predictive value of these five albumin‐related ratios and Model for End‐Stage Liver Disease (MELD) score.

Results

A total of 29 (18.0%) patients had died 30 days after admission. The prognostic roles of CAR, DAR, PTAR, NAR, and BAR in HBV‐DeCi were different. CAR, PTAR, NAR, and BAR were significantly higher in non‐survivors compared with survivors. However, DAR did not differ between the two groups. The predictive power of BAR was superior to that of the other four albumin‐related biomarkers and similar to that of MELD score. On multivariate analysis, BAR and MELD score were identified as independent prognostic factors, and the combination of BAR and MELD score may improve the prognostic accuracy in HBV‐DeCi.

Conclusion

The present findings suggest that BAR may be a simple and useful prognostic tool to predict mortality in HBV‐DeCi patients.

DIC Score Combined With CLIF-C OF Score Is More Effective in Predicting Prognosis in Patients With Hepatitis B Virus Acute-on-Chronic Liver Failure

Coagulation and fibrinolysis disorders are major prognostic factors in hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) patients. Here, we aimed to clarify the role of disseminated intravascular coagulation (DIC) scores in predicting HBV-ACLF patient prognosis. We assessed the DIC score from HBV-ACLF patients at Huashan Hospital in Shanghai, China from June 2013 to May 2021 and evaluated it in relation to short-term mortality, clinical course, and infection. A novel prognostic scoring model was proposed based on DIC scores. A total of 163 transplant-free HBV-ACLF patients were enrolled. DIC scores were higher in non-survivors than survivors (6 vs. 4, P = 0.000) and were independently associated with short-term mortality [hazard ratio (HR): 1.397, 95% confidence interval (95% CI): 1.040–1.875, P = 0.026]. DIC scores were associated with ACLF grade, clinical course, and infection. Moreover, they were correlated with model for end-stage liver disease (MELD) scores (r = 0.521, P < 0.001). The area under the receiver operating curve (auROC) of CLIF-C OF-DICs [a novel prognostic score based on age, DIC score, and Chronic liver failure-consortium organ function score (CLIF-C OFs)] for 90-day mortality was 0.936, which was higher than six other generic prognostic scoring models. These results were confirmed in a validation cohort (n = 82). In conclusion, elevated DIC score is associated with poor prognosis in HBV-ACLF patients, and can be used jointly with CLIF-C OFs to improve the accuracy of prognosis prediction.

Predictive Role of the D-Dimer Level in Acute Kidney Injury in Living Donor Liver Transplantation: A Retrospective Observational Cohort Study

This study aimed to determine the association between serum D-dimer levels and the risk of acute kidney injury (AKI) in patients undergoing living donor liver transplantation (LDLT). Clinical data of 675 patients undergoing LDLT were retrospectively analyzed. The exclusion criteria included a history of kidney dysfunction, emergency cases, and missing data. The final study population of 617 patients was divided into the normal and high D-dimer groups (cutoff: 0.5 mg/L). After LDLT, 145 patients (23.5%) developed AKI. A high D-dimer level (>0.5 mg/L) was an independent predictor of postoperative development of AKI in the multivariate analysis when combined with diabetes mellitus [DM], platelet count, and hourly urine output. AKI was significantly higher in the high D-dimer group than in the normal D-dimer group (odds ratio [OR], 2.792; 95% confidence interval [CI], 1.227-6.353). Patients with a high D-dimer exhibited a higher incidence of early allograft dysfunction, longer intensive care unit stay, and a higher mortality rate. These results could improve the risk stratification of postoperative AKI development by encouraging the determination of preoperative D-dimer levels in patients undergoing LDLT.

A model integrated fibrinogen and D-dimer for prediction of hepatocellular carcinoma recurrence following liver transplantation: a multicentre study

BACKGROUND

We aimed to investigate whether D-dimer and fibrinogen levels could predict prognosis of patients with hepatocellular carcinoma (HCC) following liver transplantation.

METHODS

From January 2015 to January 2020, we conducted a study on patients with hepatitis B-related liver cancer. Two hundred seventy (270) liver transplant recipients were recruited. Considering D-dimer and plasma fibrinogen levels, a model was established to predict liver cancer recurrence following liver transplantation. Subsequent verification was performed on a validation cohort of 295 recipients from two other hospitals.

RESULTS

Elevated D-dimer and plasma fibrinogen levels demonstrated independent correlation between overall survival and tumour-free survival among patients with HCC who underwent liver transplantation. Those who had preoperative fibrinogen ≥2.27 g/L had significantly reduced overall survival and tumour-free survival than those who had preoperative fibrinogen <2.27 g/L, in the discovery cohort. Recipients with increased risk had preoperative plasma D-dimer ≥2400 µg/L. The model was: Y= logit (P) =0.91* fibrinogen concentration +0.967* D-dimer +0.585* alpha-fetoprotein +1.623* Milan criteria +0.68* microvascular invasion -3.159. At a cut-off score of -1.524, the validation cohort had area under curve values of 0.764 and 0.828 respectively; analysis of this data optimised predictive performance for overall and tumour-free survival.

CONCLUSIONS

For patients who have undergone liver transplantation for HCC, preoperative D-dimer and fibrinogen levels independently predicted key outcomes such as overall survival and tumour-free survival.

Hemostatic parameters predict 90-day mortality in hospitalized cirrhotic patients with acute decompensation: a prospective cohort study

Hemostatic disturbances are common in patients with cirrhosis. Few studies have evaluated the prognostic role of hemostatic parameters in cirrhosis with acute decompensation. This study aims to determine the prognostic ability of standard hemostatic parameters in hospitalized cirrhotic patients with acute decompensation. Cirrhotic patients admitted with acute decompensation were prospectively enrolled. Hemostatic parameters were determined within 24 h, and the DIC (disseminated intravascular coagulation) score was calculated based on platelet count, prothrombin time (PT), fibrinogen, and D-dimer. New onset of in-hospital major bleeding and 90-day mortality were assessed. Eighty-nine patients were included (MELD 13.6 ± 5.7). The indications of admission were infection (38.2%), and portal hypertension-related bleeding (31.5%). 14.6% developed in-hospital major bleeding, and 90-day mortality rate was 21.3%. Major bleeding group and 90-day nonsurvivors had significantly higher activated partial thromboplastin time (aPTT), PT, and DIC score. The 90-day mortality rate was higher in major bleeding group (46.2 vs. 17.1%, P = 0.029). By multivariate logistic regression analysis, DIC score was associated with 90-day mortality. The AUROC of DIC score for 90-day mortality prediction was significantly higher than of MELD score (0.78 vs. 0.59, P = 0.04). DIC score at least 4 predicted 90-day mortality with a sensitivity of 88.9%. The cumulative 90-day survival was significantly lower in patients with DIC score at least 4 (57.2 vs. 93.6%, P = 0.0003). The development of in-hospital major bleeding significantly increases mortality in cirrhotic patients with acute decompensation. The DIC score within 24 h can be used as a simple and reliable predictor for 90-day mortality in these patients.

Long-term follow-up of portal vein thrombosis in an American Cocker Spaniel with lobular dissecting hepatitis: a case report

BACKGROUND

Lobular dissecting hepatitis (LDH) is a rare form of canine liver cirrhosis that may be accompanied by portal hypertension in American Cocker Spaniels. In human patients with liver cirrhosis, portal vein thrombosis (PVT) is a common complication. However, PVT has not been reported in dogs with LDH. Herein, we describe the long-term follow-up of PVT in an American Cocker Spaniel with LDH.

CASE PRESENTATION

An 8-year-old neutered male American Cocker Spaniel presented with a 1-month history of severe abdominal effusion. The dog was histopathologically diagnosed with LDH and treated with low-dose prednisolone on day 14. On day 115, computed tomography angiography (CTA) confirmed the presence of a thrombus in the portal vein. Therefore, the dog was subcutaneously administered with the anticoagulant dalteparin, and low-dose prednisolone was continued. As a follow-up for PVT, CTA examinations were performed on days 207, 515, 886, and 1168, and the dog's antithrombin and D-dimer levels were measured. Following anticoagulant therapy, the dog was confirmed to have gradually increased antithrombin activity and decreased D-dimer concentrations. In addition, although the thrombus was confirmed to be in the same area of the portal vein system by CTA, atrophy and increased CT values due to organization were observed during the follow-up period. The dog's condition remained stable without clinical signs until day 1112 when it developed hepatic encephalopathy. The dog died on day 1208. On postmortem examination, histopathologically, the liver showed marked bile duct hyperplasia and fibrosis with chronic thrombus in the portal vein.

CONCLUSIONS

This case demonstrated that low-dose glucocorticoid combined with dalteparin allowed long-term follow-up of PVT in an American Cocker Spaniel with LDH.

The Interrelationship between Liver Function Test and the Coronavirus Disease 2019: A Systematic Review and Meta-Analysis

Background

The outbreak of the coronavirus disease-2019 (COVID-19) has become a global public health challenge. Assessing the effect of COVID-19 on liver injury is of great importance. A systematic review and meta-analysis were conducted to establish the characteristics of liver function tests in COVID-19 patients.

Methods

A systematic search of publications from December 2019 up to April 2020 in Web of Science, Scopus, and Medline (via PubMed) databases was performed. Both cross-sectional and case series studies reporting an association between liver injury and COVID-19 infection were included. The data were analyzed using the STATA software (version 11.0) and the random-effects model for I2>50% was used to pool the results.

Results

In this meta-analysis, 42 articles comprising a total of 6,557 COVID-19 patients were studied. The prevalence of increase in alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels was 30% and 21% in non-severe patients and 38% and 48% in severe patients, respectively. Patients with severe COVID-19 infection were 4.22, 4.96, and 4.13 times more likely to have elevated AST, ALT, and lactate dehydrogenase (LDH) levels, respectively.

Conclusion

Elevation in liver function tests was higher in patients with severe than non-severe COVID-19 infection. Given the widespread use of drugs that increases the risk of hepatotoxicity, healthcare providers should be aware of changes in liver enzymes in COVID-19 patients. The inclusion of other studies from outside China could confirm the pattern of elevation in liver function tests in COVID-19 patients across the globe. Preprint of this article is available on medRxiv, https://www.medrxiv.org/content/10.1101/2020.05.20.20108357v1.

Chronic Liver Disease Presenting as Immune Hemolytic Anemia: The Challenges of Diagnosis in the Critically Ill in a Resource-Limited Health Care Setting

Immune hemolytic anemia is very rarely associated with chronic liver disease. Diagnosis is often complicated in critically ill patients, where an etiological diagnosis can be elusive, especially in routine health care settings.

A 48-year-old man presented with jaundice for three months. Ultrasonography showed features of chronic liver disease. Fibroscan showed increased parenchymal stiffness suggesting cirrhosis. Investigations revealed immune hemolytic anemia and thrombocytopenia. A percutaneous liver biopsy was not performed due to worsening thrombocytopenia. Isolated protein C deficiency and portal vein thrombosis were noted in subsequent testing. The patient eventually succumbed to illness.

Coagulopathy such as protein C and D-dimer elevation discovered in subsequent rounds of testing may be misleading in rapidly deteriorating patients, emphasizing the need for timely coagulation workup and imaging. Despite comprehensive testing, lack of liver biopsy, as seen herein, may hamper clinical management. Training residents in the skill of transjugular liver biopsy is necessary to manage critical patients at secondary health care facilities.

Acute Clinical Syndromes and Suspicion of SARS-CoV-2 Infection: The Experience of a Single Romanian Center in the Early Pandemic Period

Background and Objectives: During the coronavirus disease 2019 (COVID-19) pandemic, patients with chronic diseases suffering exacerbations have required acute medical care. The purpose of our study was to determine useful criteria for the differentiation of patients with acute clinical syndromes and suspicion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Materials and Methods: This was an observational retrospective study, conducted in an internal medicine clinic from April to May 2020. We collected clinical, biological, and computed tomography (CT) data on patients with exacerbations of chronic diseases and clinical suspicion of SARS-CoV-2 infection. Patients with an already-positive real-time reverse-transcription polymerase chain reaction (RT-PCR) test for SARS-CoV-2 on presentation at the emergency department were excluded from our study. Results: Of 253 suspected cases, 20 were laboratory-confirmed as having SARS-CoV-2 infection by RT-PCR, whereas COVID-19 diagnosis was ruled out in the remaining 233. Venous thromboembolism (VTE) correlated significantly with COVID-19 diagnosis in suspected patients, while laboratory markers were not significantly different between the two groups. Of the suspected patients, significantly higher percentages of dry cough, fever, myalgias, sore throat, loss of smell and appetite, and ground-glass opacities (GGOs) on CT were found in SARS-CoV-2-positive individuals. Conclusions: The study demonstrated that, until receiving the result of an RT-PCR test for SARS-CoV-2 (usually 12-24 h), association with VTE as a comorbidity, fever, dry cough, and myalgia as clinical features, and GGO on CT are the main markers for the identification of COVID-19 patients among those suspected with acute clinical syndromes. Our results also provide evidence for doctors not to rely solely on biological markers in the case of suspected SARS-CoV-2 infection in patients with exacerbations of chronic diseases. These data are useful for faster decision-making with regard to suspected COVID-19 patients before receiving RT-PCR test results, thus avoiding keeping patients in crowded emergency departments.

Thromboelastography maximum amplitude predicts short-term mortality in patients with hepatitis B virus-related acute-on-chronic liver failure

Patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) exhibit complex hemostatic defects. Thromboelastography (TEG) can be used to reveal global hemostasis in patients with liver disease; however, little is known about the association between TEG and the outcome of patients with HBV-related ACLF. The present study aimed to investigate the value of TEG for predicting 90 day mortality in patients with HBV-related ACLF. A total of 51 patients with HBV-related ACLF, 26 patients with chronic hepatitis B (CHB) and 26 healthy controls (HC) were enrolled in the present study. TEG, standard coagulation tests, routine blood tests, biochemical markers and demographic variables were recorded and assessed for prognostic value. The results indicated that a prolonged reaction and kinetics (K) time, a shortened α angle and a decreased maximum amplitude (MA) and coagulation index (CI) were observed in patients with HBV-related ACLF, compared with CHB and HC subjects. Patients with HBV-related ACLF in the mortality group exhibited a decrease in α angle, MA, lysis at 30 min, CI, fibrinogen and platelet count, and an increase in K time, international normalized ratio (INR) and the model for end-stage liver disease (MELD) score in comparison with the survival group. MA and INR were two independent predictors of 90 day mortality in patients with HBV-related ACLF, with hazard ratios of 0.918 (95% CI, 0.867-0.971; P=0.003) and 3.141 (95% CI, 1.843-5.354; P<0.001) respectively. When predicting 90 day mortality, MA + INR exhibited the highest area under the receiver operating characteristic curve, followed by INR, MELD score and MA. Patients with ACLF and MA ≤51.5 mm exhibited a poorer outcome than those with MA >51.5 mm, as revealed via the Kaplan-Meier analysis. In summary, the findings of the present study suggested that TEG MA was associated with 90 day mortality in patients with HBV-related ACLF, and a combination of MA and INR was superior to MA, INR and MELD score in terms of prognostic value.

Evaluation of plasma D-dimer for the diagnosis in Chinese patients with hepatocellular carcinoma: A meta-analysis

BACKGROUND

To evaluate the value of plasma D-dimer levels for the diagnosis of hepatocellular carcinoma (HCC).

METHODS

The following databases were searched for relevant studies published from 1990 to 2018: Wanfang Data, SinoMed, VIP Chinese Science and Technology Periodicals Database, China National Knowledge Infrastructure, Superstar Journals Database, Cochrane library, and PubMed. The studies were selected according to the diagnosis of HCC by plasma D-dimer levels. Quality assessment of the diagnostic accuracy of the studied items was conducted for rigorous quality evaluation of the studies that met the inclusion criteria. After extracting the relevant data, Stata 15.0 software was adopted for the analysis of the diagnostic odds ratio (DOR), sensitivity, specificity, and positive and negative likelihood ratios. A summary receiver operating characteristic (SROC) curve was constructed to comprehensively evaluate the value of plasma D-dimer levels for the diagnosis of HCC.

RESULTS

A total of 6 studies conducted in China with 475 cases in the patient groups and 727 in the control groups were included. The confidence level was expressed as the 95% confidence interval (CI). The pooled sensitivity, specificity, positive and negative likelihood ratios, and DOR of plasma D-dimer levels for the diagnosis of HCC were 0.75 (95% CI = 0.66-0.82), 0.93 (95% CI = 0.86-0.97), 11.4 (95% CI = 5.3-24.5), 0.27 (95% CI = 0.20-0.36), and 42 (95% CI = 19-93), respectively. The area under the SROC curve was 0.88 (95% CI = 0.85-0.91).

CONCLUSIONS

Plasma D-dimer has high sensitivity and specificity, and is expected to be an important plasma marker for the clinical diagnosis of HCC. Due to the limited quality and quantity of the included studies, the above results should be further validated.

Plasma D-dimer as a novel biomarker for predicting poor outcomes in HBV-related decompensated cirrhosis

This study aim was to evaluate whether plasma D-dimer levels could serve as a novel prognostic biomarker for 1-month mortality in patients with HBV-related decompensated cirrhosis (HBV-DeCi).This was a retrospective study that enrolled 132 HBV-DeCi patients. Univariate and multivariate regression models were used to identify risk factors for mortality. The area under the receiver operating characteristic curve was calculated to estimate and compare the predictive values of different prognostic markers.In the present study, the plasma D-dimer levels were higher in the nonsurviving group than in the surviving group. Additionally, the D-dimer level was positively correlated with the model for end-stage liver disease (MELD) score. The results of multivariate analysis showed that both the MELD score and D-dimer level are independent predictors of 1-month mortality in HBV-DeCi patients (both P < .01).Plasma D-dimer can be considered a new additional prognostic marker for 1-month mortality in HBV-DeCi patients.

Plasma D-Dimer Levels are Elevated in Radiation Oncology Patients

D-dimer plasma levels were evaluated to determine whether they are altered by radiation. D-dimer levels were measured in radiation oncology patients, who were diagnosed with prostate, breast or lung cancer, or leukemia, as well as in healthy subjects serving as controls. Blood samples from radiotherapy patients were taken at three different time points: pre-, on- and post-radiotherapy. For the patients, considered together, differences between the D-dimer levels at these three time points compared to controls were statistically significant. Compared to the pre-radiotherapy measurements, radiation exposure was associated with a significant increase in the D-dimer levels at the on- and post-radiotherapy time points. At the post-radiotherapy time point, D-dimer levels in the patients were not significantly reduced compared to the on-radiotherapy levels, indicating that the risk for developing disseminated intravascular coagulation (DIC) may be increased in some radiation oncology patients. Of particular concern are the post-radiotherapy results observed for the D-dimer levels in the leukemia patients, in which the average fold increase in the D-dimer levels was 5.43 (compared to the pre-radiotherapy levels). These results suggest that leukemia patients might benefit from frequent assessment of their D-dimer levels after their total-body irradiation-conditioning regimen to detect early signs of DIC development. It is hoped that the results described here will lead to heightened awareness in the radiation oncology community that the risk of DIC development is greatly increased in some of these patients.

The D-dimer assay

D-dimer is an indirect marker of fibrinolysis and fibrin turnover; this molecule exhibits unique properties as a biological marker of hemostatic abnormalities as well as an indicator of intravascular thrombosis. D-dimer is a soluble fibrin degradation product that results from the systematic degradation of vascular thrombi through the fibrinolytic mechanism. Because of this, the D-dimer serves as a valuable marker of activation of coagulation and fibrinolysis in a number of clinical scenarios. Most commonly, D-dimer has been extensively investigated for excluding the diagnosis of venous thromboembolism (VTE) and is used routinely for this indication. In addition, D-dimer has been evaluated for determining the optimal duration of anticoagulation in VTE patients, for diagnosing and monitoring disseminated intravascular coagulation, and for monitoring other conditions in which the patient is at high risk of bleeding or thrombosis. Limitations of the assay include D-dimer elevation in a constellation of clinical scenarios (age, pregnancy, and cancer) and lack of clinical standardization.

Risk factors associated with portal vein thrombosis in liver cirrhosis: A case-control study

Portal vein thrombosis (PVT) in patients with liver cirrhosis is a common complication associated with adverse outcomes. Aim. To build a predictive model for PVT in cirrhotic patients. Materials and methods. A single centre case-control study was carried out. From the database of 1512 cirrhotic patients 94 with newly diagnosed PVT based on contrast-enhanced computed tomography were referred to the Case group. Malignant PVT was an exclusion criterion. Patients without PVT were stratified and matched according to sex, age and etiology of cirrhosis; case-control ratio was 1 : 3-4. The prevalence of PVT in the database, clinical, laboratory, instrumental parameters of the groups were evaluated. Logistic regression model was used to estimate association between variables and PVT. Results and discussion. The overall prevalence of PVT was 6.2% with the highest rates among the patients with HBV infection - 16.7%, nonalcoholic steatohepatitis - 15.6%, alcohol abuse in combination with HCV infection - 11.7%. The best predictive model included variables: Child-Pugh classes B-C (coefficient of regression β=1.853, р=0.001), ascites (β=0.460, р=0.003), hepatocellular carcinoma without vascular invasion (β=2.126, р=0.0001), endoscopic band ligation (β=0.774, р=0.003), azygoportal disconnection (β=2.734, р=0.001), portal hypertensive gastropathy (β=0.793, р=0.017), portal vein diameter (β=0.203, р=0.004), and local factors - ulcerative colitis flare, Clostridium difficile enterocolitis, spontaneous bacterial peritonitis, colorectal cancer, splenectomy, cholecystectomy (β=2.075, р=0.017). The model had accuracy 85.8% (95% CI 81.7-89.4%), sensitivity - 55.1% (95% CI 43.4-66.4%), specificity - 95% (95% CI 91.6-97.3%), and AUC - 0.871 (95% CI 0.826-0.916). Conclusion. Child-Pugh classes B-C, severe portal hypertension, hepatocellular carcinoma without vascular invasion, and local factors were estimated as risk factors of PVT in cirrhotic patients.

Elevated D-dimer is associated with increased 28-day mortality in acute-on-chronic liver failure in China: a retrospective study

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by profound disrupted coagulation and fibrinolysis. Fibrinolytic marker D-dimer is increased in critically ill patients with cirrhosis which is associated with poorer prognosis. We aim to determine the potential association of D-dimer with the 28-day mortality in ACLF patients.

METHODS

In a single center retrospective study performed in China, we collected data of 115 patients with ACLF from October 1, 2012 to December 31, 2016. We investigated correlations between D-dimer and other laboratory tests and prognostic scores. The relationship between D-dimer and 28-day mortality was explored by smoothing plot with an adjustment for potential confounders. Logistic regression analyses with crude and adjusted models were performed to explore the association of D-dimer with 28-day mortality in ACLF patients.

RESULTS

In ACLF patients, D-dimer at admission was correlated with all prognostic scores (MELD-Na: r = 0.385, P < 0.001; CLIF-C ADs: r = 0.443, P < 0.001; CLIF-C ACLFs: r = 0.375, P < 0.001). A nonlinear relation between D-dimer and 28-day mortality was found with a turning point at 6.5 mg/L FEU. D-dimer level was independently associated with 28-day mortality with an adjusted odds ratio of [1.4 (1.0-1.9), P = 0.030] as continuous variable and [10.3 (1.3, 81.5), P = 0.028] as a classified variable with the cut-off of 6.5 mg/L FEU. An elevated D-dimer within the following 10 days also tended to be associated with higher risk of 28-day mortality [OR: 27.5 (0.9, 814.9), P = 0.055].

CONCLUSIONS

Elevated D-dimer levels was associated with increased risk of 28-day mortality in patients with ACLF in China.

Elevated liver stiffness is linked to increased biomarkers of inflammation and immune activation in HIV/hepatitis C virus-coinfected patients

OBJECTIVES

Immune dysregulation is a hallmark of HIV and hepatitis C virus (HCV) infections. We aimed to evaluate the relationship between liver stiffness measurement (LSM) and biomarkers of T-cell activation, bacterial translocation, inflammation, endothelial dysfunction, and coagulopathy in HIV/HCV-coinfected patients.

DESIGN

Cross-sectional study.

METHODS

We studied 238 HIV/HCV-coinfected patients, 32 healthy controls, and 39 HIV-monoinfected patients. Patients were stratified according to LSM into four groups: less than 12.5, 12.5-25, 25-40, and more than 40 kPa. T-cell subsets were measured using flow cytometry and plasma biomarkers using immunoassays.

RESULTS

HIV/HCV-coinfected patients had higher biomarker levels of immune activation in peripheral blood [T-cell activation (CD4CD38 and CD8CD38), bacterial translocation (soluble CD14), inflammation [IL-1b, IL-6, IL-8, IL-18, IFN-γ-inducible protein 10 (IP-10)] endothelial dysfunction [soluble vascular cell adhesion molecule 1 (sVCAM1), soluble intercellular cell adhesion molecule 1 (sICAM1), and soluble tumor necrosis factor receptor 1 (sTNFR1)], and coagulopathy (plasminogen activator inhibitor-1)] than healthy controls and HIV-monoinfected patients. Moreover, in HIV/HCV-coinfected patients, a direct relationship between LSM and immune activation [T-cell activation (CD8CD38 bacterial translocation (lipopolysaccharide), inflammation (IL-8, IP-10), endothelial dysfunction (sVCAM1, sICAM1, and sTNFR1), and coagulopathy (D-dimer)] was found. Subsequently, patients were stratified into different fibrosis stages, finding that patients with cirrhosis who had LSM at least 40 kPa showed higher biomarker values of immune activation [T-cell activation (CD4CD38 and CD8CD38), bacterial translocation (lipopolysaccharide), inflammation (IL-8, IL-6, IP-10), endothelial dysfunction (sVCAM1, sICAM1, and sTNFR1), and coagulopathy (D-dimer)] than patients from the other three groups (<12.5, 12.5-25, and 25-40 kPa).

CONCLUSION

T-cell activation, bacterial translocation, inflammation, endothelial dysfunction, and coagulopathy increased with the severity of liver fibrosis in HIV/HCV-coinfected patients, particularly in patients who had LSM at least 40 kPa.