Higher Incidence Of Hepatic Encephalopathy Research Articles

Comparison of Endoscopic Ultrasound-guided Cyanoacrylate Injection and Transjugular Intrahepatic Portosystemic Shunt in the Prevention of Gastric Varices Rebleeding.

The purpose of this study was to investigate the efficacy and safety of endoscopic ultrasound (EUS)-guided injection of cyanoacrylate (CYA) and transjugular intrahepatic portal shunts (TIPSs) in the treatment of patients with cirrhosis with ruptured gastric varices. In this retrospective study, 105 patients with liver cirrhosis and gastric varicose veins who were admitted to the First Affiliated Hospital of Anhui Medical University between April 2018 and April 2023 without nonselective β-blockers treatment and no portal vein thrombosis were evaluated. The patients were divided into the transjugular intrahepatic portal shunt (TIPS) group (n = 60) and the EUS-CYA group (n = 45) for the purpose of evaluating postoperative rebleeding rates, complications, survival rates, and other factors. During the follow-up, there was no significant difference in the rebleeding rates between the TIPS group and EUS-CYA group within 3 months (5% vs 2.2%; P = 0.825; 10% vs 20%, P = 0.147). However, the TIPS group had significantly lower rebleeding rates than the EUS-CYA group at 6 months (10% vs 33.3%; P = 0.030) and 1 year or longer (11.7% vs 42.2%; P < 0.01). In terms of hepatic encephalopathy, the incidence rate of the TIPS group was significantly higher than that of the EUS-CYA group (20% vs 2.2%; P = 0.006). In addition, there was no difference in the survival rates between the two groups (93.3% vs 97.8%; P = 0.552). TIPS is superior to EUS in preventing rebleeding in patients with ruptured varices of the fundus, but it has a higher incidence of hepatic encephalopathy, and there is no difference in long-term survival between the two groups.

Spleen volume is associated with overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with portal hypertension.

Portal shunt and immune status related to the spleen are related to the occurrence of hepatic encephalopathy (HE). It is unknown whether spleen volume before transjugular intrahepatic portosystemic shunt (TIPS) is related to postoperative HE. To investigate the relationship between spleen volume and the occurrence of HE. This study included 135 patients with liver cirrhosis who underwent TIPS, and liver and spleen volumes were elevated upon computed tomography imaging. The Kaplan-Meier curve was used to compare the difference in the incidence rate of HE among patients with different spleen volumes. Univariate and multivariate Cox regression analyses were performed to identify the factors affecting overt HE (OHE). Restricted cubic spline was used to examine the shapes of the dose-response association between spleen volumes and OHE risk. The results showed that 37 (27.2%) of 135 patients experienced OHE during a 1-year follow-up period. Compared with preoperative spleen volume (901.30 ± 471.90 cm3), there was a significant decrease in spleen volume after TIPS (697.60 ± 281.0 cm3) in OHE patients. As the severity of OHE increased, the spleen volume significantly decreased (P < 0.05). Compared with patients with a spleen volume ≥ 782.4 cm3, those with a spleen volume < 782.4 cm3 had a higher incidence of HE (P < 0.05). Cox regression analysis showed that spleen volume was an independent risk factor for post-TIPS OHE (hazard ratio = 0.494, P < 0.05). Restricted cubic spline model showed that with an increasing spleen volume, OHE risk showed an initial increase and then decrease (P < 0.05). Spleen volume is related to the occurrence of OHE after TIPS. Preoperative spleen volume is an independent risk factor for post-TIPS OHE.

The Impact of Race and Sex on the Clinical Outcomes of Homeless Patients With Alcoholic Liver Disease: Propensity Score Matched Analysis of US Hospitals.

Among patients with alcoholic liver disease (ALD), homelessness poses significant medical and psychosocial risks; however, less is known about the effects of race and sex on the hospital outcomes of admitted homeless patients with ALD. The National Inpatient Sample database from 2012 to 2017 was used to isolate homeless patients with ALD, and the cohort was further stratified by race and sex for comparisons. Propensity score matching was utilized to minimize covariate confounding. The primary endpoints of this study include mortality, hospital length of stay, and hospital costs; secondary endpoints included the incidence of liver complications. There were 3972 females/males postmatch, as well as 2224 Blacks/Whites and 4575 Hispanics/Whites postmatch. In multivariate, there were no significant differences observed in mortality rate, length of stay, and costs between sexes. Comparing liver outcomes, females had a higher incidence of hepatic encephalopathy [adjusted odds ratio (aOR) 1.02, 95% CI: 1.01-1.04, P <0.001]. In comparing Blacks versus Whites, Black patients had higher hospitalization costs (aOR 1.13, 95% CI: 1.03-1.24, P =0.01); however, there were no significant differences in mortality, length of stay, or liver complications. In comparing Hispanics versus Whites, Hispanic patients had longer length of hospital stay (aOR 1.12, 95% CI: 1.06-1.19, P <0.001), greater costs (aOR 1.15, 95% CI: 1.09-1.22, P <0.001), as well as higher prevalence of liver complications including varices (aOR 1.04, 95% CI: 1.02-1.06, P <0.001), hepatic encephalopathy (aOR 1.03, 95% CI: 1.02-1.04, P <0.001), and hepatorenal syndrome (aOR 1.01, 95% CI 1.00-1.01, P =0.03). However, there was no difference in mortality between White and Hispanic patients. Black and Hispanic ALD patients experiencing homelessness were found to incur higher hospital charges; furthermore, Hispanic patients also had greater length of stay and higher incidence of liver-related complications compared with White counterparts.

SODIUM AND CALCIUM LEVELS IN PATIENTS WITH CIRRHOSIS OF THE LIVER AND ITS CORRELATION WITH HEPATIC ENCEPHALOPATHY

Introduction: Patients with chronic liver disease have a specific susceptibility to an electrolyte imbalance that can deteriorate their condition to hepatic encephalopathy. It occursin about 57% of hospitalized patients with cirrhosis. Hyponatremia in cirrhosis is an in dependent risk factor for mortality and is common in patients with end-stage liver disease. These patients had a significantly higher incidence of hepatic encephalopathy, hepatorenal syndrome, and spontaneous bacterial peritonitis. Hepatic encephalopathy is worsened by the presence of hyponatremia and hypocalcemia. Aim:The aim of this study is to evaluate sodium and calcium levels in CLD patients and its correlation with hepatic encephalopathy. Methods: This cross-sectional study was conducted in SMHS Hospital,Govt.Medical College Srinagar, Jammu Kashmir,India, during a three-year period. 150 patients with chronic liver disease admitted to the general medicine and gastroenterology department were included. Data was entered in SPSS software version 20. Qualitative data were analyzed using chi-square, and quantitative data were analyzed using independent t-tests. A P-value &lt;0.05 was considered significant. Results: Our study on 150 CLD patients showed that the serum sodium level and serum calcium level were significantly lower in patients with hepatic encephalopathy with P-Values of 0.0006 and 0.002, respectively. Conclusion: It seems that reducing serum sodium and calcium level can be predictive of hepatic encephalopathy inpatients with chronic liver disease.

S1302 Effect of Bed Size of the Hospital on the Risk of Development of Acute on Chronic Liver Failure (ACLF) in Patients With Decompensated Cirrhosis

Introduction: The healthcare cost and utilization project has classified hospitals as small, medium, and large bed size. This division is based on the hospital's region, location, and teaching status. To our knowledge, there have been no studies assessing the impact of bed size on the development of acute on chronic liver failure (ACLF) in patients with decompensated cirrhosis. We hypothesize that large bed size hospitals care for a sicker population and admitted patients have a higher incidence and risk of developing ACLF. Methods: We queried the National Inpatient Sample (NIS) database using ICD-10 codes. ACLF was defined as the presence of renal failure or hepatic encephalopathy and one other organ dysfunction or two non-renal organ failures in patients with cirrhosis and a decompensating event. Decompensating events were defined as presence of ascites, varices, hepatic encephalopathy, or infection. The relationship between hospital bed size and ACLF in patients with decompensated cirrhosis was examined using multivariate analysis. Results: A total of 1.78 million adult patients were admitted with a diagnosis of acute decompensation of cirrhosis. Of these, 945,440 (52.8%) were admitted to large bed size hospitals. Patients admitted to large bed size hospitals had a higher incidence of hepatic encephalopathy, ascites, and variceal bleeding. Patient demographics are presented in Table. Of the total patients admitted with a decompensating event, 830,365 patients (46.4%) met criteria for ACLF. A total of 453,095 patients (54.6%) who developed ACLF were admitted to large bed size hospitals. Our study found that patients admitted to large bed size hospitals have 20% higher odds of developing ACLF (aOR-1.20, 95% CI-1.17-1.23, p< 0.001). Large bed size hospitals were also associated with a higher risk of developing ACLF grades 2 and 3 (aOR-1.27, 95% CI-1.24-1.32, p< 0.001 and aOR-1.73, 95% CI-1.51-1.98, p< 0.001, respectively). Conclusion: Our study identifies hospital bed size as a significant predictor for development of ACLF in patients admitted with decompensated cirrhosis. Targeted education and implementation of best practices focused on large hospitals may help reduce the risk of ACLF. Table 1. - Characteristics of patients with decompensated cirrhosis stratified by bed size of the hospital Small bed size Medium bed size Large bed size Age category < 0.001 18-44 31,090 (9.47) 50,045 (9.73) 101,445 (10.73) 45-64 171,485 (52.23) 272,360 (52.93) 512,485 (54.21) >65 125,725 (38.3) 192,165 (37.34) 331,510 (35.06) Gender < 0.001 Males 189,850 (57.83) 300,920 (58.48) 556,670 (58.88) Females 138,450 (42.17) 213,650 (41.52) 388,770 (41.12) Race < 0.001 White 227,390 (69.26) 340,635 (66.2) 625,285 (66.14) Black 29,690 (9.04) 48,575 (9.44) 92,860 (9.82) Hispanic 50,625 (15.42) 91,275 (17.74) 162,900 (17.23) Asian/Pacific Islander 6,020 (1.83) 9,455 (1.84) 21,015 (2.22) Primary expected payer < 0.001 Medicare 162,880 (49.61) 247,930 (48.18) 441,145 (46.66) Medicaid 77,670 (23.66) 123,200 (23.94) 244,975 (25.91) Private 60,210 (18.34) 96,575 (18.77) 178,480 (18.88) Uninsured 16,945 (5.16) 29,410 (5.72) 50,160 (5.31) Median household income < 0.001 Lowest quartile 95,060 (28.96) 172,670 (33.56) 350,665 (37.09) Second quartile 90,575 (27.59) 135,295 (26.29) 250,605 (26.51) Third quartile 82,330 (25.08) 116,010 (22.55) 207,695 (21.97) Highest quartile 60,335 (18.38) 90,595 (17.61) 136,475 (14.44) Region of hospital < 0.001 Northeast 66,420 (20.23) 94,705 (18.4) 129,295 (13.68) Midwest 67,370 (20.52) 75,890 (14.75) 208,140 (22.02) South 130,055 (39.61) 238,385 (46.33) 365,320 (38.64) West 64,455 (19.63) 105,590 (20.52) 242,685 (25.67) Location < 0.001 Rural 16,570 (5.05) 24,690 (4.8) 86,345 (9.13) Urban 311,730 (94.95) 489,880 (95.2) 859,095 (90.87) Hospital teaching status < 0.001 Non-Teaching 71,525 (21.79) 150,630 (29.27) 292,045 (30.89) Teaching 256,775 (78.21) 363,940 (70.73) 653,395 (69.11) Etiology Alcoholic liver disease 156,510 (47.67) 244,380 (47.49) 446,455 (47.22) 0.3666 Hepatitis C 34,540 (10.52) 56,480 (10.98) 100,680 (10.65) 0.1372 Decompensations Hepatic encephalopathy 115,795 (35.27) 185,220 (36.00) 354,280 (37.47) < 0.001 Ascites 186,590 (56.84) 300,505 (58.4) 582,875 (61.65) < 0.001 Varices 24,005 (7.31) 42,230 (8.21) 75,715 (8.01) < 0.001 Bacterial infections 145,525 (44.33) 221,525 (43.05) 386,985 (40.93) < 0.001 ACLF 142,565 (43.43) 234,705 (45.61) 453,095 (47.92) < 0.001

Prediction of Patient Hepatic Encephalopathy Risk with Freiburg Index of Post-TIPS Survival Score Following Transjugular Intrahepatic Portosystemic Shunts: A Retrospective Study.

BackgroundHepatic encephalopathy is a complication of portal hypertension. The Freiburg index of transjugular portosystemic shunt (TIPS) and patient outcomes have recently been described. This retrospective study was conducted at a single center in China and included 241 patients with portal hypertension who underwent TIPS implantation to evaluate the Freiburg index of post-TIPS survival score (FIPS) to predict hepatic encephalopathy.MethodsA single-center retrospective study including 241 patients who underwent TIPS operation between April 2015 and July 2019 was conducted. Clinical demographics and relevant clinical parameters within 24h after admission were collected. The prediction performances of FIPS, Child–Pugh and the model for end-stage liver disease (MELD) scores were compared by decision curve analysis and receiver operating characteristic (ROC) curve analysis. In addition, multivariate analyses were performed to identify independent predictors.ResultsEighty-three out of 241 patients (34.4%) finally developed post-TIPS hepatic encephalopathy. The area under the ROC curve of FIPS was 0.744 (95% confidence interval: 0.684–0.798). FIPS was identified as an independent risk factor for post-TIPS hepatic encephalopathy (hazard ratio: 2.23, 95% confidence interval: 1.71–2.90, p<0.001). Moreover, we further grouped the FIPS scores into two categories (FIPS ≤-0.97, low-risk; FIPS >-0.97, high risk) to improve its applicability. Patients with high FIPS scores had a significantly higher incidence of hepatic encephalopathy than patients with low FIPS scores (P<0.05).ConclusionThis study showed that FIPS could be used to evaluate the risk of hepatic encephalopathy in this patient group with improved predictive performance when compared with the Child–Pugh and MELD scores.

The improvement in body composition including subcutaneous and visceral fat reduces ammonia and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt.

BackgroundSarcopenia and myosteatosis have been associated to a poor prognosis of cirrhosis and to a higher incidence of hepatic encephalopathy (HE). The prognostic implications of visceral and subcutaneous adiposity are less known.AimTo evaluate the modifications of visceral and subcutaneous adipose tissue after TIPS and to investigate their relationships with the modification of muscle mass and with the incidence of post‐TIPS HE.Patients and Methods35 cirrhotic patients submitted to TIPS were retrospectively studied. The modification of skeletal muscle index (SMI), muscle attenuation (myosteatosis), subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), assessed by CT‐scan and plasma ammonia were evaluated before and after a mean follow‐up of 19 ± 15 months after TIPS. The number of episodes of overt HE was also recorded.ResultsDuring the follow‐up, the mean SMI and muscle attenuation increased significantly; SATI significantly increased while VATI significantly decreased, although not uniformly in all patients. By comparing the patients with or without improvement in their nutritional status after TIPS, MELD remained stable while the number of episodes of overt HE was significantly lower in the patients with improved SMI and in the patients with improved SATI. Finally, inverse correlation was observed between the variation of ammonia and SATI (r = −.40; P < .05).ConclusionIn addition to muscle mass, adipose tissue is modified after TIPS. The improvement of subcutaneous adipose tissue as well as of sarcopenia and myosteatosis is associated to the amelioration of cognitive impairment independently of liver function. The correlation between adipose tissue and ammonia modification may suggest an active role of the adipose tissue in the inter‐organ ammonia trafficking.

The prognosis and incidence of hepatic encephalopathy of patients with liver cirrhosis treated with proton pump inhibitors: A multicenter retrospective study in Japan.

Gastrointestinal bleeding, hepatic encephalopathy (HE), and hepatocarcinogenesis are associated with the prognosis of patients with liver cirrhosis (LC). Proton pump inhibitors (PPIs) have been used to prevent bleeding, however the effects of PPIs on overall survival have not yet been elucidated. Therefore, this multicenter retrospective study aimed to assess the effect of PPI on the prognosis and HE occurrence of the patients with liver cirrhosis in Japan.A total of 456 patients diagnosed with LC at the 4 institutes during the study period (2010–2014) were assessed. PPI-treated and non-treated patients were compared using propensity score matching analysis. Primary and secondary endpoints of the study were set as the occurrence of HE and overall survival, respectively.A comparison of all cases showed a significantly poorer hepatic reserve function in the PPI-treated patients. The propensity-score matching analysis was performed and 120 PPI-treated patients were 1:1 matched with non-treated patients. The analysis revealed a higher incidence of HE in the PPI-treated than in the non-treated patients (P = .032; hazard ratio [HR], 2.162; 95% confidence interval [CI], 1.066–4.176), but the prognosis of PPI-treated patients was no worse than that of non-treated patients (P = .676; HR, 1.101; 95% CI, 0.702–1.726).This retrospective study showed that PPI administration for the patients with liver cirrhosis may partly be related to the increased incidence of HE but not worsen the patient prognosis.

Transjugular intrahepatic portosystemic shunt in patients treated with a balloon tamponade for variceal hemorrhage without response to high doses of vasoactive drugs: A real-world multicenter retrospective study.

To evaluate the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) and non-TIPS therapy (endoscopy and/or nonselective beta-blockers [NSBB]) in patients with cirrhosis and active variceal hemorrhage who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis. Medical records of cirrhotic patients who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis at five university hospitals in China between January 2011 and December 2018 were reviewed. Treatment outcomes were compared between the TIPS and the non-TIPS groups. Treatment failure of variceal hemorrhage within 5 days was reported in six patients of the non-TIPS group (N=70) and none of the TIPS group (N=66) (P=.028). The TIPS group had a higher 1-year variceal rebleeding-free rate compared with the non-TIPS group (95.5% vs 60.0%, P < .001). One patient treated with TIPS and nine with non-TIPS therapy experienced rebleeding within 5 days and 6 weeks after the intervention (P=.009). The cumulative 1-year survival rate was higher in the TIPS group than in the non-TIPS group (93.9% vs 78.6%, P=.01). The TIPS group had a higher incidence of hepatic encephalopathy within one year compared with the non-TIPS group (18.2% vs 4.3%, P=.026). For patients with cirrhosis and active variceal bleeding who do not respond to high-dose vasoactive agents and require a balloon tamponade for hemostasis, TIPS may be an appropriate treatment choice.

Low Serum 25-Hydroxy Vitamin D (25-OHD) and Hepatic Encephalopathy in HCV-Related Liver Cirrhosis.

Background Patients with liver cirrhosis experience a large variety of metabolic disorders associated with more hepatic decompensation. Hepatic encephalopathy (HE) is a significant complication in liver cirrhosis patients, presenting a wide spectrum of neuropsychological symptoms. A deficiency of 25-hydroxy vitamin D (25-OHD) in the general population is associated with a loss of cognitive function, dementia, and Alzheimer's disease. Aim of the Study. Our study aims to check the relationship between low serum 25-OHD and HE in patients with HCV-related liver cirrhosis and assess its link with patient mortality. Patients and Methods. This study was observationally carried out on 100 patients with HCV-related liver cirrhosis. The patients were divided into 2 groups: Group A—included 50 HCV-related cirrhotic patients with HE, and Group B—included 50 HCV-related cirrhotic patients without HE. Assessment of disease severity using the end-stage liver disease (MELD) model and Child Turcotte Pugh (CTP) scores were done, and 25-OHD levels were measured. Comparison of vitamin D levels in different etiologies and different CTP categories was made using one-way ANOVA. Pearson's correlation between the level of vitamin D and other biomarkers was applied. Results There was a statistically significant Vitamin D level difference between the two groups. A lower level of vitamin D was observed in the HE group where the severe deficiency was 16%, while it was 6% in the other group and the moderate deficiency was 24% in HE group as compared to 10% in the other group. The insufficient vitamin D level represented 46% of the non-HE group while none of the HE group falls in this category. Vitamin D level was statistically higher in Grade 1 HE than in Grade 2 which is higher than in Grades 3 to 4. Vitamin D level was also significantly higher in those who improved from HE as compared to those who died. Conclusion The lower levels of 25-OHD were associated with the higher incidence of HE in cirrhotic HCV patients. The worsening vitamin D deficiency was associated with increased severity of the liver disease, so vitamin D may be considered a prognostic factor for the severity of liver cirrhosis and high mortality rate in HE patients.

S1033 Clinical Characteristics and Mortality in Hospitalized Patients With Acetaminophen-Induced Acute Liver Failure in the United States

INTRODUCTION: Acetaminophen toxicity is a common cause of acute liver failure (ALF) in the United States. In this study, we systematically evaluate the liver-related risk factors associated with mortality in hospitalized patients with acetaminophen-induced ALF using a national database. METHODS: The analysis was performed using the 2011–2017 National Inpatient Sample. ICD-9/10 codes were used to select patients with acetaminophen-induced acute liver failure, who were further stratified according to survival status. Univariate and multivariate analysis were used to identify the risk factors associated with hospital mortality. RESULTS: Of the 2765 cases with acetaminophen-induced ALF identified from the database, 379 cases were deceased (13.7%). The deceased cohort was older (49.1 vs 42.4y P < 0.01), but no difference was found in gender distribution (female 72.3 vs 69% P = 0.22) and racial distribution (P = 0.65). In the deceased cohort, the length of stay was shorter (4.71 vs 7.61d P < 0.01) and hospitalization costs were higher ($119,470 vs $83,605 P < 0.01). In terms of hepatic events, the deceased cohort had a higher incidence of ascites (7.92 vs 2.93% P < 0.01, OR 2.84 95%CI 1.83–4.43), as well as higher incidences of ascites-mediated events including spontaneous bacterial peritonitis (1.32 vs 0.17% P < 0.01 OR 7.96 95%CI 1.70–40.3) and hepatorenal syndrome (7.92 vs 2.01% P < 0.01, OR 4.19 95%CI 2.62–6.7). The deceased cohort also had a higher incidence of hepatic encephalopathy (26.9 vs 13.3% P < 0.01, OR 2.39 95%CI 1.85–3.09), but no difference was found in the incidence of variceal bleeding (0.53 vs 0.13% P = 0.14 OR 4.21 95%CI 0.35–36.9). The deceased cohort had higher incidences of sepsis (35.4 vs 10.2% P < 0.01, OR 4.82 95%CI 3.76–6.19) and acute kidney injury (85 vs 39.6% P < 0.01, OR 8.60 95%CI 6.41–11.53). In a multivariate model, acute kidney injury (P < 0.01, aOR 5.90 95%CI 4.36–8.10) and sepsis (P < 0.01, aOR 2.76 95%CI 2.10–3.63) were strongly associated with increased mortality, despite controlling for age, gender, race, common comorbidities, liver etiologies, and hepatic events. CONCLUSION: Our findings from a national database reinforce the prognostic implications of sepsis and impaired renal function in hospitalized patients with acetaminophen-induced ALF. These patients therefore require early risk-assessment, followed by multidisciplinary management of sepsis and acute kidney injury with antibiotics and renal-preserving therapies.Figure 1.: Multivariate Model: acute kidney injury and sepsis are independent risk factors associated with hospital mortality in patients with acetaminophen-induced acute liver failure.

Comparison of the curative effect of transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stent and drug combined with gastroscopy as the secondary prevention of esophageal -gastric variceal bleeding in portal hypertension

Objective: To compare the clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) with expanded polytetrafluoroethylene (ePTFE)-covered stent and drug combined with gastroscopy as the secondary prevention of esophageal-gastric variceal bleeding in portal hypertension. Methods: Patients with esophageal-gastric variceal bleeding who received TIPS treatment (ePTFE covered stent) or gastroscopy for the first time as the secondary prevention for portal hypertension at Nanfang Hospital of Southern Medical University through March to July 2017 were selected. One year after the operation, liver function changes, ascites remission rates, incidence of hepatic encephalopathy, re-bleeding rate, average hospitalization frequency and expenses, survival time, as well as the TIPS patency conditions were analyzed in the two groups of patients. 2 test, Kaplan-Meier method and Mann-Whitney U test were used to analyze the data. Results: There were 74 and 66 cases in the TIPS and the drug combined gastroscopy group and the follow-up duration (14.57 ± 0.79) was 12-16 months. One year after surgery, the remission rate of ascites in the TIPS group was higher 57.1% (32/56) than that of the drug combined gastroscopy group (0), and the difference was statistically significant (χ(2) = 2 = 36.73, P < 0.01). The cumulative incidence of hepatic encephalopathy at 1, 3, 6, and 12 months after surgery in the TIPS group was 32.4% (24/74), 37.8% (28/74), 40.5% (30/74), and 40.5% (30/74), respectively. The cumulative incidence of hepatic encephalopathy in the drug combined gastroscopy group was 3.0% (2/66), 3.0% (2/66), 3.0% (2/66), and 6.1% (4/66), respectively. Kaplan-Meier analysis showed that the cumulative incidence of hepatic encephalopathy in the TIPS group was higher than that of the drug combined gastroscopy group (χ(2) = 11.29, P < 0.01). The incidence of severe hepatic encephalopathy ( grade III to IV) at 1, 3, 6, and 12 months after surgery in the TIPS group was 2.7% (2/74), 0, 0, and 0, respectively. The incidence of severe hepatic encephalopathy in drug combined gastroscopy group was 0, and there was no statistically significant difference in development of hepatic encephalopathy between the two groups (P > 0.05). The re-bleeding rates of TIPS group and drug combined gastroscopy group were 0 and 27.3% (18/66), respectively, and the difference was statistically significant (χ(2) = 22.42, P < 0.01). There was no death reported during the follow-up period between both groups. The hospitalization frequency times (1.45 ± 0.80) in TIPS group was lower than that of the drug combined gastroscopy group times (3.24 ± 1.80), and the difference was statistically significant (U = -4.52, P < 0.01). Conclusion: In the prevention of esophageal-gastric variceal bleeding, TIPS (ePTFE-covered stent) treatment has the advantages of reducing re-bleeding rate, high ascites remission rate and hospitalizations frequency. In addition, patients treated with TIPS have a higher incidence of hepatic encephalopathy than that of drugs combined with gastroscopy. However, TIPS did not exacerbate the incidence of hepatic encephalopathy, and there was no significant difference in the 1-year survival rate after TIPS and drugs combined with gastroscopy treatment.

Paracentesis-Induced Circulatory Dysfunction With Modest-Volume Paracentesis Is Partly Ameliorated by Albumin Infusion in Acute-on-Chronic Liver Failure.

Paracentesis-induced circulatory dysfunction (PICD) is a serious complication of large-volume (>5L) paracentesis in cirrhosis and is reduced with albumin infusion. There is a lack of data on PICD in acute-on-chronic liver failure (ACLF). Because ACLF patients have greater hemodynamic derangements than patients with decompensated cirrhosis, we investigated whether PICD could develop with modest-volume paracentesis (MVP) and the role of albumin infusion. A total of 80 ACLF patients undergoing <5L paracentesis were randomized to receive albumin (8 g/dL of ascitic fluid; n=40) or no albumin (n=40) and serially followed to detect PICD. Baseline characteristics were comparable between groups, including volume of ascitic tap (4.16±0.23 versus 4.14±0.27 L; P=0.72) and plasma renin activity (PRA; 20.5±7.03 versus 23.2±8.24ng/mL/hour; P=0.12). PICD was more frequent in the no-albumin group than the albumin group (70% versus 30%; P=0.001), with higher incidence of hepatic encephalopathy (50% versus 27.5%; P=0.04), hyponatremia (67.5% versus 22.5%; P<0.001), acute kidney injury (62.5% versus 30%; P=0.001), and in-house mortality (62.5% versus 27.5%; P=0.003). PRA of 25.15ng/mL at day 3 had sensitivity and specificity of 71% and 68%, respectively, for development of PICD at day 6. Albumin infusion decreased the incidence of PICD at day 6 (odds ratio, 0.068; 95% confidence interval, 0.011-0.43; P=0.005). PICD is common and develops even with MVP in ACLF patients. Albumin infusion decreases the incidence of PICD and mortality in patients with ACLF. Clinical trial identifier: NCT02467348.

Cystatin C and Sarcopenia Predict Acute on Chronic Liver Failure Development and Mortality in Patients on the Liver Transplant Waiting List.

Cystatin C (CysC) is an early biomarker of renal dysfunction scarcely studied in patients awaiting liver transplantation (LT). Sarcopenia is frequent in cirrhosis and impacts prognosis. We aimed to assess the capability of these factors to predict survival and acute-on-chronic liver failure (ACLF) in patients awaiting LT, as well as early post-LT outcomes. Single-center study that included all cirrhotic patients listed for LT between 2014 and 2017. Competing risk regression analysis was used to evaluate the capability of liver-, kidney-, and global status-related variables at waitlist (WL) inclusion to predict WL mortality and ACLF. Variables associated with post-LT outcomes were evaluated with logistic regression analysis. One-hundred-and-eighty patients were included. Fifty-six (31%) patients developed ACLF, 54 (30%) underwent LT and 35 (19%) died. In the adjusted competing risk regression analysis, CysC ≥ 1.5 mg/L, sarcopenia and MELD-Na were independent predictors of ACLF in the WL, while CysC ≥ 1.5 mg/L, sarcopenia and albumin were independent predictors of mortality. The cumulative incidence of ACLF and mortality at 12 months were 50% and 34% in patients with sarcopenia and CysC ≥1.5 mg/L. An estimated glomerular filtration rate by chronic kidney disease (CKD)-EPI-CysC-creatinine <60 mL/min/1.73 m at WL inclusion was an independent predictor of the need for renal replacement therapy (RRT) in the first month post-LT. Higher levels of CysC and sarcopenia are strongly associated with the ACLF and mortality in WL. The assessment of both risk factors may improve the prognostic evaluation and allow identifying a group of patients with a very high risk of poor outcomes while awaiting LT.

Comparision between portosystemic shunts and endoscopic therapy for prevention of variceal re-bleeding

Background:Portosystemic shunts, including surgical portosystemic shunts and transjugular intra-hepatic portosystemic shunt (TIPS), may have benefit over endoscopic therapy (ET) for treatment of variceal bleeding in patients with cirrhotic portal hypertension; however, whether there being a survival benefit among them remains unclear. This study was to compare the effect of three above-mentioned therapies on the short-term and long-term survival in patient with cirrhosis.Methods:Using the terms “variceal hemorrhage or variceal bleeding or variceal re-bleeding” OR “esophageal and gastric varices” OR “portal hypertension” and “liver cirrhosis,” the Cochrane Central Register of Controlled Trials, PubMed, Embase, and the references of identified trials were searched for human randomized controlled trials (RCTs) published in any language with full texts or abstracts (last search June 2017). Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated using random effects model by Review Manager. The quality of the included studies was evaluated using the Cochrane Collaboration's tool for the assessment of the risk of bias.Results:Twenty-six publications comprising 28 RCTs were included in this analysis. These studies included a total of 2845 patients: 496 (4 RCTs) underwent either surgical portosystemic shunts or TIPS, 1244 (9 RCTs) underwent either surgical portosystemic shunts or ET, and 1105 (15 RCTs) underwent either TIPS or ET. There was no significant difference in overall mortality and 30-day or 6-week survival among three interventions. Compared with TIPS and ET, separately, surgical portosystemic shunts were both associated with a lower bleeding-related mortality (RR = 0.07, 95% CI = 0.01–0.32; P < 0.001; RR = 0.17, 95% CI = 0.06–0.51, P < 0.005) and rate of variceal re-bleeding (RR = 0.23, 95% CI = 0.10–0.51, P < 0.001; RR = 0.10, 95% CI = 0.04–0.24, P < 0.001), without a significant difference in the rate of postoperative hepatic encephalopathy (RR = 0.52, 95% CI = 0.25–1.00, P = 0.14; RR = 1.09, 95% CI = 0.59–2.01, P = 0.78). TIPS showed a trend toward lower variceal re-bleeding (RR = 0.46, 95% CI = 0.36–0.58, P < 0.001), but a higher incidence of hepatic encephalopathy than ET (RR = 1.78, 95% CI = 1.34–2.36, P < 0.001).Conclusions:The overall analysis revealed that there seem to be no short-term and long-term survival advantage, but surgical portosystemic shunts are with the lowest bleeding-related mortality among the three therapies. Surgical portosystemic shunts may be the most effective without an increased risk of hepatic encephalopathy and TIPS is superior to ET but at the cost of a higher incidence of hepatic encephalopathy. However, some of findings should be interpreted with caution due to the lower level of evidence and the existence of significant heterogeneity.

Abstract No. 621 Sarcopenia helps predict risk of hepatic encephalopathy and transplantation-free survival after transjugular intrahepatic portosystemic shunt in cirrhosis

This study was aimed to evaluate the association between preoperative sarcopenia and incidence of hepatic encephalopathy (HE) and transplantation (LT)-free survival after transjugular intrahepatic portosystemic shunt (TIPS) with covered stents. CT images taken at the 3rd lumbar vertebra from 189 patients were quantified for skeletal muscle index. Cox proportional hazards regression model were conducted to assess associations between preoperative sarcopenia and incidence of HE and LT-free survival after TIPS. Discriminative performance of various scores was assessed by concordance statistic (C-statistic). Sarcopenia was present in 74 (39.2%) patients. Patients with sarcopenia had significant higher incidence of HE (p=0.009) and tendency of lower LT-free survival (p=0.082) than those without sarcopenia. By Cox regression analysis, sarcopenia (OR 1.776, p=0.024), sodium (OR 1.112, p=0.003) and age (OR 1.032, p=0.006) were identified as independent predictors for overall incidence of HE. A SSA score included all three parameters and yielded a C-statistic of 0.714 for overall HE prediction. The other BSA score included bilirubin (OR 1.025, p=0.014), sarcopenia (OR 2.495, p=0.025) and albumin (OR 1.186, p<0.001) as predictors and gave a higher C-statistic (0.770, 95%CI 0.689-0.850) than MELD (0.639, 95%CI 0.539-0.739), MELDNa (0.685, 95%CI 0.583-0.787), MELD-sarcopenia (0.681, 95%CI 0.565-0.797) and MELD-L3SMI (0.644, 95%CI 0.538-0.750) for overall LT-free survival. The BSA score showed better discriminative performance in earlier months after TIPS. Both scores also gave excellent C-statistics at 3-, 6- and 12-month for corresponding outcomes. Sarcopenia was independently associated with a higher risk of HE and a lower LT-free survival after TIPS. Sarcopenia-based SSA score provided quantitative prediction for risk of HE after TIPS. The other sarcopenia-based BSA score were more advantageous in predicting LT-free survival than conventional MELD-based scores. Further validation of these prognostic indices in larger cohorts of cirrhotic patients is warranted.

HCV Co-Infection in Patients With HBV Infection in Urban Minority Population in a U.S. Major City - A Closer Look

Introduction: Hepatitis B Virus (HBV) and Hepatitis C virus (HCV) infections are major global health problems causing life threatening liver infections.The Model of End-stage Liver Disease (MELD) score used to predict mortality risk and the severity of chronic liver diseases. Many studies have shown dually infected patients to be at higher risk of more severe liver cirrhosis. However, few studies are conducted in U.S. major city involving urban minority population. Methods: Retrospective observational study- all patients with chronic HBV infection. Patients were divided into 2 groups: Group A- HBV infection; Group B- Coinfection with HBV and HCV. Demographics, epidemiology and disease severity were compared. Results: Total patients with chronic HBV infection were n=273, of which 151(55.3%) had HBV monoinfection (Group A) and 122 (44.7%) had co-infection with HCV (group B). Patients >40 years were higher in group B (92%) compared to group A (77%). Majority of the patients were males in both groups (55% and 66% respectively) and of African American ethnicity (88% and 74% respectively). Prevalence of smoking, alcohol and IV drug use (IVDU) was higher in Group B (76%, 80% and 49% respectively) compared to Group A (45%, 56% and 41% respectively). HBV immunization rates were low in both groups, group A (6.6%) and group B (1.6%). Majority of the patients were treatment naïve in both groups with Group A (92%) greater than Group B (78%). Group B had higher incidence of hepatic encephalopathy (15%) and ascites (18%) compared to group A (12% and 9% respectively). MELD scores distribution was similar in both groups for MELD 30, there were increased patients in Group B (18%) compared to group A (5%). Conclusion: A high number of patients with chronic HBV had co-infection with HCV, majority of them being males, over 40 years of age, and African American ethnicity. The incidence of smoking and alcohol use although higher in group B, IVDU was comparable similar in both groups.Both groups had comparable disease severity with moderately higher rates of hepatic encephalopathy and ascites among patients with co-infection. Patients with co-infection had a greater 3- month mortality prediction compared to mono-infection group.Overall this study throws light on the very low HBV immunization rates in the urban minority population and the high rate of co-infection, resulting in increased disease burden and mortality risk as considered by the measured MELD scores in this population.

Methylation status of the estrogen receptor 1 promoter predicts poor prognosis of acute-on-chronic hepatitis B liver failure.

Acute-on-chronic hepatitis B liver failure (ACHBLF) is an acute deteriorating liver disease and rapidly progresses to multiple organ failure. There is currently no adequate accurate predictive models of ACHBLF prognosis. To identify the methylation frequency of the estrogen receptor 1 (ESR1) promoter in ACHBLF and analyze the associated prognostic significance. Methylation-specific PCR (MSP) was used to determine the methylation frequency of the ESR1 promoter in peripheral blood mononuclear cells from a training and validation cohort of patients. The training cohort included 113 patients with ACHBLF, 73 with chronic hepatitis B (CHB) and 40 healthy controls (HCs). The validation cohort consisted of 37 patients with ACHBLF. Another 18 patients with pre-ACHBLF who progressed to ACHBLF were used to dynamically evaluate ESR1 promoter methylation changes associated with a severe clinical condition. Death from ACHBLF was associated with hyperbilirubinemia, a higher score in the model for end-stage liver disease (MELD), a higher incidence of hepatic encephalopathy (HE) and an increased frequency of ESR1 promoter methylation during the 28 day follow-up. HE, MELD score and ESR1 promoter methylation were the independent risk factors associated with 28-day mortality from ACHBLF. The frequency of ESR1 promoter methylation was significantly higher than in patients with CHB and HCs. Albumin and the MELD score were significantly associated with ESR1 promoter methylation. Moreover, ESR1 promoter methylation frequency increased with ACHBLF progression. More importantly, ESR1 promoter methylation was an independent risk factor and had a high value to predict 28-day mortality from ACHBLF. Abnormal ESR1 methylation could be a prognostic biomarker for ACHBLF.

Role of Diabetes Mellitus in Liver Cirrhosis in the Anhui Region of China

Aims: The aim of this study was to investigate the frequency of diabetes mellitus (DM) among cirrhotic inpatients with different etiologies and the impact of DM on the prognosis of these patients. Methods: A retrospective study of the association between DM and cirrhosis was performed on 672 cirrhotic inpatients at the First Affiliated Hospital of Anhui Medical University from January 1, 2012 to March 1, 2013. Data were assessed using SPSS 20.0. Results: The DM prevalences involving different etiologies were 45.08%, 40.43%, 42.85%, 41.67%, and 25.56% among 672 patients with alcoholic cirrhosis, cryptogenic cirrhosis, schistosomiasis, chronic hepatitis C, and chronic hepatitis B, respectively. Multivariate analysis indicated that relative to non-diabetic patients, patients with DM were older (OR 2.83, 95% CI 2.78 - 2.87, p < 0.001), had higher white blood cell levels (OR 3.01, 95% CI 2.83 - 3.22, p = 0.001) and were more frequently Child-Pugh class C (OR 1.28, 95% CI 1.14 - 1.55, p < 0.001); these differences were also statistically significant in univariate analysis. Univariate analysis suggested that the presence of DM was associated with a higher international normalized ratio (p = 0.013), a higher incidence of hepatic encephalopathy (p = 0.014), and a more frequent incidence of spontaneous bacterial peritonitis (p < 0.001). Conclusion: DM is extremely common among cirrhotic patients and is particularly prevalent among alcoholic cirrhosis patients in the examined region of China. The presence of DM in cirrhotic patients was strongly associated with an elevated Child-Pugh score and an accelerated progression of cirrhosis.

The Evolution of Transjugular Intrahepatic Portosystemic Shunt: Tips.

Since Richter's description in the literature in 1989 of the first procedure on human patients, transjugular intrahepatic portosystemic shunt (TIPS) has been worldwide considered as a noninvasive technique to manage portal hypertension complications. TIPS succeeds in lowering the hepatic sinusoidal pressure and in increasing the circulatory flow, thus reducing sodium retention, ascites recurrence, and variceal bleeding. Required several revisions of the shunt TIPS can be performed in case of different conditions such as hepatorenal syndrome, hepatichydrothorax, portal vein thrombosis, and Budd-Chiari syndrome. Most of the previous studies on TIPS procedure were based on the use of bare stents and most patients chose TIPS 2-3 years after traditional treatment, thus making TIPS appear to be not superior to endoscopy in survival rates. Bare stents were associated with higher incidence of shunt failure and consequently patients required several revisions during the follow-up. With the introduction of a dedicated e-PTFE covered stent-graft, these problems were completely solved, No more reinterventions are required with a tremendous improvement of patient's quality of life. One of the main drawbacks of the use of e-PTFE covered stent-graft is higher incidence of hepatic encephalopathy. In those cases refractory to the conventional medical therapy, a shunt reduction must be performed.