Characteristics and outcome of anti-hepatitis D virus positive patients with hepatocellular carcinoma

BACKGROUND & AIMS

Chronic hepatitis D virus (HDV) often leads to end-stage liver disease and hepatocellular carcinoma (HCC). Comprehensive data pertaining to large populations with HDV and HCC are missing, therefore we sought to assess the characteristics, management, and outcome of these patients, comparing them to patients with hepatitis B virus (HBV) infection.

METHODS

We analysed the Italian Liver Cancer database focusing on patients with positivity for HBV surface antigen and anti-HDV antibodies (HBV/HDV, n = 107) and patients with HBV infection alone (n = 588). Clinical and oncological characteristics, treatment, and survival were compared in the two groups.

RESULTS

Patients with HBV/HDV had worse liver function [Model for End-stage Liver Disease score: 11 vs. 9, p < .0001; Child-Turcotte-Pugh score: 7 vs. 5, p < .0001] than patients with HBV. HCC was more frequently diagnosed during surveillance (72.9% vs. 52.4%, p = .0002), and the oncological stage was more frequently Milan-in (67.3% vs. 52.7%, p = .005) in patients with HBV/HDV. Liver transplantation was more frequently performed in HBV/HDV than in HBV patients (36.4% vs. 9.5%), while the opposite was observed for resection (8.4% vs. 20.1%, p < .0001), and in a competing risk analysis, HBV/HDV patients had a higher probability of receiving transplantation, independently of liver function and oncological stage. A trend towards longer survival was observed in patients with HBV/HDV (50.4 vs. 44.4 months, p = .106).

CONCLUSIONS

In patients with HBV/HDV, HCC is diagnosed more frequently during surveillance, resulting in a less advanced cancer stage in patients with more deranged liver function than HBV alone. Patients with HBV/HDV have a heightened benefit from liver transplantation, positively influencing survival.

Sorafenib and Metronomic Capecitabine in Child-Pugh B patients with advanced HCC: A real-life comparison with best supportive care

BACKGROUND AND AIMS

The efficacy of systemic therapy for unresectable advanced hepatocellular carcinoma (aHCC) has not been proven in patients with Child-Pugh (C-P) B cirrhosis. Nevertheless, in real-world these patients are treated both with tyrosine kinase inhibitors (TKIs) and with metronomic capecitabine (MC). This study aimed to compare sorafenib and MC outcomes versus best supportive care (BSC) in C-P B patients.

METHOD

Between 2008 and 2020, among 774 C-P B patients with aHCC not amenable/responsive to locoregional treatments, 410 underwent sorafenib, 62 MC, and 302 BSC. The propensity score matching method was used to correct the baseline unbalanced prognostic factors.

RESULTS

In the unmatched population, median OS was 9.7 months in patients treated with sorafenib, 8.0 with MC, and 3.9 months with BSC. In sorafenib vs. BSC-matched patients (135 couples), median OS was 7.3 (4.9-9.6) vs. 3.9 (2.6-5.2) months (p<0.001). ECOG-Performance Status, tumor size, macrovascular invasion, AFP, treatment-naive, and sorafenib were independent predictors of survival. In MC vs. BSC-matched patients (40 couples), median OS was 9.0 (0.2-17.8) vs.3.0 (2.2-3.8) months (p<0.001). Median OS did not differ (p = 0.283) in sorafenib vs. MC-matched patients (55 couples).

CONCLUSION

C-P B patients with aHCC undergoing BSC have poor survival. Both Sorafenib and MC treatment improve their prognosis.

Predictors of non-transplantable recurrence in hepatocellular carcinoma patients treated with frontline liver resection

BACKGROUND AND AIMS

Hepatocellular carcinoma (HCC) recurrence is common in patients treated with liver resection (LR). In this study, we aimed to evaluate the incidence and preoperative predictors of non-transplantable recurrence in patients with single HCC ≤5 cm treated with frontline LR.

METHODS

From the Italian Liver Cancer (ITA.LI.CA) database, 512 patients receiving frontline LR for single HCC ≤5 cm were retrieved. Incidence and predictors of recurrence beyond Milan criteria (MC) and up-to-seven criteria were compared between patients with HCC <4 and ≥4 cm.

RESULTS

During a median follow-up of 4.2 years, the overall recurrence rate was 55.9%. In the ≥4 cm group, a significantly higher proportion of patients recurred beyond MC at first recurrence (28.9% vs. 14.1%; p < 0.001) and overall (44.4% vs. 25.2%; p < 0.001). Similar results were found considering recurrence beyond up-to-seven criteria. Compared to those with larger tumours, patients with HCC <4 cm had a longer recurrence-free survival and overall survival. HCC size ≥4 cm and high alpha-fetoprotein (AFP) level at the time of LR were independent predictors of recurrence beyond MC (and up-to-seven criteria). In the subgroup of patients with available histologic information (n = 354), microvascular invasion and microsatellite lesions were identified as additional independent risk factors for non-transplantable recurrence.

CONCLUSIONS

Despite the high recurrence rate, LR for single HCC ≤5 cm offers excellent long-term survival. Non-transplantable recurrence is predicted by HCC size and AFP levels, among pre-operatively available variables. High-risk patients could be considered for frontline LT or listed for transplantation even before recurrence.

Can We Slow Down Biological Age Progression? Study Protocol for the proBNPage Reduction (PBAR) Randomized, Double-Blind, Placebo-Controlled Trial (Effects of 4 "Anti-Aging" Food Supplements in Healthy Older Adults)

Purpose

The availability of a simple and reliable marker of biological age might allow an acceleration of the research in the field of longevity extension. Previous studies suggest that this marker might be the N-terminal of B-type natriuretic peptide precursor (NT-proBNP), from which proBNPage, a biological age surrogate, can be calculated. Objectives of the study: 1) To fine-tune the method of proBNPage progression assessment and 2) To establish whether 4 "anti-aging" treatments, which provided promising results in previous studies, can modify proBNPage progression.

Patients and Methods

This is a double-blind randomized placebo-controlled clinical trial on 120 adults aged 65-80 years, free of cardiovascular diseases. Participants will be randomized into 3 groups: A) Coenzyme Q10 100 mg bid + Selenium 100 mcg; B) Resveratrol 350 mg bid + TA-65 (Astragalus Membranaceus extract) 100U; C) Placebo-1 bid + Placebo-2. They will be followed for 2 years and checked 8 times, to assess both proBNPage progression and treatment safety. Secondary variables (handgrip strength, aerobic capacity at the step test and quality of life) will also be assessed. Primary outcome will be the demonstration of significant changes of proBNPage, compared to baseline, in the 3 groups at 6, 12, 18 and 24 months. Secondary outcome will be the demonstration of similar changes of secondary variables. Statistical analyses will be mainly performed by repeated measures ANOVA (both according to intention to treat and per protocol) and paired t tests. The study was approved by the Ethics Committee Area Vasta Emilia Centro, Emilia-Romagna Region, ID: 64/2022/Sper/AOUBo. Trial registration: ClinicalTrials.gov, NCT05500742.

Conclusion

The use of proBNPage as a surrogate of biological age may prove an easy method to select anti-aging treatments worthy of further, more complex assessments.

Landscape of alcohol-related hepatocellular carcinoma in the last 15 years highlights the need to expand surveillance programs

BACKGROUND & AIMS

Alcohol abuse and metabolic disorders are leading causes of hepatocellular carcinoma (HCC) worldwide. Alcohol-related aetiology is associated with a worse prognosis compared with viral agents, because of the lower percentage of patients diagnosed with HCC under routine surveillance and a higher burden of comorbidity in alcohol abusers. This study aimed to describe the evolving clinical scenario of alcohol-related HCC over 15 years (2006-2020) in Italy.

METHODS

Data from the Italian Liver Cancer (ITA.LI.CA) registry were used: 1,391 patients were allocated to three groups based on the year of HCC diagnosis (2006-2010; 2011-2015; 2016-2020). Patient characteristics, HCC treatment, and overall survival were compared among groups. Survival predictors were also investigated.

RESULTS

Approximately 80% of alcohol-related HCCs were classified as cases of metabolic dysfunction-associated fatty liver disease. Throughout the quinquennia, <50% of HCCs were detected by surveillance programmes. The tumour burden at diagnosis was slightly reduced but not enough to change the distribution of the ITA.LI.CA cancer stages. Intra-arterial and targeted systemic therapies increased across quinquennia. A modest improvement in survival was observed in the last quinquennia, particularly after 12 months of patient observation. Cancer stage, HCC treatment, and presence of oesophageal varices were independent predictors of survival.

CONCLUSIONS

In the past 15 years, modest improvements have been obtained in outcomes of alcohol-related HCC, attributed mainly to underuse of surveillance programmes and the consequent low amenability to curative treatments. Metabolic dysfunction-associated fatty liver disease is a widespread condition in alcohol abusers, but its presence did not show a pivotal prognostic role once HCC had developed. Instead, the presence of oesophageal varices, an independent poor prognosticator, should be considered in patient management and refining of prognostic systems.

IMPACT AND IMPLICATIONS

Alcohol abuse is a leading and growing cause of hepatocellular carcinoma (HCC) worldwide and is associated with a worse prognosis compared with other aetiologies. We assessed the evolutionary landscape of alcohol-related HCC over 15 years in Italy. A high cumulative prevalence (78%) of metabolic dysfunction-associated fatty liver disease, with signs of metabolic dysfunction, was observed in HCC patients with unhealthy excessive alcohol consumption. The alcohol + metabolic dysfunction-associated fatty liver disease condition tended to progressively increase over time. A modest improvement in survival occurred over the study period, likely because of the persistent underuse of surveillance programmes and, consequently, the lack of improvement in the cancer stage at diagnosis and the patients' eligibility for curative treatments. Alongside the known prognostic factors for HCC (cancer stage and treatment), the presence of oesophageal varices was an independent predictor of poor survival, suggesting that this clinical feature should be carefully considered in patient management and should be included in prognostic systems/scores for HCC to improve their performance.

Potential feasibility of atezolizumab-bevacizumab therapy in patients with hepatocellular carcinoma treated with tyrosine-kinase inhibitors

BACKGROUND

The combination of atezolizumab-bevacizumab has been proven to be superior to sorafenib for the treatment of unresectable hepatocellular carcinoma not amenable to locoregional treatments, becoming the standard of care of systemic therapy.

AIM

This study aimed at assessing real-world feasibility of atezolizumab-bevacizumab in patients treated with tyrosine-kinase inhibitors.

METHODS

Among 1447 patients treated with tyrosine-kinase inhibitors from January 2010 to December 2020, we assessed the percentage of those potentially eligible to atezolizumab-bevacizumab (according to IMbrave-150 trial criteria), and the overall survival of eligible and non-eligible patients.

RESULTS

422 (29%) patients were qualified for atezolizumab-bevacizumab therapy. The main exclusion causes were Child-Pugh class and Performance Status. Adopting the more permissive inclusion criteria of SHARP trial, 535 patients became eligible. The median overall survival of tyrosine-kinase inhibitors patients was 14.9 months, longer in eligible patients than in their counterpart due to better baseline liver function and oncological features.

CONCLUSION

Real-world data indicate that less than one-third of hepatocellular carcinoma patients treated with tyrosine-kinase inhibitors are potentially eligible to atezolizumab-bevacizumab according to the registration trial criteria. These patients have a longer survival than the non-eligible ones. If the selection criteria of atezolizumab-bevacizumab trial are maintained in clinical practice, tyrosine-kinase inhibitors will remain the most used systemic therapy for hepatocellular carcinoma patients.

Characteristics and survival of patients with primary biliary cholangitis and hepatocellular carcinoma

BACKGROUND

Comprehensive and contemporary data pertaining large populations of patients with Primary Biliary Cholangitis (PBC) and hepatocellular carcinoma (HCC) are missing.

AIM

To describe main characteristics and outcome of PBC patients with HCC diagnosed in the new millennium.

METHODS

Analysing the Italian Liver Cancer registry we identified 80 PBC patients with HCC diagnosed after the year 2000, and described their clinical characteristics, access to treatment and survival.

RESULTS

Median age of patients was 71 years and 50.0% were males. Cirrhosis was present in 86.3% of patients, being well-compensated in 58.0%. Median HCC diameter was smaller in patients under surveillance (2.6 vs 4.0 cm, P = 0.007). Curative treatment, feasible in 50.0% of patients, was associated with improved survival compared to palliative and supportive care (42 vs 33 vs 6 months, P<0.0001). Surveillance was associated with a non-significant improved survival (36 vs 23 months), likely due to similar rate of curative treatment in patients under (51.4%) and outside surveillance (42.6%).

CONCLUSIONS

PBC patients with HCC are often elderly males with well-preserved liver function. Feasibility of curative treatment is high and associated with improved prognosis. Description of these patients may help focus surveillance to identify earlier tumours, increase their curability, and improve prognosis.

Transarterial Chemoembolization for Hepatocellular Carcinoma in Clinical Practice: Temporal Trends and Survival Outcomes of an Iterative Treatment

Background

Transarterial chemoembolization (TACE) is one of the most frequently applied treatments for hepatocellular carcinoma (HCC) worldwide. In this study, we aimed at evaluating whether and how TACE application and repetition, as well as the related outcome, have changed over the last three decades in Italy.

Methods

Data of 7,184 patients with HCC were retrieved from the Italian Liver Cancer (ITA.LI.CA) database. Patients were divided according to the period of diagnosis in six cohorts: P1 (1988–1993), P2 (1994–1998), P3 (1999–2004), P4 (2005–2009), P5 (2010–2014), and P6 (2015–2019). All the analyses were repeated in the overall patient population and in Barcelona Clinic Liver Cancer (BCLC) B patients, who are the subgroup of HCC patients originally supposed to receive TACE according to guidelines. TACE was defined as either the first or the main (more effective) treatment.

Results

The proportion of patients receiving TACE as first or main therapy declined over time, and less than 50% of BCLC B patients were treated with chemoembolization from P3 onward. Conversely, TACE was widely used even outside the intermediate stage. Survival of TACE-treated patients progressively increased from P1 to P6. Although TACE was performed only once in the majority of patients, there was an increasing proportion of those receiving 2 or ≥3 treatments sessions over time. The overall survival (OS) of patients undergoing repeated treatments was significantly higher compared to those managed with a single TACE (median OS 40.0 vs. 65.0 vs. 71.8 months in 1, 2, and ≥3 TACE groups, respectively; p < 0.0001). However, after a first-line TACE, the adoption of curative therapies provided longer survival than repeating TACE (83.0 vs. 42.0 months; p < 0.0001), which in turn was associated with better outcomes compared to systemic therapies or best supportive care (BSC).

Conclusions

Despite a decline in the percentage of treated patients over time, TACE has still an important role in the management of HCC patients. The survival of TACE-treated patients gradually improved over time, probably due to a better patient selection. Iterative TACE is effective, but an upward shift to curative therapies provides better outcomes while transition to systemic therapies and BSC leads to a worse prognosis.

The association of proBNPage with manifestations of age-related cardiovascular, physical, and psychological impairment in community-dwelling older adults

NT-proB-type natriuretic peptide (NT-proBNP) serum concentration can be transformed by simple formulas into proBNPage, a surrogate of biological age strongly associated with chronological age, all-cause mortality, and disease count. This cross-sectional study aimed to assess whether proBNPage is also associated with other manifestations of the aging process in comparison with other variables. The study included 1117 noninstitutionalized older adults (73.1 ± 5.6 years, 537 men). Baseline measurements of serum NT-proBNP, erythrocyte sedimentation rate, hemoglobin, lymphocytes, and creatinine, which have previously been shown to be highly associated with both age and all-cause mortality, were performed. These variables were compared between subjects with and without manifestations of cardiovascular impairment (myocardial infarction (MI), stroke, peripheral artery disease (PAD), arterial revascularizations (AR)), physical impairment (long step test duration (LSTD), walking problems, falls, deficit in one or more activities of daily living), and psychological impairment (poor self-rating of health (PSRH), anxiety/depression, Mini Mental State Examination (MMSE) score < 24). ProBNPage (years) was independently associated (OR, 95% CI) with MI (1.08, 1.07-1.10), stroke (1.02, 1.00-1.05), PAD (1.04, 1.01-1.06), AR (1.06, 1.04-1.08), LSTD (1.03, 1.02-1.04), walking problems (1.02, 1.01-1.03), and PSRH (1.02, 1.01-1.02). For 5 of these 7 associations, the relationship was stronger than that of chronological age. In addition, proBNPage was univariately associated with MMSE score < 24, anxiety/depression, and falls. None of the other variables provided comparable performances. Thus, in addition to the known associations with mortality and disease count, proBNPage is also associated with cardiovascular manifestations as well as noncardiovascular manifestations of the aging process.

Clinical Role of Lung Ultrasound for the Diagnosis and Prognosis of Coronavirus Disease Pneumonia in Elderly Patients: A Pivotal Study

Background

Lung ultrasound (LUS) showed a promising role in the diagnosis and monitoring of patients hospitalized for novel coronavirus disease (COVID-19). However, no data are available on its role in elderly patients.

Aims

The aim of this study was to evaluate the diagnostic and prognostic role of LUS in elderly patients hospitalized for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pneumonia.

Methods

Consecutive elderly patients (age >65 years) hospitalized for COVID-19 were enrolled. Demographics, laboratory, comorbidity, and the clinical features of the patients were collected. All patients underwent LUS on admission to the ward. LUS characteristics have been analyzed. Uni- and multivariate analyses to evaluate predictors for in-hospital death were performed.

Results

Thirty-seven hospitalized elderly patients (19 men) with a diagnosis of SARS-CoV-2 infection were consecutively enrolled. The median age was 82 years (interquartile range 74.5–93.5). Ultrasound alterations were found in all patients enrolled; inhomogeneous interstitial syndrome with spared areas (91.9%) and pleural alterations (100%) were the most frequent findings. At univariate analysis, LUS score (hazard ratio [HR] 1.168, 95% CI 1.049–1.301) and pleural effusions (HR 3.995, 95% CI 1.056–15.110) were associated with in-hospital death. At multivariate analysis, only LUS score (HR 1.168, 95% CI 1.049–1.301) was independelty associated with in-hospital death. The LUS score's best cutoff for distinguishing patients experiencing in-hospital death was 17 (at multivariate analysis LUS score ≥17, HR 4.827, 95% CI 1.452–16.040). In-hospital death was significantly different according to the LUS score cutoff of 17 (p = 0.0046).

Conclusion

LUS could play a role in the diagnosis and prognosis in elderly patients hospitalized for SARS-CoV-2 infection.

Inverse Association Between Neck Pain and All-Cause Mortality in Community-Dwelling Older Adults

Objective

In a previous study, we found an apparent protective effect of neck pain on all-cause mortality in subjects older than age 85 years. The present longitudinal investigation was performed to verify this unexpected finding in a larger sample and to establish its significance.

Design

Population follow-up study.

Setting

Three towns of Northern Italy.

Subjects

We examined 5,253 community-dwelling residents age 65-102 years (55% female).

Methods

Through a postal questionnaire, baseline information was obtained concerning cardiovascular risk factors, self-rated health, physical activity, cardiovascular events, medical therapy, and presence of pain in the main joints. Seven-year all-cause mortality was the end point.

Results

During follow-up, 1,250 people died. After adjustment for age, sex, anti-inflammatory drugs, physical activity, and main risk factors, neck pain was inversely associated with mortality (hazard ratio = 0.74, 95% confidence interval = 0.64-0.86, P < 0.001). This association was present, with high significance, in each of the eight following subgroups: men, women, age 65-74 years, age 75-84 years, age ≥85 years and residents of each of the three towns. The subjects without neck pain (N = 3,158) were older, more often men, less often hypercholesterolemic, less physically active, and had more frequently had a stroke than the subjects with neck pain (N = 2,095). There were no differences in the causes of death between subjects with or without neck pain.

Conclusion

This study has confirmed the existence of an independent inverse association between neck pain and mortality in the elderly, suggesting that reduced sensitivity to neck pain may be a new marker of frailty.

Predictors of cognitive impairment assessed by Mini Mental State Examination in community-dwelling older adults: relevance of the step test

BACKGROUND

Several predictors of cognitive impairment assessed by Mini Mental State Examination (MMSE) have previously been identified. However, which predictors are the most relevant and what is their effect on MMSE categories remains unclear.

METHODS

Cross-sectional and longitudinal study using data from 1116 older adults (72.6 ± 5.6 years, 579 female), 350 of whom were followed for 7 years. At baseline, the following variables were collected: personal data, marital status, occupation, anthropometric measures, risk factors, previous cardiovascular events, self-rated health and physical activity during the last week. Furthermore, routine laboratory tests, abdominal echography and a step test (with measurement of the time needed to ascend and descend two steps 20 times) were performed. The associations of these variables with cross-sectional cognitive deficit (MMSE < 24) and longitudinal cognitive decline (decrease of MMSE score over 7 years of follow-up) were investigated using logistic regression models.

RESULTS

Cross-sectional cognitive deficit was independently associated with school education ≤ 5 years, prolonged step test duration, having been blue collar or housewife (P ≤ 0.0001 for all) and, with lower significance, with advanced age, previous stroke and poor recent physical activity (P < 0.05). Longitudinal cognitive decline was mainly associated with step test duration (P = 0.0001) and diastolic blood pressure (P = 0.0002). The MMSE categories mostly associated with step test duration were orientation, attention, calculation and language, while memory appeared to be poorly or not affected.

CONCLUSIONS

In our cohort of older adults, step test duration was the most relevant predictor of cognitive impairment.

A Case of Acute Liver Failure during Ritonavir-Boosted Paritaprevir, Ombitasvir and Dasabuvir Therapy in a Patient with HCV Genotype 1b Cirrhosis

BACKGROUND

Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir plus Ribavirin is one of the current recommended therapies for HCV genotype 1b monoinfected patients in compensated (Child-Pugh A) cirrhosis. Whether it is known that the worsening of liver function is a rare but possible complication of Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir therapy, to our knowledge no description of treatment-related acute liver failure is available in the literature.

CASE PRESENTATION

An 84-year-old Caucasian man with chronic compensated HCV genotype 1b cirrhosis received Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir plus Ribavirin therapy. After 13 days he developed grade 4 hyperbilirubinaemia and ascites. Even though treatment was promptly stopped, patient's clinical condition worsened, and he underwent hospitalization, several paracentheses, and developed sub-acute kidney injury. The bilirubinemia returned under three times the upper normal limit only after five months. Notably, he achieved sustained virological response despite the very short duration of therapy.

CONCLUSION

Hepatic decompensation and acute liver failure are rare but severe complications of Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir plus Ribavirin therapy in patients with compensated cirrhosis. Close monitoring for signs or symptoms of worsening of liver disease is mandatory, and further research for stratifying risk factors are required.

Usefulness of the MrWALLETS Scoring System to Predict First Diagnosed Atrial Fibrillation in Patients With Ischemic Stroke

Some cryptogenic strokes are caused by undetected paroxysmal atrial fibrillation (AF) and could benefit from oral anticoagulation. In this study, we searched for echocardiographic parameters associated with first diagnosed AF, to form a scoring system for the identification of patients with AF. We examined 571 patients with ischemic stroke (72.7 ± 13.5 years, 50.6% women), subdivided into 4 groups: documented cause without AF, first diagnosed AF, known paroxysmal AF, and permanent AF. All patients underwent transthoracic echocardiography, brain computed tomography scan, carotid/vertebral ultrasound, and continuous electrocardiographic monitoring. Eight factors independently characterized first diagnosed AF and formed the "MrWALLETS" score: mitral regurgitation, mild-to-moderate (+1), white matter lesions (-1), age ≥75 years (+1), left atrium ≥4 cm (+1), cerebral lesion diameter ≥4 cm (+1), left ventricular end-diastolic volume <65 ml (+1), tricuspid regurgitation ≥moderate (+1), carotid stenosis ≥50% (-1). In the patients with ≥3 points, positive predictive value was 80%, specificity 97.5%, and sensitivity 57.1%. In the patients with ≥2 points sensitivity rose to 85.7%, but positive predictive value was 47.1%. The area under the receiver-operating characteristic curve was 0.89 (95% CI 0.83 to 0.95). There were important differences among AF groups, which therefore could not be merged. In conclusion, 4 echocardiographic parameters, 3 additional instrumental parameters, and age allow the identification of stroke patients with first diagnosed AF with high positive predictive value.

A Case of Acute Liver Failure during Ritonavir-Boosted Paritaprevir, Ombitasvir and Dasabuvir Therapy in a Patient with HCV Genotype 1b Cirrhosis

Background: Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir plus Ribavirin is one of the current recommended therapies for HCV genotype 1b monoinfected patients in compensated (Child-Pugh A) cirrhosis. Whether it is known that the worsening of liver function is a rare but possible complication of Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir therapy, to our knowledge no description of treatment-related acute liver failure is available in the literature. Case presentation: An 84-year-old Caucasian man with chronic compensated HCV genotype 1b cirrhosis received Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir plus Ribavirin therapy. After 13 days he developed grade 4 hyperbilirubinaemia and ascites. Even though treatment was promptly stopped, patient’s clinical condition worsened, and he underwent hospitalization, several paracentheses, and developed sub-acute kidney injury. The bilirubinemia returned under three times the upper normal limit only after five months. Notably, he achieved sustained virological response despite the very short duration of therapy. Conclusion: Hepatic decompensation and acute liver failure are rare but severe complications of Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir plus Ribavirin therapy in patients with compensated cirrhosis. Close monitoring for signs or symptoms of worsening of liver disease is mandatory, and further research for stratifying risk factors are required. Abbreviations: 3D: Ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir; AKI: Acute Kidney Injury; ALP: Alkaline phosphatase; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CKD-EPI: Chronic Kidney Disease Epidemiology Collaboration; GGT: gamma-glutamyl transpeptidase; GT1b: Genotype 1b; HCV: Hepatitis C Virus; INR: International Normalized Ratio; MELD: Model for End-Stage Liver Disease; RBV: Ribavirin; UNL: Upper Normal Limit.

Prognostic significance of carotid and vertebral ultrasound in ischemic stroke patients

OBJECTIVES

The ultrasound investigation of carotid and vertebral arteries is routinely performed in stroke patients to determine the etiopathogenetic classification and possible need of revascularization. However, the medium and long-term prognostic implications of carotid and vertebral ultrasound in ischemic stroke patients are not yet known.

METHODS

This study included 309 ischemic stroke patients (mean age 76.3; 160 men). They all had undergone carotid and vertebral ultrasound (carotid stenoses were measured according to the European Carotid Surgery Trial [ECST] method). After a median interval of 9.4 months, a telephone follow-up was performed to determine their outcome. Dependency or death (modified Rankin scale-mRS >2) and all cause mortality were the study end-points.

RESULTS

At follow-up, 158 patients had a mRS >2. In multivariate analysis, of 13 variables univariately predictive of dependency or death, only National Institutes of Health Stroke Scale (NIHSS) score (P < 0.0001), age (P < 0.0001) and ipsi- or contralateral carotid stenosis ≥60% (O.R. 3.5, 95% C.I. 1.5-8.6, P = 0.006) remained associated with a mRS >2. Sixty-nine patients had died. In a Cox proportional hazards regression, of 10 variables univariately predictive of mortality, only NIHSS score (P < 0.0001), age (P = 0.003), total anterior circulation syndrome (P = 0.004), vertebral Doppler abnormalities (O.R. 2.2, 95% C.I. 1.3-3.6, P = 0.006), male sex (P = 0.02), and hypercholesterolemia (P = 0.04, inverse relationship) remained associated with mortality.

CONCLUSIONS

In stroke patients, carotid stenoses ≥60%, ipsi- or contralateral to cerebral lesions, were associated with an increased medium and long-term probability of dependency or death, and abnormalities of vertebrobasilar flow were a significant indicator of death risk, independent of stroke severity and age.

No Direct Survival Effect of Light to Moderate Alcohol Drinking in Community-Dwelling Older Adults

OBJECTIVES

To assess the relationship between light to moderate alcohol consumption and mortality, particularly accounting for baseline health status and physical activity.

DESIGN

Prospective, longitudinal, population-based study.

SETTING

The Pianoro Study, which consisted of community-dwelling older adults in three towns in northern Italy.

PARTICIPANTS

Noninstitutionalized individuals of both sexes aged 65 and older (N = 5,256; 2,318 abstainers, 2,309 light to moderate drinkers (≤2 alcoholic units/d)).

MEASUREMENTS

Baseline information about demographic characteristics, lifestyle factors, physical activity (Physical Activity Scale for the Elderly (PASE)), perceived health status (visual analog scale (VAS)), dependency level, risk factors, and previous cardiovascular events was obtained using a structured questionnaire. Follow-up information was obtained 6 years later from 2,752 survivors, and mortality information was obtained from death certificates.

RESULTS

Male sex, being physically active, and good health status were independently associated with light to moderate drinking (P < .001). An apparent protective effect of light to moderate drinking on mortality was evident in the unadjusted analysis and after adjusting for age, sex, risk factors, and cardiovascular events (adjusted hazard ratio (aHR) = 0.77, 95% confidence interval (CI) = 0.68-0.88, P < .001), but after also adjusting for PASE and VAS, the relationship was no longer significant (aHR = 0.92, 95% CI = 0.80-1.05, P = .19). Follow-up physical activity was associated with baseline alcohol consumption; baseline physical activity did not predict alcohol consumption during follow-up.

CONCLUSION

After accounting for health status and physical activity, light to moderate alcohol drinking had no direct protective effect on mortality.

Changes of liver enzymes and bilirubin during ischemic stroke: mechanisms and possible significance

Background

Small changes of bilirubin and liver enzymes are often detected during the acute phase of stroke, but their origin and significance are still poorly understood.

Methods

On days 0, 3, 7, and 14 after admission, 180 patients with ischemic stroke underwent serial determinations of bilirubin, GOT, GPT, γGT, alkaline phosphatase, C-reactive protein (CRP) and complete blood count. On days 0 and 7 common bile duct diameter was measured by ultrasound, and on day 3 cerebral infarct volume (IV) was calculated from CT scan slices.

Results

During the first week GOT, GPT, γGT (P < 0.001) and CRP (P = 0.03) increased with subsequent plateau, while significant decrements (P < 0.001) concerned unconjugated bilirubin, erythrocytes and haemoglobin. Alkaline phosphatase, direct bilirubin and common bile duct diameter remained stable. IV correlated with CRP, leukocytes, GOT, γGT (r > 0.3, P < 0.001 for all) and direct bilirubin (r = 0.23, P = 0.008). In multivariate analysis only CRP and GOT remained independently associated with IV (P < =0.001). The correlation of IV with GOT increased progressively from admission to day 14. GOT independently correlated with GPT which, in turn, correlated with γGT. γGT was also highly correlated with leukocytes. Unconjugated bilirubin correlated with haemoglobin, which was inversely correlated with CRP.

Conclusions

The changes of bilirubin and liver enzymes during ischemic stroke reflect two phenomena, which are both related to IV: 1) inflammation, with consequent increment of CRP, leukocytes and γGT, and decrease of haemoglobin and unconjugated bilirubin and 2) an unknown signal, independent from inflammation, leading to increasing GOT and GPT levels.

A comparison of risk factors as predictors of cardiovascular and non-cardiovascular mortality in the elderly people--relevance of N-terminal pro-B-type natriuretic peptide and low systolic blood pressure

BACKGROUND

Many risk factors are known to predict ischaemic events and mortality in the elderly people, but their ranking of importance remains uncertain. This study was designed to identify and compare the main predictors of total mortality (TM), cardiovascular mortality (CVM) and non-cardiovascular mortality (NCVM) in older adults.

METHODS

Nine hundred and seventy-nine community resident adults aged ≥ 65 years, free of previous heart failure and cardiovascular events, participated in the study. The univariate and multivariate (Cox regression) relationships of baseline cardiovascular risk factors, treatments and laboratory data with TM, CVM and NCVM were assessed after a median follow up of 6.7 years.

RESULTS

Overall, there were 104 deaths (30 because of CVM and 74 to NCVM). In multivariate analysis, the following factors remained independently associated with mortality: NT pro-B-type natriuretic peptide (NT-proBNP) upper quintile (≥ 237 pg/ml for men, ≥ 280 pg/ml for women): hazard ratio (HR) vs. the rest of the population (95% confidence interval) 2.34 (1.52-3.60), p < 0.001 for TM; HR 5.41 (2.32-12.65), p < 0.001 for CVM; systolic blood pressure lower quintile (≤ 130 mmHg): HR 3.06 (1.80-5.21), p < 0.001 for NCVM; diabetes: HR 2.46 (1.29-4.72), p = 0.007 for NCVM; erythrocyte sedimentation rate (ESR) upper decile (≥ 41 mm/h): HR 2.33 (1.16-4.69), p = 0.02 for NCVM; platelet count lower quintile (≤ 177 × 10(9) /l): HR 2.09 (1.20-3.64), p = 0.009 for NCVM; ever-smoker status: HR 2.08 (1.23-3.52), p = 0.007 for NCVM.

CONCLUSIONS

In elderly community dwellers, NT-proBNP was the strongest predictor of TM and CVM, while especially low systolic blood pressure, together with diabetes, ESR, reduced platelet count and ever-smoker status, were the main predictors of NCVM.

Metabolic syndrome and all-cause mortality in older men and women

BACKGROUND

Prevalence of metabolic syndrome (MetS) increases with age, but its association with all-cause mortality in older persons remains uncertain. This study investigated the association of all-cause mortality with MetS and its individual components in older men and women.

METHODS

A total of 917 men and 1043 women aged 65 years and older from two Italian population-based cohorts were included in the study. MetS was defined according to four different definitions: National Cholesterol Education Program (NCEP), NCEP revised according to the American Heart Association and National Heart Lung Blood Institute (NCEP-R), International Diabetes Organization (IDF) and Joint Interim Statement (JIS). All of these definitions include abdominal obesity, hyperglycaemia, hypertriglyceridaemia, low high-density lipoprotein cholesterol and hypertension. Hazard Ratios (HR) and their corresponding 95% confidence interval (95%CI) estimated from multivariable-adjusted Cox regression models were used to investigate the associations of all-cause mortality with baseline MetS status and individual MetS components.

RESULTS

After 6·5 ± 1·8 years of follow-up, there were 179 deaths among women and 193 among men. Mortality risk was increased in women with MetS by any definition, regardless of individual components, but limited to age 70-79 years (NCEP, HR = 2·02, 95%CI, 1·16-3·53; NCEP-R, HR = 2·51, 95%CI, 1·45-4·34; IDF, HR = 2·16, 95%CI, 1·26-3·72; JIS, HR = 2·16, 95%CI, 1·26-3·72). Mortality risk of men was associated with hypertriglyceridaemia below age 70 years (HR = 2·50, 95%CI, 1·19-5·25), but unrelated to MetS status.

CONCLUSIONS

Metabolic Syndrome is associated with all-cause mortality in older women but not in men. The association, however, is limited to a narrow age range.

Liver hemangioma and vascular liver diseases in patients with systemic lupus erythematosus

AIM: To investigate whether systemic lupus erythematosus (SLE) is associated with benign focal liver lesions and vascular liver diseases, since these have been occasionally reported in SLE patients.

METHODS: Thirty-five consecutive adult patients with SLE and 35 age- and sex-matched healthy controls were evaluated. Hepatic and portal vein patency and presence of focal liver lesions were studied by colour-Doppler ultrasound, computerized tomography and magnetic resonance were used to refine the diagnosis, clinical data of SLE patients were reviewed.

RESULTS: Benign hepatic lesions were common in SLE patients (54% vs 14% controls, P < 0.0001), with hemangioma being the most commonly observed lesion in the two groups. SLE was associated with the presence of single hemangioma [odds ratios (OR) 5.05; 95% confidence interval (CI) 1.91-13.38] and multiple hemangiomas (OR 4.13; 95% CI 1.03-16.55). Multiple hemangiomas were associated with a longer duration of SLE (9.9 ± 6.5 vs 5.5 ± 6.4 years; P = 0.04). Imaging prior to SLE onset was available in 9 patients with SLE and hemangioma, showing absence of lesions in 7/9. The clinical data of our patients suggest that SLE possibly plays a role in the development of hemangioma. In addition, a Budd-Chiari syndrome associated with nodular regenerative hyperplasia (NRH), and a NRH associated with hepatic hemangioma were observed, both in patients hospitalized for abdominal symptoms, suggesting that vascular liver diseases should be specifically investigated in this population.

CONCLUSION: SLE is associated with 5-fold increased odds of liver hemangiomas, suggesting that these might be considered among the hepatic manifestations of SLE.

Chronic endurance exercise training prevents aging-related cognitive decline in healthy older adults: a randomized controlled trial

OBJECTIVE

To evaluate the effects of endurance exercise training (EET) on the cognitive status of healthy community-dwelling older adults.

METHODS

A randomized controlled trial was conducted involving community-dwelling older adults from the town of Pianoro (northern Italy). We randomized 120 healthy subjects aged 65-74 years, both genders, to treatment (N = 60) and control (N = 60) groups. The treatment consisted of 12 months of supervised EET in a community gym, 3 h a week. All participants were assessed both at baseline and after 12 months on an intention-to-treat analysis. Cognitive status was assessed by one single test (Mini Mental State Examination, MMSE). Anthropometric indexes, routine laboratory measurements and C-reactive protein (CRP) were also assessed.

RESULTS

The control group showed a significant decrease in MMSE score (mean difference -1.21, 95% CI -1.83/-0.60, p = 0.0002), which differed significantly (p = 0.02) from the treatment group scores (-0.21, 95% CI -0.79/0.37, p = 0.47). The odds ratio for the treated older adults to have a stable cognitive status after 1 year, as compared to the control group, was 2.74 (95% CI 1.16/6.48) after adjustment for age, gender, educational level and several other possible confounders. Blood pressure, body mass index, waist circumference and serum cholesterol did not differ significantly between the two groups, while CRP decreased only in the treatment group.

CONCLUSIONS

A 12-month EET intervention may reduce the progression of age-related cognitive decline in healthy older adults.

Age dependency of regional impedance indices regardless of clinical stage in patients with cirrhosis of the liver

PURPOSE

To prospectively assess if ageing itself induces modifications of the impedance indices (resistance and pulsatility indexes) of hepatic, splenic, superior mesenteric and renal arteries in patients with liver cirrhosis.

MATERIALS AND METHODS

78 consecutive patients with cirrhosis (41 males, 37 females, Child-Pugh score 7 [range 5 - 12]) were studied by colour-Doppler ultrasound. The resistance index (RI) and pulsatility index (PI) were determined in the main hepatic artery, intraparenchymal branches of hepatic, splenic, and renal arteries, and superior mesenteric artery; clinical data were simultaneously collected. Logistic regression analysis was performed to assess the relative impact of age, severity of liver disease and other relevant variables on the increase of impedance indices. Linear regression analysis was used to identify a coefficient to adjust RIs and PIs to age.

RESULTS

Resistance and pulsatility indices of all the vessels studied except of the superior mesenteric artery showed a direct correlation with age (e. g. splenic artery RI: R = 0.520, p < 0.0001), and correlated most strongly with Child-Pugh score (e. g. right renal artery PI: R = 0.462, p < 0.0001). Age was associated independently with increased PI and RI in hepatic, splenic and renal arterial districts. In these vessels, the RI threshold of normality can be adjusted to the decade of age adding a correction of 0.03.

CONCLUSION

Ageing itself induces an increase of hepatic, splenic and renal impedance indices in cirrhotic patients. The threshold of normality for these indices in cirrhosis should be adjusted according to the patients' age.

Spleen enlargement on follow-up evaluation: a noninvasive predictor of complications of portal hypertension in cirrhosis

BACKGROUND & AIMS

Splenomegaly is observed in most but not all patients with cirrhosis, and has been detected more often in patients showing complications of portal hypertension. We aimed to test the hypotheses that spleen enlarges over time in cirrhosis, and that a progressive enlargement may be associated with portal hypertension-related events.

METHODS

A total of 127 cirrhotic patients (Child-Pugh, 6.7 +/- 1.7; range, 5-11), observed at our center and followed-up clinically, endoscopically, and with periodic abdominal ultrasound for at least 1 year, were included. Spleen diameter was recorded at each ultrasound examination. The change of spleen diameter over time was calculated. The occurrence of clinical complications of cirrhosis on follow-up evaluation was recorded.

RESULTS

At inclusion, spleen diameter was 14.9 +/- 3.1 cm; 83% of the patients had splenomegaly. Spleen was larger in patients with decompensated disease (n = 39) versus patients with compensated disease (n = 88) (16.1 +/- 3.5 vs 14.5 +/- 2.7; P = .012). The mean follow-up period was 53 +/- 37 months. Spleen progressively enlarged over time (analysis of variance, P < .0001). A total of 46.4% of patients showed a spleen enlargement of 1 cm or more at 1 year. Over 5 years of follow-up evaluation patients showing spleen enlargement showed a higher actuarial probability of esophageal varices formation (84.6% vs 16.6%; P = .001) and growth (63.3% vs 20.6%; P = .001). Among patients with compensated cirrhosis at inclusion, those showing a spleen enlargement had a higher actuarial probability of developing the first clinical decompensation of cirrhosis (51.1% vs 19.5%, P = .002).

CONCLUSIONS

Spleen enlargement at follow-up evaluation outlines a subgroup of cirrhotic patients at higher risk of complications of portal hypertension. Noninvasive monitoring of spleen diameter allows a prognostic stratification of cirrhotic patients.

Physical activity is negatively associated with the metabolic syndrome in the elderly

BACKGROUND

An inverse association between physical activity and metabolic syndrome has been reported in several cohorts, but very few specific studies are available in the elderly, in whom neurological and musculo-skeletal diseases are expected to lead to a remarkable age-related decline of physical activity.

AIM AND DESIGN

The relationships among physical activity, insulin resistance and metabolic syndrome were assessed in a cross-sectional study concerning 1144 subjects aged 65-91 years resident in Pianoro (northern Italy). Household and leisure-time activities were assessed by a self-administered questionnaire (Physical Activity Scale for Elderly--PASE). Routine clinical and biochemical data (including fasting insulin) were used to assess insulin resistance [Homeostasis Model Assessment (HOMA) method] and the prevalence of metabolic syndrome.

RESULTS

All PASE scores were inversely correlated with waist circumference, triglycerides and HOMA index, with highest significance for leisure-time activities (P < or = 0.005). The PASE score for household activities was also correlated inversely with blood glucose (P < 0.05), and directly with HDL cholesterol (P < 0.001). In logistic regression analysis, the metabolic syndrome was more prevalent among sedentary subjects (corresponding to the low tertile of leisure-time activities) than in the remaining more active population (odds ratio 1.51, 95% confidence interval 1.12-2.03, P = 0.007), independently of possible confounders.

CONCLUSION

Physical activity is inversely associated with insulin resistance and the metabolic syndrome even in the elderly. Community programs favoring physical activity are expected to significantly improve the health status in these subjects.

Determinants of mean platelet volume (MPV) in an elderly population: relevance of body fat, blood glucose and ischaemic electrocardiographic changes

Mean platelet volume (MPV) is increased in patients with coronary heart disease or at risk for stroke. However, MPV determinants have never been assessed in a population study. The present investigation is a cross-sectional study involving 366 non-selected subjects (both sexes, mean age 72.9 +/- 5.5 [1 SD] years). The main cardiovascular risk factors, several indexes of adiposity (including percent body fat as estimated by skinfold measurement, and ultrasound detection of hepatic steatosis and thickness of abdominal subcutaneous and visceral fat) and ischaemic electrocardiographic (ECG) changes were assessed in all subjects. Platelet parameters were determined by a Bayer ADVIA 120 counter. In addition to being associated directly with platelet distribution width (PDW) and inversely with platelet count (p < 0.0001 for both), MPV values were associated with subcutaneous abdominal fat (p = 0.02), fasting blood glucose (p = 0.002) and the prevalence of ischaemic ECG changes (p = 0.004), and tended to be higher in the subjects with a greater prevalence of hepatic steatosis (p = 0.07) and higher Homeostasis Model Assessment (HOMA) index (p = 0.09). In multiple logistic regression, of the non-platelet parameters only percent body fat (p = 0.006), ischaemic ECG changes (p = 0.01) and blood glucose (p = 0.03) remained independently associated with an MPV < or =8.4 fl (high tertile). The relative risk (odds ratio) of having ischaemic ECG changes for the subjects with MPV < or =8.4 fl was 4.2 (95% confidence interval: 2.5-7.1; p = 0.006) with respect to the subjects with lower MPV values. Blood glucose, percent body fat and ischaemic ECG changes were the main MPV determinants in our elderly population.

New abdominal collaterals at ultrasound: a clue of progression of portal hypertension

BACKGROUND

Abdominal ultrasound can detect non-invasively the presence of abdominal portal-systemic collaterals in patients with liver cirrhosis. Abdominal portal-systemic collaterals may be protective from the formation and growth of oesophageal varices, but available data are inconclusive.

AIM

We aimed at investigating the relationship between abdominal portal-systemic collaterals and variceal formation and growth.

METHODS

We studied 126 cirrhotic patients without (n=43) or with small (n=83) oesophageal varices who entered a protocol of serial ultrasonographic and endoscopic examinations for a median of 55 months. Presence and kind of abdominal portal-systemic collaterals was recorded on first ultrasonography and on each control thereafter.

RESULTS

At inclusion, abdominal portal-systemic collaterals were found in 19/43 patients without varices and in 23/83 patients with small varices (NS). There was no difference in variceal formation and growth between patients with and without abdominal portal-systemic collaterals at inclusion. However, patients developing new abdominal portal-systemic collaterals during follow-up had a significantly higher rate of variceal formation (56.2% vs. 22.2%; p=0.024) and growth (52.9% vs. 30.6%; p=0.041) compared with patients with unchanged ultrasonography.

CONCLUSIONS

Abdominal collaterals are not protective from the formation or growth of oesophageal varices. Conversely, new abdominal portal-systemic collaterals emergence is a non-invasive clue of formation and progression of varices. Therefore, endoscopy is probably indicated whenever new abdominal portal-systemic collaterals are detected in cirrhotic patients.

Serum C3 is a stronger inflammatory marker of insulin resistance than C-reactive protein, leukocyte count, and erythrocyte sedimentation rate: comparison study in an elderly population

OBJECTIVE

This study was performed to ascertain the relative relevance of some inflammatory markers in insulin resistance.

RESEARCH DESIGN AND METHODS

Four inflammatory markers (leukocyte count, erythrocyte sedimentation rate [ESR], high-sensitivity C-reactive protein [CRP], and C3 complement) were assessed as possible determinants of the homeostasis model assessment (HOMA) index, together with the five elements of the metabolic syndrome (National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel III] definition), total cholesterol, physical activity, and four indicators of adiposity (BMI, waist circumference, percent body fat, and hepatic steatosis) in an unselected population of 990 subjects aged 65-91 years (the Pianoro Study).

RESULTS

In univariable analysis, C3, CRP, and leukocyte count, but not ESR, were significantly correlated with HOMA index. In multivariable analysis, C3 remained associated with insulin resistance with the highest partial R(2) value (0.049), independently of all other covariates. The other most significant (P < 0.0001) determinants of HOMA index were total cholesterol (inverse association, R(2) = 0.026), waist circumference (R(2) = 0.023), triglycerides (R(2) = 0.022), and hepatic steatosis (R(2) = 0.021) (R(2) = 0.450 for the whole model). The adjusted relative risks of having the metabolic syndrome for the subjects with inflammatory markers in the high tertile, with respect to those with lower values, were (prevalence ratio [95% CI]): 1.77 (1.41-2.22) for C3, 1.38 (1.12-1.70) for leukocyte count, 1.17 (0.94-1.46) for CRP, and 1.13 (0.91-1.40) for ESR.

CONCLUSIONS

Of the four inflammatory markers simultaneously assessed in our elderly population, only C3 was strongly associated with insulin resistance, independently of the components of the metabolic syndrome and the main indexes of abdominal and general obesity.

Renovascular Impedance Correlates with Portal Pressure in Patients with Liver Cirrhosis

PURPOSE

To prospectively evaluate, in patients with liver cirrhosis, the correlation between the renovascular impedance measured by using color flow and pulsed wave Doppler ultrasonography (US) and the portal pressure measured by using the hepatic venous pressure gradient (HVPG).

MATERIALS AND METHODS

The study was approved by the senior staff committee (comparable to institutional review board) of the university hospital, and written informed consent was obtained from all patients. Thirty-one patients with cirrhosis (22 men, nine women; mean age, 57.6 years +/- 8.8 [standard deviation]) and esophageal varices were consecutively enrolled in the study. Having fasted, the patients underwent color flow and pulsed wave Doppler US of the right interlobar renal artery (RRA) and the left interlobar renal artery (LRA). The resistance index (RI) and pulsatility index (PI) were determined. On the same day, with fluoroscopic guidance, a 5-F balloon-tipped catheter was advanced, via the right basilic vein, into the right hepatic vein; HVPG was calculated as the difference between the wedged and free hepatic pressures. All measurements were performed in triplicate, and permanent tracings were recorded. Correlations were made by using the Pearson test. The positive predictive value of renovascular impedance for detection of severe portal hypertension was determined.

RESULTS

Mean RI and PI values were 0.67 +/- 0.07 and 1.21 +/- 0.25, respectively, for the RRA, and 0.68 +/- 0.07 and 1.24 +/- 0.26, respectively, for the LRA. All patients had portal hypertension (mean HVPG, 19.3 mm Hg +/- 4.7; range, 11.5-33.5 mm Hg). Neither portal pressure nor renal impedance correlated with Child-Pugh score for cirrhosis. Renal artery impedance indexes correlated with the HVPG (for RRA RI: R = 0.424, P = .03; for RRA PI: R = 0.402, P = .04; for LRA RI: R = 0.352, P = .05; for LRA PI: R = 0.393, P = .02). A higher-than-normal renal impedance had a high positive predictive value (RRA RI and PI, 100%; LRA RI, 92%; LRA PI, 84%) for the detection of severe portal hypertension.

CONCLUSION

Renovascular impedance had a direct correlation with HVPG.

Peliosis hepatis as an early histological finding in idiopathic portal hypertension: A case report

Peliosis hepatis is a rare condition characterized by dilatation of hepatic sinusoids and blood-filled spaces in the liver mainly observed in subjects exposed to toxic substances or estrogens, which is frequently asymptomatic. Non-cirrhotic idiopathic portal hypertension (NCIPH) is also a vascular disease of the liver rarely observed in European countries, which is usually diagnosed only when the hemorrhagic complications of portal hypertension occur. We report a case of NCIPH in a young Caucasian male who was diagnosed with liver peliosis, showing ultrasonographic and endoscopic signs of portal hypertension four years after. A second biopsy was diagnostic for NCIPH. Even if the pathogenesis remains obscure, peliosis hepatis can be considered as an early sign of vascular disease of the liver, which may progress to more definite conditions.

Octreotide in the outpatient therapy of cirrhotic chylous ascites: a case report

Chylous ascites is a rare complication of liver cirrhosis associated with a poor short-term prognosis. We report the case of an 80-year-old male cirrhotic patient with refractory chylous ascites associated with portal hypertension. He was treated with total parenteral nutrition but chylous ascites relapsed at suspension. Patient was put on long-term subcutaneous octreotide (100 microg t.i.d.) as an outpatient. The treatment was well tolerated and led to clinical improvement, markedly reducing the need of total paracentesis and the amount of ascites. Octreotide was stopped after 6 months, and massive ascites did not relapse. After 1 year the patient was alive, with no need of paracentesis. Octreotide therapy should be considered in patients with cirrhosis and chylous ascites to simplify the outpatient management of the disease.

Primary prophylaxis with nadolol in cirrhotic patients: Doppler patterns of splanchnic hemodynamics in good and poor responders

BACKGROUND/AIMS

We aimed to characterize by echo-color-Doppler the splanchnic hemodynamics of patients good and poor responders to primary prophylaxis with nadolol.

METHODS

Thirty cirrhotic patients (Child-score 7.0+/-1.8) with medium/large esophageal varices without previous bleedings were consecutively enrolled. At inclusion and after 3 months of treatment with nadolol, they underwent a splanchnic echo-color-Doppler study and a measurement of hepatic venous pressure gradient (HVPG).

RESULTS

Nadolol (60+/-36 mg/day; range 20-160) induced a significant reduction of HVPG (16.6+/-6.1 vs. 19.4+/-4.6 mmHg, P < 0.0001). 13 patients (43.3%) were hemodynamic responders. Responders and Poor-responders had similar baseline clinical characteristics. Poor-responders at baseline were characterized by lower impedance indexes in superior mesenteric artery (SMA) (PI 2.29+/-0.45 vs. 2.74+/-0.46; P = 0.01; RI 0.83+/-0.04 vs. 0.86+/-0.03; P = 0.02), hepatic artery (HA) (PI 1.41+/-0.19 vs. 1.79+/-0.48; P = 0.03; RI 0.71+/-0.05 vs. 0.80+/-0.07; P = 0.02), and splenic artery (SA) (PI 1.18+/-0.27 vs. 1.73+/-0.40; P = 0.01; RI 0.66+/-0.07 vs. 0.73+/-0.09; P = 0.02), and by higher mean flow velocity of HA (52.6+/-21.6 vs. 26.5+/-9.5 cm/s; P = 0.02) and SMA (49.7+/-14.5 vs. 33.9+/-13.1 cm/s; P = 0.06).

CONCLUSIONS

Cirrhotic patients poor-responders to nadolol show a pronounced arterial splanchnic vasodilatation at a baseline echo-color-Doppler study. This can be considered a non-invasive clue for the a priori identification of this subgroup of patients.

Non-cardiac determinants of NT-proBNP levels in the elderly: relevance of haematocrit and hepatic steatosis

BACKGROUND

The levels of B-type natriuretic peptide (BNP), a marker of heart failure, are higher in women and anaemic subjects, and tend to be lower in obese people. These relationships are still largely unexplained and it is unclear whether they also apply to the N-terminal portion of BNP precursor (NT-proBNP).

AIMS

This cross-sectional study was performed to assess general and abdominal obesity, sex and other variables as possible extra-cardiac determinants of NT-proBNP.

METHODS AND RESULTS

A random sample of 713 subjects aged 65-74 years resident of Pianoro (Northern Italy) underwent assessment of NT-proBNP, several haemato-chemical variables, body mass index (BMI), body fat estimation (through skinfold measurement), waist circumference, intra-abdominal thickness and possible presence of hepatic steatosis (by ultrasound examination). An echocardiogram was performed in a subset of 125 subjects. In multivariable analysis NT-proBNP was inversely associated with haematocrit (r=0.22, P<0.0001) and hepatic steatosis (r=0.13, P=0.0001), while no association was found with BMI and body fat estimation. NT-proBNP was higher in women, but this relationship disappeared when haematocrit was included in the multivariable model. The associations with haematocrit and hepatic steatosis were independent from echocardiographic measurements.

CONCLUSION

NT-proBNP is increased in subjects with low haematocrit, which explains the higher values in women. Although NT-proBNP is not affected by general adiposity, low levels of NT-proBNP are associated with hepatic steatosis.

Endothelial dysfunction and cardiovascular risk profile in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is consistently associated with features of the metabolic syndrome, a condition carrying a high risk of cardiovascular events. We measured the vasodilatory response of the brachial artery in response to ischemia (a test of endothelial function) (FMV) as well as cardiovascular risk profile in 52 NAFLD cases and 28 age- and sex-matched controls. The 10-year risk of coronary events was calculated according to the Framingham equation and the scores derived from the PROCAM study and NCEP-ATPIII proposals. FMV was 6.33% +/- 5.93% in NAFLD versus 12.22% +/- 5.05% in controls (P < .0001), and higher in pure fatty liver (9.93%) compared with nonalcoholic steatohepatitis (4.94%) (P = .010). No differences were observed in flow-independent vasodilation (response to sublingual nitroglycerin). Percent FMV was negatively associated with insulin resistance (homeostasis model assessment) in the whole population (r = -0.243; P = .030). In logistic regression analysis, NAFLD was associated with a percent FMV in the lower tertile (OR, 6.7; 95% CI, 1.26-36.1), after adjustment for age, sex, body mass index, and insulin resistance. Among NAFLD patients, low FMV was associated with nonalcoholic steatohepatitis (adjusted OR, 6.8; 95% CI, 1.2-40.2). The 10-year probability of cardiovascular events was moderately increased in NAFLD, and particularly in nonalcoholic steatohepatitis. In conclusion, our study provides evidence of endothelial dysfunction and increased risk of cardiovascular events in NAFLD. The risk of advanced liver disease is well recognized in NAFLD patients, but the large majority of cases might experience cardiovascular disease in the long term, indirectly limiting the burden of liver failure.

Postprandial splanchnic haemodynamic changes in patients with liver cirrhosis and patent paraumbilical vein

OBJECTIVE

The haemodynamic changes induced by a meal on collateral vessels in portal hypertensive cirrhotic patients are not well characterized. We aimed to study the postprandial modifications of splanchnic circulation in patients with a patent paraumbilical vein (PUV).

METHODS

We studied 10 cirrhotic patients with patent PUV and 10 matched cirrhotic patients without PUV, by using echo colour Doppler at baseline and 15, 30 and 45 min after a standard mixed liquid meal (400 ml; 600 kcal). Calibre and blood flow velocities of the superior mesenteric artery, portal vein and PUV were obtained; congestion index of portal vein, portal blood flow, paraumbilical blood flow and effective portal liver perfusion were calculated; intrahepatic and intrasplenic arterial resistance and pulsatility indexes were recorded.

RESULTS

We observed a postprandial splanchnic hyperaemia (superior mesenteric artery and portal vein blood flow increased after the meal in both groups; ANOVA P < 0.05), with no changes of hepatic impedance. In PUV patients, PUV constricted significantly postprandially, maximally at 30 min (calibre -17.5 +/- 7.0%; P = 0.003). Intrasplenic impedance, which may reflect portal pressure, increased, maximally at 30 min (pulsatility index +22.6 +/- 27.0%; P = 0.01), and inversely correlated with PUV vasoconstriction (R = 0.75, P = 0.01). In non-PUV patients intrasplenic impedance did not change. Portal liver perfusion increased similarly in both groups.

CONCLUSIONS

PUV constricts after the meal, and this vasoconstriction is associated with an increase of splenic impedance which may indicate the postprandial increase of portal pressure observed in cirrhosis. The increase in postprandial portal liver perfusion in the PUV group is allowed by a paradox constriction of the collateral vessel.

Splanchnic haemodynamics in non-alcoholic fatty liver disease: effect of a dietary/pharmacological treatment. A pilot study

BACKGROUND

Previous studies demonstrated that in experimental animals fatty liver is associated with reduced hepatic blood flow and that metformin reverses steatosis, while no data were reported in humans.

AIMS

To evaluate the clinical relevance of echo-Doppler measurements and the effects of therapy in non-alcoholic fatty liver disease.

PATIENTS

Twenty patients with biopsy proven non-alcoholic fatty liver disease.

METHODS

Abdominal echo-Doppler examination was performed at enrolment and, in 11 patients, after 6 months of dietary/pharmacological therapy (metformin 500 mg three times a day).

RESULTS

Non-alcoholic fatty liver disease was characterised by hepatomegaly, bright echotexture and posterior attenuation. Mean portal blood velocity and flow were low-normal. Brightness and posterior attenuation significantly correlated with fat score in liver biopsies as well as with the hepatic veins spectrum. After therapy, echotexture improved and liver volume significantly decreased. Portal blood velocity and flow significantly increased, intrahepatic arterial indexes decreased and the spectrum of hepatic veins improved.

CONCLUSIONS

Fatty liver is associated with an impaired hepatic blood flow characterised by increased intrahepatic resistances. Vascular changes are reversed by treatment and can be measured by echo-Doppler which may be useful to evaluate the natural course of non-alcoholic fatty liver disease, and to monitor the putative beneficial effects of therapy.

PERCEPTION OF HEALTH-RELATED QUALITY OF LIFE AND PSYCHOLOGICAL STATUS IN OLDEST HOSPITALIZED PATIENTS WITHOUT COGNITIVE IMPAIRMENT

The most diffuse questionnaires on health-related quality of life (HRQL) and/or psychological status (PS) consider all subjects older than 74 years, for normative reference values, in a single group without any further separation for age decades. Their authors assume that there are no further age-related differences, since older patients had a severely limited autonomy and lose the capacity of grading the severity of the diseases they are affected. Healthy subjects older than 80, without mental impairment (WMI) present an acceptable HRQL, PS and a perception of health status. No data are available on the oldest patients, carrying chronic diseases, admitted to hospital departments for acute health problems.We collected 46 WMI oldest patients (>/= 80 years), admitted for such troubles. They were investigated by the mini mental state examination (MMSE) and, in random order, the Nottingham health profile (NHP) and the psychological general well-being instrument(PGWBI). Clinical data recordings were carried out by the medical personnel, using standardized forms. The value of any individual domain of each patient was compared to the age - (>/=75-year) and sex-matched control group derived from two large Italian population studies, using the Z-score. Charlson's comorbidity index, the index of coexistent disease (ICED), and the cumulative illness rating scale (CIRS) were also calculated. Patients older than 80 did show difference in NHP domains in comparison with normative values only for social isolation, but presented significantly worse Z-scores in all domains ofPGWBI. A relationship was observed between number of daily medications and Z-scores of physical mobility and energy (NHP). Similarly, vitality (PGWBI) correlated with all comorbidity indices, ICED with positive well-being (PGWBI), pain (NHP) with CIRS subscales. Hospitalized WMI oldest subjects maintain a HRQL quite comparable to normative group of subjects older than 74 years. Furthermore, they showed a preserved correct perception of factors/diseases that possibly affect their psychological status and autonomy.

Splanchnic haemodynamics in patients with coeliac disease: effects of a gluten-free diet

BACKGROUND

Coeliac disease is characterized by structural and functional changes in the small bowel which may also result in haemodynamic changes.

AIMS

To establish whether splanchnic haemodynamics can be modified by a gluten-free diet.

PATIENTS

Ten coeliac patients and 10 paired healthy subjects.

METHODS

Echo-Doppler measurements were made of splanchnic vessels both fasting and after a standard meal before and after 9 months of a gluten-free diet.

RESULTS

In comparison to controls, coeliac patients had higher superior mesenteric artery blood velocity and flow, with lower resistance indexes and higher portal vein velocity and flow, particularly 3 h after a meal. Postprandial hyperaemia was reduced and delayed in time. Intrasplenic resistance indexes were also significantly lower both fasting and after a meal. After 9 months of a gluten-free diet, no significant differences were observed between coeliac patients and controls, both fasting and after a meal.

CONCLUSIONS

Splanchnic haemodynamics is significantly changed in coeliac patients, mainly after a meal. On treatment with a gluten-free diet, both fasting and postprandial haemodynamics became normal.

Impact of interferon therapy on the natural history of hepatitis C virus related cirrhosis

BACKGROUND

The role of interferon treatment on the natural history of hepatitis C virus related cirrhosis is under debate.

AIM

To evaluate the effect of interferon on the clinical course of compensated hepatitis C virus related cirrhosis.

PATIENTS AND METHODS

Seventy two cirrhotic patients treated with interferon and 72 untreated controls matched treated patients with for quinquennia of age, sex, and Child-Pugh's score were enrolled in a prospective non-randomised controlled trial. Treated patients received leucocytic interferon alfa, with an escalating schedule for 12 months. The incidence and risk (Cox regression analysis) of clinical complications (hepatocellular carcinoma, ascites, jaundice, variceal bleeding, and encephalopathy) and death were calculated.

RESULTS

Over median follow up periods of 55 months for treated and 58 for untreated subjects, seven and nine patients, respectively, died, and 20 and 32, respectively, developed at least one clinical complication (ns). Hepatocellular carcinoma developed in six treated and 19 untreated patients (p=0.018). Seven treated patients showed sustained aminotranferase normalisation and none died or developed complications. Clinical complications were significantly associated with low albumin, bilirubin, and prothrombin activity while hepatocellular carcinoma was significantly related to no treatment with interferon, oesophageal varices, and high alpha fetoprotein levels. By stratified analysis, the beneficial effect of interferon was statistically evident only in patients with baseline alpha fetoprotein levels > or =20 ng/ml.

CONCLUSIONS

Interferon does not seem to affect overall or event free survival of patients with hepatitis C virus related cirrhosis while it seems to prevent the development of hepatocellular carcinoma. Patients who achieved sustained aminotransferase normalisation survived and did not develop any complications during follow up.

Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index

OBJECTIVE

The best known indicator of risk for first bleeding in patients with cirrhosis without previous bleeding is the index devised by the North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices (NIEC index), which results from the combination of size of esophageal varices, severity of red wale marks, and Child-Pugh class. Its efficiency is far from optimal, and validation studies have reported sensitivities and specificities markedly lower than those reported in the original study. In the present study we analyzed the efficiency of NIEC index in a large series of cirrhotic patients with varices without previous bleeding. In addition, we tried to improve the effectiveness of the index by modifying it, and to validate the modifications in an independent group of patients.

METHODS

A total of 627 patients were enrolled and followed until either a variceal bleeding or for a maximum of 2 yr. During this time, 117 experienced a first variceal

RESULTS

Using Cox's regression analysis, size of varices, severity of red wale marks, and Child-Pugh score were significant and independent predictors of first bleeding, as already noted in the original report of the NIEC group. However, coefficients and standard errors were markedly different, and the importance of size of esophageal varices in the regression was much larger, whereas that of Child-Pugh score was much lower. According to these data, a revised index was developed (Rev-NIEC). Using receiver operating characteristic (ROC) curve analysis, the revised index showed a larger efficiency, and the area under the curve was significantly larger (0.80 +/- 0.02 vs 0.74 +/- 0.02; p < 0.01). In particular, the curve showed that for a specificity of 75%, the new index had a sensitivity of 72% compared to that of 55% of the NIEC index. Validation in an independent sample of 84 patients showed good agreement between predicted and observed risk for bleeding. Validation with the bootstrap technique also showed adequate stability of the results.

CONCLUSIONS

The revised index seems to be superior to the traditional index, and may turn out to be more useful in the selection of patients for different therapeutic procedures and in the stratification of patients in clinical trials.

Natural history of cirrhotic patients with small esophageal varices: a prospective study

OBJECTIVE

Contrasting data are available on the natural history and bleeding risk of small esophageal varices. The aim of this prospective study was to evaluate a large series of consecutive cirrhotics with a first endoscopic diagnosis of small varices.

METHODS

Between 1987 and 1992, 258 patients with small varices and no previous bleeding were enrolled. Patients were clinically examined every 6 months and were followed until a first episode of bleeding and/or death, or until June 1998. None received any treatment to prevent bleeding. Endoscopies were planned at 18-month intervals.

RESULTS

The cumulative risk of bleeding was low (3% at 2 yr and 8% at 4 yr) and remained low in patients in whom varices remained small at 2nd endoscopy, whereas it increased significantly when varices enlarged. The increase of varices appeared to be rather linear in time: at the 2nd endoscopy varices remained small in 79% of patients and increased in 21%; at the 3rd endoscopy varices remained small in 55%, whereas at the 4th 33% of patients still had small varices. Clinical and biochemical data at the 1st and 2nd endoscopy were included in a multiple logistic regression analysis. Only the increase in Child-Pugh score appeared to be a significant predictor of enlarged varices; the risk of aggravation increased by 37.5% for every unit of impairment of the score.

CONCLUSIONS

The present study shows that patients with small varices have a low bleeding risk. An increase in Child-Pugh score during follow-up suggests enlargement of varices, thus an increase in bleeding risk. In these patients closer endoscopic surveillance is recommended.

Prostaglandin E1 infusion and functional hepatic flow in control subjects and in patients with cirrhosis

Metabolic effects of prostaglandin E1 have been previously demonstrated in cirrhosis, apparently independent of changes in large splanchnic vessel hemodynamics. The effects of prostaglandin E1 on functional liver blood flow were tested by measuring the extrarenal clearance of D-sorbitol in six controls and eight patients with cirrhosis during systemic superinfusion of saline or prostaglandin E1 (30 microg/hr), in random order. Doppler ultrasonography of systemic and splanchnic circulation was also performed before the test and at the end of the two study periods. Prostaglandin E1 infusion increased femoral blood flow by nearly 60% in controls and over 30% in cirrhosis, without any effect on mean arterial pressure and heart rate. Mesenteric artery and portal blood flow were unchanged, as were Doppler-measured resistance indices in the liver, spleen and kidney. Sorbitol-assessed functional hepatic flow was 30% lower in cirrhosis, and did not change systematically during prostaglandin E1 infusion. We conclude that prostaglandin E1, at doses able to elicit metabolic effects and changes in systemic hemodynamics, does not affect splanchnic blood flow and/or hepatic microcirculation in normal subjects and in portal-hypertensive patients with cirrhosis.

Total and functional hepatic blood flow decrease in parallel with ageing

OBJECTIVES

To study changes in hepatic blood flow with age.

DESIGN

Functional hepatic flow (FHF) and total hepatic flow (THF) were determined by non-invasive methods in 40 normal subjects in four age groups (<45, 45-60, 61-75 and >75 years). All subjects had normal routine liver function tests and no history of liver disease.

RESULTS

THF was measured by pulsed echo-Doppler, as the sum of portal and hepatic artery blood flow; FHF was measured by the hepatic clearance of D-sorbitol. THF significantly decreased with age, particularly in subjects over 75 (from 1445+/-220 ml/min to 1020+/-148; P<0.001), and a similar reduction was observed in FHF (from 1514+/-250 ml/min to 1015+/-163; P<0.001). THF and FHF were strictly correlated in the whole population (r = 0.871; P<0.001) and both correlated with age (r = -0.510 and r = -0.596; P<0.005).

CONCLUSION

With ageing there is a reduction of hepatic blood flow without any additional intrahepatic shunting.

Transient spontaneous regression of hepatocellular carcinoma

We report on 2 patients with liver cirrhosis and biopsy-proven hepatocellular carcinoma who underwent spontaneous regression. In 1 case the tumor became undetectable at ultrasonography, while, in the other, the liver lesions decreased in size and showed inner calcifications. In both patients, alpha-fetoprotein, which was high at first diagnosis, returned to normal values. After a tumor-free period of 4 years and 17 months, respectively, liver cancer reappeared and patients died from complications. We advance the hypothesis that tumor regression, when it occurs in cirrhotic patients, is always transient, with chronic liver disease being the oncogenic triggering factor.

Effects of systemic prostaglandin E1 on hepatic amino acid-nitrogen metabolism in patients with cirrhosis

Prostaglandins of the E (PGE) series have long been considered "catabolic" hormones, but recent data suggest that they may be secreted in critically ill patients to counteract stress hormones, stimulating protein synthesis. Their use is under scrutiny to improve hepatic microcirculation and as cytoprotective agents. We tested the effects of PGE1 on hepatic and whole-body nitrogen metabolism in eight patients with cirrhosis. Urea-nitrogen synthesis rate, alpha-amino-nitrogen levels, and nitrogen exchange were measured in the basal, postabsorptive state and in response to continuous alanine infusion, in paired experiments, during superinfusion of PGE1 or saline. Splanchnic and systemic hemodynamics were assessed by echo-Doppler at the beginning and at the end of each experiment. PGE1 produced a rapid fall in plasma amino acids and in urea-nitrogen synthesis rate, as well as a positive nitrogen exchange. The slope of the regression of alpha-amino-nitrogen levels on urea-nitrogen synthesis rate, a measure of liver cell metabolic activity, was not affected, but the regression line was shifted rightward, suggesting a nitrogen-sparing effect of PGE1. Mesenteric artery and portal flow were unchanged, whereas femoral artery flow increased by 30%. Insulin and glucagon levels were not systematically different. We conclude that PGE1 reduces hepatic urea synthesis rate, independent of hormones and/or hepatic flow, possibly acting at the peripheral level on amino acid transport, thus reducing amino acid supply to the liver. The resulting net nitrogen sparing might be the basis for the beneficial effect of PGE1 in clinical hepatology.

Effects of systemic prostaglandin E1 on splanchnic and peripheral haemodynamics in control subjects and in patients with cirrhosis

Prostaglandins of the E series showed metabolic and clinical effects in patients with liver disease; changes in splanchnic haemodynamics might be involved. Blood flow in femoral and mesenteric artery and in the portal vein was measured by echo-Doppler in 10 controls and 14 cirrhotic patients, in response to the systemic infusion of a PGE1 analogue (30 micrograms/h for 2-6 h) or saline, performed in random order. Intraparenchymal resistive and pulsatility indices in the liver, spleen and kidney were also measured. In both groups PGE1 increased femoral artery flow by 40%, irrespective of infusion time. Heart rate increased slightly, whereas mean arterial pressure decreased. There were no changes in mesenteric artery and portal vein flow, as well as in resistance indices. Saline infusion increased femoral artery flow by 4%. PGE1 infusion does not produces significant effects on Doppler-assessed splanchnic hemodynamics in controls and in cirrhotic patients, in spite of significant effects on peripheral circulation.

Evaluation of a new endoscopic index to predict first bleeding from the upper gastrointestinal tract in patients with cirrhosis

The aim of this study was to prospectively evaluate the usefulness of the Italian Liver Cirrhosis Project (ILCP) classification of esophageal varices, together with the gastric features of portal hypertension, in predicting the first upper gastrointestinal bleeding in cirrhosis. The efficiency of these endoscopic parameters in predicting bleeding was also compared with the efficiency of the North Italian Endoscopic Club (NIEC) index. Three hundred forty-four cirrhotic patients with esophageal varices but without any previous bleeding were enrolled in the study. The following endoscopic parameters of esophageal varices were recorded: location, size, occupancy, blue tone, and red color signs. Gastric varices were graded as absent or present, while congestive gastropathy was considered as absent, mild to moderate, or severe. All patients were followed until the first upper gastrointestinal bleeding and/or death, or for at least 24 months. No patient received any treatment to prevent bleeding. Sixty-five patients bled from the upper gastrointestinal tract during the study. Univariate analysis showed that all endoscopic parameters were predictors of bleeding. According to multivariate analysis (Cox's model), size, gastric varices and congestive gastropathy were the only independent predictors of bleeding, and the following prognostic index (PI) was developed: PI = (size x 0.0395) + (congestive gastropathy x 0.878) + (gastric varices x 0.705). This index, which was validated using a split-sample technique, and which appears to be superior to the NIEC index in predicting bleeding, may be useful in decision making for primary prophylaxis.