Child-Turcotte-Pugh Research Articles

Predictive Power of the Albumin-Bilirubin Score for Hepatotoxicity in Stereotactic Ablative Radiation Therapy for Hepatocellular Carcinoma.

Assessment of liver function is crucial in predicting treatment outcomes for hepatocellular carcinoma (HCC). This study aimed to evaluate the prognostic performance of the albumin-bilirubin (ALBI) score for predicting hepatotoxicity following stereotactic body radiation therapy (SBRT) in HCC patients. A retrospective analysis was conducted on 123 HCC cases treated between 2018 and 2020. ALBI and Child-Turcotte-Pugh (CTP) scores were calculated, and hepatotoxicity was defined as a post-SBRT CTP score increase ≥2. Receiver operating characteristic (ROC) curves were used for comparison. The optimal cutoff value of the ALBI score was determined. Among the 121 patients analyzed, hepatotoxicity occurred in 5%. The ALBI score showed better predictive accuracy (area under the ROC curve: 0.77) than the CTP score. The optimal cutoff value of the ALBI score was -2.47, with a sensitivity of 85.7% and a specificity of 71.1%. Multivariable analysis revealed that ALBI score and PTV were significant factors for hepatotoxicity. In conclusion, the ALBI score demonstrated prognostic value for hepatotoxicity prediction after SBRT in HCC patients. Considering the ALBI score and PTV provides valuable insights for assessing hepatotoxicity risk during SBRT treatment for HCC.

Triage policy to postpone endoscopy for patients with low-risk varices is safe during the lockdown period of COVID-19 pandemic

Background & aimsDuring the COVID-19 pandemic, most of the endoscopic services were electively postponed or suspended. We aimed to assess the safety of a triage policy in patients receiving esophageal variceal ligation during the COVID-19 pandemic.MethodsTriage policy of endoscopic variceal ligation (EVL) was implemented in our hospital during the lockdown period from 15th May 2021 to 26th July 2021. One experienced gastroenterologist reviewed the prior-scheduled list of patients for the EVL prophylaxisprogram. We compared the clinical characteristics and outcomes with those receiving endoscopy due to esophageal varices from 17th May 2020 to 28th July 2020.ResultsOf the 124 patients receiving EVL, a higher percentage of esophageal variceal bleeding (EVB) was noted (9/32, 28.1% vs. 8/92, 8.7%, p = 0.006) during the lockdown period, with a higher percentage of EVB in the referrals (7/9, 77.8% vs. 2/14, 14.2%, p = 0.007). Among patients who received prophylactic EVL, 6 of 78 (7.7%) experienced EVB during the normal period, which is no different to 2 of 23 (8.7%) during the lockdown period. Twenty-three patients whose endoscopies were postponed by triage policy due to low-risk or eradicated varices did not experience EVB during the lockdown period. Child-Turcotte-Pugh (CTP) class C was predictive of EVB (relative risk 8.400, P = 0.033), entering the program of prophylactic EVL was the protective factor of EVB (relative risk 0.016, P = 0.002).ConclusionEntrance into the prophylaxis program does not only decreases risk of EVB but also fosters comprehensive triage to postpone endoscopy during the lockdown period.

Absolute eosinophil count is a reliable prognostic marker in patients with liver cirrhosis: a cross-sectional study at rural central India

BackgroundVarious laboratory parameters like C-reactive protein (CRP), Cortisol, and Von Willebrand factor antigen have been evaluated independently in foreseeing outcomes of cirrhotic patients. As these parameters lack cost-effectiveness in a rural setup, there is a need for a cost effective and feasible prognostic marker for cirrhotic patients. The present study was aimed at evaluating the role of Absolute Eosinophil Count (AEC) as a prognostic marker in cirrhotic patients.MethodsThis cross-sectional study was conducted at a rural tertiary care teaching hospital in central India from August 2019 to September 2021. AEC was measured from counter report as a part of automated complete blood counts. Child-Turcotte-Pugh (CTP) score and Model for end stage liver disease (MELD) score were calculated at the time of admission. AEC levels on admission were correlated with mortality and with CTP score and MELD score.ResultsA total of 110 patients were enrolled with mean age of 46.37 ± 11.6 years. AEC was the significant predictor of mortality at cut off point of ≤ 120 with 80.30% (AUC 0.803; 95% CI: 0.716 to 0.873). AEC was the significant predictor of CTP score ≥ 11 at cut off point of ≤ 148 (AUC 0.726; 95% CI: 0.633 to 0.807). AEC was the significant predictor of MELD score ≥ 25 at cut off point of ≤ 136 (AUC 0.74; 95% CI: 0.647 to 0.819). Significant negative correlation was seen between AEC with Child–Pugh score and MELD score with correlation coefficient of -0.257 and -0.258.ConclusionLow level of AEC on admission fairly predicted raised CTP score and MELD score on admission. Low AEC levels predicted increased mortality in cirrhotic patients making it a cheap and reliable prognostic marker in a rural setup.

Correlation of Liver Elastography as a Predictor of Esophageal Varices and Its Comparison With Ultrasound Abdomen and Liver Function Tests in Patients With Chronic Liver Disease.

Variceal haemorrhage is a life-threatening complication that occurs in up to 40% of patients with chronic liver disease including cirrhosis. It is associated with a mortality rate of 20%with each episode of variceal bleeding. Esophagogastroduodenoscopy is the gold standard for the detection of esophageal varices but is an invasive procedure and not verycost-effective. Our study was designed to correlate the presence of esophageal varices on endoscopywith the liver stiffness measurement using liver elastography inpatients with chronic liver disease. We also comparedvarious non-invasive predictors like laboratory parameters and ultrasound features andcorrelated them with the presence of varices inpatients with chronic liver disease. This prospective observational study was conducted ina tertiary-care hospital in South Indiafrom November 2017 to April 2019.All patients withchronic liver disease were subjected to endoscopy, and the presence ofesophageal varicesand their grading was noted. The predictive efficacy of ultrasound elastographyusing Toshiba Aplio 500 ultrasound two-dimensional shear wave elastography (2D-SWE) in predicting esophageal varices was calculated and compared with the efficacy of predictingesophageal varices by other non-invasive parameters like laboratory investigations, abdominal ultrasound, and liver scores like Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease (MELD) score, fibrosis 4 (FIB-4) score,aspartate aminotransferase-to-platelet ratio index (APRI) score, andaspartate aminotransferase/alanine aminotransferase ratio (AAR). The study includeda total of 168 patients out ofwhich 57% (96 patients) had no varices. About 52 patients(72.2%) had F1/Grade I varices,9(12.5%) had F2/Grade II varices, and 11 (15.3%) had F3/Grade III varices. The greatest predictive value for esophageal variceswas liver stiffness with a diagnostic accuracy of 81.7%.Ultrasound features likecoarse echotexture of the liver (66.7%), splenomegaly (67%), dilated portal vein (78.6%), and presence of moderate ascites (66.7%) had asignificantstatistical association with the presence of esophageal varices. Laboratory parameters like thrombocytopeniaof less than 1.5 lakhs/cu.mm (52.8%), albumin <3 g/dL (60.4%), and reversal of albumin/globulin ratio(52.4%) weresignificant predictors of esophageal varices. The odds ratio for significant scores in predicting oesophageal varices using binary logistic regression was significant in patients whose liver elastography grade wasmore than F4, CTP score was B, MELD score was >11, and FIB-4 scoreswas >3.25 and between 1.46 and 3.25. Liver elastography is a non-invasiveprocedure that can be a useful tool in predicting esophageal varices in chronic liver disease. Other non-invasive predictorslike ultrasound abdomen and laboratory parameters canalso be considered a replacement for repeatedinvasive endoscopy, thusfacilitating early intervention and avoiding unfavourable outcomes in patients withchronic liver disease.

Outcomes of patients with advanced liver disease undergoing cardiac surgery

ObjectiveLiver disease (LD) is considered a risk factor for inferior outcomes in general and cardiac surgery, yet current cardiac surgery risk estimators exclude LD, and literature on the topic remains scant. We sought to evaluate whether the presence of advanced LD is associated with inferior outcomes following cardiac surgery. MethodsThis single-center, retrospective, observational study included 285 patients diagnosed with LD who underwent cardiac surgery in 2010 to 2020. The cohort contained 3 groups, Child-Turcotte-Pugh (CTP) class A (n = 219), CTP early-class B (n = 34), and CTP advanced-class B (n = 32). A model for end-stage liver disease score of 12.7 points (determined using a receiver-operating characteristic curve analysis on 30-day mortality) dichotomized class B into early- and advanced-groups. Univariate and multivariate logistic regression analyses were performed to identify predictors of 30-day mortality. ResultsPatients in CTP advanced-class B had the longest length of stay (14 days), highest incidence of prolonged ventilation (46.9%), renal failure (21.9%), 30-day mortality (18.8%), and in-hospital mortality (18.8%). Incidence of ≥1 postoperative complication was higher in CTP advanced-class B (59.4%), compared with CTP class A (37.9%) and CTP early-class B (38.2%). Multivariate logistic regression analysis demonstrated that female sex (odds ratio, 3.01; 95% CI, 1.07-8.77; P = .037) and peripheral vascular disease (odds ratio, 4.01; 95% CI, 1.33-12.2; P = .013) were independent predictors of 30-day mortality in patients with advanced LD. ConclusionsSeverity of LD influences perioperative outcomes following cardiac surgery. Our data suggest that patients in CTP class A and selected patients in CTP class B (model for end-stage liver disease score <12.7) can undergo surgery with acceptable risk.

Platelet-albumin-bilirubin score - a risk stratification scoring system to predict outcome of acute variceal bleeding in patients with cirrhosis.

Acute variceal bleed is a common complication of cirrhosis of liver. Up to 25% of patients with newly diagnosed varices will experience bleeding within 2 years. Of patients who have stopped bleeding, approximately one-third will rebleed within the next 6 weeks. Though scores like Child-Turcotte-Pugh (CTP) and Model of End-stage Liver Disease (MELD) predict the survival of upper gastrointestinal bleed, they have certain limitations in this regard. So, there is a need for reliable scoring system to assess the outcome of patients who had acute variceal bleed. To evaluate the platelet-albumin-bilirubin (PALBI) score in predicting outcome of acute variceal bleeding in patients with cirrhosis. A total of 130 patients who presented to our institute with acute variceal bleed over a period of 1 year were analyzed. CTP, MELD Na and PALBI scores were calculated for these patients on admission and the outcome was compared in the form of 90-day rebleeding rates. The areas under the receiver operating characteristic curves (AUROC) were calculated for this purpose. Mean age was 56 years; 80 were male (61.5%), 50 were female (38.5%), 62 CTP-A (47.7%), 53 CTP-B (40.8%), 15 CTP-C (11.5%); 63 PALBI 1 (48.5%), 23 PALBI 2 (17.8%), and 44 PALBI 3 (33.8%). 1 patient died in the due course of the study. The AUROC for predicting rebleeding was 0.732, 0.71 and 0.803 for CTP, MELD Na and PALBI scores, respectively. PALBI score on admission is a good predictor of outcomes in cirrhotics with acute variceal bleed.

Prognostic and diagnostic anthropometric biomarkers of sarcopenia in a cohort of Egyptian patients with hepatitis C-induced liver cirrhosis

BackgroundChronic hepatitis C (HCV) infection is a leading cause of liver cirrhosis (LC) worldwide with decompensation-related clinical sequelae. Sarcopenia is currently recognized as a fundamental complication of LC owing to various mechanisms. This study aimed to assess the role of anthropometric measures of sarcopenia in predicting the outcome of LC as assessed by the Child-Turcotte-Pugh (CTP) grade.ResultsA cross-sectional study was carried out on 80 patients with HCV-related LC with different CTP grades. The diagnosis of sarcopenia was based on the 2018 definition of sarcopenia according to the European Working Group on Sarcopenia in Older People (EWGSOP). Muscle strength was assessed by hand grip strength (HGS) and lower leg extension strength (LES). Assessment of muscle mass was performed by measuring mid-calf circumference (MCC) and mid-arm muscle circumference (MAMC). HGS varied significantly between the different CTP grades, being highest in CTP grade C. Additionally, the number of patients diagnosed with “definitive sarcopenia” using either HGS/MCC or LES/MCC varied significantly between CTP grades, being highest in CTP grade C.ConclusionsHGS is a better predictor of worse outcomes of liver cirrhosis than LES. The combination of MCC and HGS or LES is a potentially promising noninvasive prognostic biomarker of liver disease.

T1 relaxation time analysis in predicting hepatic dysfunction and prognosis in patients with HCC undergoing transarterial chemoembolization

ObjectiveTo evaluate the value of T1 mapping in predicting hepatic dysfunction and prognosis in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). Material and Methods100 consecutive patients with treatment-naive HCC treated with TACE were prospectively analyzed. Clinical, laboratory, and MRI parameters (liver and tumor T1 relaxation times (T1L, T1T)) before and/or following TACE were measured and calculated. Clinical parameters included the Child-Turcotte-Pugh (CTP) classification, Barcelona Clinic Liver Cancer Classification (BCLC) criteria, and albumin-bilirubin (ALBI) score. Laboratory parameters were the gold standard for hepatic dysfunction. T1L and T1T were combined by stepwise multivariate logistic regression to yield a T1-related probability index (T1com) for further analysis. Study endpoints included hepatic dysfunction and progression-free survival (PFS) rate. Results38 patients (38%) were diagnosed with hepatic dysfunction following TACE. There was no significant difference in clinical parameters between the groups with and without hepatic dysfunction. Logistic regression analysis showed that T1L and T1T were independent risk factors for assessing hepatic dysfunction. T1com showed a better AUC than T1L and T1T (0.81 vs. 0.76 and 0.69, P = 0.007 and 0.006). Patients with low T1com (≤0.42) showed a better median PFS than patients with high T1com (>0.42) (167.0 vs. 215.9 days, P = 0.010). In comparison, CTP, BCLC, and ALBI scores were not statistically significant in predicting PFS in HCC patients treated with TACE (P > 0.05). ConclusionCompared with widely used clinical parameters, T1 was more capable of predicting hepatic dysfunction after TACE. Stratification of patients with HCC undergoing TACE according to T1 may help clinicians to develop treatment strategies in preventing the occurrence of hepatic dysfunction and improving individual prognoses.

Correlation of Model for End Stage Liver Disease (MELD), MELD-Sodium (MELD-Na), and Child-Turcotte-Pugh (CTP) Score With Frailty in Patients With Hepatitis C Virus (HCV) Related Cirrhosis.

The model for end stage liver disease (MELD), model for end stage liver disease-sodium (MELD Na), and Child-Turcotte-Pugh (CTP) score are independent predictors of mortality in cirrhotic patients.Approximately 43% of cirrhotic patients with advanced disease are frail and can have detrimental effects on the disease prognosis and survival including delisting from the transplant list and increased risk of post-transplant complications. Therefore, our aim was to determine the correlation of MELD, MELD-Na, and CTP score with frailty in patients with hepatitis C virus (HCV) related cirrhosis. This cross-sectional study was conducted at the Department of Hepato-gastroenterology, Sindh Institute of Urology and Transplantation from 1stJanuary 2022 to 30thJune 2022. All the patients of either gender aged between 18 and 70 years with serological evidence of HCV and features of cirrhosis on ultrasound abdomen were included in the study. Patients with conditions over estimating frailty were excluded from the study. Liver Frailty Index (LFI) was calculated using grip strength measured in kilograms, timed chair stands, and balance testing. CTP and MELD-Na scores for each patient were also recorded. All the data were analyzed using SPSS version 22.0 (IBM Corp., Armonk, NY). The correlation of MELD, MELD-Na, and CTP with LFI was analyzed using the Pearson correlation coefficient and a p-value < 0.05 was considered statistically significant. A total of 274 patients were included in the study. Out of them, 185 (67.5%) were males. The mean CTP score was 8.1 + 2.1, MELD score of 13.6 + 7.1, MELD-Na score of 15 + 6.6, and LFI of 4.1 + 0.83. LFI was found to be weakly correlated with MELD (r = 0.278) (p < 0.001), MELD-Na score (r = 0.41) (p < 0.001), and CTP score (r = 0.325) (p < 0.001). Weak correlation was noted between LFI, CTP, MELD, and MELD-Na scores in HCV-associated chronic liver disease. Therefore, frailty along with MELD, MELD-Na, and CTP must be assessed before considering the patients for liver transplantation.

Predictors of Short-term Mortality in Patients of Cirrhosis of Liver Presenting as Acute Kidney Injury: An In-hospital Prospective Observational Study

Acute kidney injury (AKI) is known to be associated with increased short-term mortality among cirrhotic patients. On this background, we designed this study to evaluate various causes of AKI among admitted patients with cirrhosis of liver and predictors of 90-day mortality. One hundred and two consecutive adult patients with cirrhosis of liver with AKI hospitalized between November 2016 and March 2018 were enrolled in this prospective study. Their detailed clinical profile, including biochemical parameters, the etiology of AKI, and their clinical outcome of survival or mortality at 90-days, were recorded. The most common causes of AKI were infections, followed by hypovolemia, seen in 55.88% and 31.37% of the patients, respectively. Hepatorenal syndrome (HRS) was seen in 10.78%, while parenchymal renal disease was the least common (1.9%). The in-hospital mortality rate was 28.4%, while 90-day mortality was 39.21%. The HRS group had a high 90-day mortality rate of 54.54%. ROC analysis of various biochemical parameters revealed that serum creatinine (sCr), Model for End-Stage Liver Disease (MELD), International Normalized Ratio (INR), and Neutrophil-Lymphocyte ratio (NLR), followed by Child Turcotte Pugh (CTP), had high area under the curves of 0.785, 0.773, 0.747, 0.740, and 0.718, respectively, for the prediction of 90-day mortality. Infection is the commonest cause of AKI in cirrhosis; however, mortality in patients with HRS-AKI is higher than that in those with infection-related AKI. Serum creatinine at admission, INR, NLR, and CTP scores predict short-term mortality among patients with AKI in cirrhosis. Further, large prospective studies are needed to confirm these findings.

Visceral adiposity in cirrhosis: Association with disease severity and impact of liver transplantation.

Changes in adipose tissue distribution in liver cirrhosis are poorly characterized and may affect clinical outcomes. Adult liver transplant (LT) January 2008-August 2017 recipients with abdominal MRI within 6 months pre-LT were retrospectively assessed. Visceral adipose tissue, subcutaneous adipose tissue, and skeletal muscle area (cm2) were determined at L3. Visceral-to-subcutaneous adipose tissue ratio (VSR) was used to define relative adipose distribution, stratified by sex. Correlation was tested with Pearson. Body composition measures were compared by Child-Turcotte-Pugh (CTP) class, before and after LT, and evaluated as predictors of clinical outcomes. A total of 318 patients were studied. Mean age was 56 years, 33.64% were female, and 47.80% had CTP C cirrhosis. CTP C was associated with a 0.42-point increase in VSR compared with CTP A (95% CI = 0.13-0.71, p < 0.01), adjusting for age, sex, diabetes, and HCC. Among the 79 (24.84%) patients with repeat MRI 1-2 years after LT, VSR significantly improved from before LT (1.31 vs. 0.95, p < 0.01). In adjusted analysis, CTP C was associated with a 0.86-point decrease in post-LT VSR compared with pre-LT VSR (95% CI = -1.27 to -0.44, p < 0.01). Body mass index poorly correlated with VSR before and after LT. Elevated pre-LT VSR trended toward an association with a 7.17-point decrease in pre-LT glomerular filtration rate (95% CI = -14.35 to -0.02, p = 0.05), adjusting for CTP C, age, sex, diabetes, hypertension, pre-LT sarcopenia, and hepatocellular carcinoma. Elevated pre-LT VSR did not affect 3-year post-LT mortality (log-rank p = 0.24). Poorly represented by body mass index, visceral adiposity is increased in cirrhosis and is associated with CTP class. However, this adipose redistribution may be modifiable by LT.

Risk factors for the prognosis of patients with decompensated hepatitis B cirrhosis and their predictive values.

Abstract. We aimed to investigate the risk factors affecting the progno-sis of patients with decompensated hepatitis B cirrhosis and their predictive values.The clinical data of 149 patients with decompensated hepatitis B cir-rhosis, treated from August 2015 to June 2019, were analyzed retrospectively. They were divided into death and survival groups during a one-year follow-up. Their baseline data were compared, and the risk factors affecting death, corre-lations among risk factors, and predictive values of these factors for death were analyzed. Survival analysis was conducted. During a one-year follow-up, 103 pa-tients survived, and 46 died. High neutrophil-lymphocyte ratio (NLR), red cell distribution width (RDW), the model for end-stage liver disease (MELD) score, the Child-Turcotte-Pugh (CTP) score, and low serum sodium were independent risk factors for death in patients with decompensated hepatitis B cirrhosis. NLR correlated positively with CTP and MELD scores (r=0.346, p=0.0001, r=0.243, p=0.0003, respectively). Likewise, the RDW had positive correlations with CTP and MELD scores (r=0.417, p=0.0001, r=0.413, p=0.0003, respectively). Se-rum sodium was negatively correlated with CTP and MELD scores (r=-0.484, p=0.0001, r=-0.476, p=0.0001, respectively). The survival rate was high in patients with NLR&lt;7.38, RDW&lt;16.15%, serum sodium&gt;146.31 mmol/L, CTP score&lt;10.26 points, and MELD score&lt;11.31 points (p=0.0001). NLR, RDW, serum sodium, MELD, and CTP scores had high death predictive values.NLR, RDW, serum sodium, CTP score, and MELD score can be considered as critical indices for evaluating and predicting the prognosis of patients with decompen-sated hepatitis B cirrhosis.

Study of Correlation of Bone Mineral Density with Severity of Liver Cirrhosis.

Liver cirrhosis is a common ailment that is widely prevalent in our country and across the world. There are several manifestations of this disease. Metabolic bone disease also has an association with cirrhosis. The present study was designed to study the correlation between bone mineral density (BMD) and the severity of liver cirrhosis. This was a case-control study. A total of 35 diagnosed cases of liver cirrhosis and 35 age and sex-matched controls were included in the study. BMD was measured by dual-energy X-ray absorptiometry (DEXA) at the hip joint and lumbar spine. Child-Turcotte-Pugh (CTP) score was used for assessing the severity of liver cirrhosis. Out of the 35 cases of cirrhosis, 25 had either osteopenia or osteoporosis. The mean T-score at the hip joint in cases was -1.47 ± 1.62 and in controls, it was -0.56 ± 1.67 (p &lt; 0.001). The mean T-score detected in the lumbar spine was -1.33 ± 1.66 and in controls -0.41 ± 1.67 (p &lt; 0.001). There was a significant inverse correlation between CTP scores and BMD. The present study revealed that abnormal BMD is highly prevalent in patients with liver cirrhosis. There is also a significant relationship between the severity of cirrhosis and BMD.

Treatment of Tuberculosis in special situations

Treatment of Tuberculosis in special situations implies overcoming special challenges in patients with diabetes, pregnant women, people aged over 65 years, and those with chronic kidney or liver disease.Rifampicin is a potent hepatic enzyme inducer, may lower plasma levels of sulphonyl urea and can increase the hypoglycemic effect of metformin. Since insulin is not metabolized, no pharmacokinetic interactions with anti-TB drugs occur. Gastrointestinal upset and hepatitis are reported as the most frequent adverse events in older people. In patients &gt;80 years,pyrazinamide may be omitted. In TB patients with chronic kidney disease (CKD), an inappropriate dosage of anti-TB drugs can result in unsuccessful treatment or side effects. Current guidelines for first-line anti-TB drugs therefore recommend that dosages of ethambutol (EMB) and pyrazinamide (PZA) be adjusted according to patient renal function and body weight, although no change in dosage is necessary for patients with mild renal insufficiency . However, it remains unknown how the renal function-based dosage adjustments recommended by the guidelines affect efficacy outcomes for TB patients with CKD. In chronic liver disease (CLD) patients, The Child–Turcotte–Pugh (CTP) score can be used as a guide for designing appropriate regimens. In stable CLD (CTP d”7), a treatment regimen including isoniazid, rifampicin, and ethambutol is recommended, a 2-month intensive phase with the three drugs, followed by isoniazid and rifampicin continuation phase for 7 months partially liver-sparing regimen consisting of Ethambutol, Rifampicin, and a quinolone for 9 months is advisable in case of more severe CLD (CTP 8–10).If CLD is very advanced (CTP £11), a total liver-sparing regimen consisting of Ethambutol and a quinolone (Levofloxacin or Moxifloxacin) for 12 months. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 196-197

Pretreatment Predictors Associated with Improvement in Hepatitis C Virus Related Decompensated Cirrhosis after Direct-Acting Antiviral Therapy

Background and Aim: The availability of hepatitis C virus (HCV) direct-acting antivirals (DAAs) has led to a paradigm change in the care of HCV related decompensated cirrhosis. Achieving a stained virologic response (SVR) is associated with considerable improvements in both Child-Turcotte- Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores in decompensated cirrhosis. We aimed to evaluate the pretreatment predictors associated with improvement in CTP B cirrhosis after DAAs and evaluate the efficacy and safety of DAAs in these patients.&#x0D; Patients and Methods: A prospective study conducted on 213 decompensated patients (CTP B, 134 received DAAs for 24 weeks and 79 for 12 weeks). Clinical and laboratory data obtained at baseline, during treatment, 12 weeks after end of treatment (EOT), 36 weeks after treatment start, and 24 weeks after SVR.&#x0D; Results: We had 48.4 % and 55.9 % had improved to CTP A at 36 weeks of treatment start and 24 weeks after SVR respectively. A high baseline BE3A score (which includes Body mass index (BMI), Encephalopathy, Ascites, Alanine aminotransferase (ALT) and Albumin) was the significant predictor of attaining CTP A at 36 weeks of treatment start, while high baseline ALT (&gt; 60 IU/L) was the significant predictor of attaining CTP A at 24 weeks after SVR. SVR 12 achieved in 97.3% and DAAs were safe with mild tolerable adverse events.&#x0D; Conclusion: High baseline ALT and BE3A score were the significant predictors of hepatic improvement from CTP B to CTP A after DAAs. HCV DAAs were safe and effective with high SVR rates (97.3%) in decompensated cirrhosis.

Acute Kidney Injury in Cirrhosis of Liver: it’s Clinical Spectrum and Association of Various Clinical Outcomes with Advancing Cirrhosis of the Liver

Background &amp; Objectives: Pakistan in tandem marks mortality of advance cirrhosis due to complications like hepatic encephalopathy, upper gastrointestinal bleeding and Acute kidney injury (AKI) contributing further morbidity and mortality. The study aimed to determine frequency, types and severity of AKI among cirrhotics and find association between AKI with various clinical outcomes among advance cirrhotics. Methods: All cirrhotics (both genders), age &gt; 18 years of various aetiologies with confirmed AKI were included and analysed retrospectively. Clinical, antiviral treatment and biochemical predictors of mortality in AKI were analysed by univariate regression however independent risk factors were analysed by multi regression (significant P values &lt; 0.05). Results: Out of 271 cirrhotics, 188 (69.37%) had AKI. Commonest to least common AKI pattern was pre-renal (59.5%), intrinsic (37.7%) post-renal (2.1%). Majority (45.2%) had international club of ascites (ICA-AKI) stage 3, (33.5%) ICA-AKI stage 2 and (21.3%) ICA-AKI stage 1. The overall mortality with AKI at 1,6 and 12 months were 12.8%, 39.1% and 54.3% respectively (significant p 0.001). Increased creatinine, international normalized ratio (INR), bilirubin, albumin, Child Turcotte Pugh (CTP) and Model of end stage liver disease (MELD) were in-hospital predictors of mortality where INR and albumin proved significant. Conclusion: AKI being frequent challenge among cirrhotics has commonest pattern as pre-renal with majority having severe AKI, ICA-Stage 3. Patients with AKI had higher mortality versus non-AKI. Rising creatinine, serum bilirubin, severity of cirrhosis (CTP and MELD score) were the significant predictors of in-hospital mortality where INR and albumin were most significant. Keywords: Acute kidney injury, international club of ascites, cirrhosis of liver, child Turcotte Pugh, International normalized ratio

Pulmonary Arterial Hypertension Associated with Portal Hypertension and HIV Infection: Comparative Characteristics and Prognostic Predictors.

Pulmonary arterial hypertension (PAH) may complicate both portal hypertension (Po-PAH) and HIV infection (HIV-PAH). These two conditions, however, frequently coexist in the same patient (HIV/Po-PAH). We evaluated clinical, functional, hemodynamic characteristics and prognostic parameters of these three groups of patients. We included patients with Po-PAH, HIV-PAH and HIV/Po-PAH referred to a single center. We compared clinical, functional and hemodynamic parameters, severity of liver disease [Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease-Na (MELD-Na) scores], CD4 count and highly active antiretroviral therapy (HAART) administration. Prognostic variables were identified through Cox-regression analysis. Patients with Po-PAH (n = 128) were the oldest, patients with HIV-PAH (n = 41) had the worst hemodynamic profile and patients with HIV/Po-PAH (n = 35) had the best exercise capacity. Independent predictors of mortality were age and CTP score for Po-PAH, HAART administration for HIV-PAH, MELD-Na score and hepatic venous-portal gradient for HIV/Po-PAH. Patients with HIV/Po-PAH are younger and have a better exercise capacity than patients with Po-PAH, have a better exercise capacity and hemodynamic profile compared to patients with HIV-PAH, and their prognosis seems to be related to the hepatic disease rather than to HIV infection. The prognosis of patients with Po-PAH and HIV-PAH seems to be related to the underlying disease.

A modified Child-Turcotte-Pugh score based on plasma ammonia predicts survival for patients with decompensated cirrhosis.

Plasma ammonia has been shown to be an independent prognostic factor for patients with liver cirrhosis. We aimed to investigate the discrimination and calibration of a new prognostic model (aCTP) based on plasma ammonia (Amm) replacing hepatic encephalopathy (HE) in the Child-Turcotte-Pugh (CTP) score. Diagnostic test, paired design. Baseline Amm levels were corrected to the upper limit of normal (Amm-ULN). We designed the new model based on the cut-off value of Amm-ULN in the observational cohort of 554 clinically stable cirrhotic patients from January 2012 to July 2019. External validation was carried out using prospective data from 185 patients with liver cirrhosis. Our analysis showed that each 1-point increase in Amm-ULN was associated with a 2-fold increase in the likelihood of mortality [hazard ratio (HR), 2.06; 95% CI: 1.81-2.36, P < 0.001]. In the aCTP score, Amm-ULN < 1.0 was defined as a score of 1, 1.0 ≤ Amm-ULN < 1.4 as 2 and ≥1.4 as 3. The survival curves among three aCTP grades were significantly different (P < 0.0001). The aCTP score showed the better agreements between predicted and observed events in the validating cohorts than the CTP score (C-statistics: 0.75 and 0.69, P < 0.001). The aCTP score showed inspiring power to predict acute decompensation (C-statistics: 0.76; 95% CI: 0.71-0.81) and acute-on-chronic liver failure (C-statistics: 0.81; 95% CI: 0.77-0.86). This study demonstrates the feasibility and the potential for plasma Amm replacing HE (aCTP) to enhance the prognostication of transplant-free survival provided by the CTP score for patients with decompensated cirrhosis.

Thromboelastography parameters in chronic viral liver disease and liver resection: a retrospective study.

Thromboelastography (TEG) provides a global assessment of haemostasis and is potentially applicable to liver disease. The present study aimed to explore the utility of TEG for the evaluation of patients with chronic viral liver disease, which has previously not been investigated. Demographic characteristics and TEG parameters were collected before surgery. Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were used to categorise stages of liver cirrhosis. Liver resections were classified as low, medium and high complexity. A total of 344 patients were included. Results showed significantly longer K-time, smaller α-angle and lower maximum amplitude (MA) with increasing liver disease severity as measured by the CTP and MELD scores ( P < 0.05 for all). After multivariable adjustment (including age, sex, liver disease aetiology, alanine aminotransferase [ALT], aspartate aminotransferase [AST], albumin, total bilirubin, haemoglobin and platelet count), TEG parameters (except R-times) were either weakly or inversely related to the severity of liver disease as defined by the MELD score (absolute r < 0.2 and P < 0.05 for all except R-times). R-times obtained before surgery were weakly correlated with perioperative blood loss ( r < 0.2 and P < 0.05 for all). The correlation between TEG parameters and severity of liver disease was weak. In addition, R-times obtained before liver resection were weakly associated with perioperative blood loss after multivariable adjustments. TEG utility for haemostasis assessment and prediction of blood loss during liver resection should be further explored in high-quality studies.

Nonselective beta-blockers in primary prophylaxis of esophageal variceal bleeding in patients with ascites waitlisted for liver transplantation

Objective: to determine the efficacy of non-selective beta-blockers (NSBBs) in the primary prevention of bleeding esophageal varices and to assess their impact on the survival of patients with ascites enrolled in the liver transplant waiting list (LTWL).Materials and methods. We carried out a retrospective comparative study of cirrhotic patients with severe ascites and esophageal varices without bleeding before enrollment in the LTWL. Primary prophylaxis of variceal bleeding included the use of NSBBs (n = 97, group 1). These drugs were not used in the other patients (n = 91, group 2).Results. There were no significant differences between the groups in terms of clinical, laboratory and demographic parameters, MELD scores and Child-Turcotte-Pugh (CTP) classes for cirrhosis. Patient groups included in the study had no significant differences with respect to incidence of medium- and large-sized varices and incidence of severe ascites. Bleeding incidence was significantly lower in the NSBBs group than in the non-NSBBs group (52.6% and 95.6%, respectively, p = 0.0001).Conclusion. NSBBs constitute an efficacious therapy in primary prophylaxis of esophageal variceal bleeding, thereby saving life and preventing delisting of patients with ascites from the LTWL.