CTP Score Research Articles

Management of Hepatitis C Virus Genotype 4 Treatment Failure: A Real-World Single Center Experience

Background: Treatment failure with direct-acting antiviral (DAA) therapy is associated with worsening of liver disease especially in cirrhotic patients. Moreover, data on retreatment of HCV genotype 4 patients (G4) with DAA failure are still very limited, since they are under- represented in most clinical trials.
 Aims: To evaluate the efficacy of retreatment of Egyptian HCV G4 DAA failure patients based on the use of a new DAA class from currently available first- generation DAA regimens other than the patient had relapsed to.
 Methods: 29 Egyptian HCV G4 DAA failure patients were retreated by switch to a new DAA class from first- generation DAA regimens than the patient had relapsed to independent of RAS testing. 25 out of these 29 patients completed retreatment and 4 patients were lost for follow–up.
 Results: Among other risk factors, by logistic regression analysis, only older age, high CTP score and high base-line viral load were independent predictors of DAA failure among our cohort. Also SOF/RBV regimen was the most common prior DAA regimen associated with treatment failure (48.3%).
 All our DAA failure patients were cirrhotics that made prompt retreatment of them a rescue strategy to halt viral replication and disease progression.
 After retreatment, 22 (88%) of the 25 patients who completed retreatment achieved SVR12 and the remaining 3 (12%) failed.
 These 3 patients completed a second retreatment, one achieved SVR and the other 2 relapsed again (re-relapsers)
 Conclusion: The overall SVR rate (88%) demonstrated in this real –world study, clearly shows that, the retreatment policy of DAA failure patients by switch to – or addition of a new drug class independent of RAS testing is a good retreatment option, that may be of importance for many areas of the world with no or difficult access to RAS testing or second-generation rescue regimens.

Predictors of early re-bleeding and mortality in patients with first attack of gastric variceal hemorrhage

Background: Gastric varices (GV) bleed less frequently than esophageal varices however, gastric variceal bleeding is more severe with higher mortality and rebleeding rates. Treatment of Gastric variceal bleeding (GVB) by tissue adhesive mainly cyanoacrylate glues has been used for Gastric variceal obturation. We aimed to determine predictors of early rebleeding and mortality in patients with the first attack of GVB. Materials and methods: The study included 120 patients with a first attack of GVB.The patients subjected to thorough history, full examination, laboratory, and radiological investigations. Child Turcott Pugh score (CTP), and model of end stage liver disease (MELD) score were calculated. Upper gastrointestinal (GI) endoscopy with gastric variceal obturation (GVO) by cyanoacrylate glues were done for all included patients. Follow up during hospitalization and 6 weeks after discharge to determine early rebleeding (within 14 days) and early mortality (within 6 weeks). Results: Among 120 included patients in the study, 24 patients (20%) were presented with early rebleeding and 19 patients (15.83%) were presented with early mortality. Multi-variable logestic regression analysis showed that, Child Pugh Score was an independent prognostic factor associated with early rebleeding and early mortality. It was found that, current smoking, increased bilirubin, INR, creatinine, decreased albumin, presence of ascites, higher CTP and MELD scores are significantly more in early rebleeding and early mortality groups, while lower platelet count in early rebleeding only. Moreover, hepatic encephalopathy, and higher transaminases are more in early mortality group. There was no significant difference in gastric variceal signs between the study groups except that increase mortality in patients with more than one varix. Conclusion: Child Turcott Pugh score was an independent prognostic factor associated with early rebleeding and early mortality in patients with GVB.

Hepatogenous Diabetes - A Report from Central India

Cirrhosis of liver is associated with loss of liver function, portal hypertension, and pancreatic β-cell dysfunction leading to hepatogenous diabetes (HD). Often HD is an underestimated and understudied problem, particularly in the Indian subcontinent, where the prevalence of both Chronic liver disease (CLD) and diabetes is high. Hence this study was planned to highlight the prevalence of HD and its association with the severity of cirrhosis. A total of 121 cirrhotic patients without a history of diabetes were included in this prospective cross-sectional study. Seventy five g oral glucose tolerance test (OGTT) was done in all patients. Fasting serum insulin levels were done to calculate insulin resistance (IR) using homeostatic model assessment-insulin resistance (HOMA-IR). Upper gastrointestinal endoscopy was done to detect varices. Patients were divided into HD group and non-HD group for comparison of results. HD was seen in 52 (42.98%) patients; among them, 63.4% did not show evidence of HD by fasting plasma glucose (FPG) levels. Impaired glucose tolerance (IGT) was seen in 58 (47.93%) patients. Compared with the non-HD group, the HD group had significantly higher model for end-stage liver disease (MELD) score (P=0.038), HOMA-IR (P<0.001), incidence of large varices (P<0.001) and variceal bleeding (P<0.001). A statistically significant association was noted between HD and Hepatocellular carcinoma (HCC) (P<0.001). Patients with cirrhosis had a high prevalence of IGT, IR, and HD. The presence of HD is well associated with the severity of cirrhosis in the form of higher MELD score (>15), CTP score (>10), higher bilirubin levels, large varices, bleeding varices, and HCC. FPG levels and glycated hemoglobin (HbA1c) cannot be relied upon, and OGTT aids in the unmasking of HD in these patients.

Predictors of hepatorenal syndrome in patient with decompensated liver cirrhosis

Introduction: Hepatorenal syndrome (HRS) is one of the severe complications of decompensated liver cirrhosis which has poor outcome. Predictive models are important aspect in assessment of high risk patient.&#x0D; Method: This prospective analytical study was conducted in Gastroenterology unit of Bir hospital from December 2018 to April 2020. Seventy patient of liver cirrhosis with ascites (CTP score 7 or more) were followed for a period of three months. The outcome of study was hepatorenal syndrome. Predictors were assessed from baseline variables.&#x0D; Result: Total 65 patients completed the study. The mean age of study population was 47.38 ±11.38 years and 52(80%) were male. The most common aetiology was alcohol 55(84 %). Eight (12.5%) developed HRS. Hepatorenal syndrome was precipitated by spontaneous bacterial peritonitis 5(62.5%), upper gastrointestinal bleeding 2(25%) and unknown 1(12.5%). In Bivariate analysis total leucocyte count, Serum sodium, Model for End-stage Liver Disease – Sodium (MELD- Na), serum bilirubin and use of rifaximin were predictors of HRS. Only use of rifaximin was the predictor in multivariate analysis.&#x0D; Conclusion: Serum sodium, bilirubin and MELD Na are important predictors of the hepatorenal syndrome. Rifaximin use may be preventive for HRS.&#x0D; Keywords: Decompensation, hepatorenal syndrome, liver cirrhosis, predictors

Chemopreventive Effect of Statin on Hepatocellular Carcinoma in Patients With Nonalcoholic Steatohepatitis Cirrhosis.

To estimate the annual incidence of hepatocellular carcinoma (HCC) in patients with nonalcoholic steatohepatitis (NASH) with advanced liver fibrosis, to determine the risk factors for the development of HCC, and to evaluate the chemoprotective effect of statin use stratified by fibrosis stage. We conducted a retrospective study at 2 US tertiary academic centers, including patients with NASH-related advanced liver fibrosis (bridging fibrosis [F3] and cirrhosis [F4]) followed between July 2002 and June 2016. Patients were followed from the date of diagnosis to the time of last abdominal imaging, liver transplantation, or HCC diagnosis. Multivariable Cox regression analysis was performed to evaluate the risk factors associated with HCC development, stratified by fibrosis stage. A total of 1,072 patients were included: 122 patients with F3 fibrosis and 950 patients with cirrhosis. No HCC was observed during 602 person-year follow-up among F3 patients. Among patients with cirrhosis, HCC developed in 82 patients with the annual incidence rate of 1.90 per 100 person-years (95% confidence interval [CI], 1.53-2.35). Multivariable analysis in patients with cirrhosis demonstrated that HCC development was associated with male sex (hazard ratio [HR] 4.06, 95% CI, 2.54-6.51, P < 0.001), older age (HR, 1.05, 95% CI, 1.03-1.08, P < 0.001), and CTP score (HR, 1.38, 95% CI, 1.18-1.60, P < 0.001). Statin use was associated with a lower risk of developing HCC (HR, 0.40, 95% CI, 0.24-0.67, P = 0.001). Each 365 increment in cumulative defined daily dose of statin use reduced HCC risk by 23.6%. Our findings suggest that patients with NASH and bridging fibrosis have a low risk of HCC. Dose-dependent statin use reduced HCC risk significantly in patients with NASH cirrhosis.

Atypically located spider angioma

To the Editor,&#x0D; A spider angioma or spider naevus is a type of telangiectasis found slightly beneath the skin surface, often containing a central arteriole and many small vessels which radiate outwards like a spider's web. Applying pressure to the center of the lesion leads to fading of the lesion. Spider angioma is a common presentation of liver cirrhosis, especially alcoholic cirrhosis. Spider angiomas are found only in the distribution of the superior vena cava, and are thus commonly found on the face, neck, upper chest and upper arm. Spider angioma is rarely observed on hand (1, 2). Here, we report a a very rare case with spider angioma on back of hand.&#x0D; A 54-year-old male patient admitted to our clinic with icterus and ascites. The patient had a diagnosis of alcoholic liver cirrhosis one month before. On physical examination, he had icterus and ascites. He had spider angiomas on his back, neck and on the back of his right hand, just proximal to second metacarpophalangeal joint (Figure 1). The patient’s Child Turcotte Pugh score (CTP) and model for end stage liver disease (MELD) scores were 12 and 22, respectively. Abdomen ultrasound showed cirrhosis with massive ascites. Endoscopy revealed grade 1 esophageal varices and portal hypertensive gastropathy. The patient gave written consent regarding this article.&#x0D; Spider angioma appears frequently in alcoholic cirrhotic or noncirrhotic alcoholic liver diseases with deuteriation of liver functions. Although, the exact cause of SA is not known, there have been many theories of possible etiologic factors such as disturbance of sex hormones (increased level of luteinizing hormone, decreased level of testosterone and a higher estradiol/testosterone ratio), angiogenesis, vasodilation, alcohol abuse, hyperdynamic circulation state, and liver dysfunction[3, 4]. The number and size of SA are correlated with the degree of liver disease (1, 3, 4). &#x0D; Our patient was a heavy drinker and had alcoholic liver cirrhosis with high CTP and MELD score. Although, our patient had multiple telangiectasias, it is a very rare finding of SA, observed on back of hand.

Maternal and fetal outcomes of patients with liver cirrhosis: a case-control study

BackgroundWe aimed to describe the characteristics and outcomes in pregnant women with liver cirrhosis, and identify the predictors of adverse events of mother and fetus.MethodsRetrospectively collected mothers with liver cirrhosis in our center from 6/2010 to 6/2019. Women without liver cirrhosis were selected as a control in a 1:2 ratio. The primary assessment was the frequency of maternal and fetal adverse events. The secondary assessment was the adverse events in patients continuing pregnancy or not and the factors to predict the severe adverse events.ResultsOf 126 pregnancies enrolled, 29 pregnancies were terminated for worrying disease progression and 97 pregnancies continued. One hundred ninety-four pregnancies without liver cirrhosis were selected as control. At baseline, patients with liver cirrhosis have a lower level of platelet, hemoglobin, prothrombin activity, and a higher level of ALT, total Bilirubin, creatinine. Compared to control, patients with liver cirrhosis had a higher frequency of adverse events, including bleeding gums (7.2%vs. 1.0%), TBA elevation (18.6%vs.3.1%), infection (10.3%vs.0.5%), cesarean section (73.6%vs.49.5%), postpartum hemorrhage (13.8% vs 2.1%), blood transfusion (28.9% vs 2.1%), new ascites or aggravating ascites (6.2% vs.0%), MODS (7.2% vs.0.5%) and intensive care unit admissions (24.1% vs 1.1%). The incidence of severe maternal adverse events was also higher (32.0% vs 1.5%). Women who chose to terminated the pregnancy had less severe adverse events (3.4% vs.32.0%).A higher frequency of fetal/infants’ complications was observed in liver cirrhosis population than control, including newborn asphyxia (10.2% vs1.1%), low birth weight infant (13.6% vs. 2.6%). In patients who progressed into the third trimester, multivariable regression analysis demonstrated that severe adverse events were associated with a higher CTP score (OR 2.128, 95% CI [1.002, 4.521], p = 0.049). Wilson’s disease related liver cirrhosis has a better prognosis (OR = 0.009, 95% CI [0, 0.763], p = 0.038).ConclusionsThe incidence of the adverse events was significantly increased in pregnancies complicated by cirrhosis. The predictor of severe adverse events is higher CTP score. Wilson’s disease induced liver cirrhosis have a better prognosis. Timely termination of pregnancy during the first trimester may avoid the incidence of severe adverse events.

A novel prognostic model to predict outcome of artificial liver support system treatment

The prognosis of Artificial liver support system (ALSS) for hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is hard to be expected, which results in multiple operations of ALSS and excessive consumption of plasma, increase in clinical cost. A total of 375 HBV-ACLF patients receiving ALSS treatment were randomly divided a train set and an independent test set. Logistic regression analysis was conducted and a decision tree was built based on 3-month survival as outcome. The ratio of total bilirubin before and after the first time of ALSS treatment was the most significant prognostic factor, we named it RPTB. Further, a decision tree based on the multivariate logistic regression model using CTP score and the RPTB was built, dividing patients into 3 main groups such as favorable prognosis group, moderate prognosis group and poor prognosis group. A clearly-presented and easily-understood decision tree was built with a good predictive value of prognosis in HBV-related ACLF patients after first-time ALSS treatment. It will help maximal the therapeutic value of ALSS treatment and may play an important role in organ allocation for liver transplantation in the future.

CHILD-TURCOTTE-PUGH /ALBUMINURIA AS A PREDICTOR OF ACUTE KIDNEY INJURY AMONG HOSPITALIZED PATIENTS WITH LIVER CIRRHOSIS

Background: The incidence of acute kidney injury (AKI) in cirrhotic patients about fifteen percent of hospitalized cirrhotic patient, Prediction of AKI indicated in all patients with liver cirrhosis. Albuminuria in cirrhotic patient can predict AKI. Objective: To assess the role of Child-Turcotte Pugh/Albuminuria (CTP-Alb), in prediction of AKI among hospitalized patients with liver cirrhosis. Patients and Methods: After departmental ethics committee approval and patient consents were obtained, 60 patients with liver cirrhosis screened for AKI during hospital admission at hepatogastroenterology unit, Department of Internal Medicine in Al-Hussein Hospital, Al-Azhar University, and The study was carried out during the period from September 2019 and September 2020, The diagnosis of liver cirrhosis based on clinical, biochemical and ultrasonography findings. Patients with Fib-4 ≥ 3.5 in the absence of liver decomposition were categorized as compensated liver cirrhosis. Severity of liver disease was assessed using the CTP score, model for end stage liver disease (MELD) score and CTP-Alb score. Diagnosis of acute kidney injury was based on the changes in serum creatinine. The baseline renal assessment at first day of hospital admission was included serum creatinine, estimated glomerular filtration rate (eGFR), albumin/creatinine ratio, and abdominal ultrasonography. AKI was categorized as hepatorenal syndrome (HRS), pre-renal azotemia, post-renal azotemia or intrinsic acute kidney injury. Results: A total of 60 patients included. They were 40 (66.66%) males and 20 (33.34%) females. Their mean age was 50 ± 33 years, of them 8 (13.33%) patients developed AKI during hospital admission with their mean age was 60.6 ± 10.9 years. They were 5 (62.5%) males and 3 (37.5%) females, Hypoalbuminemia, Child score at admission and Child-albuminuria score at admission were identified as independent risk factors for AKI by multivariate analysis (p < 0.05). Conclusion: Thirteen percent of cirrhotic patients developed AKI during hospital admission according to our results. The majority of patients were child C in our series; CTP/Albuminuria score, Hypoalbuminemia and ACLF has promising sensitivity, specificity and accuracy in prediction of AKI in hospitalized cirrhotic patient.

Quality of Life Among Chronic Liver Disease Patients: An Exploratory Cross Sectional Survey

Background: QOL is the general well-being of individuals and societies, outlining negative and positivefeatures of life. It observes life satisfaction, including everything from physical health, family, education,employment, wealth, religious beliefs, finance and the environment.1 Quality of life has an important statusin patient management suffering from chronic liver disease.Objectives: The present study was done to assess the quality of life among patients suffering from ChronicLiver Diseases.Material and Methods: A descriptive explorative cross-sectional research design was used. Data wascollected from 165 patients using purposive sampling technique. The quality of life Scale (QOLS) was usedto assess the quality of life among chronic liver diseases patient admitted at Institute of Liver and BiliarySciences. MELD and CTP score was used to assess the mortality and survival rate among chronic liverdiseases patient. The study participants and their care givers were informed that the study is harmless; all thegathered data was treated confidentially and used for research purpose only.Results: The results of the study revealed that 0.6 percent of the patients have poor, in 35.2 percent of thepeople have moderate whereas 64.2 percent of the people have good quality of life. In terms of physicalwellbeing of patient 11.52 percent of the people have poor, 73.93 percent have moderate while only 14.55percent have good quality of life. In relation with social wellbeing of the patient 0.61 percent of the peoplehave poor, 27.88 percent have moderate while only 17.51 percent have good quality of life. As per emotionalwellbeing of the patient 3.03 percent of the people have poor, 87.88 percent have moderate while only 9.09percent have good quality of life. In terms of functional wellbeing of patient 3.03 percent of the peoplehave poor, 60 percent have moderate while only 36.97 percent have good quality of life. The quality of lifein terms of cost showed that 11.52 percent of the patient had poor, 73.93 percent had moderate, and 14.55percent of the patient has good quality of life. The quality of life in terms of limitation due to signs andsymptoms showed that 1.21 percent of the patient have poor, 81.82 percent have moderate whereas 16.97percent of the patient had good quality of life. The weak positive correlation (r=0.48) was found betweenMELD and CTP score.Conclusion: The study concluded that only 35.2 percent of the patient have moderate quality of life, morethan half (64.2%) of the patient have good quality of life. So, the effective steps need to be taken to improvethe quality of life among patients with Chronic Liver Diseases.

Gender-related disparities in the frequencies of PD-1 and PD-L1 positive peripheral blood T and B lymphocytes in patients with alcohol-related liver disease: a single center pilot study.

BackgroundExposure to excessive alcohol consumption dysregulates immune signaling. The programed cell death 1 (PD-1) receptor and its ligand PD-L1 play a critical role in the protection against immune-mediated tissue damage. The aim of our study was evaluation of the PD-1/PDL-1 expression on peripheral T and B lymphocytes, its correlation with markers of inflammation and the severity of liver dysfunction in the course of alcohol-related liver disease (ALD).Material and MethodsFifty-six inpatients with ALD (38 males, 18 females, aged 49.23 ± 10.66) were prospectively enrolled and assigned to subgroups based on their: (1) gender, (2) severity of liver dysfunction (Child-Pugh, MELD scores, mDF), (3) presence of ALD complications, and followed for 30 days. Twenty-five age- and gender-matched healthy volunteers served as the control group. Flow cytometric analysis of the PD-1/PD-L1 expression on peripheral lymphocyte subsets were performed.ResultsGeneral frequencies of PD-1/PD-L1 positive T and B subsets did not differ between the ALD and control group. When patients were analyzed based on their gender, significantly higher frequencies of PD1/PD-L1 positive B cells in ALD females compared to controls were observed. ALD females presented with significantly higher frequencies of PD-1+ and PD-L1+ B cells, as well as PD-L1+ all T cell subsets in comparison with ALD males. The same gender pattern of the PD-1/PDL1 expression was found in the subgroups with mDF > 32 and MELD > 20. No correlations of PD-1+ and PD-L1+ lymphocyte percentages with mDF, CTP and MELD scores, nor with complications of ALD were observed. Significant correlations of PD-L1 positive B cell frequencies with conventional markers of inflammation were found.ConclusionsGender-related differences in the frequencies of PD-1/PD-L1 positive T and B cells were observed in patients with ALD. Upregulation of PD-1+/PD-L1+ lymphocytes paralleled both the severity of alcoholic hepatitis and liver dysfunction in ALD females.

Serum C-reactive Protein Predicts Early Mortality in Patients with Decompensated Cirrhosis of Liver

Serum C-reactive protein is a marker of systemic inflammation, which has been studied to predict mortality and cirrhosis related complication in decompensated cirrhosis of liver. To evaluate the role of serum C- reactive protein as a predictor of early mortality in patients with decompensated cirrhosis of liver. This was a prospective observational study, carried out in the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka between October 2017 to February 2019. A total of 89 patients with decompensated cirrhosis of liver were included in the study. Baseline serum CRP was measured and patients were longitudinally followed for a period of 30 days. Patients were divided into two groups, survival and non-survival. The groups were compared of CRP level, CTP score, MELD score and cirrhosis related complications. Chi-Square test was used to analyze the categorical variables and Student t-test was used to analyze continuous variables. Receiver-operator characteristic curve was used to detect serum CRP level for prediction of mortality within 30 days. The mean age was found 49.02±13.90 years in survival group and 47.52±11.30 years in non-survival group. Male patients were predominant in both groups. Total WBC count, serum CRP, serum sodium, serum bilirubin, CTP score &amp; MELD score were statistically significant (p&lt;0.05) between the groups. In multivariate analysis, only serum CRP level (OR 1.075, 95% CI, 1.027-1.122%, p=0.001) was found significantly associated with mortality within 30 days. Receiver-operator characteristic (ROC) was constructed, using serum CRP level, which gave a cut off value of 31mg/L, with 78% sensitivity and 90% specificity for prediction of mortality within 30 days. Elevated serum CRP level is an independent predictor of early mortality in patients with decompensated cirrhosis of liver. It was also observed that, high serum CRP level was associated with increased frequency of cirrhosis related complications.&#x0D; Bangladesh Med J. 2020 Jan; 49 (1): 1-6

A study on outcome of patients with acute-on-chronic liver failure at a tertiary care hospital

Acute-on-chronic liver failure (ACLF) is relatively recent entity and is not well described in the literature. The term acute-on-chronic liver failure was first used in 1995 to describe a condition in which two insults to the liver are operating simultaneously, one of them being ongoing and chronic and the other one acute. However, a clear definition of ACLF is still lacking, and this term is being used to mean different entities by different clinicians. Any patient who had underlying chronic liver disease with superimposed acute insult is being labeled as having ACLF. Whatsoever may be the case the most important is the denominator, the presence or absence of underlying liver disease. Prospectively collected data of all patients included demographics, clinical presentation, course in hospital and outcome. All patients had routine hematological biochemical and liver function tests. The etiology of superimposed acute event and chronic liver disease was investigated in detail and prognostic scores were calculated within 24hrs of admission. 60 patients included in our study were followed up for next three months, of which 30 patients died and 30 patients survived. All patients were classified in Child- Pugh class based on CTP score. There were only three patients Child-Pugh class A and none of them died. Child- Pugh class B had 10 patients, out of these 2 patients died & 8 patients survived. Total 47 patients were classified in Child-Pugh class C and 28 (59.57%) & this difference was statistically significant (p=0.013). According EASL-CLIF consortium grading, 23 out of 30 patients of Grade 3 ACLF, 5 out of 16 Grade 2 ACLF, 2 out of 11 Grade 1 ACLF & none of the Grade 0 ACLF patients died. These findings are statistically very much significant (P=0.0001). Even MELD score was significantly high among Non survivors when compared to the Survivors. (30.04 ± 2.37 Vs 25.53 ± 1.81) (p=0.0001).

Observational study on the response of tenofovir monotherapy versus tenofovir plus telbivudine dual therapy in patients with hepatitis B virus related acute on chronic liver failure.

Introduction:HBV is major health problem globally due to complications, including ACLF, cirrhosis and hepa¬tocellular carcinoma. ACLF due to exacerbation of CHB is associate with 30%-70% mortality. Reduction of HBV-DNA is therefore a target of therapy in ACLF-B.Methods:Patients with spontaneous reactivation of HBV [(ALT >5×ULN or >2× baseline) and HBV-DNA >20,000 IU/ml] were randomized to Tenofovir mono therapy (300 mg/day) or Tenofovir plus Telbivudine (600 mg/day) dual therapy with standard care. Clinical and biochemical parameters were evaluated at baseline, 1 week, 4 weeks and at 3 months. Virological evaluation was done at baseline and at 3 months. Primary end points were reduction of HBV-DNA and resolution of ascites, as applied. Secondary end point was reduction of liver related complications, therapy related adverse effects and survival at 3 months.Results:27 patients were enrolled. 15 received mono therapy with Tenofovir and 12 received dual therapy (Tenofovir plus Telbivudine). Baseline parameters in 2 groups had no significant difference. In both groups there was significant improvement of S. bilirubin, ALT, INR, CTP score and MELD score. Only MELD score showed significant improvement in patient with dual therapy at 3 months in comparison to mono therapy. 11 patients on Tenofovir mono therapy (n=15) showed undetected HBV-DNA (91.7%) at 3 months and one patient had detectable HBV-DNA (<2,000 IU/ml). 10 patients on dual therapy (n=12) had undetectable HBV-DNA (100%). Ascites resolved in 3 patients in both groups. Patients receiving dual therapy showed significant improvement in AKI on follow up compared to those on Tenofovir mono therapy. Among 5 deaths, 3 received mono therapy with Tenofovir and 2 dual therapy. Predictors of mortality had high S. bilirubin, HBV-DNA, MELD score and CTP score.Conclusion:In spontaneous reactivation of HBV presenting as ACLF, combination of Telbivudine plus Tenofovir is safer with less nephrotoxicity and better outcomes.

Role of tenofovir and telbivudine in treatment of hepatitis B related acute on chronic liver failure.

Introduction:ACLF is characterized by acute deterioration of liver function in patients with chronic liver disease. HBV is one of the most important causes of both acute insult and underlying chronic liver disease in ACLF. Reactivation of HBV is one of the common causes of ACLF in our region. ACLF requires multiple organ support and is associated with high short and medium term mortality. This is the reason why early, rapid reduction of HBV DNA is essential in treating ACLF-B.Methods:Consecutive patients of ACLF-B due to spontaneous reactivation of HBV (ALT> 5xULN or >2 x baseline and HBV DNA >20,000 IU/ml) were randomized into tenofovir group (300mg/day) and telbivudine group (600mg/day) along with standard medical treatment. Clinical and laboratory parameters were evaluated at baseline, day-7, day-14, day-30 and day-90. HBV DNA was evaluated at baseline and after three months of therapy. Primary end point was survival or death at three months. Secondary end point was improvement of liver function assessed by Child-Turcotte Pugh score and MELD score at three months.Results:30 patients were enrolled in the study and 15 of them received tenofovir and 15 patients received telbivudine. Most of the baseline parameters showed no difference except serum AST and serum creatinine level that showed statistically significant difference between two groups. After antiviral therapy both groups showed significant clinical improvement along with CTP and MELD scores. However statistically significant improvement between tenofovir and telbivudine groups was only seen with MELD score. Survival rate was 80% in tenofovir group and 60% in telbivudine group, but this was not statistically significant. Low serum albumin at baseline was predictor of mortality.Conclusion:In patients of ACLF-B, antiviral therapy with both tenofovir and telbivudine improve liver function, but there is no statistically significant difference in survival between tenofovir and telbivudine.

Impact of metabolic risk factors on the severity and outcome of patients with alcohol-associated acute-on-chronic liver failure.

Metabolic risk factors may impact the severity and outcome of alcoholic liver disease. The present study evaluated this effect in patients with alcohol-associated acute-on-chronic liver failure (ACLF). One thousand two hundred and sixteen prospectively enrolled patients with ACLF (males 98%, mean age 42.5±9.4years, mean CTP, MELD and AARC scores of 12±1.4, 29.7±7 and 9.8±2 respectively) from the Asian Pacific Association for the Study of the Liver (APASL) ACLF Research Consortium (AARC) database were analysed retrospectively. Patients with or without metabolic risk factors were compared for severity (CTP, MELD, AARC scores) and day 30 and 90 mortality. Information on overweight/obesity, type 2 diabetes mellitus (T2DM), hypertension and dyslipidaemia were available in 1028 (85%), 1019 (84%), 1017 (84%) and 965 (79%) patients respectively. Overall, 392 (32%) patients died at day 30 and 528 (43%) at day 90. Overweight/obesity, T2DM, hypertension and dyslipidaemia were present in 154 (15%), 142 (14%), 66 (7%) and 141 (15%) patients, respectively, with no risk factors in 809 (67%) patients. Patients with overweight/obesity had higher MELD scores (30.6±7.1 vs 29.2±6.9, P=.007) and those with dyslipidaemia had higher AARC scores (10.4±1.2 vs 9.8±2, P=.014). Overweight/obesity was associated with increased day 30 mortality (HR 1.54, 95% CI 1.06-2.24, P=.023). None of other metabolic risk factors, alone or in combination, had any impact on disease severity or mortality. On multivariate analysis, overweight or obesity was significantly associated with 30-day mortality (aHR 1.91, 95% CI 1.41-2.59, P<.001), independent of age, CTP, MELD and AARC scores. Overweight/obesity and dyslipidaemia increase the severity of alcohol-associated ACLF, and the former also increases the short-term mortality in these patients.

A Comparison of Serum Bilirubin, CTP and Meld Score in Patients with HBV-ACLF

A Comparison of Serum Bilirubin, CTP and Meld Score in Patients with HBV-ACLF

Application of Hepatic Venous Pressure Gradient to Predict Prognosis in Cirrhotic Patients with a Low Model for End-Stage Liver Disease Score.

Background/aim: We aimed to derive a model representing the dynamic status of cirrhosis and to discriminate patients with poor prognosis even if the Model for End-Stage Liver Disease (MELD) score is low. Methods: This study retrospectively enrolled 700 cirrhotic patients with a MELD score of less than 20 who underwent hepatic venous pressure gradient (HVPG) measurement. A model named H6C score (= HVPG + 6 × CTP score) to predict overall survival was derived and internal and external validations were conducted with the derivation and validation cohorts. Results: The H6C score using the HVPG was developed based on a multivariate Cox regression analysis. The H6C score showed a great predictive power for overall survival with a time-dependent AUC of 0.733, which was superior to that of a MELD of 0.602. In patients with viral etiology, the performance of the H6C score was much improved with a time-dependent AUC of 0.850 and was consistently superior to that of the MELD (0.748). Patients with an H6C score below 45 demonstrated an excellent overall survival with a 5-year survival rate of 91.5%. Whereas, patients with an H6C score above 64 showed a dismal prognosis with a 5-year survival rate of 51.1%. The performance of the H6C score was further verified to be excellent in the validation cohort. Conclusion: This new model using the HVPG provides an excellent predictive power in cirrhotic patients, especially with viral etiology. In patients with H6C above 64, it would be wise to consider early liver transplantation to positively impact long-term survival, even when the MELD score is low.

S3284 Portosystemic Encephalopathy (PSE) Recurrence in Cirrhotic Patients and Its Risk Factors

INTRODUCTION: Recurrence PSE in the cirrhotic patients is associated with worse outcomes. It is important to assess the risk factors for recurrent PSE so that appropriate prevention and prognostication can be done. METHODS: It is a retrospective study done in the section of Gastroenterology, The Aga Khan University Hospital, Karachi, Pakistan from Jan 1, 2019, till December 31, 2019. Patients who were admitted with the first time with PSE and admitted within 3 months of index PSE were enrolled in the study. Grading of PSE Grade (I-VI), laboratory tests(Bilirubin, Albumin, Creatinine ), ascites with SBP, gastrointestinal bleeding (GIB), acute kidney injury ( AKI) and( CTP, MELD) were collected by chart review and analyzed by SPSS version 20. RESULTS: Total 61 patients were included in study and 10 were lost to follow up. Mean age was 59+/- 10, male were 58 %. Diabetic were (64%) and 54% were hypertensive. As per etiology HCV (59%) ,HBV(27%), Alcohol(7%),other (7%).Out 51 patients 33 readmitted with PSE, 6 were expired and rest followed in clinic. Risk factors were UTI ( 19%),AKI (15%),Constipation(15%),Hyponatremia(14%),SBP( 12%),Hypokalemia (13%), GIB (8%) .Most of patient were in CTP score C ,(75%),CTP Score B (25%).MELD >18 ( 65%), TB > 3( 41%), >6(10%),< 3(49%) and Albumin >3.5 (42%), < 2.8(20%),2.8-3.5(38%).PSE Grade 1-2( 42%),PSE-3(39%),PSE-4(19%).All patients who were expired were in PSE-4 with raised creatinine >3. CONCLUSION: MELD score >18, raised TB > 6mg/dl, decreased sodium and low Albumin significantly associated with PSE recurrence.

Assessing the prognostic scores for the prediction of the mortality of patients with acute-on-chronic liver failure: a retrospective study.

BackgroundAcute-on-chronic liver failure (ACLF), which is characterized by rapid deterioration of liver function and multiorgan failure, has high mortality. This study was designed to identify prognostic scores to predict short-term and long-term outcome in patients with ACLF to facilitate early treatment and thereby improve patient survival.Materials and MethodsWe retrospectively analyzed 102 ACLF patients who were hospitalized in the gastroenterology department. The EASL-CLIF criteria were used to define the ACLF. The demographic characteristics and biochemical examination results of the patients were acquired, and seven scores (CTP score, MELD score, MELD-Na, CLIF ACLF score, CLIF-C OF score, and CLIF SOFA score) were calculated 24 h after admission. All patients were observed until loss to follow-up, death, or specific follow-up times (28 days, 3 months, and 6 months), which were calculated after the initial hospital admission. The receiver operating characteristic (ROC) curve was employed to estimate the power of six scores to forecast ACLF patients’ outcome.ResultsAll scores were distinctly higher in nonsurviving patients than in surviving patients and had predictive value for outcome in patients with ACLF at all time points (P < 0.050). The areas under the ROC curve (AUROCs) of the CLIF-SOFA score were higher than those of other scores at all time points. The comparison of the AUROC of the CLIF-SOFA score with other scores was statistically significant at 28 days (P < 0.050), which was the only time point at which it was greater than 0.800.ConclusionPatients with ACLF have high mortality. These six scores are effective tools for assessing the prognosis of ACLF patients. The CLIF-SOFA score is especially effective for evaluating 28-day mortality.