Liver dysfunction is associated with early postoperative complications following revision total shoulder arthroplasty.

Increased preoperative aspartate aminotransferase-to-platelet ratio index predicts complications following total shoulder arthroplasty

Aspartate Aminotransferase-to-Platelet Ratio Index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy which is resource-intensive and invasive. This study investigates the association between various degrees of liver dysfunction based on APRI and 30-day postoperative complications following arthroscopic rotator cuff repair (aRCR). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent aRCR between 2015 and 2021. The study population was divided into four groups based on preoperative APRI: normal/reference (APRI ≤ 0.5), mild fibrosis (0.5 < APRI ≤ 0.7), significant fibrosis (0.7 < APRI ≤ 1), and cirrhosis (APRI > 1). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative APRI and postoperative complications. Compared to normal liver function, mild fibrosis was significantly associated with male gender, lower BMI, American Society of Anesthesiologists (ASA) classification ≥ 3, and comorbid diabetes, hypertension, chronic obstructive pulmonary disease, and bleeding disorders. Significant fibrosis was significantly associated with male gender, greater BMI, ASA classification ≥ 3, and comorbid diabetes, hypertension, and bleeding disorders. Cirrhosis was significantly associated with younger age, ASA classification ≥ 3, smokers, and comorbid diabetes and bleeding disorders. Compared to normal liver function, fibrosis was not associated with complications, significant fibrosis was associated with myocardial infarction, and cirrhosis was associated with major complications, sepsis, non-home discharge, and mortality. However, mild fibrosis, significant fibrosis, and cirrhosis were independently associated with any adverse 30-day postoperative complications following aRCR. Among those with predicted liver damage based on preoperative APRI, 30-day postoperative complications following aRCR were not found to be independently associated with preoperative mild fibrosis, significant fibrosis, or cirrhosis. Our results suggest that APRI predictive of liver dysfunction may be a weaker deterrent to undergoing aRCR compared to other orthopedic surgeries.

This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a simple readily available measure of malnutrition risk, and 30-day postoperative complications following revision total shoulder arthroplasty (TSA). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2022. The study population was divided into three groups based on preoperative GNRI: normal/reference (GNRI > 98), moderate malnutrition (92 ≤ GNRI ≤ 98), and severe malnutrition (GNRI < 92). Logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications. Compared to normal nutrition, moderate malnutrition was not independently associated with postoperative complications. Compared to normal nutrition, severe malnutrition was independently associated with a greater likelihood of experiencing any complication (odds ratio (OR) 3.08, 95% confidence interval (CI) 1.80-5.27; P < 0.001), blood transfusions (OR 3.68, 95% CI 1.40-9.66; P = 0.008), non-home discharge (OR 2.99, 95% CI 1.50-5.98; P = 0.002), and length of stay >2 days (OR 3.10, 95% CI 1.77-5.42; P < 0.001). Severe malnutrition based on GNRI is a predictor of early complications following revision TSA, however moderate malnutrition is not.

PurposeThis study investigates the association between preoperative serum sodium levels and 30-day postoperative complications following aseptic revision total shoulder arthroplasty (TSA).MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent aseptic revision TSA from 2015 to 2022. The study population was divided into two groups based on preoperative serum sodium levels: eunatremia (135–144 mEq/L) and hyponatremia (< 135 mEq/L). Logistic regression analysis was performed to investigate the relationship between hyponatremia and early postoperative complications.ResultsCompared to eunatremia, hyponatremia was independently associated with a significantly greater likelihood of experiencing any complication (odds ratio [OR] 1.65, 95% confidence interval [CI] 1.14–2.40; P = .008), blood transfusions (OR 2.45, 95% CI 1.24–4.83; P = .010), unplanned reoperation (OR 2.27, 95% CI 1.07–4.79; P = .032), and length of stay > 2 days (OR 1.63, 95% CI 1.09–2.45; P = .017).ConclusionHyponatremia was associated with a greater rate of early postoperative complications following noninfectious revision TSA. This study sheds light on the role of preoperative hyponatremia as a risk factor for postoperative complications and may help surgeons better select surgical candidates and improve surgical outcomes in the setting of revision TSA.

Patient outcomes after revision total shoulder arthroplasty in an inpatient vs. outpatient setting.

BackgroundNeoadjuvant chemotherapy (NeoCTx) is performed for most patients with colorectal cancer liver metastases (CRCLM). However, chemotherapy-associated liver injury (CALI) has been associated with poor postoperative outcome. To date, however, no clinically applicable and noninvasive tool exists to assess CALI before liver resection.MethodsRoutine blood parameters were assessed in 339 patients before and after completion of NeoCTx and before surgery. The study assessed the prognostic potential of the aspartate aminotransferase (AST)-to-platelet ratio index (APRI), the albumin-bilirubin grade (ALBI), and their combinations. Furthermore, an independent multi-center validation cohort (n = 161) was included to confirm the findings concerning the prediction of postoperative outcome.ResultsHigher ALBI, APRI, and APRI + ALBI were found in patients with postoperative morbidity (P = 0.001, P = 0.064, P = 0.001, respectively), liver dysfunction (LD) (P = 0.009, P = 0.012, P < 0.001), or mortality (P = 0.037, P = 0.045, P = 0.016), and APRI + ALBI had the highest predictive potential for LD (area under the curve [AUC], 0.695). An increase in APRI + ALBI was observed during NeoCTx (P < 0.001). Patients with longer periods between NeoCTx and surgery showed a greater decrease in APRI + ALBI (P = 0.006) and a trend for decreased CALI at surgery. A cutoff for APRI + ALBI at − 2.46 before surgery was found to identify patients with CALI (P = 0.002) and patients at risk for a prolonged hospital stay (P = 0.001), intensive care (P < 0.001), morbidity (P < 0.001), LD (P < 0.001), and mortality (P = 0.021). Importantly, the study was able to confirm the predictive potential of APRI + ALBI for postoperative LD and mortality in a multicenter validation cohort.ConclusionDetermination of APRI + ALBI before surgery enables identification of high-risk patients for liver resection. The combined score seems to dynamically reflect CALI. Thus, APRI + ALBI could be a clinically relevant tool for optimizing timing of surgery in CRCLM patients after NeoCTx.

There is limited data on the effect of antiviral therapies on clinical outcomes in HIV and hepatitis B virus (HBV)-infected individuals in sub-Saharan Africa. Single center, prospective longitudinal cohort study at Management and Development for Health supported HIV Care and Treatment clinics in Dar es Salaam, Tanzania. Between April 2014 and December 2015, HIV-infected, HBV-infected and HIV/HBV-coinfected, treatment naïve, Tanzanian adults more than 18 years of age were eligible for enrollment and followed for 10-18 months after initiating antivirals. All HIV-infected and HIV/HBV-coinfected participants received tenofovir, lamivudine and efavirenz; HBV-infected participants received lamivudine. Multivariate regression models were constructed to identify factors associated with mortality in HIV-infected and HIV/HBV-coinfected participants. A total of 265 HIV-infected, 165 HBV-infected and 64 HIV/HBV-coinfected participants were analyzed. At baseline, HBV-infected participants were younger and had a higher BMI than HIV-infected and HIV/HBV-coinfected participants. After a median of 371 (interquartile range 50) days on treatment, there were 40 deaths. Mortality was significantly higher among HIV/HBV-coinfected participants compared with HIV and HBV-infected participants [HIV/HBV-coinfected 12 of 64 (19%) vs. HIV-infected 26 of 265 (10%) and HBV-infected two of 265 (1%), P < 0.01]. High baseline HIV RNA and low hemoglobin levels, but not HBV coinfection were independently associated with early mortality in multivariate analyses of HIV-infected participants. High rates of early mortality were observed after treatment initiation in HIV/HBV-coinfected individuals compared with participants with HIV or HBV alone, despite robust aspartate aminotransferase to platelet ratio index declines and high rates of virologic suppression. HIV rather than HBV-related factors are more important contributors to mortality in these individuals.

Introduction: The aspartate aminotransferase to platelet ratio index (APRI) has been used as a noninvasive marker to identify patients with cirrhosis. Cirrhotic patients are known to have significant mortality from bleeding. We sought to examine if cirrhosis, as defined as an APRI >1, would be associated with outcomes from spontaneous subarachnoid hemorrhage (SAH). Methods: We reviewed prospectively collected data on patients presenting with spontaneous SAH to a single academic institution between January 2013 and March 2015. Patients with SAH due to trauma, primary intracerebral hemorrhage, arteriovenous malformation, or other underlying mass lesion were excluded. Patients were divided into two groups based on APRI >1 or APRI < 1. Demographic, clinical, radiologic, and oucome data was compared between the two groups. Results: 110 patients were included in the analysis, 100 with APRI < 1 and 10 with APRI >1. 76 patients (69%) had an aneurysm identified on angiogram, 24 patients (22%) were angiogram negative for aneurysm, and 10 patients (9%) did not undergo angiography (unknown presence of aneurysm). Baseline age, gender, and Fisher score were similar between the two groups. The APRI >1 group had a higher rate of Hunt and Hess (HH) grade 5 SAH (40%) compared with the APRI < 1 group (11%; p=0.04). The APRI >1 also had significantly lower platelet counts (169±55 vs. 238±86; p=0.003), higher ALT (87±49 vs. 25±13; p=0.003), and higher AST (130±95 vs. 25±13.3; p=0.007). Regarding outcomes, patients with an APRI >1 had significantly higher in-hospital mortality (40%) than patients with APRI < 1 (11%; p=0.02). Median length of stay was found to be shorter in the APRI >1 group (10 vs. 12 days; p=0.05). Patients who died while in the hospital had a significantly higher mean APRI (1.1±1.7) than survivors (0.37±0.37; p < 0.001). Conclusion: Cirrhosis as defined by APRI is associated with higher HH grade and increased mortality after spontaneous SAH. It is possible that cirrhosis, as defined by APRI >1, predisposes patients to higher grade SAH. Further studies are needed to understand the relationship between APRI and SAH outcomes, as APRI may be beneficial for risk stratification in patients with SAH.

Liver function abnormalities have been reported in patients with Turner syndrome (TS); however, the pathophysiological mechanisms have not been well elucidated. Low-grade inflammation has been associated with metabolic dysfunction-associated steatotic liver disease. We studied systemic inflammatory indices [aspartate transaminase to lymphocyte ratio index (ALRI), aspartate transaminase to platelet ratio index (APRI), gamma-glutamyl transferase to platelet ratio (GPR), neutrophil-lymphocyte-ratio (NLR), and platelet lymphocyte ratio and examined their associations with the hepatic abnormalities observed in these subjects. We performed a retrospective analysis of the medical records of 79 patients with TS (mean age 32.5 ± 9.2 SD years) who were treated at the University Hospital of Nancy. Using matched-pair analyses based on age and body mass index (BMI), we compared 66 patients with TS (25.6 ± 7.3 years; BMI 25.9 ± 6.3 kg/m2) to 66 healthy control participants (24.7 ± 6.8 years; BMI 26 ± 6.7 kg/m2). Liver function abnormalities were present in 57% of the patients with TS. The ALRI, APRI, GPR, and NLR were significantly greater in patients with TS who presented with liver dysfunction than in patients with TS who had normal liver function. According to the matched-pair analyses, the ALRI, APRI, and GPR were greater in patients with TS than in healthy control participants. Logistic regression revealed that a diagnosis of TS was significantly associated with ALRI, APRI, and GPR and liver dysfunction. Noninvasive inflammatory indices (ALRI, APRI, and GPR) might be a promising indicators of liver dysfunction in patients with TS. Future prospective studies are needed to confirm our findings and to explore the clinical significance and prognostic value of systemic inflammatory indices in Turner syndrome.

BackgroundThis study investigates the association between preoperative leukopenia and leukocytosis with 30-day postoperative complications following noninfectious revision total shoulder arthroplasty (TSA).MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent noninfectious revision TSA from 2015 to 2022. The study population was divided into three groups based on preoperative white blood cell (WBC) count: normal (WBC 4500–11,000), leukopenia (WBC ≤ 4500), and leukocytosis (WBC ≥ 11,000). Logistic regression analysis was conducted to investigate the relationship between WBC count and postoperative complications.ResultsCompared to normal WBC counts, leukocytosis was independently associated with an increased likelihood of experiencing any complication (OR 1.71, 95% CI 1.13–2.59; P = 0.012), sepsis (OR 5.31, 95% CI 1.38–20.37; P = 0.015), non-home discharge (OR 2.18, 95% CI 1.18–4.05; P = 0.013), readmission (OR 2.76, 95% CI 1.36–5.63; P = 0.005), and LOS > 2 days (OR 1.68, 95% CI 1.06–2.66; P = 0.028). Compared to normal WBC counts, leukopenia was independently associated with an increased likelihood of experiencing pneumonia (OR 14.98, 95% CI 2.32–96.56; P = 0.004) and readmission (OR 2.78, 95% CI 1.49–5.17; P = 0.001).ConclusionThe present study identified preoperative leukocytosis and leukopenia as independent risk factors for 30-day postoperative complications following revision TSA. Integrating WBC count into preoperative assessments can enhance the identification of patients at risk for postoperative complications, allowing for more tailored management strategies and potentially improving overall patient outcomes.

Racial and socioeconomic disparities in risk and reason for revision total shoulder arthroplasty.

Background The aspartate aminotransferase-to-platelet ratio index (APRI) is an effective non-invasive marker for chronic liver dysfunction. Given that heat stroke patients often suffer from poor prognosis due to multi-organ involvement, with liver injury and coagulation dysfunction being of particular concern, this study aims to investigate whether APRI can comprehensively reflect liver injury and coagulation dysfunction in heat stroke patients and explore its relationship with 28-day mortality. Methods This retrospective study analysed electronic medical records from patients treated at 57 grade A tertiary hospitals in China from May 2005 to May 2024. The primary outcome was 28-day mortality, and the secondary outcome was 7-day mortality. Restricted cubic splines (RCS) were utilized to visualize the relationship between APRI and 28-day mortality risk. The independent association between APRI and outcomes was assessed using Cox proportional hazards models, with multivariable analyses controlling for confounding factors. The predictive ability of APRI for outcomes was evaluated using receiver operating characteristic (ROC) curves. Results A total of 450 eligible patients were included, with 71 deaths occurring within 28 days. RCS analysis showed a positive correlation between APRI and 28-day mortality. Participants were divided into higher (APRI ≥ 15.14) and lower (APRI < 15.14) APRI groups. Cox proportional hazards models indicated that individuals with higher APRI had a significantly increased 28-day mortality rate (HR 5.322, 95% confidence interval [CI] 2.642-10.720, p < 0.0001). Subgroup and interaction analyses confirmed the robustness of the core findings. Additionally, the areas under the ROC (AUROC) for APRI predicting 28-day mortality was 0.823 (95% CI 0.772–0.875), significantly higher than the AST to ALT ratio (0.526, 95% CI 0.448–0.605) and total bilirubin (0.694, 95% CI 0.623–0.765). Conclusion APRI is an independent predictor of early mortality risk in heat stroke.

Objective To evaluate the prevalence and risk factors of progressive liver fibrosis in patients with non-alcoholic fatty liver disease (NAFLD). Methods A total of 2 054 subjects who underwent health check up and were diagnosed as NAFLD in 9 institutions were included in the study. Blood routine and biochemical findings were collected to calculate aspartate aminotransferase-to-platelet ratio index (APRI). Subjects were divided into three groups according to diagnostic threshold of liver fibrosis: APRI<0.43 group, APRI 0.43-0.53 group and APRI≥0.54 group. The correlation between APRI and biochemical variables was analyzed, and the risk factors of progressive fibrosis were also analyzed. Results Among 2 054 subjects (male/female 1 598/456) there were 61 cases with APRI≥0.98 (2.97%, progressive fibrosis), 318 with APRI≥0.54 (15.48%), 1 475 with APRI<0.43 (71.81%), 261 with APRI 0.43-0.53 (12.71%). Logistic stepwise regression analysis showed that TG(P=0.002, OR=1.095, 95%CI : 1.033-1.161), 2 hPG(P=0.000, OR=1.103, 95%CI : 1.058-1.151, BUN(P=0.034, OR=1.215, 95%CI: 1.014-1.454) were risk factors, and HDL-C(P=0.034, OR=0.353, 95%CI: 0.135-0.924) was a protective factor for the progression of fibrosis. Conclusion The progressive fibrosis in patients with NAFLD is closely associated to blood glucose and lipid metabolism disorder. Key words: Fatty liver; Diagnosis; Aspartate aminotransferase-to-platelet ratio index; Fibrosis

Dear Editor, In chronic liver diseases, the management of patients must include a determination of the stage of fibrosis (to select specific therapies), a prognosis, the prevention of complications, and the surveillance of the disease. Over the past several years, significant progress has been made in improving noninvasive methods of assessing liver fibrosis. The risks of liver biopsy and the potential for sampling errors with regard to fibrosis staging support the use of noninvasive modalities including serum fibrosis markers or scores and elastography. The first are classified as direct (representing components of the extracellular matrix) or indirect (reflecting hepatic inflammation and function) and included in panels for clinical use. They include patented (i.e., Fibrotest, Fibrometer) and nonpatented (ASL/ALT ratio, APRI, FIB-4, Forns, ELF, Hepascore) tests. The majority of studies has involved patients with chronic HCV infection. Direct and indirect methods have demonstrated good to excellent performance in detecting significant disease (≥ F2) and cirrhosis (F4) [1]. Transient elastography (Fibroscan®), which measures liver stiffness, has excellent accuracy in detecting cirrhosis (F4) in chronic liver diseases [2]. The APRI (AST-to-platelet count ratio) is the most simple and cheapest indirect marker of inflammation and fibrosis [3]. Its diagnostic performance in detecting advanced fibrosis has been evaluated extensively [4], showing low sensitivity (41%), low negative predictive values (64%), good specificity (95%) and high positive predictive values (88%). In a study, a group of Turkish investigators presented their experience with the APRI in patients with chronic liver disease [5]. In a retrospective series of 455 patients (207 with HBV, 108 with HCV, and 140 with NAFLD) the low value [1] median Metavir fibrosis score with median values for APRI were reported 0.46, 0.49 and 0.43 respectively in the HBV, HCV and NAFLD groups. AUROC values for the detection of fibrosis (1 to 4) versus no fibrosis (F0) were 0.58, 0.54, and 0.62, respectively, in the 3 groups. Dr. Yilmaz and his team concluded that the APRI has acceptable accuracy in assessing liver fibrosis in patients with HCV and NAFLD but not in those with HBV. There are several drawbacks and flaws in this report that render its message unrealistic and erroneous. It was a retrospective series, without validation in an independent series, with 3 categories of etiologies, each comprising a limited number of patients. It was not a consecutive series, and the indication for liver biopsy was not mentioned, preventing the results from being applicable to other clinicians throughout the world. Furthermore, it is difficult to understand the basis for the diagnosis of NAFLD: US detection of steatosis ≥ 1 and absence of other causes of liver disease. The main weaknesses of this study were that a poor marker was chosen and the use of a non-pertinent clinical endpoint (i.e., presence or of fibrosis not) in place of significant fibrosis (≥ F2) and cirrhosis (≥ F4) or advanced (≥ F3) fibrosis. Thus, it is not surprising that the APRI performed poorly, with AUROCs largely inferior to the minimal value of 80%, well accepted by the medical community [6]. Even Dr. Alberti's group in Italy [7], which has great experience with the APRI, admits that this test alone has poor and variable performance, even in the identification of cirrhosis (AUROCs from 0.61 to 0.94 and 0.69 to 0.88 for significant [i.e. ≥ F2] fibrosis) when used alone. They propose a model, called Sequential Algorithm for Fibrosis Evaluation = safe biopsy algorithm, in which APRI is used first, after which Fibrotest® is used as the second-line test in the setting of HCV and HBV, effecting 47% and 82% spared liver biopsies in significant fibrosis and cirrhosis, respectively. Our group also has experience with the APRI, and we sought to compare, independently from the promoters, its diagnostic accuracy using AUROCs for the prediction of significant, advanced, and cirrhosis in HCV and other etiologies. Fibrotest was the most effective, followed by FIB-4, FORNS, APRI, and Fibroindex, in order of decreasing accuracy. In the global series and the HCV series, the AUROCs of the APRI were 0.73 and 0.74 for the diagnosis of significant fibrosis, reinforcing the observation that the minimal cut-off of 80% was not reached. In conclusion, the APRI alone is inappropriate for use in assessing liver fibrosis.

To the Editor—As described in their letter, Post and Sabin found that an elevated aspartate aminotransferase-to-platelet ratio index (APRI) was predictive of all-cause mortality in a large cohort of individuals infected with human immunodeficiency virus (HIV) [1]. Notably, high APRI were associated with mortality among patients coinfected with HIV and hepatitis virus and among patients monoinfected with HIV. Interestingly, as in our study, the researchers found a relatively high prevalence (7%) of APRI consistent with significant fibrosis among HIV-monoinfected subjects, and they observed an association between higher APRI and both high HIV RNA levels and lower CD4+ T-cell counts [2]. Their finding of an increased risk of all-cause mortality among subjects with an elevated APRI is intriguing and deserves further study. We are interested in knowing the causes of death among the subjects who died and whether the causes of death were similar for people with high APRI and those with low APRI. The APRI has been found to be predictive of all-cause and liver-related mortality in cohorts of individuals with HIV and viral hepatitis coinfection [3, 4]. However, until now, the association between APRI and mortality among HIV-monoinfected subjects had not been evaluated. Thus, Post and Sabin have verified our findings of high APRI in HIV-monoinfected subjects and have found that these high values predict all-cause mortality. Further work is needed to understand the reasons for elevated APRI in the setting of HIV monoinfection, to determine whether an elevated APRI reflects liver disease stage, and to determine the influence of highly active antiretroviral therapy on APRI.