Mean MELD Score Research Articles

Multimedia-Based Education Led to Improvement in Disease Knowledge Among Patients with Cirrhosis.

Current evidence shows limited patient understanding of liver disease, coupled with no standard guidelines or methods to offer patient education in a busy clinical environment. We developed multimedia-based education (MBE) for those with cirrhosis & tested its effectiveness in improving patient knowledge from baseline to 1 month. This prospective study enrolled cirrhotic patients who had a scheduled visit with a hepatologist at an ambulatory academic practice or were admitted to the liver inpatient service. Once consented, patients completed a baseline knowledge questionnaire, and were given a link to watch the videos (text or email). Four videos were developed by the study team with input from clinicians and patients (liver function, symptoms and complications, medical management and preventive actions & nutrition). At month 1, the study coordinator confirmed with the patient that they had watched the videos at least once, and patients completed the same knowledge questionnaire. The scores between pre- and post-intervention were compared using the Wilcoxon signed rank test. Of the 120 enrolled, 113 completed baseline and 75 completed follow-up. 48% had alcohol-related liver disease as the underlying cause of cirrhosis. Mean MELD score at enrollment was 14.7 ± 8.14. There was a statistically significant improvement in knowledge scores across all domains from baseline to month 1 (p < 0.05). The overall knowledge score improved from 65 to 83% (p < 0.001), with highest improvement by 40% in the domain of liver function and causes of cirrhosis. MBE can help improve patients' knowledge about liver function, management, and prevention and can be used in both ambulatory and inpatient hepatology practice.

Comparison of modified extended right lobe graft versus modified right lobe graft in adult living donor liver transplantation: Experience from Pakistan.

To compare the outcomes of modified extended right lobe graft (MERLG) and modified right lobe graft (MRLG) in living-donor liver transplantation (LDLT). This retrospective study was performed at the Liver transplant department of the Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences Hospital, Gambat, Pakistan, from March 2019 to September 2020. The outcomes of 20 MERLG donors and recipients were compared to those of 74 MRLG donors and recipients. Demographics, operative parameters, complications, hospital stay, and one-year survival were compared between the two groups. The mean graft volume of the MERLG group was more (637.10 ± 71.35 g) than in the MRLG group (562.27 ± 57.77 g), (p= 0.001). Donor blood loss was higher in the MERLG group (680.10±170.60 ml) compared to the MRLG group (650.23±190.65 ml), p=0.527. In addition, the operative time was longer in the MERLG group (345.80±76.90 min) than in the MRLG group (318.12±100.80 min) (p= 0.257). The MERLG recipients were sicker (mean MELD score of 22.54±3.67) than the MRLG (18.86±4.37) (p=0.001). The drain output was higher in the MRLG group (1340 ± 470.32 ml) than in the MERLG group (1110 ± 450.60 ml) (P =0.045). No significant difference was found when comparing postoperative laboratory results and complications between the donor and recipient groups (p >0.05). Kaplan-Meier analysis showed a 95% one-year survival in MERLG group compared to 90.7% in the MRLG group (p=0.549). With appropriate technical expertise, MERLGs are technically safe and feasible in LDLT donors without any added risks. MERLGs also yielded better outcomes in sick recipients.

HYPERAMMONEMIA IS ASSOCIATED WITH INCREASING SEVERITY OF BOTH LIVER CIRRHOSIS AND HEPATIC ENCEPHALOPATHY

Hyperammonemia is a critical condition frequently observed in patients with liver cirrhosis and hepatic encephalopathy. Objectives: The study's main aim is to find that hyperammonemia is associated with increasing severity of both liver cirrhosis and hepatic encephalopathy. Methods: This retrospective cohort study was conducted at DHQ Hospital Nowshera Khyber Pakhtunkhwa from January 2023 to June 2023. A total of 175 patients diagnosed with liver cirrhosis were included in the study. Data collection was performed using the hospital's electronic medical records system. The variables collected included demographic data like patients’ age and sex and clinical data concerning the etiology of cirrhosis, Child-Pugh score, and MELD score. Results: The study included 175 patients with liver cirrhosis, with a mean age of 54.3 ± 12.7 years, of whom 64% were male and 36% female. The etiologies of cirrhosis were predominantly hepatitis C virus (45%), hepatitis B virus (30%), alcoholic liver disease (15%), and non-alcoholic steatohepatitis (10%). The mean Child-Pugh score was 8.7 ± 2.1, indicating moderate to severe liver disease, and the mean MELD score was 14.3 ± 4.5. The study found a strong positive correlation between ammonia levels and encephalopathy severity (r = 0.72, p &lt; 0.001). Conclusion: It is concluded that hyperammonemia is significantly associated with the severity of liver cirrhosis and hepatic encephalopathy.

Efficiency and safety of total plasma exchange in critically ill cirrhotic patients with acute on chronic liver failure: a pilot study.

Treatment of patients with acute on chronic liver failure (ACLF) admitted to the ICU is very limited. The aim of this pilot study was to evaluate the efficiency on liver function and safety of therapeutic plasma exchange (TPE) in critically ill cirrhotic patients admitted with ACLF in a liver ICU. This is a prospective cohort of patients with ACLF grade > 2 treated by TPE admitted to the ICU that was matched to a control group. TPE was performed using a plasma filter (TPE2000, BAXTER®) on a CRRT machine (Prismaflex®, Baxter®). Ratio and type of fluid replacement were 50% with 5% albumin solution followed by 50% with fresh frozen plasma. Seven patients with a mean age of 50.6 ± 7.8 years (all males) and 14 controls matched to age, sex, etiology and cause of decompensation were recruited. At ICU admission, mean MELD score was 39.1 ± 2.7, mean SOFA score was 11.6 ± 5.2 and mean CLIF SOFA score was 12.9 ± 2.6. The grade of ACLF was 3 for 3 patients (42.9%) and 2 for 4 patients (57.1%). The TPE group had significantly higher levels of bilirubin (392.3 ± 117.1 vs. 219 ± 185, p = 0.04), and INR values (5.7 ± 3.4 vs. 3.5 ± 0.9, p < 0.005) compared to the control group. Patient survival was respectively 28.6% and 14.3% at 30 and 90 days in the TPE group and 35.7% and 7.14% in the control group respectively (HR: 1 (95% CI 0.19- 5.2; p = 1). One patient in the TPE group had a liver transplantation 13 days after admission to ICU and is still alive and none in the control group. Two (28.6%) patients died from complications related to the double lumen catheter used for TPE. This pilot study of TPE in patients with ACLF grade 2 and 3 showed a marked but transient improvement in liver function tests. TPE worth to be evaluated in large trials in ACLF patients, with a liver transplant project, and less organ failure.

Evaluation of Left Ventricular Diastolic Function Using a Tissue-Doppler Imaging Based Algorithm According to 2016 Ase/Eacvi Guidelines in Patients with Decompensated Liver Cirrhosis: A Prospective Observational Study

Abstract Background Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. The prevalence of cirrhosis has nearly doubled over the last decade, and the number of hospitalizations has similarly increased. Aim of the Work We aimed to correlate between the severity of liver cirrhosis using new MELD score and left ventricle diastolic dysfunction using tissue doppler imaging. Patients and Methods A prospective observational study in ICU of Theodor Bilharz Research Institute Hospital and Ain Shams University Hospitals for 6 months from June 2021 till end of November 2021 on hepatic patients who were admitted to ICU of Theodor Bilharz Research Institute Hospital and Ain Shams University Hospitals. Results In the studied group, the mean age was 53.13±9.44 years with males constituting more than half of them (57.8%). The mean MELD score was 24.08±6.01, and the mean left ventricular ejection fraction (LVEF %) was 60.43±5.49%. There were 5 patients (5.6%) with normal LV diastolic function and 85 patients (94.4%) with abnormal LV diastolic dysfunction. Out of the 90 patients, 5 patients were normal, 44 patients (48.9%) had a grade I LVDD, 28 patients (31.1%) had a grade II LVDD and 13 patients (14.4%) had a grade III LVDD. There was a highly statistically significant positive association between the grades of left ventricular diastolic dysfunction according to ALT, AST, T.Bilirubin, D.Bilirubin, INR and Creatinine. Additionally, there was a highly statistically significant negative association between grading of left ventricular diastolic dysfunction according to platelet count and sodium levels. Conclusion There was a statistically significant correlation found between the severity of liver cirrhosis represented by the new MELD score and the grade of left ventricular diastolic dysfunction. Therefore, in order to prepare the best post-procedural management of cirrhotic patients, echocardiography is required for all patients before any interventional procedure or liver transplantation regardless of the stage of cirrhosis. The mechanism of cardiac involvement in patients with cirrhosis seems to be complex and multifactorial.

The Impact of Smoking History on Outcomes and Morbidity After Robotic Hepatectomy.

The detrimental effects that smoking has on patient health and postoperative morbidity are well documented. However, literature on the impact that smoking history has on robotic surgery, specifically robotic hepatectomy, is scarce. This study was undertaken to determine whether smoking history impacts the postoperative course of patients undergoing robotic hepatectomy. We prospectively followed 353 patients that underwent robotic hepatectomy. 125 patients had an apposite history of smoking (ie, smokers) and 228 patients were classified as non-smokers. Data were presented as median (mean ± SD). Patients were then propensity-score matched based on patient and tumor characteristics. Prior to the matching, the MELD score and cirrhosis status in patients who smoke were found to be significantly higher when compared to those who do not (mean MELD score 9 vs 8 and cirrhosis in 25% vs 13% of patients, respectively). Both smokers and non-smokers have similar BMIs, number of previous abdominal operations, ASA physical status classifications, and Child-Pugh scores. Six percent smokers vs one percent non-smokers experienced pulmonary complications (pneumonia, pneumothorax, and COPD exacerbation) (P = .02). No differences were found for postoperative complications of Clavien-Dindo score ≥ III, 30-day mortality, or 30-day readmissions. After the matching, no differences were found between the smokers and the non-smokers. After a propensity-score match analysis, smoking did not appear to negatively affect the intra- and postoperative outcomes after robotic liver resections. We believe that the robotic approach as the most modern minimally invasive technique in liver resection may have the potential to mitigate the known adverse effects of smoking.

Myostatin is associated with the presence and development of acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) has been linked to different pathophysiological mechanisms, including systemic inflammation and mitochondrial dysfunction. Sarcopenia has also been proposed as a potential mechanism; myostatin is a key factor inducing sarcopenia. Therefore, this study aimed to evaluate the association of myostatin levels with the development of ACLF and mortality in patients with cirrhosis. We performed a prospective cohort study, including both outpatient and hospitalized patients with cirrhosis. Clinical, biochemical, and nutritional parameters were evaluated, and the development of acute decompensation (AD) or ACLF during follow-up was recorded. ACLF was defined according to the EASL-CLIF criteria. Receiver-operating characteristic, Kaplan-Meier and Cox regression analyses were performed. A total of 186 patients with the whole spectrum of cirrhosis were included; mean age was 53.4 ± 14 years, mean Child-Pugh score was 8 ± 2.5 and mean MELD score was 15 ± 8. There was a stepwise decrease in myostatin levels from a compensated stage to AD and ACLF. Myostatin correlated positively with nutritional markers and negatively with severity scores. The prevalence of sarcopenia was 73.6%. During follow-up, 27.9% of patients developed AD and 25.8% developed ACLF. Most episodes were grade 2-3, mainly (62.5%) precipitated by infections. The most common organ failures observed were in the liver (63.3%) and the kidney (64.6%). Receiver-operating characteristic analysis yielded <1,280pg/ml as the best serum myostatin cut-off for the prediction of ACLF. In Kaplan-Meier curves and multivariate analysis, myostatin levels remained independently associated with the incidence of ACLF and survival. There is a progressive decrease in myostatin levels as cirrhosis progresses, demonstrating an association of sarcopenia with the development of ACLF and increased mortality. Myostatin is a muscle hormone, it is decreased in patients with muscle loss and is a marker of impaired muscle function. In this study we show that myostatin levels are decreased in patients with cirrhosis, with lower levels in patients with acute decompensation and acute-on chronic liver failure (ACLF). Low myostatin levels in cirrhosis predict the development of ACLF and mortality independently of liver disease severity and sex.

Is measuring serum ammonia helpful in patients with liver cirrhosis?

Background. Ammonia has been traditionally viewed as one of the main culprits for the development of hepatic encephalopathy. In the setting of liver cirrhosis or portal-systemic shunting, hepatocytes fail to metabolize ammonia, and thus excess ammonia reaches the systemic circulation, and from there, the brain. Material and methods. We performed a descriptive study involving 28 adult patients with liver cirrhosis. None of the patients had overt hepatic encephalopathy at the time of assessment, as judged by the West Haven criteria. Severity of liver cirrhosis was measured through the Child-Pugh and MELD scores. Serum ammonia was measured by venous sampling. Results. Mean age of the patients was 50±10 years-old. There were 68% males (n=19). Mean MELD score was 17±5 points. Mean Child-Pugh score was 8±2 points. Mean serum ammonia level was 76±37 μmol/L (range: 34-204 μmol/L). Serum ammonia levels correlated significantly with both scores of liver disease severity, more so with MELD (R=0.61, p=0.0005), than with the Child-Pugh score (R=0.38, p=0.04) Conclusions. We reaffirm the importance of measuring blood ammonia in patients with liver cirrhosis, since it is a helpful biomarker which correlates with liver disease severity and hepatic encephalopathy.

Delta Neutrophil Index as a New Early Mortality Predictor after Liver Transplantation.

Patients with liver disease display numerous defects of the immune system, so infection is a frequent complication of both acute and chronic liver disease. These infections are independently associated with poor outcomes after liver transplantation. Our objective was to evaluate the delta neutrophil index (DNI), a new inflammation marker, as a predictor of survival after liver transplantation (LT). This observational study retrospectively evaluated the records of 712 patients who underwent LT from January 2010 to February 2018. DNI was evaluated at pre-transplantation and 1, 7, 14, and 30 days after operation. Statistical analysis was performed using the T-test or chi-square test, and logistic regression analysis. The mean MELD score was 16.7 ± 9.4 (0-48). There were 125 mortality cases (17.8%) after liver transplantation. Mean DNI was 1.61 at pre-transplantation, 3.94 one day after operation, 2.67 seven days after operation, 1.61 fourteen days after operation, and 1.64 thirty days after operation, respectively. In multivariate analysis, DNI seven and fourteen days after operation was revealed as an independent prognostic factor for mortality after liver transplantation (p = 0.040 and p < 0.0001). The DNI is a simple and reliable predictor of patient mortality after liver transplantation.

An Echocardiographic Evaluation of Cardiopulmonary Evaluation of Cardiopulmonary Functions in Patients with Cirrhosis of Liver and Correlation with Severity of Disease

BACKGROUND Cirrhosis is the end result of varieties of chronic liver disease. A large proportion of patients with cirrhosis develop cardiopulmonary complication. The aim of this study was to evaluate the cardiopulmonary functions of patient with cirrhosis of liver and to correlate these abnormalities with CTP and MELD score.&#x0D; METHODS The study involved 81 cirrhotic patients admitted in Department of Gastroenterology of TUTH over a period of one year. The diagnosis of cirrhosis was established and clinical evaluation and investigation done.&#x0D; RESULTS The mean age of cirrhotic patients included in the study was 52 years. Alcohol was most common cause of cirrhosis (75.31%). The mean CTP score and MELD score was 10.02±1.77 and 23.59±7.53 respectively. Thirty patients (37.03%) had prolonged QTc interval, which had statistically significant association with alcohol as etiology of cirrhosis (p = 0.04). More than half (50.62%) of patients had diastolic dysfunction but it was not statistically significantly associated with CTP and MELD-Na score. Seven patients had evidence of intrapulmonary shunting, which had statistically significant association with MELD-Na score (p =0.01). Similarly, total 5 patients (6.17%) had PPHTN but there was no statistically significant association with CTP and MELD-Na score. Seventeen patients had dilated left atrium with no statistically significant association with CTP score and MELD-Na score.&#x0D; CONCLUSION There was significant incidence of cardiopulmonary abnormalities in cirrhotic patients. Every patient with decompensated cirrhosis irrespective of severity of disease should be evaluated for cardiopulmonary complication with a noninvasive, real-time, rapid imaging transthoracic contrast echocardiography.

Elevated lactate/albumin ratio as a novel predictor of in-hospital mortality in hospitalized cirrhotics

Introduction and ObjectivesNovel predictors of prognosis in cirrhotic patients have been emerging in recent years and studies show that the lactate/albumin ratio can serve as an early prognostic marker in different patient groups. We aimed to uncover the clinical significance of the lactate/albumin ratio in hospitalized patients with acutely decompensated cirrhosis. Materials and MethodsA retrospective single-center cohort study was conducted in a tertiary medical center. Subjects included had an established diagnosis of liver cirrhosis and were admitted to the ICU or the Internal Medicine department with a clinical picture of acute-on-chronic liver failure between the years 2010 and 2021. The primary outcome was to assess the utility of the lactate/albumin ratio as a prognostic marker to predict mortality in hospitalized cirrhotic patients with acute-on-chronic hepatic failure. ResultsTwo hundred seventy-nine patients were included in this study. Univariate analysis revealed that mean WBC count, platelet/creatinine ratio, aspartate transaminase (AST), lactate, and MELD score were all significantly associated with the primary outcome. Multivariate analysis showed that the lactate/albumin ratio was the strongest statistically significant (p < 0.001) predictor of death during hospitalization - OR 13.196 (95% CI 3.6–48.3), followed by mean WBC count, MELD score, and serum lactate levels. A ROC curve was constructed, which resulted in an area under the curve (AUC) equal to 0.77. Crosstabs from the ROC showed a sensitivity of 66.7% and a specificity of 76.2% when the lactate/albumin ratio chosen as a cutoff was 0.9061 ConclusionsElevated lactate/albumin ratio predicts in-hospital mortality in hospitalized cirrhotics with acute-on-chronic hepatic failure.

A new method for predicting alcohol relapse in patients undergoing liver transplantation for alcohol-related liver failure: Barratt scale.

Alcohol-induced liver disease has become one of the major causes of chronic liver disease worldwide with the increasing use of alcohol in society. The most important step in treatment is cessation of alcohol consumption. In patients with advanced liver disease, the most effective treatment is liver transplantation. Careful evaluation of patients with alcoholic liver disease before transplantation can help identify those at high risk of relapsing. Of a total of 42 patients who underwent liver transplantation for alcohol-related liver failure in our hospital between 2011 and 2022, 26 surviving patients were included in the study. Patient data were analyzed retrospectively. Demographic data, MELD score, history of alcohol consumption, alcohol treatment, post-transplant prognosis and survival were analyzed. The Barratt Impulsivity Scale-11 Short Form (BIS-11 SF) was applied to the surviving patients for impulsivity analysis to predict the possibility of relapse. Of the 26 patients who were included in the study, all were male. The mean age at transplantation was 53 (31-71) years. Mean MELD score was 22.31 (9-36). 12 patients (46.2%) received living donor liver transplantation and 14 patients (53.8%) received cadaveric liver transplantation. 25 patients (96.2%) had no post-transplant dependence, while 1 patient (3.8%) had post-transplant dependence. 5 patients (19.2%) continued to consume alcohol after transplantation. In our study, we observed that patients with high motor impulsivity tendency according to BSI-11 SF had alcohol relapse. We believe that revising this scale with more detailed questions for alcohol-dependent liver patients and applying it to patients before transplantation will be effective in better selection for transplantation and guiding patients to appropriate therapy and thus preventing relapse after transplantation.

Assessment of excessive daytime sleepiness in cirrhotic patients

Background. It is known that alterations of the sleep-wake cycle are present from the early stages of hepatic encephalopathy (starting with grade I on the West Haven criteria). However, minimal hepatic encephalopathy (which is not included in the West Haven criteria) defines the earliest form of HE, with no obvious clinical manifestations, but with subtle alterations in cognitive domains such as attention, visuo-spatial perception, psychomotor speed and response inhibition. Aim. To determine if liver cirrhosis in otherwise asymptomatic individuals (without clinically manifest hepatic encephalopathy) is associated with an increased risk of altered sleep rhythm or excessive daytime sleepiness. Additionally, to determine if this risk is correlated with liver disease severity or other clinical and biological parameters. Material and methods. Cross-sectional study involving 25 adult patients with liver cirrhosis. Patients were evaluated through a standard neurological examination and with the Epworth Sleepiness Scale. Liver disease severity was measured using the MELD and Child-Pugh scores. Blood ammonia levels were also measured. Results. Mean age of the patients was 50±12 years-old. There was a predominance of males (68%, n=17). Mean MELD score was 17±7 points. Mean Child-Pugh score was 8±2 points. Mean blood ammonia level was 34±17 μg/dL. Subjective daytime somnolence was reported by 24% of patients (n=6). Mean ESS score was 6±5 points. No correlation was noted between the ESS scores and liver disease severity as measured by the Child-Pugh and MELD scores. Only three patients (12%) scored over 10 points on the ESS (none of them obese) and were consequently diagnosed with excessive daytime sleepiness (EDS). This proportion falls into the accepted prevalence of EDS in the general population. Conclusions. In our study, liver cirrhosis was not associated with a higher prevalence of excessive daytime sleepiness than in the general population.

1999. Cefpodoxime for Spontaneous Bacterial Peritonitis Prophylaxis: Incidence of Breakthrough Infection

Abstract Background Guidelines recommend use of fluoroquinolones and sulfamethoxazole-trimethoprim (SMX-TMP) for spontaneous bacterial peritonitis (SBP) prophylaxis based on data demonstrating a decrease in one-year incidence of SBP. Our institution frequently utilizes cefpodoxime for its favorable safety profile despite the lack of robust clinical experience. We sought to compare rates of breakthrough SBP with the use of cefpodoxime compared to previously reported incidence rates with the use of SMX-TMP and fluoroquinolones. Methods This is an IRB-approved, retrospective, single-center cohort analysis. The electronic medical record at the Hospital of the University of Pennsylvania was utilized to identify cirrhotic patients newly started on cefpodoxime for SBP prophylaxis from March 1, 2016, to December 31, 2020. The primary endpoint was the incidence of breakthrough infections within 1 year in patients who received cefpodoxime for primary or secondary SBP prophylaxis. Secondary endpoints included 1-year all-cause mortality and any microbiologic data from suspected or confirmed SBP during the study timeframe. Descriptive statistics were utilized to analyze baseline characteristics and collected data points. Results Overall, 90 patients met inclusion criteria within our timeframe. The study population consisted of mostly men (65.6%) with a mean age of 59 years. The majority of patients were taking cefpodoxime for primary prophylaxis (66.7%). A large proportion of the patients also had diabetes (44.4%). Alcohol use (53.3%) was the most common cause of cirrhosis, and the mean MELD score was 20.3. Breakthrough SBP occurred in 4 (4.4%) out of 90 patients within 1 year of cefpodoxime initiation. Of the 19 patients who completed a full year of cefpodoxime, 1 (5.2%) patient experienced breakthrough SBP. Microbiologic data was significant for the growth of Citrobacter spp., Streptococcus spp., Enterococcus spp., and Candida glabrata. One patient experienced culture-negative SBP. All-cause mortality at one year in our study was 41.1%. Conclusion Cefpodoxime is a viable option for primary or secondary prophylaxis of SBP based on comparable rates of breakthrough infection. Cefpodoxime does not frequently appear to encourage colonization and infection with resistant gram-negative pathogens. Disclosures All Authors: No reported disclosures.

Good outcomes of living donor liver transplant in primary sclerosing cholangitis: an experience from North India.

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease. In the absence of effective medical therapy, liver transplant is the definitive treatment for advanced stage. However, recurrence of PSC after liver transplant is of concern which can lead to graft failure and may require retransplant. There are limited data on outcomes of living donor liver transplant (LDLT) in PSC. Also, in LDLT as donors are genetically related there can be an increased risk of recurrence. We conducted this retrospective study to analyze the outcomes of LDLT in PSC at a tertiary liver transplant center in north India. We conducted a retrospective analysis of 3213 transplant recipients who underwent LDLT from January 2006 to May 2021. Of these 26 (0.80%) patients had PSC as indication for liver transplantation (PSC = 24, PSC-AIH overlap = 2). Data analysis was done to look for baseline demographics, clinical details, transplant outcomes, PSC recurrence, and survival. Mean age of study group was 42 (± 13.8) years and 19patients (73.1%) were males. All patients had decompensated cirrhosis at the time of transplant. Mean CTP score and MELD score were 9.5 (± 1.8) and 18.9 (± 7.1), respectively. Sixteen patients received modified right lobe graft, seven extended right lobe graft and five patients received left lateral graft. Median graft weight and mean graft to recipient weight ratio (GRWR) were 633.5 (IQR 473.5-633.5) grams and 1.23 (± 0.42), respectively. Most common biliary anastomosis was hepaticojejunostomy, done in 19 (73.1%) while duct to duct anastomosis was performed in 7 (26.9%) patients. Median follow-up was 96 (36-123) months. One patient had ulcerative colitis and none had cholangiocarcinoma. Two (7.7%) patients had bile leak during early post-transplant period. Three (11.1%) patients developed graft rejection and were managed successfully with steroid pulses. Three patients died during early post-transplant period while seven deaths occurred during long-term follow-up including one death due to COVID-19. Five (21.73%) patients had recurrence of PSC of which two patients had graft loss including one after retransplantation. The one year graft and patient survival rate was 88.5%. LDLT can be performed in PSC with good long-term outcomes with a risk of PSC recurrence in about one-fifth patients.

S1336 Role of FIB-4 Score in Predicting Risk of Hepatocellular Carcinoma in Patients With Cirrhosis due to Nonalcoholic Steatohepatitis

Introduction: Hepatocellular carcinoma (HCC) represents the main cause of death in patients with nonalcoholic steatohepatitis (NASH) cirrhosis and is a leading indication for liver transplantation. Identification of high-risk patients for HCC is essential for long term monitoring of disease progression, early detection, and effective intervention. Fibrosis-4 (FIB-4) is a noninvasive index of readily available laboratory measurements and is widely validated for predicting cirrhosis and HCC. We sought to determine if FIB-4 score is associated with high risk of HCC among patients with NASH cirrhosis. Methods: We conducted a retrospective cohort study of adult patients with NASH cirrhosis (n=1,441) who were evaluated at our medical center between 2005 and 2015. Those who developed HCC were identified via ICD codes until the end of September 2021. At day of index NASH cirrhosis diagnosis, clinical and biochemical measurements were recorded on each patient. Descriptive statistics were calculated for all factors. Kaplan-Meier analysis was performed to evaluate time to HCC event. Cox regression models were used to evaluate associations between HCC and factors of interest. Models were adjusted for age, sex, number of comorbidities, and laboratory values. Results: During a median follow-up time of 8.3 years, 218 (15%) patients with NASH cirrhosis developed HCC. At index visit, the study population had a median age 57 years, 44% males, 78.6% White, median BMI 31.5 kg/m2, 26.7% had diabetes mellitus, 10.4% current smokers, mean FIB-4 score 4.2, and mean MELD score 8.1. Multivariable Cox regression models revealed that age, sex, race/ethnicity, BMI and FIB-4 were independent factors associated with development of HCC in patients with NASH cirrhosis (Table). Compared to patients with FIB-4 < 1.45, patients with FIB-4 between 1.45-3.25 had a similar risk of HCC (95% CI: 0.61-1.86, p=0.82). Patients with FIB-4 > 3.25 had a 2.51 (95% CI: 1.53-4.12, p< 0.001) increased hazard of HCC (Figure). Conclusion: Age, sex, race/ethnicity, BMI and FIB-4 were independently associated with HCC in NASH cirrhosis. We found that FIB-4 > 3.25 was an independent predictor of HCC risk. Providers should pay attention to FIB-4 for long term monitoring of disease progression. An inexpensive, available, validated marker like FIB-4 is a promising tool for identification of high-risk patients and may be used in routine clinical practice as a simple screening strategy for HCC risk in patients with NASH cirrhosis.Figure 1.: Kaplan-Meier estimates of developing HCC in patients with NASH cirrhosis by FIB-4 score within 5 years of follow up Table 1. - Factors Associated with HCC in NASH Cirrhosis: Univariate and Multivariable Analyses Univariate Multivariable Factors Unadjusted Hazard Ratio (95% Confidence Interval) p-value Adjusted Hazard Ratio (95% Confidence Interval) p-value Age group, yrs <49 1 [reference] 1 [reference] >49-59 1.40 (0.96-2.04) 0.08 1.22 (0.74-2.04) 0.43 >59-69 2.13 (1.47-3.11) 0.000 1.72 (1.02-2.90) 0.04 >69 4.26 (2.66-6.80) 0.000 3.03 (1.57-5.88) 0.001 Sex Female 1 [reference] 1 [reference] Male 2.13 (1.62-2.8) 0.000 2.00 (1.37-2.91) 0.000 Race and ethnicity Hispanic 0.72 (0.29-1.7) 0.46 0.42 (0.10-1.74) 0.23 Non-Hispanic White 1 [reference] 1 [reference] Black 0.62 (0.42-0.91) 0.01 0.70 (0.43-1.13) 0.15 Other* 0.59 (0.19-1.8) 0.36 0.50 (0.12-2.06) 0.34 BMI, Kg/m2 0.989 (0.97-1.01) 0.24 BMI category, Kg/m2 < 18.5 0.95 (0.22-4.16) 0.95 1.52 (0.34-6.85) 0.59 18.5–24.9 1 [reference] 1 [reference] 25.0–29.9 1.73 (0.96-3.11) 0.07 1.69 (0.89-3.20) 0.11 30.0–34.9 1.49 (0.81-2.7) 0.20 1.46 (0.76-2.81) 0.26 35.0–39.9 1.59 (0.83-3.02) 0.16 1.63 (0.82-3.26) 0.16 >40 0.95 (0.47-1.91) 0.89 1.16 (0.53-2.50) 0.71 Diabetes 0.76 (0.55-1.06) 0.11 Total cholesterol, mg/dL 125-200 1 [reference] >200 0.78 (0.39-1.6) 0.50 LDL, mg/dL < 130 1 [reference] >130 0.42 (0.17-1.01) 0.05 MELD score <20 1 [reference] >20 1.14 (0.60-2.16) 0.68 FIB-4 score < 1.45 1 [reference] 1 [reference] 1.45-3.25 1.22 (0.79-1.9) 0.37 1.07 (0.61-1.86) 0.82 > 3.25 2.74 (1.89-3.97) 0.000 2.51 (1.53-4.12) 0.000 Albumin, g/dL 0.685 (0.566-0.828) 0.000 INR 1.52 (1.19-1.95) 0.001 Creatinine, mg/dL 0.91 (0.77-1.07) 0.26 Total Bilirubin, mg/dL 1.04 (1.01-1.07) 0.01 Platelet count, ×109/L 0.997 (0.996-0.999) 0.001 *Other category included Asian, American Indian-Alaskan or other.

S1440 Inpatient Management of Decompensated Cirrhosis - A Quality Improvement Initiative

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

Clinical Outcomes and Patency after Transjugular Intrahepatic Portosystemic Shunt Reduction for Overshunting Adverse Events

PurposeTo assess clinical outcomes and patency after transjugular intrahepatic portosystemic shunt (TIPS) reduction for overshunting adverse events. Materials and MethodsThis multicenter, retrospective observational study included 33 patients (male-to-female ratio, 20:13; mean age, 59 years; mean Model for End-Stage Liver Disease [MELD] score, 15) who underwent TIPS reduction between 2007 and 2020. Procedure indications included medically refractory hepatic encephalopathy (HE) (85%), post-TIPS hepatic insufficiency (HI) (12%), and heart failure (3%). The measured outcomes included improvement in HE (classified using the West Haven system) and HI, patency of reduced TIPS, and transplant-free survival (TFS). ResultsTIPS reductions were successfully performed using parallel stent (94%) or other (6%) techniques at a median of 120 days after TIPS creation (HE, median, 164 days; HI, median, 5 days). The portosystemic pressure gradient increased from a mean of 10 to 17 mm Hg (P < .001). The overall HE rate after TIPS reduction was 54%; HE was persistent, improved, and resolved in 21%, 32%, and 46% cases, respectively. In patients with HI, the MELD score increased from a mean of 22 before TIPS to 34 after TIPS (P = .061), but without improvement (0%) in HI after TIPS reduction (mean MELD score, 30; P = .266). Recurrent ascites occurred in 14% of the patients. The median shunt patency was 961 days (95% confidence interval, 476–1,447). The 30-day, 6-month, 1-year, and 3-year shunt patency rates were 92%, 81%, 74%, and 37%, respectively. The median TFS was not reached. The 30-day, 6-month, 1-year, and 3-year survival rates were 97%, 90%, 81%, and 60%, respectively. ConclusionsAlthough TIPS reduction may be an effective and durable approach to treat post-TIPS medically refractory HE, shunt reduction may not achieve meaningful benefit for HI.

An observational cross-sectional study of the serum sodium levels and their association with severity in chronic liver disease patients in a tertiary care center in Haryana

Background: Chronic liver diseases (CLDs) cause significant morbidity and mortality worldwide. Reduced serum sodium concentration is a common finding in patients with cirrhosis, being the most common electrolyte disorder in this setting. Aims and Objectives: The objectives of the study were as follows: (1) To find the association of altered serum sodium levels with the disease severity (as per Child-Pugh Score [CPS] and Model for End-Stage Liver Disease [MELD]) and (2) to assess for the type of dysnatremias commonly found in CLD and its association with complications of CLD. Materials and Methods: It is an observational cross-sectional study. It was done for 18 months (June 2019 till May 2020) in the Department of General Medicine of Bhagat Phool Singh Government Medical College for Women, Khanpur Kalan, Sonipat, Haryana. Results: Among all patients with CLD, 30.8% had serum sodium levels ≤130 mEq/L), 32.5% had 131–135 mEq/L, and 36.7% had ≥136 mEq/L. Thus, hyponatremia was observed in 63.3% of the patients. Mean MELD score and mean CPS were significantly higher in patients with reduced serum sodium levels. In addition, Child-Pugh Class C was significantly more common in patients with serums sodium levels ≤130 mEq/L as compared to other patients. Hepatic encephalopathy, hepatorenal syndrome, and coagulopathy were found to occur significantly more common in patients with serums sodium levels ≤130 mEq/L. Conclusion: Hyponatremia is very common among patients with CLD. Low serum sodium level was associated with more severe liver disease, more complications, and higher mortality.

Positive Predictive Value of MELD Score ≥18 in Predicting in-Hospital Mortality in Cirrhotic Patients with Variceal Bleeding

Objective: To determine the positive predictive value of MELD score ≥18 in predicting in hospital mortality in cirrhotic patients with variceal bleeding. Study Design: Cross-sectional. Place and Duration of Study: Department of Gastroenterology-Hepatology, Shaikh Zayed Hospital, Lahore from 01 April 2013 to 31 March 2014 Methodology: Two hundred and fifty patients were selected from the Gastroenterology/Hepatology Emergency Department of Shaikh Zayed Medical Complex, Lahore. Informed consent was taken from each study participants and the participants of acute variceal bleeding were managed according to standard protocol. Blood samples were taken for biochemical testing before setting treatment plan. Study endpoint was patient outcome (alive or expired during hospital admission). Results: There were 141 (56.4%) males whereas 109 (43.6%) females. The mean age was 49.85±12.16 years, mean INR was 3.02±1.03, mean bilirubin was 2.42±0.922, mean creatinine was 2.05±1.01 and mean MELD score was 27.20±6.61. There were 99 (39.6%) deaths Conclusion: Results predict that MELD score ≥18 gives early indication of acute variceal bleeding, thus helps in managing the warning signs and to increase the life expectancy. Key words: Cirrhosis, End stage liver failure, Variceal bleeding, Hepatitis B and C, Model for end-stage liver disease