Liver Disease Score Research Articles

Dosing of ceftriaxone and outcomes after spontaneous bacterial peritonitis

Background: Spontaneous bacterial peritonitis (SBP) is a common, often fatal affliction for cirrhotic patients. Despite all clinical trials of ceftriaxone for SBP using 2g daily, it is often given at 1g daily.Aim: We evaluated outcomes of SBP as a function of ceftriaxone dosage.Methods: A retrospective cohort of all patients who received ceftriaxone for SBP (greater than 250 neutrophils in the ascites).Results: As opposed to 1 gram, median survival is longer for patients receiving 2 grams (228 days vs. 102 days (p = 0.26) and one year survival is significantly higher (p = 0.0034). After adjusting for baseline Model for End Stage Liver Disease (MELD) score, however, this difference was no longer significant. Similarly, there was a significantly shorter length of intensive care for patients receiving 2 g (0.59 ± 1.78 days vs. 3.26 ± 6.9, p = 0.034), odds ratio 0.11 (95% CI 0.02 - 0.65). This difference, too, was no longer significant after controlling for the MELD score - odds ratio 0.21 (95% CI 0.04 - 1.07). Additionally, 70% of patients received at least one additional antibiotic; over 25 different medications were used in various combinations.Conclusions: We recommend fastidious antibiotic stewardship for patients with cirrhosis and that efforts should be made to standardize the treatment of SBP. The complexity of antibiotic regimens to which cirrhotic patients are exposed must be studied further and rationalized. Patients receiving 2 g of ceftriaxone may require fewer intensive care days and enjoy an improved 1 year survival compared to those receiving 1 g daily.

Risk factors and outcome in ICU patients with end-stage liver disease

Background/aim Acute or chronic liver failure is associated with numerous complications that may occur in combination, and patients may require ICU treatment. Therefore, it seems necessary to identify prognostic clinical parameters and risk factors at the time of ICU admission. The present study aims to estimate the frequency of mortality and evaluate morbidity from cirrhosis in patients with end-stage liver disease (ESLD) admitted to the ICU and evaluate the relationship between the demographic, clinical, and laboratory data (potential risk factors) of those patients and mortality. Patients and methods A total of 120 patients with ESLD were enrolled [102 (85%) male and 18 (15%) female patients]. History taking, clinical examination, and other laboratory investigations were carried out, and patients were classified according to the Child-Turcotte-Pugh (CTP) and the model for end-stage liver disease (MELD) scores. Results Regarding the clinical presentation, hepatic encephalopathy (HE) was found in 87.5% of patients, jaundice in 60%, hematemesis in 41.7%, hepatorenal syndrome (HRS) in 35.8%, and spontaneous bacterial peritonitis in 20.8% of patients. The mortality rate was 57.5%; the main causes of death were HRS (40.8%), HE (21.7%), aspiration pneumonia (10%), septic shock (2.5%), and irreversible shock (1.7%). There was a significant relationship between mortality and old age, CTP and MELD scores, and a longer stay at the ICU. Increased white blood cell count, increased hemoglobin and decreased prothrombin concentration, and elevated creatinine were independent risk factors of mortality in ESLD patients in the ICU. Mortality rates were higher in patients with 5-6 risk factors (86.2%) than in those with 1-2 risk factors (21.7%). Conclusion Mortality rate in ESLD patients admitted to the ICU was 57.5% and the most common cause of death was HRS. CTP, MELD score, HE, HRS, and jaundice were significant predictors of mortality in ESLD patients. Mortality increased with increased number of risk factors. Creatinine level, white blood cell count, hemoglobin, and prothrombin concentration were independent risk factors of mortality in ESLD patients.

Point of Care Perioperative Coagulation Management in Liver Transplantation and Complete Portal Vein Thrombosis

Liver transplantation (LT) is a serious hemostatic challenge in patients with portal vein thrombosis (PVT). Advances in monitoring systems have improved surgery in this setting. We report the successful application of a point-of-care (POC) rotational viscoelastic thromboelastometry-guided (TEM) testing system (ROTEM) which allowed management of coagulation during LT in a 64-year-old cirrhotic patient with a model for end-stage liver disease (MELD) score of 16. Perioperatively, the patient showed complete PVT, hepatomegaly, splenomegaly, recanalization of the umbilical vein, and portosystemic shunt. Macroscopic liver and spleen adherences with collateral circulation were evident. Coagulation factors and fibrinolysis were assessed preoperatively and at graft reperfusion to evaluate the need of hemostatic therapy. Based on ROTEM findings, the patient received 16 g of human fibrinogen concentrate, half preoperatively (with prothrombin complex concentrate 2000 IU, tranexamic acid 1 g, and platelets 2 IU), and two doses of 4 g before and after graft reperfusion; we achieved normalization of all monitored parameters. No ischemia-reperfusion syndrome was present. Postoperatively portal vein flux at Color-Doppler ultrasonography was normal. After a 3-day ICU stay, the patient was moved to the Department of Surgery and discharged on day 14. The postoperative course was uneventful and did not require any further haemostatic therapy.

IL-33, an Important Biomarker in Non-small-cell Lung Cancer?

We read with interest the article by Hu et al., published in Asian Pacific Journal of Cancer Prevention, showing that circulating IL-33 levels were higher in a non-small-cell lung cancer (NSCLC) group compared with the healthy volunteers and benign lung diseases groups, correlatingwith tumor stage (Hu et al., 2013). Using a cut-off level 68 pg/ml, IL-33 showed a good diagnostic performance for NSCLC. In addition, multivariate survival analysis showed that serum IL-33 was an independent prognostic factor in the entire NSCLC group. These findings suggest that IL-33 is a promising potential diagnostic and prognostic marker in NSCLC, and IL-33 may play an important role in NSCLS. However, Naumnik et al. (2012) showed that levels of IL-33 in serum and bronchoalveolar lavage fluid (BALF) did not differ markedly between NSCLC and the control group. No correlation was found between the serum level of IL-33 before therapy and the effect of chemotherapy. No correlation was found between the BALF concentration of IL-33 and the effect of chemotherapy as well (Naumnik et al., 2012). IL-33 is the latest member of the IL-1 family, which includes IL-1α, IL-1β, IL-1 receptor antagonist, and IL-18. BALF level of IL-18 was lower in the NSCLC than that in the hypersensivity pneumonitis (HP) group, but higher than that in the sarcoidosis patients. Serum level of IL-18 was higher in the NSCLC than in the healthy subjects (Rovina et al., 2011; Naumnik et al., 2013). In addition, Fariadfar et al. showed that IL-18 gene polymorphism contributes to the lung cancer risk, particularly among squamous carcinoma patients (Farjadfar et al., 2009). Interestingly, IL-33 levels in the serum of gastric cancer patients were significantly elevated in comparison with that of healthy volunteers, and higher serum levels of IL-33 in gastric cancer patients were found to correlate with several poor prognostic factors like depth of invasion, distant metastasis and advanced stage (stage III/IV) (Sun et al., 2011). On the contrary, no significant difference in IL-33 serum levels was found in hepatocellular carcinoma patients compared to liver cirrhosis patients and healthy controls (Bergis et al., 2013). IL-33 levels did not correlate with overall survival, liver function parameters, the Model for End-Stage Liver Disease (MELD) score (Bergis et al., 2013). Recently, Gao, et al showed that transgenic expression of IL-33 attenuated tumor metastasis in the Lewis lung carcinoma (LLC) metastatic models, where the percentages and cytotoxicity of CD8+ T cells and NK cells and their infiltration into the tumor tissues were markedly increased by the transgenic expression of IL-33 in tumor-

Viral status at the time of liver transplantation for hepatocellular carcinoma: a modern predictor of longterm survival

ObjectivesThe impact of pre‐transplant hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection in patients with hepatocellular carcinoma (HCC) is not well described. This study was conducted to test the hypothesis that viral status is an independent predictor of retransplantation rates, graft survival (GS) and overall survival (OS) in patients undergoing liver transplantation for HCC. MethodsPatients with HCC were identified from the Organ Procurement and Transplantation Network database (2005–2012), and categorized by viral status according to these categories: HBV−/HCV−; HBV+/HCV−; HBV−/HCV+, and HBV+/HCV+. ResultsOf 7742 patients transplanted for HCC, 7060 had known HBV and HCV status. Five‐year GS and OS were highest in recipients who were HBV+/HCV−, at 75% and 78%, respectively, compared with patients who were HBV−/HCV− (GS = 63%, OS = 66%), HBV−/HCV+ (GS = 64%, OS = 60%) or HBV+/HCV+ (GS = 60%, OS = 62%). In multivariable analyses, HBV−/HCV+ patients were more likely than HBV+/HCV− patients to undergo repeat transplantation. Patients who were HBV−/HCV+ also had poorer GS and OS than both HBV−/HCV− and HBV+/HCV− patients. Other independent predictors of poorer OS included older age, higher Model for End‐stage Liver Disease score, African‐American race, and diabetes. The few HBV+/HCV+ patients (n = 138) showed trends toward fewer retransplantations, prolonged GS and prolonged OS compared with HBV−/HCV+ patients. In adjusted models, antiviral medications did not impact GS or OS. ConclusionsIn the era of modern selection criteria, viral status is an independent predictor of outcome following liver transplantation for HCC. Both HBV−/HCV− and HBV+/HCV− patients have superior GS and OS compared with HBV−/HCV+ patients.

Liver and Pancreas Transplantation

More than 6,000 liver transplantations are performed annually in the United States. Enhancements in patient selection and surgical technique and the availability of more powerful immunosuppressive agents have resulted in steady improvement in patient survival. As a result, liver transplantation has been accepted as the standard of care for patients with severe acute or chronic liver disease in whom conventional modalities of therapy have failed. The major obstacle to patients receiving the procedure is the critical shortage of donor organs. Many more recipients of liver transplantation are now receiving the bulk of their care from general internists, gastroenterologists, and primary care physicians. As a result, recognition of potential long-term complications and the need for appropriate immunizations and regular screening visits have become increasingly important. This chapter discusses who qualifies as a candidate for liver transplantation, contraindications to transplantation, timing of transplantation, operative procedures, complications of transplantation (e.g., perioperative and surgical complications, immunologic complications, infectious complications, complications of medical and immunosuppressive therapy, and disease-specific complications), and transplantation outcome. Pancreas transplantation, which aims at providing physiologic insulin replacement, is a therapy that reliably achieves euglycemia in patients with type 1 diabetes mellitus. The discussion of pancreas transplantation focuses on topics such as evaluation of candidates for transplantation (including islet transplantation); contraindications to transplantation; operative procedures; outcome survival; and the effect of transplantation on disorders associated with type 1 diabetes mellitus. The figures show estimated 3-month survival as a function of the Model for End-Stage Liver Disease (MELD) score, the sections of the liver that can be used for transplantation, an algorithm for evaluation of patients with type 1 diabetes mellitus being considered for pancreas transplantation, and an illustration of enteric drainage technique used in whole pancreas transplantation. The tables provide the common indications for liver transplantation, the scoring system for the Child-Turcotte-Pugh classification of liver disease severity, drug interactions with immunosuppressants, and immunization recommendations for liver transplant patients. This chapter contains 4 highly rendered figures, 4 tables, 101 references, 5 MCQs, and 1 teaching slide set.

Model for End-stage Liver Disease (MELD) in spontaneous bacterial peritonitis –a clinical study at a tertiary health center in Nepal

Background and Aims: The aim of this study was to assess the predictive value of different variables including the Model of End-stage Liver Disease (MELD) scores in hospitalized patients with spontaneous bacterial peritonitis (SBP) and its correlation with adverse outcomes. Methods: A cross-sectional study of 73 patients diagnosed with cirrhosis, ascites, and spontaneous bacterial peritonitis admitted to a gastroenterology department from February 2010 to November 2012. MELD scores were calculated using laboratory parameters and the United Network of Organ Sharing (UNOS) internet MELD tool. Results: Categorical variables and mortality status were analyzed for association by chi-square test. MELD scores and all-cause mortality were found to be positively correlated. Mortality was higher among the groups with MELD scores greater than 15. Upon stratification of the groups by mortality status, only age and urea level were novel and consistent predictors of mortality. Conclusions: In this Nepalese sample of cirrhotic patients, MELD scores along with age and urea level were confirmed as significant predictors of mortality. DOI: http://dx.doi.org/10.3126/jaim.v2i2.8776 J ournal of Advances in Internal Medicine 2013;02(02):47-51

Postoperative morbidity in patients with chronic viral hepatitis undergoing cardiac surgery: a retrospective study

Methods We studied 103 patients with documented chronic viral hepatitis who had cardiac surgery in our institution between 2001-2012. These subjects were evaluated for preoperative liver dysfunction with the Model for End Stage Liver Disease (MELD) Score. In subjects who were on anticoagulants, a modified score (MELD-XI) was used. Other comorbidities that were considered were diabetes, dyslipidemia, obesity, hypertension, COPD, history of stroke and smoking status.

Liver and Pancreas Transplantation

More than 6,000 liver transplantations are performed annually in the United States. Enhancements in patient selection and surgical technique and the availability of more powerful immunosuppressive agents have resulted in steady improvement in patient survival. As a result, liver transplantation has been accepted as the standard of care for patients with severe acute or chronic liver disease in whom conventional modalities of therapy have failed. The major obstacle to patients receiving the procedure is the critical shortage of donor organs. Many more recipients of liver transplantation are now receiving the bulk of their care from general internists, gastroenterologists, and primary care physicians. As a result, recognition of potential long-term complications and the need for appropriate immunizations and regular screening visits have become increasingly important. This chapter discusses who qualifies as a candidate for liver transplantation, contraindications to transplantation, timing of transplantation, operative procedures, complications of transplantation (e.g., perioperative and surgical complications, immunologic complications, infectious complications, complications of medical and immunosuppressive therapy, and disease-specific complications), and transplantation outcome. Pancreas transplantation, which aims at providing physiologic insulin replacement, is a therapy that reliably achieves euglycemia in patients with type 1 diabetes mellitus. The discussion of pancreas transplantation focuses on topics such as evaluation of candidates for transplantation (including islet transplantation); contraindications to transplantation; operative procedures; outcome survival; and the effect of transplantation on disorders associated with type 1 diabetes mellitus. The figures show estimated 3-month survival as a function of the Model for End-Stage Liver Disease (MELD) score, the sections of the liver that can be used for transplantation, an algorithm for evaluation of patients with type 1 diabetes mellitus being considered for pancreas transplantation, and an illustration of enteric drainage technique used in whole pancreas transplantation. The tables provide the common indications for liver transplantation, the scoring system for the Child-Turcotte-Pugh classification of liver disease severity, drug interactions with immunosuppressants, and immunization recommendations for liver transplant patients. This chapter contains 4 figures, 4 tables, 101 references, 5 Board-styled MCQs, and 1 Teaching Slide Set.

Comparison of Prognosis in Patients with Liver Cirrhosis and its Correlation with the Model for the End-Stage Liver Disease and Child-Pugh Scores in Patients with Esophageal or Gastric Variceal Bleeding

Background
 Variceal bleeding is one of the most serious complications of cirrhosis. Up to now different methods are created for predicting the complications and mortality of cirrhosis. Child- Pugh score and MELD score are two methods for this use. In this study we investigated and compared survival prognosis of cirrhotic patients by the Child-Pugh or MELD score in two groups of esophageal and gastric variceal bleeding.
 Materials and Methods
 In this cross-sectional trial, patients with upper GI bleeding were followed up for a 6 months period. The source of hemorrhage was determined by endoscopy, then patients distributed in two groups of esophageal and gastric variceal hemorrhage. Finally we investigated and compared the relationship between the variables and mortality rates in these two groups by means of the Child-Pugh and the MELD scores. The Student's t-test and Receiver Operating Characteristic were used for statistical analysis.
 Results
 34 patients (12 with gastric varices, 22 with esophageal varices) were investigated. No significant difference between these two groups was observed. In this study mean MELD score was 16.67±8.75 and mean Child-Pugh score was 9.37±2.54. Eight patients (5 with gastric varices and 3 with esophageal varices) expired before 6 weeks and 2 patients (one four each group) expired after 6 weeks. The best cut-off points are 15.5 and 10.5 for MELD and Child-Pugh scores respectively (sensitivity and specificity are 0.75 and 0.98, respectively for both scores).
 Conclusion
 Sensitivity and specificity of both scores were the same in prediction of mortality. However, the chance ratio defined that Child-Pugh score was a better predictor of mortality than MELD score, since the chance of death will increase 2.51 and 1.62 fold per each unit increase in the Child-Pugh and the MELD scores, respectively. However, no significant difference found between Child-Pugh and MELD score between two groups of patients.

Polymorphonuclear counts in ascitic fluid and microorganisms producing spontaneous bacterial peritonitis: an under-recognized relationship

Background and Aims. In cirrhotic patients with spontaneous bacterial peritonitis (SBP) higher polymorphonuclear (PMN) count in ascitic fluid have been reported in infections caused by Gram-negative bacilli (GNB) as opposed to Gram-positive cocci (GPC). However, the influence of other associated factors on the PMN count, such as the specific microorganism causing the episode of SBP, has not been well established. Methods. Retrospective observational study of 194 episodes of positive ascitic and/or blood culture SBP in 159 patients with liver cirrhosis (2001–2009). Parameters associated with PMN count in ascitic fluid at diagnosis were evaluated. Results. The multivariate analysis (model 1) showed that a virulent etiology of the infection [coefficient 3.941 (95% confidence interval (95 CI): 0.421–7.461)] and the model for end-stage liver disease (MELD) score [coefficient 0.196 (95 CI: 0.007–0.384)] were positively associated with the PMN count in ascites, while a nosocomial acquisition was inversely associated [coefficient –3.546 (95 CI: –6.855 – –0.238)]. A nonsignificant trend toward higher PMN count was found in GNB versus GPC, but there were differences between groups of microorganisms: pyogenic streptococci [median (p25–p75): 3211 (1615–8004)], Enterobacteriaceae [2958 (917–7690)], Vibrionaceae [9215 (375–17280)], nonfermenting GNB [1384 (565–3865)], viridans group streptococci [1044 (503–2354)] and enterococci [1050 (476–4655)](p = 0.005). No clear cut-offs of ascitic PMN count predicting a particular etiology could be calculated out of these data. Conclusions. In cirrhotic patients with SBP, the causing microorganism, the place of acquisition of the infection and the host liver condition were the main factors determining PMN count in ascitic fluid. Third-generation cephalosporin resistance was associated with low PMN count probably because this group included bacteria with inherent low virulence.

Ethoxybenzyl diethylenetriamine pentaacetic acid Relationship between liver function and relative signal intensity of MR cholangiography using gadolinium

Objective To evaluate the effect of liver function on the biliary visualization of MR cholangiography (CE-MRC) using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA). Methods Thirty-nine patients were divided into three groups based on Child-Pugh score (23 patients in group A,11 in B,and 5 in C).CE-MRC was scanned 50 minutes after Gd-EOBDTPA injection.Biliary visualization of CE-MRC at that time was qualitatively assessed by 5-point scale.The relative signal intensity (RSI) of the common bile duct (CBD) was quantitatively measured.The serum bilirubin level and the model of end-stage liver disease (MELD) score were recorded.Kruskal-Wallis test was used to compare the rating scores among three groups.Bonferroni method was used to further pairwise comparison.The one-way ANOVA was used to compare the RSI of CBD among three groups.And regression analysis was used to evaluate the relationship between RSI and the influenced factors. Results Visualization rating scores of the CBD,left hepatic duct (LHD),right hepatic duct (RHD),subbranches of intrahepatic bile ducts (SIBD),cystic duct (CD) and gallbladder (GB) were 4 (3,4),3 (2,4),3 (2,4),1 (1,2),3 (2,4),3 (2,4) of group A;3 (0,3),1 (0,2),1 (0,2),0 (0,1),2 (0,2),2 (0,2) of group B; and 1 (1,2),1 (1,1),1 (1,1),0 (0,0),0 (0,1),0 (0,1) of group C.Statistically significant differences were found in visualization rating scores of the CBD,LHD,RHD,SIBD,CD and GB among the 3 groups (χ2=17.881,18.707,23.328,13.016,20.170,19.938,P<0.01).Statistically pairwise comparison differences were found between group A and B,either between group A and C.The RSI of the CBD of these three groups was 17.12±0.41,3.95±0.63 and 3.33±0.30 respectively.There were statistically significant difference between 3 groups. (F=235.843,P<0.01).Statistically significant differences of the RSI were shown between group A and B,also between group A and C.The total serum bilirubin level and the MELD score predicted the RSI of the CBD (β=-0.834,-1.042,P<0.01). Conclusion Liver function could affect CE-MRC with Gd-EOB-DTPA and RSI of the CBD.The RSI may reflect liver cell function. Key words: Liver diseases; Contrast media; Magnetic resonance imaging

Difference in cardiac manifestation between liver transplantation candidates with alcoholic and hepatitis related cirrhosis

Purpose: Cardiac event is the main cause of mortality during liver transplantation and patients with cirrhosis are associated with myocardial dysfunction. However, limited data is available regarding the characteristics of cardiac function between LTx candidates with alcoholic and hepatits related cirrhosis. The aim of the study was to compare the cardiac function between patients with alcoholic and hepatitis related cirrhosis who were candidates for LTx. Methods: A total of 88 patients with cirrhosis referred for LTx and 88 age and gender- matched controls were evaluated by transthoracic echocardiography. Clinical parameters, conventional echocardiographic and tissue Doppler-derived parameters of the left ventricle (LV) were obtained in all subjects. Liver status of cirrhotic patients was evaluated by the model for end-stage liver disease (MELD) scores. Results: Despite a similar LV dimension and LV ejection fraction, patients with cirrhosis had a higher prevalence of diastolic dysfunction (54% vs. 37%, p=0.01) and LV filling pressure as estimated by E/E' ratio (10.9±3.9 vs. 7.4±1.9, p<0.01) compared with controls. Age, gender and MELD were similar between patients with alcoholic and hepatitis related cirrhosis. The prevalence of diastolic dysfunction was also similar (54% vs 52%, p=1.0). However, patients with alcoholic related cirrhosis had lower LV ejection fraction (n=20; 51±14% vs. n=68; 62±8%) and larger LV end-systolic dimension (51±22ml vs. 31±12ml) and LV mass index (104±20g/m2 vs. 87±22g/m2) compared with patients with hepatitis related cirrhosis (all p<0.01). Conclusion: LTx candidates are associated with diastolic dysfunction and a higher LV filling pressure compared with controls. Importantly, patients with alcoholic related cirrhosis had a lower LV systolic function and a larger LV dimension compared with patients with hepatitis related cirrhosis. These important difference in cardiac dysfunction in patients with alcoholic related cirrhosis suggested the need for intensive preoperative risk stratification and monitoring during LTx.

Tu1055 High Model for End-Stage Liver Disease (MELD) Score Disproportionately Worsens Liver Transplant Outcomes for Older Recipients

Tu1055 High Model for End-Stage Liver Disease (MELD) Score Disproportionately Worsens Liver Transplant Outcomes for Older Recipients

Sa1064 Baseline Hematologic Indices With Albumin Predict Clinical Decompensation in Patients With HCV Cirrhosis Who Do Not Respond to Antiviral Therapy

Background: Patients with cirrhosis have lower response rates to the current standard treatments for hepatitis C and are at greater risk of clinical decompensation (CD) with continued infection. The risk of CD should be considered when treatment decisions for HCV are made. CD is associated with portal hypertension (PH). Because the assessment of PH requires invasive studies not widely available in the US, there is need for non-invasive markers. Abnormal hematological indices (HI), both thrombocytopenia (TH) and leukopenia (LE) have been associated with clinically significant PH. The purpose of this study is to determine if baseline HI can be used to predict decompensation prior to anti-viral therapy in a cohort of patients who did not respond to treatment. Methods: The study was a retrospective individual chart review on 427 patients identified in the Partners Research Data Repository who received HCV treatment. Inclusion criteria: .18 years, therapy with Peginterferon and Ribavirin, compensated liver disease and Metavir score of 4 on biopsy. Exclusion criteria: early stage fibrosis, post-liver transplant, HIV co-infection, untreated HCV. Baseline characteristics including HI were collected. Abnormal HI was defined as TH , 150,000, LE, 4,000 and Anemia, 13.5 g/dl (male) 11.5 g/dl (female).The primary outcome was long term occurrence of first CD defined by new ascites, jaundice, encephalopathy or variceal hemorrhage after completion of HCV therapy. Student's t test was used to compare means, Fisher exact test to compare proportions, multivariate logistic regression to identify predictors for CD. Results: 153 patients met criteria. 37 (24 %) patients had an SVR. Among the 116 patients who did not respond to therapy, at baseline, 40 (34 %) had TH, 24 (21 %) had LE and 38 (33 %) had anemia. CD occurred in 35 (30%). None of the SVR patients had CD. Among decompensation events, jaundice occurred in 74 %, encephalopathy in 54 %, ascites occurred in 51 %, and variceal hemorrhage in 6 %. Univariate analysis showed baseline TH OR 13.8 ( p-value , 0.001 ) and LE OR 3.8 (p-value = 0.006) ) were associated with CD. Anemia at baseline OR 1.6 (p-value = 0.27) was not associated with CD and not considered in further analysis. On multivariate analysis controlled for baseline abnormal HI, TH and/or LE OR 10.3 (p-value , 0.001) and albumin OR 0.14 (p-value 0.001) predicted CD while age OR 1.00 (p-value 0.88) and MELD OR 1.02 (p-value 0.83) did not. The table shows the SVR and CD rates in patients with or without abnormal HI or albumin , 4.0 g/ dl in different combinations. Conclusion: Patients with abnormal HI at baseline who do not respond to anti-viral therapy have an increased risk for CD. Using the baseline albumin and HI, an assessment of SVR and CD rates should be considered when initiating antiviral therapy. Decompensation and SVR Among Different Pre-Treatment Patient Characteristics 81% Treatment Naive (124/153) ( * Albumin in g/dL, ¥ HI=Hematologic Indices)

Pediatric acute liver failure: Etiology, outcomes, and the role of serial pediatric end‐stage liver disease scores

To describe etiology, short-term outcomes and prognostic accuracy of serial PELD scores in PALF. Retrospective analysis of children aged ≤16yr, admitted with PALF under the QLTS, Brisbane, Australia, between 1991 and 2011. PELD-MELD scores were ascertained at three time points (i) admission (ii), meeting PALF criteria, and (iii) peak value. Fifty-four children met criteria for PALF, median age 17months (1day-15.6yr) and median weight 10.2kg (1.9-57kg). Etiology was known in 69%: 26% metabolic, 15% infective, 13% drug-induced, 6% autoimmune, and 9% hemophagocytic lymphohistiocytosis. Age<3months and weight <4.7kg predicted poor survival in non-transplanted children. Significant independent predictors of poor outcome (death or LT) were peak bilirubin>220μm/L and peak INR>4. Serial PELD-MELD scores were higher in the 17 (32%) transplant recipients (mean: [i] 26.8, [ii] 31.8, [iii] 42.6); highest in the 12 (22%) non-transplanted non-survivors (mean: [i] 31.6, [ii] 37.2, [iii] 45.7) compared with the 25 (46%) transplant-free survivors (mean: [i] 25.3, [ii] 26.0, [iii] 30.3). PELD-MELD thresholds of ≥27 and ≥42 at (ii) meeting PALF criteria and (iii) peak predicted poor outcome (p<0.001). High peak bilirubin and peak INR predict poor outcome and serial PELD-MELD is superior to single admission PELD-MELD score for predicting poor outcome.

Hepatic Dysfunction in Ambulatory Patients with Heart Failure – Application of the MELD Scoring System for Outcome Prediction

Purpose Liver abnormalities have prognostic impact on the outcome of patients with advanced heart failure.We evaluated the Model of End-stage Liver Disease (MELD) score and its modified versions, established measures of liver dysfunction, as a tool to evaluate HTx urgency in ambulatory HF patients. Methods and Materials We retrospectively evaluated 343 patients undergoing HTx evaluation between 2005 and 2009. The prognostic effectiveness of MELD/MELDNa/MELD-XI for endpoint events defined as death/HTx/ventricular assist device (VAD) requirement was evaluated in our cohort and in subgroups of patients on and off oral anticoagulation. Results The MELD and MELDNa score were excellent predictors for 1 year endpoint events (AUC: 0.71 and 0.73, respectively). High scores (>12) were strongly associated with poor survival at one year (MELD: 69.3% vs. 90.4%, p Conclusions Assessment of liver dysfunction using the MELD scoring system provides additional risk information in patients with ambulatory heart failure.

Liver Dysfunction and Early Mortality after Heart Transplant

Purpose Mortality after cardiac transplant is predicted by The Model for End-Stage Liver Disease (MELD) score. The score is derived from serum bilirubin, creatinine and International Normalized Ratio (INR); abnormalities in each occurs with advanced liver disease. Given the hemodynamic burden experienced during cardiac transplant, we hypothesized that markers of milder pre-transplant liver dysfunction also predict early mortality after cardiac transplant. Methods and Materials We conducted a retrospective cohort study of adult patients at our institution that underwent their first heart transplant from 2007 to 2012. We evaluated the utility of pre-transplant aspartate aminotransferase (AST), bilirubin, albumin, INR, platelets and imaging evidence of cirrhosis and splenomegaly in predicting 30-day mortality post transplant. We used univariable logistic regression to identify hepatic predictors of mortality post transplant. We then compared a risk score that integrated these predictors to the MELD score using receiver operating characteristic (ROC) curve analysis. Results The study population consisted of 126 heart transplant recipients (Age 49±13,male 66%,ischemic etiology 27%). Mortality rate was 10.3% at 30 days. Patients that died had more sternotomies, higher pre-transplant creatinine levels and were more likely to have congenital heart disease. Univariate hepatic predictors of 30-day post-operative mortality were pre-transplant: platelet count Conclusions In our cohort, pre-transplant spleen length and platelet count, parameters not included in the MELD score, predicted mortality post heart transplant. These markers of milder liver dysfunction enhanced the MELD score’s ability to predict early mortality after cardiac transplant.

Outcomes following stereotactic body radiotherapy for patients with Child-Pugh B/C hepatocellular carcinoma.

167 Background: Assessment of outcomes in patients with hepatocellular carcinoma (HCC) and Child-Pugh B or C liver function treated with stereotactic body radiotherapy (SBRT). Methods: From 2004 – July 2012, 39 patients with HCC and Child-Pugh B/C liver function were treated with SBRT. Inclusion criteria included Child-Pugh B/C, treatment with SBRT, 5 to 15 fractions, and radical or palliative intent. Univariate analyses (UVA) were performed to assess relationships of patient demographics, liver function tests and treatment characteristics on overall survival (OS) and time to progression (TTP). Results: The majority of the 39 patients had Child-Pugh B7 liver function (69%), performance status ECOG 0-1 (82%), radiological evidence of tumor vascular thrombosis (62%) and hepatitis C as underlying liver disease (49%). 10 patients treated as bridge-to-transplant. The median dose was 3300 cGy in 6 fractions (range: 2000-4500 cGy in 5-15 fractions), individualized based on spared liver volume and underlying liver function. The median survival for all patients was 9.9 months (95% CI: 3.4-18.4). UVA demonstrated significantly reduced survival with Child-Pugh score &gt; B7, baseline AFP &gt; 1049 ng/mL (upper quartile) and gross tumor volume &gt; 93 cm3. The median survival of patients treated with SBRT as a bridge-to-transplant versus the non-bridge-to–transplant patients was 30.7 months (95% CI: 0.6-not reached) versus 7.9 months (95% CI: 3.4-15.1; p=0.008). No HCC tumors treated with SBRT demonstrated local progression during the follow-up time. The median TTP for all patients was 18.8 months (95% CI: 6.2-not reached). Model for end stage liver disease (MELD) score &gt; 12 was the only factor associated with reduced TTP on UVA. 31% of patients had a decline in Child-Pugh score by 2 or more points at 3 months. No acute treatment related toxicities of grade 3 or higher were reported. Conclusions: SBRT may be considered as a treatment option for HCC with impaired liver function. Survival is best in patients who are treated as a bridge-to-transplant, have smaller tumors, are Child-Pugh class B7, and have lower AFP levels. Randomized trials of radiation therapy in HCC patients with impaired liver function are warranted.

Incidentally Discovered HCC (iHCC) in Explant Liver-Histopathologic Features and Clinical Outcome

Incidentally discovered hepatocellular carcinomas (iHCC) are tumors which are discovered on the explanted liver which were not present on imaging prior to transplant. The natural history, histopathologic characteristics and prognosis of iHCC are not clearly defined. Methods: A retrospective analysis was performed to compare the characteristics of iHCC and established HCC within Milan criteria (eHCC) in patients who underwent liver transplantation at our center between 2000 and 2010. Results: During the study period a total of 975 adult patients were transplanted in our center; 124 (12.7%) patients had eHCC and 26 (2.6%) patients had iHCC. A larger number of patients with iHCC (73.1%) had ascites when compared to eHCC (41.3%) (p = 0.035). Patients with iHCC had a higher mean bilirubin (p 0.001) and mean INR (p = 0.05) than patients with eHCC. Around 70% of patients with iHCC had a Model for End Stage Liver Disease (MELD) score greater than 15 at the time of listing while only 25% of patients with eHCC had a MELD greater than 15 at listing (p 0.001).The mean alphafetoprotein (AFP) in patients with iHCC was significantly lower (11.6 ± 16.5) than the patients with eHCC (564.9 ± 2180; p = 0.024). In patients with iHCC, 30.8% had a multiple tumors and 23% had bilobar involvement. The average number of tumors was 1.6 and the cumulative tumor size was 2.1 cm (SD 1.4). The cumulative tumor size in iHCC was significantly smaller than in eHCC (mean 3.9 cm) (p = 0.035). American Joint Committee on Cancer (AJCC) T1 tumor stage was found in 58% of patients with iHCC and 48.4% of patients with eHCC (p = 0.829).The median survival was 9.47 years for iHCC (95% CI 7.0 - 11.9) and 8.7 years (95% CI 6.1 - 11.4) for eHCC (p = 0.328). While none of the patients with iHCC had recurrence of HCC, the incidence of recurrence in patients with eHCC was 6.4%. Conclusion: iHCC occurred in patients with more advanced liver disease than eHCC. AFP was usually not elevated in patients with iHCC. The cumulative tumor size of iHCC was smaller than eHCC but around a third of iHCC were multifocal, supporting the theory of multicentric hepatic carcinogenesis. Survival of patients with iHCC was similar to patients with eHCC and recurrence was not noted in patients with iHCC.