Child-Turcotte-Pugh Score Research Articles

Impact of Severity of Chronic Liver Disease on Health-Related Economics

Background: Chronic liver disease (CLD) is one of the leading causes of morbidity and mortality worldwide. It is accountable for a multifaceted disease encumbrance upsetting the psychological, physical, and economic health of not only the patients but also their caregivers. Objectives: The study purposes to cover the economic aspect of CLD to comprehend the financial burden imposed on the patients. Methods: This cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan. The CLD patients presenting in gastroenterology clinics were recruited, and their socio-demographic, financial, and disease-related information including Model for End-stage Liver Disease (MELD) score and Child Turcotte Pugh (CTP) scores were collected. Out of 190 CLD patients enrolled, 127 (67.2%) were males. The mean age was 50.09 years. Variables assessed include self-perceived social/economic status, self-perception of disease responsibility for worsening of social/economic situation, the impact of the disease on economic status due to medical expense, the impact of economic status on treatment compliance due to medical expenses, impact of severity of disease on socioeconomic status and treatment compliance, and impact of gender on disease status and treatment compliance. Results: Regardless of the disease duration, CLD significantly impacted a patient’s life, as 81% and 69% of the patients blamed their disease responsible for the worsening of social and economic conditions, respectively. In our study, 85% of patients had consumed all savings during their course of illness, and 67% had to borrow money for medical expenses. Nearly half of the patients had to leave or cut short their medicines, skip the physician's appointment, or defer their children's education. One-third of patients had unpaid medical and utility bills or even skipped their meals. The severity of disease affected the socioeconomic status significantly (89% in CTP class C vs. 40% in CTP class A). Patients with worsening socioeconomic status had significantly higher MELD scores as compared to those with stable socioeconomic status. Conclusions: Chronic liver disease imposes incredible socioeconomic encumbrance on patients and the family unit, and CLD associated expenditures influence the family unit’s everyday working and therapeutic compliance, which is directly linked to the severity of disease expressed in terms of CTP and MELD scores.

Changes in thyroid function in patients with liver failure and their clinical significance: A clinical study of non-thyroidal illness syndrome in patients with liver failure

BackgroundNon-thyroidal illness syndrome (NTIS) develops in a large proportion of critically ill patients and is associated with high risk for death. We aimed to investigate the correlation between NTIS and liver failure, and the short-term mortality of patients with these conditions. MethodsThe clinical data of 87 patients with liver failure were collected retrospectively, 73 of them were randomly selected for an observational study and to establish prognostic models, and 14 for model validation. Another 73 sex- and age-matched patients with mild chronic hepatitis were randomly selected as a control group. Serum free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) were measured. The clinical characteristics of patients with liver failure and NTIS were analyzed. The follow-up of patients lasted for 3 months. Additionally, the values for predicting short-term mortality of model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP), chronic liver failure-sequential organ failure assessment (CLIF-SOFA) scores, FT3-MELD model, and FT3 were evaluated. ResultsThe observation group had significantly lower FT3 (2.79 ± 0.71 vs. 4.43 ± 0.75 pmol/L, P < 0.001) and TSH [0.618 (0.186-1.185) vs. 1.800 (1.570-2.590) mIU/L, P < 0.001], and higher FT4 (19.51 ± 6.26 vs. 14.47 ± 2.19 pmol/L, P < 0.001) than the control group. NTIS was diagnosed in 49 of the patients with liver failure (67.12%). In the observation group, patients with NTIS had a higher mortality rate than those without (63.27% vs. 25.00%, P = 0.002). Across the whole cohort, the 3-month mortality was 50.68%. The international normalized ratios (INR) were 2.40 ± 1.41 in survivors and 3.53 ± 1.81 in deaths (P = 0.004), the creatinine (Cr) concentrations were 73.27 ± 36.94 µmol/L and 117.08 ± 87.98 µmol/L (P = 0.008), the FT3 concentrations were 3.13 ± 0.59 pmol/L and 2.47 ± 0.68 pmol/L (P < 0.001), the MELD scores were 22.19 ± 6.64 and 29.57 ± 7.99 (P < 0.001), the CTP scores were 10.67 ± 1.53 and 11.78 ± 1.25 (P = 0.001), and the CLIF-SOFA scores were 8.42 ± 1.68 and 10.16 ± 2.03 (P < 0.001), respectively. FT3 was negatively correlated with MELD score (r = −0.430, P < 0.001). An FT3-MELD model was established by subjecting FT3 concentration and MELD score to logistic regression analysis using the following formula: Logit(P) = −1.337 × FT3+0.114 × MELD+0.880. The area under the receiver operating characteristic (ROC) curve was 0.827 and the optimal cut-off value was 0.4523. The corresponding sensitivity and specificity were 67.6% and 91.7%. The areas under the ROC curve for FT3 concentration, MELD score, CTP score, and CLIF-SOFA score were 0.809, 0.779, 0.699, and 0.737, respectively. ConclusionsPatients with liver failure often develop NTIS. FT3-MELD score perform better than CTP and CLIF-SOFA scores in predicting mortality in patients with liver failure. Thus, the FT3-MELD model could be of great value for the evaluation of the short-term mortality of such patients.

The role of ALBI and IGF-CTP score in refining prognostication of HCC.

e16659 Background: Child-Turcotte-Pugh (CTP) score is widely used in the assessment of prognosis of HCC and CTP-A is the standard criterion for active therapy and clinical trials entry. Recently, ALBI and insulin-like growth factor-1 (IGF)-CTP scores have been reported to improve survival prediction over CTP score. However, comparative studies to compare both scores and to integrate IGF into Albi score are lacking. Methods: After institutional board approval, data and samples were prospectively collected. 299 HCC patients who had data to generate both IGF-CPG and Albi index were used. The ALBI index, and IGF score were calculated, Cox proportional hazards models were fitted to evaluation the association between overall survival (OS) and CTP, IGF-CTP, Albi and IGF, albumin, bilirubin. Harrell’s Concordance index (C-index) was calculated to evaluate the ability of the three score system to predict overall survival. And the U-statistics was used to compare the performance of prediction of OS between the score system. Results: OS association with CTP, IGF-CTP and Albi was performed (Table). IGF-CTP B was associated with a higher risk of death than A (HR = 1.6087, 95% CI: 1.2039, 2.1497, p = 0.0013), ALBI grade 2 was also associated with a higher risk of death than 1 (HR = 2.2817, 95% CI: 1.7255, 3.0172, p &lt; 0.0001). IGF-1(analyzed as categorical variable) was independently associated with OS after adjusting for the effects of ALBI grade. Which showed IGF-1 ≤26 was significantly associated with poor OS, P = 0.001. Conclusions: Although ALBI grade and IGF-CTP score in this analysis had similar prognostic values in most cases, their benefits might be heterogenous in some specific conditions. We looked into corporation of IGF-1 into ALBI grade, IGF score with cutoff ≤26 which clearly refined OS prediction and better OS stratification of ALBI-grade.

Lipid Profile in Relation to Severity of Liver Diseases

Background: Liver cirrhosis is a life-threatening condition. It is very prevalent in Egypt. Lipids are stored and metabolized in the liver. Liver cirrhosis has an essential influence on the lipid profile. Objectives: Evaluation of the lipid profile via assessing triglyceride (TG), total cholesterol, very low-density lipoprotein, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) in cirrhotic patients and define its relationship to Child score. Patients and methods: This cross-sectional study was carried out in the Internal Medicine Department outpatient clinic, Zagazig University Hospital, Egypt. Ninety patients with liver cirrhosis were enrolled in the study. Fasting lipid profile was done. Comparison of the lipid profile in different Child classes in cirrhotic was done. Results: Total cholesterol, HDL, LDL, VLDL, and TG were compared in different childturcotte-pugh (CTP) classes. The data was analyzed on SPSS 21. Results showed significantly low levels of total cholesterol, HDL, LDL as the CTP class advances and also lower levels as compared with the control group. However, a statistically non-significant decrease in TG was observed. Conclusion: Total cholesterol, HDL, and LDL levels are significantly reduced in patients who develop liver cirrhosis and levels further decrease as the CTP classadvances. Keywords: CTP score, lipid profile,

Platelet count is closely associated with the severity of liver injury in patients with chronic hepatitis B virus infection: A cross-sectional study.

Although the platelet count may provide clues regarding the severity of liver disease, there are currently no available data supporting the utility of the platelet count to evaluate the degree of liver injury in patients with chronic hepatitis B virus (HBV) infection. The present study aimed to determine the association between the platelet count and the severity of liver injury in patients with chronic HBV infection. A total of 941 patients were included and were stratified into a Child-Turcotte-Pugh (CTP) class A group and a CTP class B/C group using the CTP scoring system. A total of 53 patients underwent liver biopsy. The pathological stage F4 was defined as cirrhosis based on the METAVIR scoring system. Compared with that in patients with CTP class A, the platelet count in patients with CTP class B/C was lower (P<0.001). Similarly, for patients with normal alanine aminotransferase (ALT) levels, the platelet count was significantly different between the CTP class B/C and A groups (P<0.001). The platelet count was inversely correlated with the CTP score (r=-0.420, P<0.001) and independently associated with CTP grade B/C [odds ratio (OR), 0.994; 95% CI, 0.990-0.999; P=0.009]. The area under the receiver operating characteristic curve (AUC) of the platelet count to distinguish CTP grade B/C from A was 0.712 and 0.791, respectively, in all patients with HBV infection and the subset with normal ALT levels. In addition, compared to patients with chronic hepatitis B, patients with cirrhosis had a lower platelet count and higher aspartate transaminase-to-platelet ratio index (APRI) and fibrosis index based on four factors (FIB-4) (P<0.001). The platelet count was inversely correlated with FIB-4 (r=-0.855, P<0.001) and APRI (r=-0.741, P<0.001). The AUC for the platelet count to distinguish cirrhosis from chronic hepatitis B was 0.927 (sensitivity, 78.76%; specificity, 92.22%). Among patients who underwent liver biopsy, the platelet count in those with F4 was lower compared with that in patients with ≤F3 (P=0.013). The platelet count was inversely correlated with the pathological stage (r=-0.295, P=0.032) and was independently associated with F4 (OR, 0.978; 95% CI, 0.960-0.997; P=0.026). The AUC of the platelet count to distinguish F4 from patients with ≤F3 was 0.761. In conclusion, the platelet count may be used as a non-invasive marker to assess the severity of liver injury and of liver fibrosis in patients with chronic HBV infection.

The Predictive Scoring Systems for Outcomes of Heart Transplantation in Patients with Pre-Existing Liver Cirrhosis

There are few data assessing factors and clinical outcomes in patients with liver cirrhosis for heart transplantation. The aim of this study was to compare the Model for End-Stage Liver Disease (MELD) score, the MELD-XI score and Child-Turcotte-Pugh (CTP) score risk prediction in cirrhotic patients undergoing heart transplantation. Between 1994 and 2018, forty-nine consecutive patients (19 men and 30 women, median age 46 years, range 12-68 years) had liver cirrhosis, among 170 patients underwent heart transplantations in our institution. Potential preoperative predictors of outcomes, as well as preoperative MELD score, MELD-XI score and CTP classification were calculated. Causes of heart failure were dilated cardiomyopathy in 26, ischemic disease in 7, congenital heart disease in 6 and valvular heart disease 7 patients. Cause of liver cirrhosis was majority of cardiac origin, except hepatitis in two and alcoholism in one patient. The median follow-up duration was 45.2 months. The MELD score (p=0.010) and MELD-XI score (p=<0.001) were significantly differed between survivors and non-survivors. Cox regression analysis showed high MELD score (HR 1.211; 95% CI, 1.059-1.386; p=0.005), MELD-XI score (HR, 1.184; 95% CI, 1.042-1.345; p=0.010) and CTP score (HR, 1.694; 95% CI, 1.040-2.760; p=0.034) were associated with the risk of all-cause mortality. Receiver operating characteristic (ROC) curve analysis revealed the optimal cut-off value of MELD, MELD-XI and CTP score was 12.2, 12.0 and 7.5, respectively (sensitivity: 69.2 vs. 61.5 vs. 69.2%, specificity 68.6 vs. 60.0 vs. 62.9%) for all-cause mortality (AUC: 0.745 vs. 0.690, 0.729). The patients with advanced heart failure and liver cirrhosis were high mortality and morbidity of heart transplantation. However, these scoring systems can be a tool to risk-stratification for liver cirrhotic patients undergoing heart transplantation.

Platelet-albumin-bilirubin score - a predictor of outcome of acute variceal bleeding in patients with cirrhosis.

BACKGROUNDThe albumin-bilirubin (ALBI) score was validated as a prognostic indicator in patients with liver disease and hepatocellular carcinoma. Incorporating platelet count in the platelet-albumin-bilirubin (PALBI) score improved validity in predicting outcome of patients undergoing resection and ablation.AIMTo evaluate the PALBI score in predicting outcome of acute variceal bleeding in patients with cirrhosis.METHODSThe data of 1517 patients with cirrhosis presenting with variceal bleeding were analyzed. Child Turcotte Pugh (CTP) class, Model of End-stage Liver Disease (MELD), ALBI and PALBI scores were calculated on admission, and were correlated to the outcome of variceal bleeding. Areas under the receiving-operator characteristic curve (AUROC) were calculated for survival and rebleeding.RESULTSMean age was 52.6 years; 1176 were male (77.5%), 69 CTP-A (4.5%), 434 CTP-B (29.2%), 1014 CTP-C (66.8%); 306 PALBI-1 (20.2%), 285 PALBI-2 (18.8%), and 926 PALBI-3 (61.1%). Three hundred and thirty-two patients died during hospitalization (21.9%). Bleeding-related mortality occurred in 11% of CTP-B, 28% of CTP-C, in 21.8% of PALBI-2 and 34.4% of PALBI-3 patients. The AUROC for predicting survival of acute variceal bleeding was 0.668, 0.689, 0.803 and 0.871 for CTP, MELD, ALBI and PALBI scores, respectively. For predicting rebleeding the AUROC was 0.681, 0.74, 0.766 and 0.794 for CTP, MELD, ALBI and PALBI scores, respectively.CONCLUSIONPALBI score on admission is a good prognostic indicator for patients with acute variceal bleeding and predicts early mortality and rebleeding.

Lymphocyte-To-Monocyte Ratio as the Best Simple Predictor of Bacterial Infection in Patients with Liver Cirrhosis.

Background and aim: The aim of this study was to assess the diagnostic performance of new morphology-related indices and Child–Turcotte–Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores during hospitalization in predicting the onset of bacterial infection in patients with liver cirrhosis. Material and methods: A total of 171 patients (56.9% males; median age 59 years; total number of hospitalizations 209) with liver cirrhosis were included in this observational study. The diagnosis of cirrhosis was made on the basis of clinical, biochemical, ultrasonic, histological, and endoscopic findings. The neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), modified aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), Fibrosis-4 index (FIB-4), platelet-to-lymphocyte ratio (PLR), neutrophil-to-monocyte ratio (NMR), and CTP and MELD scores were calculated for the cases of patients with cirrhosis. Results: Bacterial infection was diagnosed in 60 of the 209 (28.7%) hospitalizations of patients with cirrhosis. The most common infections were urinary tract infection (UTI), followed by pneumonia and sepsis. The more severe the liver failure, the greater the bacterial infection prevalence and mortality. Patients with decompensated liver cirrhosis were infected more often than subjects with compensated cirrhosis (50.0% vs. 12.9%, p = 0.003). The calculated MELD score, CTP, NLR, LMR, AAR, monocyte count, and C-reactive protein (CRP) concentration were also related to the bacterial infection prevalence, and mortality areas under the curve (AUC) were 0.629, 0.687, 0.606, 0.715, 0.610, 0.648, and 0.685, respectively. The combined model with two variables (LMR and CTP) had the best AUC of 0.757. The most common bacteria isolated from patients with UTI were Escherichia coli, Enterococcus faecalis, and Klebsiella pneumonia. Gram-negative bacteria were also responsible for spontaneous bacterial peritonitis (SBP), and together with gram-positive streptococci and staphylococci, these microorganisms were isolated from blood cultures of patients with sepsis. Significant differences were found between CTP classification, MELD score, NLR, LMR, AAR, CRP, and PLR in patients with cirrhosis with, or without, bacterial infection. Conclusions: Bacterial infection prevalence is relatively high in patients with liver cirrhosis. Although all analyzed scores, including the LMR, NLR, aspartate aminotransferase (AST)/alanine aminotransferase (ALT), CRP, CTP, and MELD, allowed the prediction of bacterial occurrence, the LMR had the highest clinical utility, according to the area under the curve (AUC) and odds ratio (OR).

Predictive value of insulin-like growth factor 1-Child-Turcotte-Pugh score for mortality in patients with decompensated cirrhosis

BackgroundPrevious studies have used a modified version of the Child-Turcotte-Pugh (CTP) score to include insulin-like growth factor 1 (IGF-1) concentrations, denoted the Insulin-like Growth Factor 1-Child-Turcotte-Pugh (IGF-CTP) system. We evaluated the predictive power of IGF-CTP for 1-year mortality in patients with decompensated cirrhosis (DC). MethodsA total of 386 patients with DC were retrospectively analyzed. Comparison of distribution of patients with decompensated cirrhosis according to Insulin-like Growth Factor-1-Child-Turcotte-Pugh and Child-Turcotte-Pugh scores were performed. Area under the receiver operating characteristic curves (AUROCs) for IGF-CTP, CTP and the Model for End-stage Liver Disease (MELD) scores were evaluated to compare predictive value. Univariate and multivariate analyses were carried out to determine potential risk factors for 1-y mortality. ResultsDuring the 1-y follow-up, 94 patients died. Significantly more patients (both surviving and non-surviving) were classified as IGF-CTP stage C than CTP stage C. The AUROC of IGF-CTP was significantly higher than that of CTP and MELD in the training and validation cohorts. Multivariate analysis indicated IGF-CTP score and IGF-1 to be independently associated with mortality. ConclusionThe IGF-CTP score is independently associated with mortality for patients with DC, and offers more accurate prediction of 1-y mortality than either CTP or MELD score for these patients.

Intractable hepatic encephalopathy in cirrhotic patients: mid-term efficacy of balloon-occluded retrograde portosystemic shunt obliteration.

To evaluate the efficacy and intermediate-term outcome of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hepatic encephalopathy (HE) secondary to portosystemic shunt (PSS) in cirrhotic patients. Institutional review board (IRB) approval was obtained for this study and hospital records of patients who underwent BRTO, from August 2011 to August 2015, were analyzed. Based on the inclusion and exclusion criteria, 39 patients (age, 54.07 ± 9.1years (37-67years); 33 males and 6 females) with cirrhosis and spontaneous PSS were included. Clinical and laboratory parameters and HE grade were evaluated in all patients before and after the procedure. Forty sessions of BRTO were attempted in 39 patients. Follow-up imaging revealed complete obliteration of the treated PSS in all patients with clinical success in 37 patients (94.9%). The 1-, 2-, 3-, 4-, 5-, 6-, and 7-year HE-free survival rates among responders were 91.7%, 91.7%, 88.8%, 85.5%, 80.8%, 80.8%, and 80.8% respectively and overall survival rates were 89.7%, 82.1%, 76.9%, 74.4%, 74.4%, 64.8%, and 64.8% respectively. Logistic regression highlighted Child-Turcotte-Pugh (CTP) score at 6months as a positive predictive factor of HE recurrence with a cutoff of ≥ 9. Five patients (12.8%) had fever and leukocytosis and 1 (2.6%) patient developed spontaneous bacterial peritonitis after the procedure. BRTO is an effective treatment for refractory HE in cirrhotics secondary to large PSS with a few possible complications. • BRTO is an effective and safe treatment for refractory HE, arising from PSS in cirrhotic patients. • Patients with preserved liver function show better outcome and CTP score is the most important predictor of relapse during follow-up.

The significance of C-reactive protein to albumin ratio in patients with decompensated cirrhosis.

BackgroundPrognostic indicators in patients with decompensated cirrhosis are vital for the estimation of death risk. The ratio of C-reactive protein to albumin (CAR) has been verified as a prognostic marker in patients with hepatocellular carcinoma and decompensated cirrhosis related to hepatitis B virus. Neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and gamma globulins have been separately studied in cirrhosis. We evaluated the predictive role of CAR and other inflammatory markers in decompensated patients.MethodsWe prospectively studied 159 patients with stable decompensated cirrhosis, calculating the following indexes: CAR, NLR, LMR, Child-Turcotte-Pugh (CTP), and model for end-stage liver disease (MELD).ResultsMELD (area under the curve [AUC] 0.814) and CTP score (AUC 0.752) were superior to the other markers above in predicting patients’ mortality (P<0.05). Patients with CAR<2.17 (median value) presented better times of survival: 20 months (12-27) vs. 14 months (10-17) (log rank P=0.015). NLR and LMR barely discriminated patients’ prognosis. In multivariate analysis, only MELD and CTP scores were significant risk factors, whether using the proposed cutoff of 1.3 (hazard ratio [HR] 1.17 [1.106-2.44], P<0.001) or the median 2.17 CAR categorical variable (HR 1.17 [1.104-1.243], P<0.001). When patients who underwent liver transplantation were excluded, apart from the MELD and CTP scores CAR 2.17 was the only significant factor associated with the outcome (HR 3.61 [0.96-13.6], P=0.05) and detected different survival times: 10 (1-48) vs. 11 (2-38) months, log rank P=0.003. Patients with LMR≥1.9 presented significantly better renal function, in terms of true glomerular filtration rate (80±34 vs. 64±33 mL/min, P=0.004) and creatinine levels: 0.84 (0.1-1.8) vs. 0.98 (0.59-3.3) mg/dL (P=0.001).ConclusionOur findings demonstrate the significance of CAR and LMR in the outcome and renal function of decompensated patients.

Hepatocellular Carcinoma (HCC), Where do we stand? Current situation.

Objective:To identify the stage of Hepatocellular Carcinoma (HCC) at the time of presentation.Methods:This cross sectional observational prospective study was carried out at Gastro Department of Combined Military Hospital (CMH) Multan from August 2017 to December 2018. Patients were diagnosed on the basis of alpha fetoprotein, abdominal ultrasound, triphasic contrast enhanced computerized tomography (CECT). They were evaluated for etiology including Hepatitis B, C and non B & C. The patients were inquired about the previous treatment and when they came to know about the HCC. Staging of the tumor was done on the basis BCLC (Barcelona cancer liver clinic) and Melan’s criteria. Performance status (PS) of the patient was checked by Eastern Cooperative Oncology Group (ECOG) criteria. Severity of cirrhosis was assessed by CTP (Child Turcotte Pugh) and Model for end stage liver disease (MELD) score. The data was analyzed in IBM SPSS version 22.Results:Out of 135 patients 78% were males and 22% females. Age Mean SD was 58.81± 9.366. Frequency of hepatitis C, B, combined B, C and non-B non-C was 80%, 11%, 2.8% and 6.2% respectively. 96(73.8%) never got the treatment before for Hepatitis. 81(62.3%) came to know first time on this index admission. Maximum numbers of patients were in BCLC stage B i.e. 82(55.2%) with ECOG grade of one i.e.57 (39.3%), at the time of presentation. Mean MELD and CTP score were 12.24, 7.34 (class B) respectively.Conclusion:HCV was the most common in HCC, never treated before, presented for the first time in advance stage of the disease where very limited treatment options left behind.

Non-invasive assessment of liver fibrosis in alcoholic liver disease.

Aim of the studyTo assess the severity of fibrosis in patients with alcoholic liver disease (ALD) by a non-invasive method (transient elastography – TE).Material and methodsA cross sectional study was conducted on 130 cases of ALD over a period of 2 years. Upper gastrointestinal (GI) endoscopy and transient elastography were done. Liver fibrosis was staged with the METAVIR system and severity of fibrosis was correlated with complications, duration of alcohol abuse, aspartate transaminase (AST) to platelet ratio index (APRI) and Child-Turcotte-Pugh (CTP) score. To establish the relationship between various parameters, Spearman’s correlation coefficient (r) and their associated probability (p) were used.ResultsDistribution in 130 patients according to the METAVIR stage (median liver stiffness measurement [LSM]) was: F0: n = 16 (5.08 kPa); F1: n = 19 (6.6 kPa); F2: n = 9 (9.3 kPa); F3: n = 26 (16.3 kPa) and F4: n = 60 (50.5 kPa) (p < 0.0001). Liver stiffness measurement (LSM) score was significantly correlated with CTP score (r = 0.492, p < 0.0001), APRI (r = 0.435, p < 0.0001), duration of alcohol consumption (r = 0.816, p < 0.0001), presence of ascites (r = 0.756, p < 0.0001), presence of esophageal varices (r = 0.567, p < 0.0001), and presence of variceal bleeding (r = 0.383, p < 0.0001).ConclusionsTE is an inexpensive and non-invasive modality to assess the severity of liver fibrosis in ALD. It can be used as a good screening tool to identify patients with cirrhosis without the use of invasive liver biopsy, enabling better prognostication for the development of complications.

Portal hypertensive gastropathy is associated with iron deficiency anemia.

SummaryBackground and aimsPortal hypertensive gastropathy (PHG) is common in patients with cirrhosis and may cause bleeding. This study systematically explored the independent impact of patient characteristics, portal hypertension and hepatic dysfunction on PHG severity and associated anemia.MethodsPatients with cirrhosis undergoing endoscopy were included in this retrospective analysis and PHG was endoscopically graded as absent, mild or severe. Clinical and laboratory parameters and hepatic venous pressure gradient (HVPG) were assessed with respect to an association with severity of PHG.ResultsA total of 110 patients (mean age: 57 years, 69% male) with mostly alcoholic liver disease (49%) or viral hepatitis (30%) were included: 15 (13.6%) patients had no PHG, 59 (53.6%) had mild PHG, and 36 (32.7%) had severe PHG. Severe PHG was significantly associated with male sex (83.3% vs. 62.2% in no or mild PHG; p = 0.024) and higher Child-Turcotte-Pugh (CTP) stage (CTP-C: 38.9% vs. 27.0% in no or mild PHG; p = 0.030), while MELD was similar (p = 0.253). Patients with severe PHG had significantly lower hemoglobin values (11.2 ± 0.4 g/dL vs. 12.4 ± 0.2 g/dL; p = 0.008) and a higher prevalence of iron-deficiency anemia (IDA: 48.5% vs. 26.9%; p = 0.032). Interestingly, HVPG was not significantly higher in severe PHG (median 20 mm Hg) vs. mild PHG (19 mm Hg) and no PHG (18 mm Hg; p = 0.252). On multivariate analysis, CTP score (odds ratio, OR: 1.25, 95% confidence interval, CI 1.02–1.53; p = 0.033) was independently associated with severe PHG, while only a trend towards an independent association with IDA was observed (OR: 2.28, 95% CI 0.91–5.72; p = 0.078).ConclusionThe CTP score but not HVPG or MELD were risk factors for severe PHG. Importantly, anemia and especially IDA are significantly more common in patients with severe PHG.Electronic supplementary materialThe online version of this article (10.1007/s00508-019-01593-w) contains supplementary material, which is available to authorized users.

Pre-Existing Liver Disease Is Associated with Poor Outcome in Patients with SARS CoV-2 Infection; The APCOLIS Study (APASL COVID-19 Liver Injury Spectrum Study)

Background and Aims: COVID-19 is a dominant pulmonary disease, with multisystem involvement, depending upon co morbidities. Its profile in patients with pre-existing chronic liver disease (CLD) is largely unknown. We studied the liver injury patterns of SARS-Cov-2 in CLD patients, with or without cirrhosis. Methods: Data was collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19. Result: Altogether, 228 patients [ 185 CLD without cirrhosis and 43 with cirrhosis] were enrolled, with comorbidities in nearly 80%. Metabolism associated fatty liver disease (113, 61%) and viral etiology (26, 60%) were common. In CLD without cirrhosis, diabetes [57.7% vs 39.7%, OR=2.1(1.1-3.7), p=0.01] and in cirrhotics, obesity, [64.3% vs. 17.2%, OR=8.1(1.9-38.8), p=0.002) predisposed more to liver injury than those without these. Forty three percent of CLD without cirrhosis presented as acute liver injury and 20% cirrhotics presented with either acute-on-chronic liver failure [5(11.6%)] or acute decompensation [4(9%)]. Liver related complications increased (p<0.05) with stage of liver disease; a Child-Turcotte Pugh score of 9 or more at presentation predicted poor outcome [AUROC-0.94, HR=19.2(95CI 2.3-163.3), p<0.001, sensitivity 85.7% and specificity 94.4%). In decompensated cirrhotics, the liver injury was progressive in 57% patients, with 43% mortality. Rising bilirubin and AST/ALT ratio predicted mortality among cirrhosis. Conclusions: SARS-Cov-2 infection causes significant liver injury in CLD patients, decompensating one fifth of cirrhosis, and worsening the clinical status of the already decompensated. The CLD patients with diabetes and obesity are more vulnerable and should be closely monitored. Trial Registration: [NCT04345640] Funding Statement: None. Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: Institutional ethics committee approval was obtained.

Surgical Resection of Hepatocellular Carcinoma in Compensated Cirrhotic Liver: The Benefits and Selection Criteria

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Profile of Acute Kidney Injury in Patients with Decompensated Cirrhosis at a Tertiary-Care Center in Uttarakhand, India

Objectives: To study the clinical profile and predictors of acute kidney injury (AKI) in patients with decompensated cirrhosis. Materials and Methods: This observational study was conducted at Himalayan Institute of Medical Sciences, Dehradun, India, on 175 consecutive patients with decompensated cirrhosis. Patients were studied for AKI as per International Club of Ascites-AKI criteria. Results: The prevalence of AKI was 40.6%, with prerenal AKI 67.6%, hepatorenal syndrome (HRS) 23.8%, intrinsic renal AKI 7%, and postrenal AKI 1.4%. Mean arterial pressure (MAP), platelet count, and serum albumin were significantly lower and total leucocyte count (TLC), blood urea nitrogen, serum creatinine (SCr), total bilirubin, aspartate aminotransferase, international normalized ratio, Child-Turcotte-Pugh (CTP) score, and model for end-stage liver disease (MELD) score higher in cirrhosis patients with AKI than without AKI (p < 0.05 each). MAP, hemoglobin, TLC, and SCr were significantly different in various types of AKI (p < 0.05 each). AKI had a significant association with CTP score, alcohol, spontaneous bacterial peritonitis (SBP), sepsis, and shock (p < 0.05 each). Type of AKI had significant association with SBP, sepsis, and shock (p < 0.05 each). Mortality occurred in 33.8% patients with AKI with 64.7% mortality in patients with HRS. Outcome had significant association with AKI, stage and type of AKI (p < 0.05 each). Multivariate analysis showed SBP, sepsis, and shock as independent predictors of AKI (p < 0.05 each). Conclusions: AKI occurred commonly in patients with decompensated cirrhosis. Prerenal AKI and HRS were the most common types of AKI. SBP, sepsis, and shock were important predictors of AKI.

Child-Turcotte-Pugh Score, MELD Score and MELD-Na Score as Predictors of Short-Term Mortality among Patients with End-Stage Liver Disease in Northern India

Background and Objectives: Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD) and MELD-sodium (MELD-Na) scores are used for predicting disease severity and mortality among patients with end-stage liver disease. However, data regarding their usefulness in predicting the short-term outcome of end-stage liver disease are not available in India. This prospective study compared the CTP score, MELD score and MELD-Na score as predictors of short-term outcome among patients with end-stage liver disease. Methods: CTP, MELD and MELD-Na scores were determined in 171 patients with end-stage liver disease at a tertiary healthcare centre in India at the time of admission, and the concordance (C-) statistics of the three scores for 3-month mortality were assessed and compared. The aetiology of end-stage liver disease and the clinical presentation were determined. Results: The CTP score, MELD score and MELD-Na score on day 1 were significantly higher among non-survivors than among survivors (p < 0.0001 each). The C-statistic for 3-month mortality for the CTP score was 0.93 (p < 0.0001), that for the MELD score was 0.86 (p < 0.0001) and that for the MELD-Na score was 0.83 (p < 0.0001). The C-statistics of these scores differed significantly for 3-month mortality, and the CTP score was better than the MELD (p < 0.0001) and MELD-Na (p < 0.0001) scores in predicting 3-month mortality. Conclusions: The CTP, MELD and MELD-Na scores were very good predictors of mortality at 3 months among patients with end-stage liver disease. The CTP score was superior to the MELD and MELD-Na scores in predicting 3-month mortality.

1119 Assessment of Utility of Prognostic Models for Predicting Short-Term Mortality of Patients With Acute-on-Chronic Liver Failure

INTRODUCTION: Acute-on-chronic liver failure (ACLF) is a clinical syndrome associated with high short-term mortality. Numerous models have been proposed to predict outcomes in ACLF patients, including novel ones by Asian Pacific Association for the Study of the Liver (APASL) ACLF Research Consortium (AARC), but their utility in a heterogeneous population of ACLF patients remains inconclusive. The study aims to assess the performance of established and newer models for predicting mortality of ACLF patients. METHODS: A retrospective study of 96 patients fulfilling either APASL or European Association for the Study of the Liver (EASL) criteria for ACLF admitted to a tertiary hospital in Singapore between 2004 and 2018 was performed. Child-Turcotte-Pugh (CTP) score, Model for End-Stage Liver Disease (MELD)-Na, Chronic Liver Failure Consortium (CLIF)-SOFA, CLIF-C ACLF and AARC prognostic scores (MELD-lactate, AARC-ACLF) were calculated on days 1, 4, 7 of hospital admission and days 1, 4 of ICU admission. Outcomes assessed were survival to discharge without transplant, 30-day survival and 90-day survival. The scores were evaluated by measuring area under receiver operating characteristic (AUROC) curve at each time point and compared. RESULTS: 28 patients (29.2%) survived to discharge without transplant, 21 patients (21.9%) underwent urgent transplant and 47 patients (49%) died before discharge. 30-day transplant-free survival was 21.9% and 90-day survival was 19.8%. CTP, MELD-Na, MELD-lactate, CLIF-C ACLF and AARC-ACLF scores had high accuracy in predicting hospital mortality on day 4 admission (CTP D1 AUROC 0.642, D4 0.715; MELD-Na D1 0.607, D4 0.721; MELD-lactate D1 0.664, D4 0.861; CLIF-C ACLF D1 0.559, D4 0.697; AARC-ACLF D1 0.571, D4 0.747). CTP, MELD-Na and MELD-lactate scores also had good predictive utility on day 7 admission (CTP D7 0.684; MELD-Na 0.67; MELD-lactate 0.848). This held true regardless of whether APASL or EASL criteria was applied. In addition, the sequential change in CLIF-SOFA and CLIF-C ACLF scores from day 1 to day 4 was significantly associated with need for urgent transplant or death before discharge. CONCLUSION: CTP, MELD-Na and MELD-lactate scores are superior at prognosticating outcomes on day 4 and 7 of admission in our multi-ethnic Asian population. The trend of CLIF-SOFA and CLIF-C ACLF scores from day 1 to day 4 of admission may also contribute valuable information to our assessment of ACLF patients.

NEW IMMUNIZATION SCHEDULE EFFECTIVENESS AGAINST HEPATITIS B IN LIVER TRANSPLANTATION PATIENTS.

Although liver transplantation is considered to be a high-risk procedure, it is well-established as a treatment option for the cure and quality of life enhancement for individuals who suffer from diseases. Preventing an infection by hepatitis B virus through immunization schedules has been the most effective way to reduce complications, since it decreases the number of people who suffer from chronic hepatitis caused by the hepatitis B virus and eradicates its transmission. 1. Analyzing evidence in the literature on various schedules employed for immunization against hepatitis B in patients who have received a liver transplantation. 2. Suggesting potential immunization schedules against hepatitis B in patients who suffer from liver cirrhosis, without previous verifying documentation, using the Child-Turcotte Pugh score, according to evidences found in the literature. Systematic review of the literature, conducted on the data bases MedLine, PubMed, and Lilacs, between September, 2017 and January, 2018, by using the following keywords: "Liver Transplantation, "Immunization Schedule", "Hepatitis B Vaccines". In order to analyze the articles, a summary figure was especially designed and both the results and discussion were presented in a descriptive way. We included 24 studies; among them, eight had accelerated immunization schedules, 13 followed the conventional schedules, and three had super accelerated schedules. Regarding immunization, 21 studies were conducted with patients in the pre-transplant period, one with a transplanted patient, one with a pre-transplant group, and one with a post-transplant group. Found articles suggest that, disregarding the chosen immunization schedule, seroconversion rates tended to be lower as the liver disease advanced, compared to the healthy population. The studies did not find seroconversion superiority between the different immunization schedules (conventional and unconventional). However, since candidates to liver transplantation are usually very vulnerable, results show that super accelerated immunization schedules are possibly recommended for such group of patients; serologic test results will be higher when the immunization schedule is completed in the pre-transplant period.