Complication Of Cirrhosis Research Articles

Nonalcoholic Fatty Liver Disease and Chronic Kidney Disease: Epidemiology, Pathogenesis, and Clinical and Research Implications.

Nonalcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease worldwide, affecting up to ~30% of adult populations. NAFLD defines a spectrum of progressive liver conditions ranging from simple steatosis to nonalcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma, which often occur in close and bidirectional associations with metabolic disorders. Chronic kidney disease (CKD) is characterized by anatomic and/or functional renal damage, ultimately resulting in a reduced glomerular filtration rate. The physiological axis linking the liver and kidneys often passes unnoticed until clinically significant portal hypertension, as a major complication of cirrhosis, becomes apparent in the form of ascites, refractory ascites, or hepatorenal syndrome. However, the extensive evidence accumulated since 2008 indicates that noncirrhotic NAFLD is associated with a higher risk of incident CKD, independent of obesity, type 2 diabetes, and other common renal risk factors. In addition, subclinical portal hypertension has been demonstrated to occur in noncirrhotic NAFLD, with a potential adverse impact on renal vasoregulation. However, the mechanisms underlying this association remain unexplored to a substantial extent. With this background, in this review we discuss the current evidence showing a strong association between NAFLD and the risk of CKD, and the putative biological mechanisms underpinning this association. We also discuss in depth the potential pathogenic role of the hepatorenal reflex, which may be triggered by subclinical portal hypertension and is a poorly investigated but promising research topic. Finally, we address emerging pharmacotherapies for NAFLD that may also beneficially affect the risk of developing CKD in individuals with NAFLD.

Role of Oral Health, Frailty, and Minimal Hepatic Encephalopathy in the Risk of Hospitalization: A Prospective Multi-Center Cohort of Outpatients With Cirrhosis

Hospitalizations are a sentinel event in cirrhosis; however, the changing demographics in patients with cirrhosis require updated hospitalization prediction models. Periodontitis is a risk factor for liver disease and potentially progression. The aim of this study was to determine factors, including poor oral health, associated with 3-month hospitalizations in a multi-center cohort of outpatients with cirrhosis. North American Consortium for Study of End-stage Liver Disease (NACSELD-3), a new study cohort, recruits outpatients with cirrhosis. Cirrhosis details, demographics, minimal hepatic encephalopathy (MHE), frailty, and comorbid conditions including oral health were collected. All patients were followed for 3 months for nonelective hospitalizations. Multi-variable models were created for this outcome using demographics, cirrhosis details, oral health, MHE, frailty, and comorbid conditions with K-fold internal validation using 25%/75% split. A total of 442 outpatients (70% men; 37% compensated; Model for End-stage Liver Disease-Sodium, 12; 42% ascites; and 33% prior HE) were included. MHE was found in 70%, frailty in 10%; and both in 8%. In terms of oral health, 15% were edentulous and 10% had prior periodontitis. Regarding 3-month hospitalizations, 14% were admitted for mostly liver-related reasons. These patients were more likely to be decompensated with higher cirrhosis complications, MHE, frailty and periodontitis history. Multi-variable analysis showed prior periodontitis (P= .026), composite MHE+ frailty score (P= .0016), ascites (P= .004), prior HE (P= .008), and hydrothorax (P= .004) were associated with admissions using the training and validation subsets. In a contemporaneous, prospective, multi-center cohort study in outpatients with cirrhosis, poor oral health is significantly associated with 3-month hospitalizations independent of portal hypertensive complications, MHE, and frailty. Potential strategies to reduce hospitalizations should consider oral evaluation in addition to MHE and frailty assessment in practice pathways.

Prediction and evaluation of high-risk patients with primary biliary cholangitis receiving ursodeoxycholic acid therapy: an early criterion

Background and aimsCurrent treatment guidelines recommend ursodeoxycholic acid (UDCA) as the first-line treatment for new-diagnosed primary biliary cholangitis (PBC) patients. However, up to 40% patients are insensitive to UDCA monotherapy, and evaluation of UDCA response at 12 months may result in long period of ineffective treatment. We aimed to develop a new criterion to reliably identify non-response patients much earlier.MethodsFive hundred sixty-nine patients with an average of 59 months (Median: 53; IQR:32–79) follow-up periods were randomly divided into either the training (70%) or the validation cohort (30%). The efficiency of different combinations of total bilirubin (TBIL), alkaline phosphatase (ALP), and aspartate aminotransferase (AST) threshold values to predict outcomes was assessed at 1, 3 or 6 month after the initiation of UDCA therapy. The endpoints were defined as adverse outcomes, including liver-related death, liver transplantation and complications of cirrhosis. Adverse outcome-free survival was compared using various published criteria and a proposed new criterion.ResultsA new criterion of evaluating UDCA responses at 1 month was established as: ALP ≤ 2.5 × upper limit of normal (ULN) and AST ≤ 2 × ULN, and TBIL ≤ 1 × ULN (Xi’an criterion). The 5 year adverse outcome-free survival rate of UDCA responders, defined by Xi’an criterion, was 97%, which was significantly higher than that of those non-responders (64%). An accurate distinguishing high-risk patients’ capacity of Xi’an criterion was confirmed in both early and late-stage PBC.ConclusionsXi’an criterion has a similar or even higher ability to distinguish high-risk PBC patients than other published criteria. Xi’an criterion can facilitate early identification of patients requiring new therapeutic approaches.

Portal Vein Thrombosis in the Setting of Cirrhosis: A Comprehensive Review.

Portal vein thrombosis constitutes the most common thrombotic event in patients with cirrhosis, with increased rates in the setting of advanced liver disease. Despite being a well-known complication of cirrhosis, the contribution of portal vein thrombosis to hepatic decompensation and overall mortality is still a matter of debate. The incorporation of direct oral anticoagulants and new radiological techniques for portal vein recanalization have expanded our therapeutic arsenal. However, the lack of large prospective observational studies and randomized trials explain the heterogenous diagnostic and therapeutic recommendations of current guidelines. This article seeks to make a comprehensive review of the pathophysiology, clinical features, diagnosis, and treatment of portal vein thrombosis in patients with cirrhosis.

Balloon-Occluded Esophageal Variceal Obliteration Procedure: A Novel Technique Report from Three Centers.

Introduction: Esophageal variceal bleeding (EVB) is a potentially fatal complication of cirrhosis. The purpose of the present study was to evaluate the safety and efficacy of a novel technique of balloon-occluded esophageal varices (EVs) obliteration (BEVO) for EVs classified as F2 (medium size, F2-EVs) and F3 (large size, F3-EVs). Materials and Methods: Between December 2020 and December 2021, a total of 73 consecutive patients with EVs were treated using BEVO. An injection of sclerosant was administered via direct puncture of the varices during balloon occlusion. Immediate postprocedural Doppler endoscopic ultrasonography (EUS) was conducted to evaluate the blood flow in the EVs. Several factors, including the technical success, controlling of acute bleeding, intraoperative bleeding at the injection site, variceal eradication, variceal recurrence, and BEVO-related complications, were assessed. Results: BEVO was successfully performed in all patients. Immediate hemostasis was achieved in 100% (25/25) of patients with active EVB. The incidence of injection site intraoperative bleeding presenting as oozing and spurting bleeding was 76.71% (56/73) and 8.22% (6/73), respectively. Based on Doppler EUS and endoscopic examination, EVs were completely eradicated in 71 out of 73 patients (97.26%) after three sessions. A total of 3 (4.11%) patients were diagnosed with EV recurrence during follow-up after complete EV eradication. Retrosternal chest discomfort (13.70%; 10/73) and abdominal bloating (2.74%; 2/73) were spontaneously relieved after a few days. No serious BEVO-related complications were observed. Discussion: BEVO is a convenient and effective treatment for obliterating F2 and F3 EVs. Clinical Trial Registration No. ChiCTR2000039974.

Post-paracentesis Ascitic Fluid Leak in Patients with Cirrhosis of Liver and its Management: A Prospective Study

Ascites is the most common complication of decompensated cirrhosis of liver requiring paracentesis for diagnostic and therapeutic purposes. The ascitic fluid leak can develop after paracentesis in patients with cirrhosis leading to significant morbidity if persistent. We aimed to study the incidence and predictors of post-paracentesis leak in patients with ascites. In this prospective study, patients with cirrhosis undergoing therapeutic paracentesis were followed up, and those patients who developed persistent leak were included as cases. Controls were randomly selected in a 2:1 ratio from the group of patients who did not develop leak. Clinical and laboratory parameters were compared between the two groups. A total of 256 patients underwent 1126 sessions of therapeutic abdominal paracentesis over a period of 14 months. Post-paracentesis leak was seen in 55 (4.8%) patients while only 20 (1.7%) patients had persistent leak. The management of leak was in a stepwise manner initially with tincture benzoin with tight dressing followed by topical cyanoacrylate adhesive and followed by autologous blood patch in those not responding. The persistent leak group had higher proportion of patients with parietal edema, higher PT-INR and Child-Pugh score, lower mid-upper arm circumference, short physical performance battery score, and handgrip strength. On multivariate analysis, only the presence of parietal edema was an independent predictor of post-paracentesis persistent leak (odds ratio 10.35, 95% confidence interval 1.61-66.54, P=0.014). Persistent leak after paracentesis develops in a minority of patients with cirrhosis. The presence of parietal edema is a risk factor for persistent leak. The majority of these patients can be managed in a stepwise approach.

Nonalcoholic Steatohepatitis: A 9-Year Follow Up Cohort Study.

Background and aim: Non-alcoholic fatty liver disease (NAFLD) may progress to severe liver fibrosis and cirrhosis. A limited number of studies with a long follow up assessed fibrosis progression and related predictors in untreated patients with a histological diagnosis of NAFLD. This study aims to investigate rate and predictors of NAFLD progression. Methods: For 9 (2–16.7) years, we followed up a cohort of patients histologically diagnosed. Disease progression was defined by a composite endpoint as evidence of cirrhosis in patients without cirrhosis at baseline, evidence of de novo occurrence of cirrhosis complications, histologically established worsening of stage 1 of fibrosis or increase of 20% in liver stiffness by transient elastography in patients rejecting a second liver biopsy. Results: A total of 91 patients were enrolled. Of them, 31 had NAFL and 60 NASH. A second liver biopsy was performed in 22 NASH patients and in 4 NAFL. Disease progression was observed in 38.5% NASH and in 12.0% NAFL (p = 0.034). Patients with portal inflammation had a higher risk of progression (66.7% vs 26%, p = 0.021). High triglycerides levels, advanced fibrosis at baseline and the duration of follow-up predict disease progression (p = 0.021; OR = 6.93, 95% CI 1.33–36.08, p = 0.43; OR 8.37; 95% CI 1.07–65.58 and p = 0.034; OR = 0.88; 95% CI 0.78–0.99, respectively). Conclusions: Our results reinforce the evidence that, in the absence of pharmacologic treatment, NASH progresses in about 40% of patients. Liver biopsy is the only mean to discriminate NAFL from NASH. The prognostic role of portal inflammation needs to be explored in larger series.

Use of Human Albumin Administration for the Prevention and Treatment of Hyponatremia in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis.

Background. Hyponatremia is a common complication of liver cirrhosis and aggravates patients’ outcomes. It may be corrected by human albumin (HA) infusion. Herein, we have conducted a systematic review and meta-analysis to evaluate the efficacy of intravenous HA administration for the prevention and treatment of hyponatremia in liver cirrhosis. Methods. Literature was searched in the PubMed, EMBASE, and Cochrane Library databases. If possible, a meta-analysis would be conducted. Incidence of hyponatremia, rate of resolution of hyponatremia, and serum sodium level were compared between cirrhotic patients who received and did not receive HA infusion. Odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated. The quality of evidence was assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Results. Initially, 3231 papers were identified. Among them, 30 studies, including 25 randomized controlled trials (RCTs) and 5 cohort studies, were eligible. Among cirrhotic patients without hyponatremia, the HA infusion group had significantly lower incidence of hyponatremia (OR = 0.55, 95%CI = 0.38–0.80, p = 0.001) and higher serum sodium level (MD = 0.95, 95%CI = 0.47–1.43, p = 0.0001) as compared to the control group. Among cirrhotic patients with hyponatremia, the HA infusion group had a significantly higher rate of resolution of hyponatremia (OR = 1.50, 95%CI = 1.17–1.92, p = 0.001) as compared to the control group. Generally, the quality of available evidence is low. Conclusions. Based on the current evidence, HA may be considered for preventing the development of hyponatremia in liver cirrhosis, especially in those undergoing LVP, and treating hyponatremia. Well-designed studies are required to clarify the effects of HA infusion on hyponatremia in liver cirrhosis.

HFA-PEFF score as a prognostic factor in patients with liver cirrhosis

Abstract Introduction Cardiovascular complications of liver cirrhosis which are frequently referred to as cirrhotic cardiomyopathy (CCM), include high cardiac output, reduced afterload and diastolic dysfunction. However, there are only scarce or even conflicting data about the prognostic significance of CCM. HFA-PEFF score is a diagnostic score for heart failure with preserved ejection fraction (HFpEF), which has prognostic value in HFpEF patients. It has functional, morphological and biomarker domains and the score may vary from 0 to 6. Score of 5 or 6 is diagnostic of HFpEF in symptomatic patients. No study has calculated HFA-PEFF score in cirrhotic patients to date. Purpose The purpose of this prospective study was to calculate HFA-PEFF score in cirrhotic patients, correlate it with disease severity and determine its prognostic significance. Methods A total number of 92 consecutive cirrhotic outpatients were prospectively examined and 72 fulfilled the inclusion criteria. Patients older than 75 years old or patients with ejection fraction (LVEF) <50%, coronary artery disease, moderate or severe valvular heart disease, atrial fibrillation, ongoing alcohol consumption, hepatocellular carcinoma and poor acoustic window were excluded. In all patients a thorough echocardiographic examination was performed, BNP or NT-pro-BNP levels were measured and subsequently HFA-PEFF score was calculated. MELD score was used to define the severity of cirrhosis. The median follow-up was 20 months and the study end-point was defined as the composite of all-cause death. Results Mean age was 58.5±8.3 years, 52 (72.2%) were males, median Meld score was 12.9 (8.5–16.3) and mean LVEF was 61.1±5.4%. HFA-PEFF score was 5 or 6 in 38 (52.8%), 2–4 in 27 (37.5%) and 0 or 1 in 9 (9.7%) patients. According to Spearman's coefficient analysis, HFA-PEFF score was correlated with MELD score (rho=0.566, p<0.001), but not with age, systolic blood pressure (SBP) and heart rate. The survival analysis stratified by the HFA-PEFF score [low, score 0–4 (N=34) vs. high, score 5–6 (N=38)] indicated that the HFA-PEFF score successfully predicted all cause two-year survival (log-rank test p<0.001). According to the Cox-regression proportion hazard models HFA-PEFF score as a continuous variable correlated with six-month, one year and two year survival. When HFA-PEFF was treated as a categorical variable, hazard models were significant for the one and two-year survival. The multivatiate COX regression survival analysis showed that the increased HFA-PEFF score (low: score 0–4, N=34 vs high: score 5–6, N=38) was significantly associated with decreased two-year survival when patient age, gender and MELD score are taken into account [HR=3.659 (1.068–12.536), p=0.039]. Conclusions HFA-PEFF score is high among patients with liver cirrhosis, especially those with increased disease severity. HFA-PEFF score is associated with survival even when adjusting for the severity of the cirrhosis. Funding Acknowledgement Type of funding sources: None.

S1404 Outcomes and Complications of Hospitalized Cirrhosis Patients With H. pylori Infection

S1404 Outcomes and Complications of Hospitalized Cirrhosis Patients With H. pylori Infection

Procalcitonin and C-reactive protein in the diagnosis of spontaneous bacterial peritonitis.

BackgroundSpontaneous bacterial peritonitis (SBP) is a serious complication of cirrhosis and is associated with high morbidity and mortality. Rapid institution of appropriate antibiotics is central to the improved patient outcome. Correctly obtaining ascites fluid for analysis has several technical and logistic limitations resulting in overuse of empiric antibiotics when patients are admitted to the hospital with suspected SBP. Procalcitonin and C-reactive protein (CRP) are non-invasive markers of infection. We conducted a study to illustrate the role of these markers in making the diagnosis of SBP in patients with cirrhosis.MethodsA total of 45 patients were enrolled in this prospective cohort study, 14 (31.1%) of which were found to have SBP. Ascitic fluid neutrophils, serum procalcitonin and CRP levels were measured prior to initiation of antibiotics and these parameters were compared between the two groups. Area under receiver operator characteristic (AUROC) curves were used to assess the diagnostic accuracy of procalcitonin and CRP in this population. We defined neutrocytic SBP group as a combination of patients who had classic SBP (positive ascitic culture and >250 neutrophils/mm3) and culture-negative neutrocytic ascites.ResultsSerum procalcitonin (2.81±2.59 vs. 0.43±0.48 ng/mL; P=0.0032), serum CRP (60.30±44.48 vs. 22.2±23.28; P=0.0055) and ascitic fluid neutrophil levels (49.23±30.90 vs. 16.7±20.39; P=0.0064) were significantly higher in SBP group than non-SBP group. AUROC for procalcitonin (cut-off >2.0 ng/mL) was 0.75 (95% CI, 0.61–0.88), CRP (cut-off >3.0 mg/L) was 0.55 (95% CI, 0.43–0.68) and for procalcitonin combined with CRP was 0.76 (95% CI, 0.61–0.90) for diagnosing all-cause SBP. In a subgroup analysis of patients with neutrocytic SBP, AUROC for procalcitonin was 0.88 (95% CI, 0.74–1.00), CRP was 0.62 (95% CI, 0.45–0.79) and for procalcitonin combined with CRP was 0.93 (95% CI, 0.81–1.00). Addition of CRP to procalcitonin did not significantly change the AUROC for diagnosis of SBP.ConclusionsSerum procalcitonin could be used as an adjunctive non-invasive biomarker in diagnosing SBP with a high degree of accuracy in cirrhotic patients. Addition of CRP does not seem to significantly increase the diagnostic accuracy of procalcitonin.

S1309 Can Sarcopenia Diagnosed by Hand Grip Strength Provide a Better MELD-Na Cutoff in Predicting Complications of Cirrhosis?

Introduction: Computerized Tomography (CT) measured Skeletal Muscle Index (SMI) is the best investigation to diagnose sarcopenia. However, in developing countries, it is not feasible due to cost and unavailability. Hand grip strength using hand grip dynamometry is a simple, economical and repeaTable bedside tool to assess sarcopenia in cirrhotics. MELD-Na score is a better marker for short term mortality and transplant allocation rather than predicting decompensation events in cirrhotics. In the present study, we showed that hand grip strength with MELD-Na score can correlate with complications of cirrhosis and predict survival. Methods: A total of 72 patients between December 2019 and June 2021 diagnosed with liver cirrhosis on the basis of imaging were included in our study. Hand grip strength was measured by hand grip dynamometer in the non-dominant hand in sitting position with semi-flexed arm. Mean of three values was taken as final reading. Cut-offs of < 26 kg for men and < 18 kg for women were taken from Asian Working Group for Sarcopenia 2014 consensus. Patients were followed up for a period of 6 months. Results: In our study, the prevalence of sarcopenia was 83.3%. The mean MELD-Na score was 20. Presence of sarcopenia correlated with complications like bleeding esophageal varices (p = 0.01), Hepatic Encephalopathy (HE) (p = 0.002) and Hepatorenal Syndrome (HRS) (p = 0.006). On univariate analysis, when MELD-Na was > 20.5, sarcopenia was significantly associated with HE [Odd’s Ratio (OR), 9.33; 95% confidence interval (CI), 1.86 - 46.68; p = 0.007], bleeding esophageal varices [OR, 4.29; 95% CI, 1.35 - 13.58; p = 0.01] and HRS [OR, 12.43; 95% CI, 1.46 -105.74; p = 0.02]. The MELD-Na score of more than 20.5 with sarcopenia predicted mortality with sensitivity 100%, specificity 65% and p = 0.038. The estimated survival of sarcopenics at 6 months with MELD-Na > 20.5 was 83.3%. Conclusion: Hand grip strength is a simple, non-expensive test to diagnose sarcopenia. In resource limited countries, it can be used instead of CT scan measured SMI. As a measure of sarcopenia, it shows a statistically significant association with decompensation events of cirrhosis. In patients not yet listed for transplant, hand grip strength measured sarcopenia along with MELD-Na score cut-off of 20.5 can be utilized to optimize medical treatment, to prevent decompensation, recurrent hospitalization and ensure good quality of life.

S1397 Hospital Utilization and Survival Analysis in a Model of Outpatient Paracentesis by Interventional Radiology

Introduction: There has been a significant change in outpatient cirrhosis care, as paracentesis is currently performed by interventional radiologists (IR) rather than gastroenterologists/hepatologists or internists. In this model of care, patients’ access could be limited by scheduling availability, and there is no evaluation of their renal function or adjustment of their medications at the time of paracentesis. This study was aimed to analyze hospital utilization and cirrhosis complications within six months of index outpatient paracentesis by IR and to identify potential areas of improvement in care. Methods: This is a retrospective study of patients with cirrhosis and ascites who underwent outpatient paracentesis by IR from October 2015 to October 2018 at a tertiary academic medical center. We collected demographics, data on cirrhosis etiology/complications, laboratory tests, provider notes, outpatient paracenteses dates, emergency department (ED) visits, hospitalizations, and ICU admissions within the following six months post-index paracentesis. Overall survival was analyzed using product-limited survival estimates (Kaplan-Meier). The log-rank test was used to test for differences by cause. Kaplan-Meier survival curves were plotted for overall and stratified survival. Cox regression analyses examined survival by cause while controlling for age and MELD score. Hazard ratios are reported. (Figure) Results: Within 6 months from index paracentesis, 44 patients (64.7%) underwent repeat IR outpatient paracentesis (total 187 paracenteses, 4.25 paracenteses/patient); 42 (61.7%) had ER visits (total 118 ER visits, 2.8/patient), 40 (58.5%) had hospital admissions (total 88 admissions, 2.2/patient) and 11 had ICU admission. On multivariate analysis, the predictive factors for mortality were older age (p=0.04) and MELD score (p=0.082). Baseline MELD was predictive of acute kidney injury (p=0.0184), UGI bleed (p=0.0096), and ICU admission (p=0.0064). The mean overall survival was 35.6 (SD +/- 2.68) months. Mean survival stratified by cause was 36.2 (SD +/- 3.78) months for patients with cirrhosis due to alcohol use, and 41.7 (SD +/- 4.1) months for cirrhosis due to hepatitis B or C. (Table) Conclusion: In this contemporary cohort of patients with cirrhosis undergoing IR outpatient paracentesis, we found a high rate of short-term cirrhosis complications and hospital utilization, while TIPS consideration was very low. Further data is needed to identify specific gaps in care and to analyze long-term survival.Figure 1.: (a) Survival curve using Kaplan-Meier estimator with the cause of cirrhosis as strata. (b) Survival curve for each cause at the average age (60.5) and average MELD score (17.7) Table 1. - demonstrates baseline demographics such as age, gender, and cause of cirrhosis, the most common reasons for readmissions with a 6-month mortality rate, and TIPS status Age n (%) Less than 60 32 (46.37) 60 or more 37 (53.62) Average 60.47 Gender n (%) Male 49 (71.01) Female 20 (28.98) Cause of Cirrhosis n (%) Alcohol 37 (53.62) Hepatitis B and/or C 15 (21.74) Other 17 (24.64) Most common reasons for admissions % Hepatic encephalopathy 39.7% Acute Kidney Injury 38.2% Upper gastrointestinal (UGI) bleed 14.7% Spontaneous bacterial peritonitis (SBP) 14.7% 6-month mortality rate 6.9% TIPS n (%) TIPS performed 4 (0.09) No documentation of TIPS consideration 31 (70.4)

Distribution of chronic hepatitis C genotype and evaluation of clinical factors affecting direct-acting antiviral treatment responses in the Western Black Sea Region, Turkey.

Chronic Hepatitis C (CHC) is a substantial global public health issue with significant variation between countries because of the genotypic differences. A sustained viral response (SVR) is essential to reduce the complications associated with CHC and can be achieved in most patients via direct-acting antivirals (DAAs). The present study aimed at determining the genotype distribution in patients with CHC in our region and the SVR in DAA therapy patients. The study was conducted retrospectively on 272 patients treated with DAA between September 2016 and 2021. Data including demographic and clinical characteristics of the patients (HCV RNA level, genotype, hepatitis B and HIV serology, cirrhosis and decompensation, presence of hepatocellular cancer, degree of hepatosteatosis, previous anti-HCV treatment experience, comorbidities) were recorded. The study's primary endpoint was to determine the SVR at week 24. Genotype 1 was the most common genotype (94.5%), with genotype 1b accounting for most patients (78%) among those. It was observed that the patients received Ombitasvir/Paritaprevir/Ritonavir/Dasabuvir (OPRD) (47%), Ledipasvir/sofosbuvir (LDS) (38%), and Glecaprevir/pibrentasvir (GCP) (15%) as DAA treatment. SVR was observed in 92% (223) of the 240 patients at the end of 24 weeks. SVR-24 was significantly higher in the patient group with serum HCV RNA level ≤ 852.533 (p=0.002), in the hypertensive group (p=0.018), and without the psychiatric disease group (p<0.001). A high rate of SVR-24 was achieved by DAAs in CHC patients, most of whom were genotype 1 in the Western Black Sea Region, Turkey. Also, high viral load, hypertension, and psychiatric disease affected SVR-24, and clinical factors, such as cirrhosis, cirrhosis complications, hepatosteatosis, and other comorbidities did not.

S1440 Inpatient Management of Decompensated Cirrhosis - A Quality Improvement Initiative

Introduction: Cirrhosis management is centered on the treatment of the causes and management of the complications. The AASLD provides clear recommendations for inpatient management of cirrhosis decompensated by ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy (HE), and hepatorenal syndrome (HRS). Methods: We evaluated the current hospital practice for 150 consecutively admitted patients with cirrhosis complications in the period between 2017 and 2021. Decompensated cirrhosis was identified using ICD code K70.30/K70.31 (alcoholic cirrhosis) or K74.69/K74.60 (cirrhosis without alcohol), in addition to R18.8 (ascites), plus/minus any of the following: K65.2 (SBP), K72.91 (HE), and K76.7 (HRS). Results: 21/150 patients had no evidence of clinically decompensated cirrhosis on chart review and thus 129 patients represented the study cohort (decompensated cirrhosis, by at least ascites). The mean age of the cohort was 60±14 years. 83 patients were men, and the majority were White (88 patients, 68%). The most common cause of cirrhosis was alcohol related (72 patients, 56%), most patients had Child Pugh C (64%), and a mean MELD score of 21±7.7 and 20±7.5 on admission and discharge, respectively. Only 49/129 (38%) patients with cirrhotic ascites underwent diagnostic/therapeutic paracentesis. The second most common complication was esophageal varices (52 patients (40%)). SBP was noted in 8 patients, all of whom received appropriate medical treatment. SBP prophylaxis was indicated in 13 patients, and 10 of whom only received prophylaxis on discharge (77%). 41 patients had history of HE, and 21 of whom (51%) were on lactulose treatment. 14 patients developed HRS and were all started on albumin and octreotide therapy. 72 patients (56%) were placed on the appropriate cirrhotic diet, and daily weight was measured in 33/129 patients (26%) undergoing diuresis during the hospital stay. The mean length of stay was 5.9±4.4 days. 54 patients (42%) were re-admitted, and 13 patients (10%) died during the 90-day follow up period. Conclusion: We here demonstrated that further improvement in the medical care provided to hospitalized cirrhotic patients remains necessary. We recommend further education of the medical staff on the current guidelines to improve the care provided as well as adopting an electronic medical record order set (Figure) topromote consistent evidence-based practice, decrease errors of omission, and support provider efficiency.Figure 1.: Cirrhosis complications order set

Hepatic venous pressure gradient (HVPG) predicts liver failure after transjugular intrahepatic portal shunt: a retrospective cohort study.

Esophagogastric variceal bleeding is a serious complication of decompensated cirrhosis. Transjugular intrahepatic portal shunt (TIPS) is a salvage treatment with clear hemostatic results. However, various complications may occur after TIPS, including postoperative liver failure, and the prognosis is very poor once occurs. Liver failure is a common symptom of severe liver disease with a high mortality rate. This study investigated the incidence of liver failure after TIPS treatment for varicose bleeding. We analyzed the data of patients admitted to the First Affiliated Hospital of Soochow University between January 2013 and December 2018 with portal hypertension with an episode of acute gastroesophageal variceal bleeding. A total of 121 patients were referred to the regional liver unit for TIPS. Hepatic venous pressure gradient (HVPG) and clinical data were collected. Patients with incomplete data were excluded, and 93 patients were ultimately enrolled in the study. Primary outcomes were morbidity and hospital mortality within 4 weeks of surgery. The data were retrospectively and consecutively collected and evaluated by univariate and multivariate analyses to identify risk factors of liver failure. The patients included 58 males (62.37%) and 35 females (37.63%), and the mean age was 58.43±11.85 years. The main cause was hepatitis B virus (HBV), which was found in 50.54% of patient. The overall surgical success rate was 83.87% (78/93). Of 15 treatment-failure patients, 9 (9.68%) died in hospital. Four patients died of liver failure, accounting for 44.44% of postoperative all-cause deaths. Univariate logistic regression analysis showed that only hepatic venous pressure gradient (HVPG) was an independent risk factor for post-TIPS morbidity [relative risk (RR) 1.156; 95% confidence interval (CI): 1.041 to 1.283; P=0.006]. In addition, HVPG was an independent risk factor for hospital mortality within 4 weeks (RR 1.133; 95% CI: 1.021 to 0.539; P=0.016). Post-TIPS liver failure is a serious complication in patients with cirrhosis. Pre-TIPS HVPG level may be used as a predictor of potential short-term postoperative adverse events.

S3304 Acute Occlusive Mesenteric Ischemia From Venous and Aortic Thrombosis in a Patient with Hyperhomocysteinemia and Liver Cirrhosis

Introduction: Portal vein thrombosis (PVT) is a severe complication of liver cirrhosis and one of its major consequences include intestinal ischemia. Hyperhomocysteinemia (HHcy) has been suggested to be an independent risk factor for deep venous thrombosis, but limited data are available on the prevalence of HHcy in patients with PVT complicating liver cirrhosis. Several clinical studies have also demonstrated the role of HHcy in arterial and venous thrombosis. Case Description/Methods: We report a case of a 57 year old male with Liver Cirrhosis from Alcoholic Liver Disease, who presented at our ED with a two week history of dull periumbilical pain which worsened on the day of consult. Plain abdominal CT scan showed nonspecific small bowel enteritis. He was placed on general liquid diet and started on Ciprofloxacin and Metronidazole intravenously. However, on the third hospital day, he complained of sudden severe abdominal pain accompanied by abdominal distention, guarding, and direct and rebound tenderness on all quadrants. He had hypotension and on laboratory workup, had decreasing hemoglobin levels with elevated WBC count and lactate. Contrast-enhanced abdominal CT scan revealed portal and superior mesenteric vein thrombosis, bowel wall ischemia along the segment of the jejenum in the left hemiabdomen, and infrarenal abdominal aorta and ascending aorta thrombi. Emergency exploratory laparotomy was done with segmental jejunoileal resection and primary end-to-end anastomosis with intraoperative findings of gangrenous small bowels measuring 100 cm in length, with the rest of the proximal small bowels noted to be dilated and edematous. The patient was transferred to the intensive care unit post-operatively for closer monitoring; Heparin drip was started 24 hours post-surgery. Histopathology results showed extensive transmural infarction, hemorrhage, and necrosis on small bowel segments; organizing thrombi were seen on mesenteric vessels. The patient was worked-up for other causes of hypercoagulable states which showed elevated Homocysteine levels at 20.6 (NV: 5-12). Discussion: It is likely that HHcy may increase the risk of patients with liver cirrhosis to develop arterial and venous thrombosis considering the pivotal role the liver plays in the metabolism of sulphur amino acids and Hcy-related vitamin storage. Therefore, identification of this high-risk group may be important to plan prevention management, such as vitamin supplementation, other Hcy-lowering strategies, or long-term anticoagulation.

Portal Interventions in the Setting of Venous Thrombosis or Occlusion.

Portal vein thrombosis most commonly occurs as a complication of liver cirrhosis and can result in worsening symptoms of portal hypertension, which often can be challenging to treat with conventional decompression therapies. In addition, because complete portal vein thrombosis is associated with higher posttransplant morbidity and mortality, it is regarded as a relative contraindication to liver transplant. Often, the diagnosis of portal vein thrombosis is incidental; hence, imaging remains the mainstay for diagnosing this complication and is used to guide subsequent treatment. Although anticoagulation is the initial approach used to treat acute portal vein thrombosis, endovascular and/or surgical interventions may be necessary when there is concern for impending bowel ischemia. Treatment of chronic portal vein thrombosis is primarily aimed at alleviating the symptoms of portal hypertension and improving the chance of candidacy for liver transplant. Awareness of the portal venous anatomy to differentiate it from the periportal collaterals is key during recanalization of a chronically occluded portal vein. The authors provide an overview of the pathophysiology, acute and chronic imaging findings, and management of portal vein thrombosis, with a specific focus on endovascular management, as well as a summary of the current related literature. An invited commentary by Lopera and Yamaguchi is available online. ©RSNA, 2022.

Prognostic importance of interleukin 2 receptor for patients with a history of cirrhotic variceal bleeding.

Variceal hemorrhage is a fatal complication of cirrhosis. In this study, we aimed to investigate the role of serum interleukin 2 receptor (sIL-2R) as a predictive indicator in patients with a previous history of cirrhosis-related variceal bleeding. A total of 340 cirrhotic patients who had experienced variceal bleeding from December 2016 to December 2018 were enrolled, and were randomly assigned to the modeling group and the validation group. The 3-year variceal rebleeding rate and other outcomes including adverse events were analyzed between patients with different sIL-2R levels. A time-dependent receiver operating characteristic (ROC) curve of variceal rebleeding indicated that sIL-2R had an area under the ROC curve (AUROC] of 0.731 and 0.837 for the modeling and validation groups, respectively, with a cut-off value of 426 U/mL. Kaplan-Meier analysis showed that higher sIL-2R level was related to an increased risk of variceal rebleeding rate (55.33% vs 24.34%, P=0.024 and 51.28% vs 15.32%, P=0.049) and decreased 3-year survival rate (91.16% vs 98.92%, P=0.013 and 90.52% vs 97.50%, P=0.180) in the modeling and validation groups. Elevated sIL-2R levels were associated with an increased risk of portal vein thrombosis and severe ascites as well as inferior liver function, hypercoagulable state, and increased portal pressure. High sIL-2R levels were associated with poor prognosis in cirrhotic patients with previous variceal bleeding.

S3292 A Rare Complication of End-Stage Liver Disease: Flood Syndrome

Introduction: Flood syndrome describes a condition seen in the setting of end-stage liver disease in which an umbilical hernia ruptures leading to a rush of fluid through the defect. It is a rare complication of cirrhosis and has a high mortality rate. Herein, we present two cases of flood syndrome in patients with advanced liver disease. Case Description/Methods: Case 1: A 37-year-old female with a history of factor Leiden deficiency, MTHFR deficiency, and decompensates alcoholic cirrhosis presented with 1 day of continued fluid leakage from an umbilical wound. She was afebrile, normotensive yet tachycardic to 114 bpm. Abdominal exam showed a positive fluid wave shift and small umbilical hernia with ascitic fluid in the stoma bag. Labs showed a total bilirubin of 11.6 mg/dl, AST of 61 U/L, ALT of 36 U/L, and ALP of 79 U/L. She was treated with antibiotics and underwent hernia repair. She later required large volume paracentesis before the fluid leakage stopped and she was discharged home. Case 2: A 48-year-old female with alcoholic cirrhosis and a history of incisional abdominal hernia secondary to laparotomy presented with abdominal distension, pain and leakage of fluid through the hernia site. Exam showed a midline abdominal protuberance with an ulcerated hernia. CT confirmed the abdominal wall hernia with sigmoid colon in the hernia sac and ascitic fluid and air (Figure 1). She was treated with antibiotics and the defect was closed by general surgery prior to discharge. Discussion: Flood syndrome is a rare complication seen in cirrhotic patients with ascites defined as a rush of fluid through rupture of an umbilical hernia. It is associated with serious complications and a high mortality rate of up to 30%. As such, the most important step in management of ascites is prevention. Sodium and fluid restrictions and diuretics may be used to reduce hypervolemia in these patients. Paracentesis is often necessary to aid in fluid removal in those with recurrent ascites; however, the procedure can also increase the risk of developing flood syndrome. Ultimately, patients may require surgery to repair the defect.Figure 1.: CT demonstrating an abdominal wall hernia with sigmoid colon in the hernia sac and ascitic fluid and air.