Mean Model For End-stage Liver Disease Research Articles

Can platelet Iymphocyte ratio and neutrophil to lymphocyte ratio be used as predictors for hepatocellular carcinoma?

Aim: To investigate the predictive value of platelet to lymphocyte and neutrophil to lymphocyte ratios for hepatocellular carcinoma outcomes Material and Methods: 37 hepatocellular carcinoma patients were retrospectively collected. All of the hepatocellular carcinoma patients were treated with conventional methods; transarterial chemoembolization, radiofrequency ablation or both. The patient and tumor characteristics, platelet to lymphocyte ratio and neutrophil to lymphocyte ratio were recorded. The association between platelet to lymphocyte ratio and neutrophil to lymphocyte ratio and tumor free survival rates, recurence rates, need of repeated conventional therapy were analyzed. Results: The mean MELD (model for end stage liver disease) score of 37 hepatocellular carcinoma patients was 10.75±4.484 (mean age 59.59±17.23 years). High platelet to lymphocyte ratio and neutrophil to lymphocyte ratio were found to be associated with hepatocellular carcinoma recurrence (p0.05). Platelet to lymphocyte ratio and neutrophil to lymphocyte ratios were significantly high in patients who had repated transarterial chemoembolisation, radiofrequency ablation or both (p

Results of Adult Living Donor Liver Transplantation with Sixth-Decade Donors: A Propensity Score Matching Study in a High-Volume Institution.

BackgroundWe assessed the prognostic impact of donor age on the outcome of adult living donor liver transplantation (LDLT).Material/MethodsThe study population comprised adult donor and recipients of right lobe grafts for LDLT performed from January 2005 to December 2016. There were 35 living donors aged ≥50 years (old-age donor group). As a control group, donors in their 20s (young-age donor group) were selected after one-to-one propensity score matching based on sex, model for end-stage liver disease (MELD) score, and primary diagnosis.ResultsDonor age was 52.5±1.5 years versus 25.4±3.1 years in the old- and young-age donor groups, respectively. Remnant volumes of the 2 groups were 38.9±3.0% versus 38.1±2.9%, respectively (p=0.98). One-month regeneration rate of the remnant liver was 101.1±10.6% versus 104.5±11.8%, respectively (p=0.08), and there was no significant difference in the incidences of donor complications. Mean MELD score was 15 versus 14, respectively (p=0.82). Graft-to-recipient weight ratio was 1.02±0.43 versus 0.91±0.63, respectively (p=0.28). In the recipients, biliary complication occurred in 11.4% versus 8.6%, respectively (p=0.12), and there was no difference in 5-year survival rates of both groups (p=0.15). The 1-week and 1-month regeneration rates of the remnant left liver were 71.6±9.9% and 100.1±10.6% in the old-age group, respectively, whereas those were 80.2±12.1% and 104.5±11.8% in the young-age group, respectively (p=0.08).ConclusionsRight lobe grafts from donors aged ≥50 years showed the usual recovery of graft function but rather delayed liver regeneration. Thus, old-aged donors should be selected prudently after consideration of hepatic resection rate, graft size, and hepatic steatosis.

On-Treatment Improvement of MELD Score Reduces Death and Hepatic Events in Patients With Hepatitis B-Related Cirrhosis

Antiviral treatment modifies the natural history of chronic hepatitis B (CHB)-related cirrhosis as reflected by improving Model for End-Stage Liver Disease (MELD) score over time. We evaluated the impact of on-treatment change of MELD score on clinical outcomes in patients with CHB-related cirrhosis. Cirrhotic CHB patients who received entecavir and/or tenofovir disoproxil fumarate for at least 6 months in Hong Kong between 2005 and 2016 were identified. The primary outcome was all-cause mortality; secondary outcomes were hepatocellular carcinoma (HCC), and hepatic events including ascites, spontaneous bacterial peritonitis, variceal bleeding, hepatorenal syndrome, hepatic encephalopathy, and liver transplantation. We identified 1743 cirrhotic CHB patients. Their mean MELD score decreased from 12.3 ± 5.5 at baseline to 11.0 ± 4.7 at month 6. At a median (interquartile range) follow-up of 3.9 (1.9-6.0) years, 290 (16.6%) patients died; 201 (11.5%) developed HCC. Among 1140 patients without prior hepatic events, 150 (13.2%) developed hepatic events. Among 464 patients with baseline MELD score ≥15, the 6-year cumulative mortality was 72.8, 36.7, and 23.1% for unchanged or increased MELD score, 1-5 point improvement in MELD score, and >5 point improvement in MELD score at month 6, respectively (log-rank test, P < 0.001); the corresponding 6-year cumulative incidence of hepatic events was 52.7, 30.5, and 23.9% in the three subgroups (Gray's test, P = 0.004). Patients with MELD score <15 at month 6 had lower risk of mortality and hepatic events (all P < 0.001). On-treatment improvement of MELD score correlates with reduced risk of mortality and hepatic events in cirrhotic CHB patients.

Correlation of baseline Portal pressure (hepatic venous pressure gradient) and Indocyanine Green Clearance Test With Post-transarterial Chemoembolization Acute Hepatic Failure

Liver failure (LF) is a serious complication of transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). This could be influenced by the hemodynamic and functional status of the underlying cirrhotic liver. We evaluated baseline hepatic venous pressure gradient (HVPG) and indocyaninegreen (ICG) clearance as predictive factors for the development of LF in patients with liver cirrhosis undergoing TACE for HCC. Forty-two patients with cirrhosis and HCC, referred for TACE, were clinically evaluated including the assessment of Child Turcotte Pugh score (CTP), Model for End-Stage Liver Disease (MELD), HVPGmeasurement, and ICG retention test. Predictors of development of hepatic failure after TACE were determined. In our study population, the mean age of the patients was 58 years, with mean CTP of 6.60±1.149 and mean MELD score of 9.57±2.923. The mean HVPG and ICG retention at 15min was 13.57±4.64mmHg and 21.571±12.434, respectively. Post-TACE Liver Failure (PTLF within 1 month after TACE) developed in 23.80% patients, whereas 76.19% patients did not have PTLF. The statistically significant preprocedure variables that might predict hepatic failure after TACE using univariate analysis were found to be high CTP, MELD score, ICG retention, HVPG, serum bilirubin, serum creatinine, alfa-fetoprotein levels, large tumor size, and low baseline serum albumin. On multivariate analysis, ICG was an independent factor predictive of hepatic failure after TACE. Pretreatment evaluation of routine liver function is of fundamental importance before TACE. Baseline ICG retention test (ICG-R15) is a marker indicating the state of liver function in patients undergoing TACE and is an independent predictor for PTLF. Our study concludes thatwith a cutoff of 25, ICG-R15 has 92.9% accuracy, 90% sensitivity, and 87.5% specificity to predict hepatic failure after TACE.

Clinical Outcomes of Acute Pancreatitis in Patients with Liver Cirrhosis - A Single-Center Experience

Introduction: Acute pancreatitis (AP) is a common gastrointestinal discharge diagnosis in the US, but outcomes in cirrhotic patients has not yet been studied. We aim to investigate these outcomes. Methods: Propensity score matching was used to match patients with and without cirrhosis on a 1:2 basis. The Cleveland Clinic acute pancreatitis registry database was used. Outcomes included inpatient mortality, organs failure, systemic inflammatory response syndrome (SIRS), length of hospital stay (LOS). Subgroup analysis of cirrhotic patients according to Child-Pugh and Model of End-stage Liver Disease (MELD) scores was performed. Multivariable logistic regression models were constructed using SAS software version 9.4 Results: 819 patients with acute pancreatitis were analyzed. Cirrhosis prevalence was 6.1%. Cirrhosis patients were mostly males and younger (table 1). Mean Child-Pugh score was 8.2, mean MELD score was 16 (table 1). Etiology of AP was similar in both groups. Cirrhosis subjects had significantly higher inpatient mortality (7.5% vs. 1.3%, P=0.1), severe AP (17.5% vs. 7.5%), Shock (7.9% vs. 3%), ARDS (10% vs. 3.8%), ICU requirement (15% vs. 6.3%) although not statistically significant, the trend was present. Surprisingly, cirrhotics had lower prevalence of admission SIRS (22.5% vs. 32.5%), SIRS day 2 (25% vs. 15%). Cirrhotics had similar rates of pancreatic necrosis, ileus, BISAP score, Marshall score, admission hematocrit, BUN and LOS (table 2). Finally, cirrhotic patients who had severe AP and/or required ICU and/or die in-hospital were mainly Child-C and had high MELD score (17-38) but they had low BISAP and Marshall scores (table 5). Conclusion: Limitations: Retrospective design. Small sample size due to low prevalence of cirrhosis. Strength: First study to analyze outcomes of cirrhosis in AP and compare according to Child-Pugh and MELD scores. Adjusted for age, gender, race, CCI. Conclusion: Acute pancreatitis patients with liver cirrhosis have higher inpatient mortality, possibly related to decompensated cirrhosis - as they appear to have lower prevalence of SIRS, low BISAP and Marshall scores as well as similar rates of pancreatic necrosis compared to non-cirrhotics. Importantly, cirrhotic patients who died were mostly Child-Pugh C and had very high MELD score.32_A Figure 1. Demographic and Baseline Characteristics32_B Figure 2. Outcomes: Characteristics of cirrhotic patients with severe pancreatitis, required ICU and/or died in the hospital32_C Figure 3. Outcomes of Cirrhotic patients: Child Pugh Class A vs. B/C

Emricasan Improves Liver Function in Patients With Cirrhosis and High Model for End-Stage Liver Disease Scores Compared With Placebo

Caspase-mediated apoptosis and inflammation contribute to progression of liver disease. Emricasan is a pan-caspase inhibitor that reduced serum markers of apoptosis and liver inflammation in patients with hepatitis C and non-alcoholic steatohepatitis (NASH). We performed a multicenter study of 86 patients with cirrhosis (Child-Pugh class A or B; mean score, 6.9; 38% with alcohol-associated cirrhosis, 29% with HCV-associated cirrhosis, and 23% with NASH) and model for end-stage liver disease (MELD) scores of 11-18 (mean, 12.8). Patients were randomly assigned to groups given placebo (N = 42) or Emricasan (25 mg, N = 44), twice daily for 3 months; subjects then received open-label Emricasan (25 mg) twice-daily for 3 months. The primary endpoint was the change from baseline in serum levels of cleaved keratin 18 (CK-18) at month3. Seventy-four patients completed the 3-month study period (40 given Emricasan and 34 given placebo); 69 patients received open-label Emricasan for 3 months afterward. At the 3-month timepoint, Emricasan significantly reduced mean MELD (P = .003) and Child-Pugh (P = .003) scores in subjects with high MELD scores (15 or more), compared with placebo, with significant reductions in INR (95% CI, -0.2882 to -0.0866) and total bilirubin (95% CI, -1.5069 to -0.0823) vs placebo. There were no significant differences between Emricasan and placebo groups in mean MELD (P = .466) or Child-Pugh (P = .124) scores overall at 3 months compared to placebo. Of patients with high MELD scores, 6/9 given Emricasan (67%) had a reduction of 2 points or more at month 3, compared with 2/10 given placebo (20%). Serum levels of full-length CK-18 (P = .02) and caspase 3/7 (P < .001), butnot cleaved CK-18 (P = .092), decreased significantly at 3 months in the Emricasan vs placebo group. Emricasan was well tolerated, and adverse events were balanced between groups. Emricasan's effects were generally maintained or increased after 6 months of treatment. In a randomized trial of patients with cirrhosis, we found 3 months treatment with Emricasan to improve liver function, compared with placebo, reducing MELD and Child-Pugh scores, INR, and total bilirubin in patients with MELD scores ≥15. ClinicalTrials.gov no: NCT02230670.

Contrast-induced Acute Kidney Injury in Patients with Liver Cirrhosis: A Retrospective Analysis.

Contrast-induced acute kidney injury (CI-AKI) has been studied less extensively in patients with liver cirrhosis (LC). It is unclear whether the presence of severe liver disease is actually a predisposing factor for CI-AKI. Liver cirrhosis is extremely common in Pakistan and is attributed to the high prevalence of chronic viral hepatitis. Patients with LC often undergo contrast-enhanced computed tomograms (CECT) for various diagnostic and therapeutic purposes, and there have been concerns regarding them being at risk for CI-AKI. The available literature on this topic is scanty, and no study has been conducted in Pakistan. The purpose of this study, therefore, was to determine the frequency of CI-AKI in patients with LC undergoing CECT and to determine any significant predispositions. We retrospectively analyzed the records of 470 LC patients at our center. The frequency of CI-AKI in our study was 5.1%. A higher mean model for end-stage liver disease (MELD), MELD including sodium (MELD-Na), and Child-Pugh (CP) scores was significantly associated with developing CI-AKI (p<0.05). Patients with CI-AKI also had a significantly higher mean international normalized ratio (INR) and serum bilirubin levels, with lower mean venous bicarbonate and serum sodium levels (p<0.05). Our results show that patients with a more advanced liver disease and poorer synthetic function are increasingly susceptible to developing CI-AKI. Further studies can investigate the role of bicarbonate therapy in preventing CI-AKI in LC.

Neutrophil-to-Lymphocyte Ratio Associates Independently With Mortality in Hospitalized Patients With Cirrhosis

The neutrophil to lymphocyte ratio (NLR) is a biomarker of immune dysregulation in patients with cirrhosis and is inexpensive to measure. We investigated the association between NLR and mortality in hospitalized patients with cirrhosis at 4 liver transplant centers, controlling for severity of acute-on-chronic liver failure (ACLF). We performed a retrospective study using data from the North American Consortium for the Study of End-stage Liver Disease on patients with index hospitalizations for cirrhosis from December 2011 through December 2016. We collected data on patient demographics, NLR, model for end-stage liver disease (MELD) scores, serum levels of Na, cirrhosis stages, infections, hepatocellular carcinomas, and ACLF severity (based on number of organ failures). Competing risk regression analysis evaluated mortality within 1 year after hospital discharge, accounting for competing events (liver transplant). At admission, the patients' mean age was 57 years, mean MELD score was 21, and mean serum levelof Na was 134 mmol/L. Sixty-eight patients had no organ failure, 21 patients had 1 organ failures, 7patients had 2 organ failures, 4 patients had 3 organ failures, and 1 patient had 4 organ failures; 36% of the patients had confirmed or suspected infections. In univariate models,risk ofdeath associated with increasing NLR, up to a value of 8 (hazard ratio [HR]=1.14; 95% CI,1.07-1.20; P < .001), and NLR quartile (for NLR range of 3-5, HR = 2.17; for NLR range of >5-9, HR=2.46; for NLR quartile >9, HR=2.84 vs the lowest quartile [NLR<3]) (P≤ .001). The NLR remained statistically significant in multivariable models, adjusting for age, MELD score, hepatocellular carcinoma, and ACLF severity. Additionally, NLR was a statistically significant independent predictor of length of index hospital stay and mortality within 90 days after discharge. In a retrospective analysis of patients with cirrhosis, we found NLR to associate with death within 1 year after non-elective hospitalization. In these patients, the risk of death associated with acute immune dysregulation persists long after their initial hospitalization.

Value of the albumin‑bilirubin score in the evaluation of hepatitis B virus‑related acute‑on‑chronic liver failure, liver cirrhosis, and hepatocellular carcinoma

The aim of the present study was to investigate the value of the albumin-bilirubin (ALBI) score in the assessment of the disease conditions of hepatitis B virus (HBV)-related acute-on-chronic liver failure (HBV-ACLF), HBV-related liver cirrhosis (HBV-LC) and HBV-related hepatocellular carcinoma (HBV-HCC). A total of 395 patients with HBV-ACLF, HBV-LC, or HBV-HCC were retrospectively studied. The ALBI, Child-Turcotte-Pugh (CTP), and Model for End-Stage Liver Disease (MELD) scores of the patients were calculated, and the relationships between the ALBI score and the CTP and MELD scores were investigated. Furthermore, the ALBI grading was tested for the evaluation of the severity and stages of HBV-ACLF, HBV-LC, and HBV-HCC, especially when classifying the clinical stages of HBV-ACLF. The mean ALBI scores of the HBV-ACLF, HBV-LC, and HBV-HCC patients were -1.17±0.55, -1.76±0.66 and -2.59±0.62, respectively; the mean CTP scores were 10.70±1.81, 8.19±1.25 and 5.81±1.22, respectively; and the mean MELD scores were 19.93±7.44, 11.10±4.39 and 7.01±3.22, respectively. The ALBI scores were positively correlated with the CTP and MELD scores. The mean ALBI score and the frequency of grade 3 disease were higher in HBV-ACLF patients than in patients with HBV-LC or HBV-HCC. A later HBV-ACLF stage resulted in a higher frequency of ALBI grades of 3. In conclusion, ALBI scores exhibited parallel tendencies to the CTP and MELD scores in HBV-ACLF, HBV-LC, and HBV-HCC patients; thus, ALBI grading may be a simple but applicable method for the evaluation of the functional status of patients with HBV-related end-stage liver diseases.

PROGNOSTIC VALUE OF MELD SCORE IN CHILD PUGH C CIRRHOTIC PATIENTS

Background and aims: Model for End Stage Liver Disease (MELD) is a scoring system used for prioritization of patients waiting liver transplantation. Patients with decompensated cirrhosisoftenshave serious complications. The aims of this study was to evaluate prognostic value of MELD score for complications (mortality, acute variceal bleeding, spontaneous bacteremia peritonitis, hepatoencephalopathy, hepatorenal syndrome) of Child Pugh C cirrhotic patients in 6 months after hospitalizing. Methods: This prospective study included 102 consecutive Child Pugh C cirrhotic patients who were admitted in the period april 2016 to February 2017 in the Gastrointestinal Department, Hue Central Hospital and the General Internal Medicine Department, Hue University Hospital. At admission the MELD score of each patient was calculated. All patients were followed up for 6 months to assess the events: mortality, acute variceal bleeding, spontaneous bacteremia peritonitis, hepatoencephalopathy, hepatorenal syndrome. Results: Mean MELD score of all patients was 19.5 ± 7.1; of male patients was 19.7 ± 7.4; of female ones was 18.43 ± 4.4; of alcoholic ones was19.5 ±7.5; of non - alcoholic ones was 19.6 ± 5.9. MELD score is available to predict mortality for 6 months after hospitalizating (with cut – off 20; AUC 0.69; sensitivity and specificity are 56.0% and 76.6%) and to predict hepatorenal syndrome (with cut – off 25; AUC 0.90; sensitivity and specificity are 83.3% and 85.4%). In this study, prognostic value of MELD score for acute variceal bleeding, spontaneous bacteremia peritonitis, hepatoencephalopathyfor 6 months after hospitalizating have not been found. Conclusions: MELD score is valuable prognostic system for mortality and hepatorenal syndrome in Child Pugh C cirrhotic patients in 6 months after hospitalizing. Key words: cirrhosis, MELD score

Liver transplantation in critically ill patients: Preoperative predictive factors of post-transplant mortality to avoid futility.

The allocation of liver transplants to patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) with multi-organ failure who are admitted in ICU remains controversial due to their high post-transplant mortality rate and the absence of identified mortality risk factors. We performed a single-center retrospective cohort study to determine the post-transplant mortality rate of patients with ALF and ACLF requiring ICU care prior to liver transplant (LT) and identified pretransplant factors of post-transplant mortality. Eighty-four patients (29 with ALF and 55 with ACLF) received a liver transplant while they were hospitalized at the ICU. Their mean model for end-stage liver disease (MELD) score was 41, and their mean sequential organ failure assessment (SOFA) was 15 the day before transplant. The overall 1-year survival rate was 66%. In multivariate analysis, pretransplant lactate level and acute respiratory distress syndrome (ARDS) were the only two independent factors associated with post-transplant mortality. The absence of ARDS and a pretransplant lactate level< 5 mmol/L led to the identification of a subgroup of ICU patients with a good 1-year post-transplant survival (>80%). Low lactatemia lactate level and the absence of ARDS could be useful criteria in selecting those patients in ICU who could be eligible for liver transplant.

Model for End Stage Liver Disease (MELD), Predictor of 30-Day Readmission Rate: A Systematic Review and Meta-Regression Analysis

Introduction: Patients admitted to the hospital with liver disease have a high rate of 30 days' readmission, particularly those with liver cirrhosis and post orthotopic liver transplantation. We performed a systemic review and meta-analysis to assess the ability of MELD score in predicting 30 days' readmission rate. Methods: A systematic search using search terms of “liver cirrhosis” and “hospital readmission” from major literature databases and manual search from their inceptions until 3 June, 2017 was conducted to identify studies examining the association between the Model for End-stage Liver Disease (MELD) and all-cause 30-day readmission rate. Meta-regression analysis was conducted to examine statistical significance with visual presentation. Results: Of the reviewed 103 articles found in the search strategy, we reviewed the full text of eligible 29 articles and excluded of those 22 articles, which resulted in a final 7 studies for analysis. A total of 14,294 patients were analyzed. The pooled mean MELD score was 16.755 with standard error 1.065 and 95% confidence intervals (CI) 14.667 to 18.842. All-cause 30-day readmission rates ranged 16.0% to 37.9%. The MELD score was associated with 30-day readmission rate (coefficient = 1.000; 95% CI 0.905 to 1.095; p <.001). Conclusion: Along with short-term mortality predictor usage, the MELD score might be used as a predictor of early hospital readmission in patients with liver cirrhosis.Table: Table. Summary of studiesFigure: Regression of MELD score on 30 days readmission rate.Figure: PRISMA study selection process for meta-regression study.

Shunt occlusion for portosystemic shunt syndrome related refractory hepatic encephalopathy-A single-center experience in 21 patients from Kerala.

Large spontaneous portosystemic shunts (SPSS) are seen in a subset of patients with liver disease and medically refractory recurrent/persistent hepatic encephalopathy (MRHE). Shunt occlusion has been shown to improve clinical outcomes. We retrospectively analyzed patient characteristics, SPSS attributes, procedural features, baseline clinical and investigational parameters, neurological outcomes, adverse effects (procedure and portal hypertension related), and risk factors predicting outcomes in liver disease patients undergoing shunt occlusion procedure for MRHE. Between October 2016 and July 2017, 21 patients (Child-Pugh score, CTP 6 to 13) with mean model of end-stage liver disease (MELD) and MELD-sodium scores 15.7 and 19.3 respectively with MRHE [3-cirrhotic Parkinsonism (CP)] were diagnosed to have single or multiple large SPSSs. A total of 29 shunts were occluded (1 surgical, 20 non-surgical). Recurrent and persistent HE and CP markedly improved in the short (n=20, 1 to 3months), intermediate (n=12, 3 to 6months), and long (n=7, 6 to 9months) follow up. None had spontaneous or persistent HE at a median follow up 105 (30 to 329) days (p<0.05). Motor, speech, sleep abnormalities, daily activities of living, and liver disease severity scores improved significantly on follow up. Baseline arterial ammonia showed a statistically significant reduction in all time periods of follow up after shunt occlusion (p<0.05). CTP >11 predicted mortality post shunt occlusion (p=0.04). Embolization of large SPSS in liver disease patients with MRHE and modestly preserved liver function is safe and efficacious and associated with improved quality of life and can function as a bridge to liver transplantation in accurately selected patients.

A quality of life assessment and the correlation between generic and disease-specific questionnaires scores in outpatients with chronic liver disease-pilot study.

Chronic liver diseases (CLD) are an important cause of morbidity and mortality in general population. The aim of this study was to analyze potential differences between patients with CLD and healthy control group, and to estimate the severity of CLD by using simple questionnaires: general health questionnaire (GHQ-12) and chronic liver disease questionnaire (CLDQ). A cross-sectional pilot study was performed in Zemun Clinical Hospital during years 2014 and 2015. Sixty participants were divided into 4 groups (15 per group): chronic alcoholic hepatitis, other chronic hepatitis, liver cirrhosis, and healthy control group. Entire study population chose one of four offered answers of structured questionnaires GHQ-12 and CLDQ, based on which mean model of end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores were calculated. Mean GHQ12 and CLDQ scores were 10.5 and 5.21 ± 1.11 respectively. Regarding certain CLDQ domain scores, a significant difference between alcoholic and non-alcoholic hepatitis groups in the worry domain was observed. Mean MELD score was 7.42 ± 2.89 and did not differ between chronic hepatitis groups, while mean CTP score was 5.73 ± 0.88. A statistically significant correlation was observed between GHQ12 and CLDQ scores (ρ = -0.404, p < 0.01), but not between subjective and objective scores. Mean GHQ12 and CLDQ scores pointed out to general psychological no-distress condition of the studied participants, as well as scarcely expressed CLD-specific complaints. Mean MELD and CTP scores indicated stable chronic liver diseases, with low three-month mortality rates in the cases of chronic hepatitis, as well as determination to Child A group in the case of liver cirrhosis.

High MELD score does not adversely affect outcome of living donor liver transplantation: Experience in 1000 recipients.

In countries where deceased organ donation is scarce, there is a big gap between demand and supply of organs and living donor liver transplantation (LDLT) plays an important role in meeting this unmet need. This study was conducted to analyze the effect of pretransplant Model for End-stage Liver Disease (MELD) score on outcomes following LDLT. The outcome of 1000 patients who underwent LDLT from July 2010 to March 2015 was analyzed retrospectively. Patients were grouped into low MELD<25 and high MELD ≥25 score to compare short-term outcomes. Cumulative overall survival rates were calculated using Kaplan-Meier methods. A total of 849 recipients were in low MELD group (Mean MELD=16.90±9.2) and 151 were in high MELD group (Mean MELD=28.77±7.2). No significant difference in etiology of CLD was observed between groups except for a higher prevalence of hepatitis C virus (29.6% vs 19.9%, P=.01) in low MELD patients. No significant difference was observed in 1-year survival (88.5% vs 84.1%, P=.12) between the groups. The multivariate analysis showed that pretransplant MELD score does not predict survival of recipients. Pretransplant high MELD score does not adversely affect outcomes after LDLT. In view of shortage of deceased organs, LDLT can be a good option in high MELD recipients.

Prognostic factors of liver cirrhosis mortality after a first episode of spontaneous bacterial peritonitis. A multicenter study.

Spontaneous bacterial peritonitis is an infectious complication with a negative impact on survival of patients with cirrhosis. To analyze the short- and long-term survival after a first episode of bacterial peritonitis and the associated prognostic factors. This was a retrospective, multicenter study of patients admitted to hospital for spontaneous bacterial peritonitis between 2008 and 2013. Independent variables related to mortality were analyzed by logistic regression. The prognostic power of the Child Pugh Score, the Model for End-Stage Liver Disease (MELD) and the Charlson index was analyzed by ROC curve. A total of 159 patients were enrolled, 72% were males with a mean age of 63.5 years and a mean MELD score of 19 (SD ± 9.5). Mortality at 30 and 90 days and one and two years was 21%, 31%, 55% and 69%, respectively. Hepatic encephalopathy (p = 0.008, OR 3.5, 95% CI 1.4-8.8) and kidney function (p = 0.026, OR 2.7, 95% CI 1.13-16.7) were independent factors for short- and long-term mortality. MELD was a good marker of short- and long-term survival (area under the curve [AUC] 0.7: 95% CI 1.02-1.4). The Charlson index was related to long-term mortality (AUC 0.68: 95% CI 0.6-0.77). Short- and long-term mortality of spontaneous bacterial peritonitis is still high. The main prognostic factors for mortality are impairment of liver and kidney function. MELD and the Charlson index are good markers of survival.

Liver transplantation for fibrolamellar hepatocellular carcinoma: A national perspective.

Fibrolamellar Hepatocellular Carcinoma (FL-HCC) is a rare primary liver tumor that usually presents in younger patients without underlying liver disease. We queried the United Network of Organ Sharing (UNOS) database between October 1988 and January 2013 to evaluate outcomes in patients with FL-HCC undergoing liver transplantation in the United States compared to patients with conventional Hepatocellular Carcinoma (HCC). Sixty-three patients were identified (57% female, mean age 30 years). Only one patient (2%) had an associated Hepatitis C Virus. Mean Model for End-Stage Liver Disease (MELD) score at the time of transplantation was 11.3. Mean waiting time was 325 days and mean cold ischemic time was 6 hr. Overall survival of FL-HCC patients at 1, 3, and 5 years was 96%, 80%, and 48% as compared to HCC patients whose rates were 89%, 77%, and 68%. Six patients had tumor recurrence (10%). The Cox Model demonstrated that MELD and cold ischemic time are the strongest predictors of overall survival in FL-HCC patients. Age and wait time were not associated with poor patient survival in this series. Good results can be obtained in selected patients transplanted for FL-HCC. FL-HCC patients had similar survival compared to those transplanted for HCC. J. Surg. Oncol. 2017;115:319-323. © 2016 Wiley Periodicals, Inc.

Abstract 11270: Liver Disease as a Novel Risk Factor for Atrial Fibrillation

Background: End-stage liver disease can significantly affect circulating inflammatory peptides, creating a pro-arrhythmic substrate. However, liver disease as a risk factor for atrial fibrillation (AF) has not been previously studied and few studies have evaluated the incidence of AF in this population. Objective: The purpose of this study was to examine incidence of AF in patients with cirrhosis and assess liver disease severity as a risk factor for AF. Methods: A single center retrospective chart review of adult patients evaluated for orthotopic liver transplantation between 1/2006 and 12/2015 was performed. Model for End-stage Liver Disease (MELD) severity scores were calculated and presence of AF assessed from chart review and billing codes. Incidence of AF for MELD score severity was quantified and Cox proportional hazard models used to analyze effect of risk factors, including quartiles of MELD score, for AF occurrence. Results: Data from 1694 subjects (age 55±12 years, LVEF 61±7.4%) was analyzed. Mean MELD score was 16±8.5 and AF prevalence was 11.2%. Median follow up was 10.8 months (range 0.5-25). Hypertension was present in 12%, diabetes mellitus in 13%, sleep apnea in 0.7%, coronary artery disease (CAD) in 0.9%, valvular heart disease (VHD) 0.5%, and left ventricular hypertrophy (LVH) in 0.8%. After adjusting for age, gender, VHD, sleep apnea, diabetes, hypertension, LVEF, left atrial enlargement, and LVH, the highest quartile (MELD &gt;30) had a HR of 12 (CI 5.3-29) with decreasing hazard ratios for the third (MELD = 21 to 30, HR of 6.8 (CI 3.8-12)) and second (MELD = 11 to 20, HR of 2.9 (CI 1.8-4.8)) compared to the lowest quartile (MELD = 1 to 10). Older age, sleep apnea, hemodynamic instability, VHD and lower LVEF also proved statistically significant. Conclusion: Patient with cirrhosis have a notable prevalence of AF. Severity of liver disease proved to be an independent risk factor for AF, even after accounting for other traditional risk factors.

Outcomes of Transjugular Intrahepatic Portosystemic Shunt Placement Prior to Abdominal Surgery in Patients with Hepatic Decompensation

Introduction: Abdominal surgery in patients with liver disease has been associated with an increased risk of perioperative mortality. Transjugular intrahepatic portosystemic shunt (TIPS) is typically performed to reduce porto-systemic pressure gradient (PSG). We aimed to evaluate the utility of pre-operative TIPS placement in patients with cirrhosis, and its effect on perioperative mortality. Methods: This is a retrospective study of 16 patietns with cirrhosis who had TIPS placement prior to abdominal surgery between 2010 and 2015. Patients with and without hepatic decompensation were included. Hepatic decompensation was defined as the presence of one or more of the following: ascites, hepatic encephalopathy (HE) or history of variceal bleeding (VB). We used the Mayo Clinic postoperative mortality risk calculator to determine the expected 30-day mortality and compared it to the observed mortality in our cohort. Results: Sixteen patients with cirrhosis (75% males, 87.5% Caucasians, with mean age of 50.3+10 years) were included. Fifteen patients had decompensated cirrhosis (ascites [14/15, 93%], VB [4/15, 26.7%] and HE [9/15, 60.0%]), while one patient had ascites due allograft dysfunction after orthotopic liver transplant (OLT). The mean PSG was reduced from 14.8+5.0 mm Hg pre-TIPS to 5.3+2.7 mm Hg post-TIPS. The mean Model for End Stage Liver Disease (MELD) score increased from 13.6+4.4 before TIPS to 15.7+4.5 after TIPS. All sixteen patients had abdominal surgeries, one was emergent and 11 were hernia repair. Median time to surgery was 39 days. Median hospital stay was four days. The mean expected post-operative 30-day mortality risk was 27.3+21.6%. Observed 30-day postoperative mortality rate was found to be 0%. Data was available on 12/16 patients at one year and the observed mortality was 8%. After TIPS, HE was reported in all 16 patients and ascites in six patients with two requiring revision of TIPS within 30 days after the surgery. One patient, with a post-operative 30-day mortality risk of 43.6%, died (78 days from surgery, 46 days of hospitalization) and five patients received liver transplant. Conclusion: Our retrospective review indicates that pre-operative TIPS placement in patients with decompensated cirrhosis, especially ascites, can help reduce the post-operative mortality. Further studies are needed to identify patient population that would most benefit from such an intervention.

Impact and safety of endoscopic ultrasound guided fine needle aspiration on patients with cirrhosis and pyrexia of unknown origin in India.

Background and aims: Etiologic diagnosis of pyrexia of unknown origin is important in patients with cirrhosis for optimal management and to prevent flare up of infectious disease after liver transplantation. However, there is very limited literature available on this subject. The present study aimed to examine the safety and impact of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with cirrhosis. Methods: The study was conducted between January 2014 and January 2016 at a tertiary care center. A total of 50 (47 lymph nodes, 3 adrenal) EUS guided FNAs were performed in 46 patients. Data are presented as median (25 – 75 IQR). Results: The study included 46 patients (40 males) whose mean age was 47.9 ± 11.1 (SD) years; mean Child-Turcotte-Pugh (CTP) score and mean MELD (Model for End-Stage Liver Disease) score were 10 (8 – 11) and 18 (12 – 20), respectively. The Child Pugh class was A in 4, B in 14, and C in 28 (including three patients with adrenal FNAs). Indications for FNA were pyrexia of unknown origin and lymphadenopathy on CT imaging. The cytopathological diagnoses were metastatic disease in 1 (adrenal), granulomatous change in 10 (6 positive with acid fast bacilli stain), histoplasmosis in three (two adrenals, one lymph node), 32 lymph nodes were reactive and four lymph node FNAs showed inadequate cellularity. The pathologic nodes had significantly lower long-to-short axis ratio [1.25 (1.09 – 1.28) versus 1.46 (1.22 – 1.87), P = 0.020]; a higher proportion of hypoechoic echotexture (5 versus 3, P = 0.017), and sharply defined borders (4 versus 2, P = 0.029). Complications included mild hepatic encephalopathy related to sedation in two patients with Child’s C status. Conclusion: EUS guided FNA is safe in patients with cirrhosis and modified the management in 14/46 (30.4 %) patients.