Cirrhosis Mortality Research Articles

Mortality trends in chronic liver disease and cirrhosis from 1981 to 2015 in Taiwan

BackgroundGlobally, the morbidity and mortality rates for chronic liver disease and cirrhosis are increasing. The National Viral Hepatitis Therapy Program in Taiwan was implemented in 2003, but evidence regarding the program’s effect on the trends of mortality for chronic liver disease and cirrhosis is limited.MethodsWe analyzed mortality rates for chronic liver disease and cirrhosis in Taiwan for the period from 1981 to 2015. An autoregressive age–period–cohort model was used to estimate age, period, and cohort effects.ResultsAge-adjusted mortality rates for chronic liver disease and cirrhosis all displayed a flat but variable trend from 1981 to 2004 and a decreasing trend thereafter for both sexes. The age–period–cohort model revealed differential age gradients between the two sexes; mortality rates in the oldest age group (90–94 years) were 12 and 66 times higher than those in the youngest age group (30–34 years) for men and women, respectively. The period effects indicated that mortality rates declined after 2004 in both sexes. Mortality rates decreased in men but increased in women in the 1891–1940 birth cohorts and increased in both sexes in the birth cohorts from 1950 onward.ConclusionsThe National Viral Hepatitis Therapy Program in Taiwan may have contributed to the decrease in mortality rates for chronic liver disease and cirrhosis in adulthood.

S1201 Age-Adjusted Mortality Rates of Liver-Related Death in a VA Cohort of Patients With Cirrhosis

Introduction: Direct-acting antiviral (DAA) therapy for hepatitis C reduces the risk of decompensation and hepatocellular carcinoma among patients with cirrhosis. Long-term population-based data quantifying the effect of DAAs on cause-specific mortality in cirrhosis remain lacking. The aim of this study was to evaluate temporal trends in overall and cause-specific mortality in a national cohort of patients with cirrhosis. Methods: We performed a retrospective cohort study of patients with cirrhosis diagnosed between 2008-2017 in the Veterans Health administration. We determined cause of death from the Mortality Death Registry and characterized these as following: all-cause mortality, mortality related to liver disease (including liver neoplasm, end-stage liver disease, infection, and GI hemorrhage), and mortality due to liver neoplasm only. Age-adjusted mortality rates, annual adjusted percent change (AAPC) in mortality rate, and inflection points (Joinpoints) were calculated using the SEER*Stat Joinpoint regression program referencing a standard population from US Census data. Results: 129,700 male patients with cirrhosis were included, 75% related to hepatitis C infection; 20.3% of the total population died during the follow-up period. All-cause mortality declined between 2008-2017, with a change in AAPC rate detected in 2015 from -2.57% to -6.93% (Figure). Similarly, composite liver mortality declined throughout the study period but accelerated after 2013 from -3.09% to -10.2%. By contrast, liver neoplasm-related mortality increased until 2012 (+0.72%), then declined after 2013 (-8.14%). Conclusion: Sharp declines in liver-related death appear to precede the widespread availability of all-oral DAA therapy by about one year suggesting significant impacts of improved general and HCC-related liver care. Both liver neoplasm-related death and composite liver mortality (including liver cancer) decreased significantly after 2013, likely due to secular changes in liver cancer care and improved management of decompensated liver disease. Overall mortality, however, decreased significantly after 2015, most likely due to increased availability of direct-acting antiviral (DAA) agents for hepatitis C. Data should be confirmed in a non-veteran population.Figure 1.: Age-Adjusted Total, Liver-Neoplasm, and Liver Composite Mortality Rates, 2008-2017.

S1218 Gender Differences in Cirrhosis: Analysis of Demographics, Outcomes and Healthcare Utilization From a National Database

Introduction: Cirrhosis is 8th leading cause of death in US. A smaller national study, restricted to cirrhosis related admissions, reported limited outcomes by gender. We studied prevalence of cirrhosis etiologies, outcomes, demographics and healthcare utilization by gender of all patients with diagnosis of cirrhosis using a national sample. Methods: The US Healthcare Cost & Utilization Project National Inpatient Sample (HCUP-NIS) 2016-2018 was queried to identify all patients with cirrhosis using ICD-10 codes. We studied patient and hospital demographics, comorbidities, cirrhosis etiologies, complications, mean length of stay (LOS), mean Total Hospital Charges (THC), adjusted odds ratio (aOR) for all-cause mortality for men vs women. Statistical analysis utilized chi-square test, univariate and multinomial logistic regression. Results: We identified 1,359,684 admissions in Men and 918,905 in Women with cirrhosis. Women were significantly older (mean age 61.5 vs 59.6 yrs, P < 0.001), less Hispanic (15% vs 17%, P < 0.001), more White (67% vs 65%, P < 0.001). Both groups had similar Black (11% each) and Asian (2% each) patients. Women were more likely to be treated in small rural, non-teaching hospitals, more likely to be on Medicare and less on Private insurance (all P < 0.001). Cirrhosis etiologies HBV/HCV, alcohol, hemochromatosis significantly higher in men while NASH/NAFLD, autoimmune hepatitis, primary biliary cirrhosis higher in women (all P < 0.001). All cirrhosis related complications (Table 1) were significantly higher in men except hepatic failure, hepatic coma higher in women (all P < 0.01). Women were less likely to undergo transplant. Medical co-morbidity prevalence was mixed - men had higher hypertension, CAD, CKD, smoking rates and women had higher diabetes, dyslipidemia, obesity. Secondary complications showed AKI, thrombocytopenia higher in men, anemia higher in women (all P < 0.01) and similar rates of sepsis. Adjusted mortality was lower in women, aOR 0.91 (0.88-0.93, P < 0.001). Men had higher LOS (6.25 vs 6.12 days, P = 0.01) and THC ($71,840 vs $67,340, P < 0.001, adjusted for patient/hospital demographics). Conclusion: Our study, largest to date, showed that despite being significantly younger and treated at large, urban and teaching hospitals, men with cirrhosis had significantly higher cirrhosis related complications, mortality and healthcare utilization. Further studies are needed to identify causes of higher complications in men with cirrhosis to improve outcomes and decrease costs.Table 1.: Cirrhosis Complications by gender.

Australia could miss the WHO hepatitis C virus elimination targets due to declining treatment uptake and ongoing burden of advanced liver disease complications.

Australia was one of the first countries to introduce government-funded unrestricted access to direct-acting antiviral (DAA) therapy, with 88,790 treated since March 2016. However, treatment uptake is declining which could potentially undermine Australia’s progress towards the WHO HCV elimination targets. Using mathematical modelling, we updated estimates for those living with chronic HCV in Australia, new cases of decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality among the HCV-cured and viraemic populations from 2015 to 2030. We considered various DAA treatment scenarios incorporating annual treatment numbers to 2020, and subsequent uptake per year of 6,790 (pessimistic), 8,100 (intermediate), and 11,310 (optimistic). We incorporated the effects of excess alcohol consumption and reduction in progression to DC and HCC among cirrhosis-cured versus viraemic individuals. At the end of 2020, we estimated 117,810 Australians were living with chronic HCV. New cases per year of DC, HCC, and liver-related mortality among the HCV viraemic population decreased rapidly from 2015 (almost eliminated by 2030). In contrast, the growing population size of those cured with advanced liver disease meant DC, HCC, and liver-related mortality declined slowly. The estimated reduction in liver-related mortality from 2015 to 2030 in the combined HCV viraemic and cured population is 25% in the intermediate scenario. With declining HCV treatment uptake and ongoing individual-level risk of advanced liver disease complications, including among cirrhosis-cured individuals, Australia is unlikely to achieve all WHO HCV elimination targets by 2030.

P-69 RELATION BETWEEN CLINICAL AND ELASTOGRAPHIC CHARACTERISTICS OF CIRRHOTIC PATIENTS WITH ENDOSCOPIC VARICEAL LIGATION: A SINGLE-CENTER EXPERIENCE IN LIMA, PERU

Endoscopic variceal ligation (EVL) is the first-line therapy for one of the most frequent causes of mortality in liver cirrhosis, the gastrointestinal bleeding. Child-Pugh, MELD-Na score and transient elastography are noninvasive evaluation of liver cirrhosis. The purpose of the study is to describe and analyze the relation between clinical and elastographic features of cirrhotic patients with EVL. Observational and analytical study. Clinical, biochemical, etiologic and elastographic characteristics of 153 cirrhotic patients with EVL admitted to the Gastroenterology Service of Hospital Nacional Arzobispo Loayza between 2017 and 2019 were analyzed using Kruskall Wallis and Mann-Whitney test. Among the 153 patients treated with EVL, 51.6% were male and 59.6% were older than 60 years. NAFLD (59.5%) was the most frequent cause of liver cirrhosis. Complications of all EVL sessions represented 5.88% (transient chest pain). Child-Pugh B (30 kPa, p = 0.0016) and MELD-Na score ≥ 15 (32.90 kPa, p = 0.0003) showed greater values of liver stiffness. No statistical difference was found in the liver stiffness measurements in relation to etiology of liver disease. Decompensated cirrhosis with EVL has greater values of liver stiffness.

1204Modelling impact of targeted hepatitis B treatment for culturally and linguistically diverse populations in Australia

Abstract Background Antiviral treatment gap in culturally and linguistically diverse (CALD) populations may be a barrier progress in national elimination. Using modelling, we estimated and predicted the impact of antiviral treatment and migration on HBV burden, and HBV-related mortality in CALD populations in Australia. Methods We developed a dynamic, deterministic mathematical model using three antiviral treatment scale-up scenarios - the baseline treatment, intermediate treatment scale-up (80% of eligible by 2030), and optimistic scale-up (20% of all HBV by 2022) to predict the incidence of HBV infection, liver cirrhosis, hepatocellular carcinoma, and HBV-related mortality in four groups of people according to their country of birth. Results The number of chronic HBV cases will remain similar, and HBV-related morbidity and mortality will increase if the baseline approach is followed to 2030. Implementing an optimistic treatment scale-up could reduce the number of new cases of liver cirrhosis (30% in European-born, and 40% in Asia-Pacific-born) by 2030. Following the optimistic scale-up approach, the incidence of HCC decreased by 30% and a 15%-25% reduction in HCC-related mortality could be achieved in the four population subgroups by 2030. Conclusions Following the current antiviral treatment coverage, HBV elimination targets in migrants may not be achieved. A rapid treatment scale-up approach reduces HBV incidence, liver cirrhosis and HCC. Key messages Targeted antiviral treatment for migrants with HBV using rapid scale-up reduces HBV-related disease and mortality and contributes to achievement of national elimination targets.

Effects of endoscopic gastric plication on portal pressure gradient in a patient with nonalcoholic steatohepatitis cirrhosis.

Video 1Endoscopic gastric plication (EGP) to treat obesity and nonalcoholic steatohepatitis (NASH) in a patient with compensated cirrhosis, as well as the application of EUS-guided portal pressure gradient (EUS-PPG) measurement to monitor changes in PPG after EGP.

Socioeconomic Inequalities in Chronic Liver Diseases and Cirrhosis Mortality in European Urban Areas before and after the Onset of the 2008 Economic Recession.

Objective: To analyse the trends in chronic liver diseases and cirrhosis mortality, and the associated socioeconomic inequalities, in nine European cities and urban areas before and after the onset of the 2008 financial crisis. Methods: This is an ecological study of trends in three periods of time: two before (2000–2003 and 2004–2008), and one after (2009–2014) the onset of the economic crisis. The units of analysis were the geographical areas of nine cities or urban areas in Europe. We analysed chronic liver diseases and cirrhosis standardised mortality ratios, smoothing them with a hierarchical Bayesian model by each city, area, and sex. An ecological regression model was fitted to analyse the trends in socioeconomic inequalities, and included the socioeconomic deprivation index, the period, and their interaction. Results: In general, chronic liver diseases and cirrhosis mortality rates were higher in men than in women. These rates decreased in all cities during the financial crisis, except among men in Athens (rates increased from 8.50 per 100,000 inhabitants during the second period to 9.42 during the third). Socioeconomic inequalities in chronic liver diseases and cirrhosis mortality were found in six cities/metropolitan areas among men, and in four among women. Finally, in the periods studied, such inequalities did not significantly change. However, among men they increased in Turin and Barcelona and among women, several cities had lower inequalities in the third period. Conclusions: There are geographical socioeconomic inequalities in chronic liver diseases and cirrhosis mortality, mainly among men, that did not change during the 2008 financial crisis. These results should be monitored in the long term.

Rifaximin Vs. Norfloxacin for Spontaneous Bacterial Peritonitis Prophylaxis: A Randomized Controlled Trial

Spontaneous bacterial peritonitis (SBP) heralds increased mortality in cirrhosis, mandating strategies for prophylaxis. Norfloxacin has been the recommended choice for SBP prevention. However, its use has raised concerns about antibiotic resistance. Rifaximin has been suggested as an alternative. We investigated the efficacy of rifaximin against norfloxacin in primary and secondary prophylaxis of SBP. In this open-labeled randomized trial, patients with either advanced cirrhosis having ascitic fluid protein levels (<1.5g/l), Child-Pugh score ≥9 points, serum bilirubin ≥3mg/dl or impaired renal function (primary prophylaxis group), or those with prior SBP (secondary prophylaxis group) received either norfloxacin (400mg once daily) or rifaximin (550mg twice daily). All patients were followed for six months, with the primary endpoint being the development of incident SBP. 142 patients were assessed for eligibility, of which 132 met the enrolment criteria; 12 were lost to follow-up, while 4 discontinued treatment. In patients on primary prophylaxis, occurrence of SBP was similar (14.3% vs. 24.3%, P= 0.5), whereas in secondary prophylaxis SBP recurrence was lower with rifaximin (7% vs. 39% P= 0.004). Rifaximin significantly reduced the odds for SBP development in secondary prophylaxis [OR (95% CI0.14 (0.02-0.73; P= 0.02)]. Patients receiving rifaximin as secondary prophylaxis also had fewer episodes of hepatic encephalopathy (23.1% vs. 51.5%, P= 0.02). 180-day survival between the arms in either group was similar (P= 0.5, P= 0.2). In comparison to norfloxacin, rifaximin significantly reduces incident events of SBP, as well as HE when used as a secondary prophylaxis, whereas for primary prophylaxis both have similar effects(NCT03695705). ClinicalTrials.gov number: NCT03695705.

Frailty as tested by the Liver Frailty Index is associated with decompensation and unplanned hospitalization in patients with compensated cirrhosis

Background and Aims Frailty is associated with morbidity and mortality in advanced cirrhosis. However, the information on the association between frailty and outcome in compensated cirrhosis is scarce. We aimed to explore the prognostic impact of frailty in compensated cirrhosis. Methods Compensated cirrhotic patients were prospectively enrolled. Frailty was defined by the Liver Frailty Index (LFI). Development of new hepatic decompensation (worsening ascites, portal hypertension-related bleeding, hepatic encephalopathy, or acute kidney injury), unplanned hospitalization, and decompensation-free survival were recorded. Quality of life (QoL) was assessed by SF-36 questionnaire. Results 152 patients were included (MELD 9.2 ± 3.4, Child-Pugh A/B 84.9%/15.1%), and 24.3% were frail. By multivariable logistic regression analysis, age > 65 years, MELD score > 10, and Child-Pugh B were associated with frailty. Compared to the robust group, pre-frail and frail patients had significantly higher cumulative 1-year probabilities of developing decompensation (0% vs. 8.5% vs. 18.4%, p = .009), and unplanned hospitalization (0% vs. 13.5% vs. 34.2%, p < .001), and lower 1-year decompensation-free survival (100% vs. 90.8% vs. 80.4%, p = .014). Two models of multivariable Cox regression analysis were done adjusted with MELD-Na and Child-Pugh B, frailty was associated with developing decompensation (HR 3.01, p = .04; and 2.98, p = .04, respectively) and unplanned hospitalization (HR 2.46, p = .02; and 2.39, p = .03, respectively), but not the decompensation-free survival. By multivariable linear regression analysis, Child-Pugh B and frailty significantly decreased both physical and mental component scores of the SF-36 questionnaire. Conclusion Frailty is prevalent in compensated cirrhosis. The LFI provides additional prognostic values to recognized risk scores regarding the development of decompensation, hospitalization, and impaired QoL.

In-hospital outcomes of transcatheter versus surgical mitral valve repair in patients with chronic liver disease.

Mitral valve transcatheter edge-to-edge repair (TEER) using MitraClip is a treatment option for patients with moderate to severe mitral regurgitation who are not surgical candidate. Liver cirrhosis is associated with higher operative morbidity and mortality; however, it is not part of preoperative risk assessments calculators. We sought to evaluate the in-hospital outcomes in TEER and surgical mitral valve repair (SMVR) in liver cirrhosis. National Inpatient Database from 2013 to 2017 was used to obtain all patients with cirrhosis who underwent TEER or SMVR using ICD-9-CM and ICD-10-CM codes. The primary outcome is to compare inpatient mortality between TEER and SMVR. Secondary outcomes were assessed including length of stay (LOS) and rate of complications including cardiogenic shock, blood transfusion and prolonged ventilation. A total of 875 patients with cirrhosis who underwent TEER (n = 123) or SMVR (n = 752) were identified in our analysis. Patients with TEER had significantly higher comorbidities such as congestive heart failure, coronary artery disease and chronic obstructive pulmonary disease. In-hospital mortality was lower in TEER group (8.2% vs 16%, P = .04). TEER was associated with lower rates of blood transfusion (30.3% vs 61.2%, P = .02) and reduced rates of prolonged mechanical ventilation (1.2% vs 17.2%, P = .042). In multivariate regression analysis, both blood transfusion and prolonged mechanical ventilation were significant predictors of mortality in liver cirrhosis. TEER was associated with lower rate of in-hospital mortality, LOS, blood transfusion and prolonged mechanical ventilation in cirrhosis patients. TEER can be considered as a viable option for cirrhosis patient with severe mitral regurgitation.

Mortality, sepsis, and organ failure in hospitalized patients with cirrhosis vary by type of infection

Infection is associated with substantial morbidity and mortality in cirrhosis, but presumably, not all infections carry the same risk of mortality. We compared outcomes of different sites of infection in a nationally representative sample of inpatients with cirrhosis. We queried the Nationwide Readmissions Database for patients with cirrhosis from 2011 to 2014. Cirrhosis and infection diagnoses were identified by previously used algorithms of ICD-9 codes. The following infections were compared: urinary tract infection (UTI), pneumonia, cellulitis, spontaneous bacterial peritonitis (SBP), and Clostridium difficile infection (CDI). The primary outcome was inpatient mortality. Secondary outcomes included sepsis, any organ failure, multiple organ failures, and 30-day readmission. Outcomes were analyzed using logistic regression and included a priori covariates. A total of 1798830 weighted index admissions were identified. Infection was present in 29.2% overall-including UTI (13.7%), pneumonia (8.9%), cellulitis (5.2%), CDI (2.8%), and SBP (2.0%). Mortality was significantly higher in pneumonia (19.6%), SBP (18.6%), and CDI (17.4%) compared with cellulitis (7.6%) and UTI (11.8%). Sepsis, any, and multiple organ failures were most commonly seen in pneumonia, SBP, and CDI. Multivariable analysis demonstrated that pneumonia had the highest associated mortality (odds ratio [OR] 2.73, confidence interval [CI] 2.68-2.80) and multiple organ failures (OR 3.59, CI 3.50-3.68). Significantly increased 30-day readmission was seen only with SBP (24.9%). Outcomes of inpatients with cirrhosis vary significantly depending on the type of infection. The severity and epidemiology of infection in cirrhosis appears to be shifting with pneumonia, not SBP, having the highest prevalence of multiple organ failures and inpatient mortality.

Inpatient Frailty Assessment Is Feasible and Predicts Nonhome Discharge and Mortality in Decompensated Cirrhosis.

Objective inpatient frailty assessments in decompensated cirrhosis are understudied. We examined the feasibility of inpatient frailty measurements and associations with nonhome discharge, readmission, and all-cause mortality among patients admitted for cirrhosis complications. We conducted a prospective study at 3 liver transplantation (LT) centers. Frailty was assessed using the liver frailty index (LFI). Multivariable logistic and competing risk models evaluated associations between frailty and clinical outcomes. We included 211 patients with median MELD-Na score 21 (interquartile range [IQR],15-27); 96 (45%) were women, and 102 (48%) were on the LT waiting list. At a median follow-up of 8.3months, 29 patients (14%) were nonhome discharged, 144 (68%) were readmitted, 70 (33%) underwent LT, and 44 (21%) died. A total of 124 patients (59%) were frail, with a median LFI of 4.71 (IQR, 4.07-5.54). Frail patients were older (mean, 59 versus 54years) and more likely to have chronic kidney disease (40% versus 20%; P=0.002) and coronary artery disease (17% versus 7%; P=0.03). Frailty was associated with hospital-acquired infections (8% versus 1%; P=0.02). In multivariable models, LFI was associated with nonhome discharge (odds ratio, 1.81 per 1-point increase; 95% confidence interval [CI], 1.14-2.86). Frailty (LFI≥4.5) was associated with all-cause mortality in models accounting for LT as competing risk (subhazard ratio [sHR], 2.4; 95% CI, 1.13-5.11); results were similar with LFI as a continuous variable (sHR, 1.62 per 1-point increase; 95% CI, 1.15-2.28). A brief, objective inpatient frailty assessment was feasible and predicted nonhome discharge and mortality in decompensated cirrhosis. Inpatient point-of-care frailty assessment prior to hospital discharge can be useful for risk stratification and targeted interventions to improve physical fitness and reduce adverse outcomes.

Prehabilitation-Driven Changes in Frailty Metrics Predict Mortality in Patients With Advanced Liver Disease.

Frailty is a predictor of morbidity and mortality in cirrhosis. Although evidence for prehabilitation is promising, the data for liver transplant (LT) candidates are limited. The primary aim of this study was to evaluate the effect of a novel prehabilitation strategy on changes in frailty metrics and survival in LT candidates. The secondary aim was to determine liver-related and extrahepatic conditions associated with frailty. In this ambispective cohort study, all patients underwent frailty assessment using the liver frailty index (LFI), 6-minute walk test, and gait speed test performed by a dedicated physical therapist. Home-based exercise prescription was individualized to each patient's baseline physical fitness. We included 517 patients (59% men, median age 61 years, and a model for end-stage liver disease score of 12) evaluated during 936 PT visits. Frailty metrics were affected by age, sex, and liver-related parameters, but not by model for end-stage liver disease. Patients with nonalcoholic fatty liver disease and alcohol-related cirrhosis had worse frailty metrics by all tools. We demonstrated the feasibility of prehabilitation in improving both LFI and 6-minute walk test, particularly in adherent patients. A median LFI improvement of 0.3 in frail patients was associated with improved survival in univariate analysis. Compliance with physical therapist visits (hazards ratio = 0.35 [0.18-0.67] for 2 visits and hazards ratio = 0.54 [0.31-0.94] for ≥3 visits) was independently associated with increased survival. Prehabilitation improves frailty metrics in LT candidates and is associated with a survival advantage. Our findings provide a framework for the standardized prehabilitation program in LT candidates while prioritizing compliance, adherence, and on-training LFI goal accomplishment.

Racial differences in prevalence and severity of non-alcoholic fatty liver disease.

The aim of this review is to assess the evidence regarding racial differences in the prevalence and severity of nonalcoholic fatty liver disease (NAFLD). We reviewed the published literature that reported prevalence, severity, and genetic associations of NAFLD in different ethnic groups. The metabolic syndrome (MetS) has been associated with NAFLD, but each component of the MetS is present in various races in different percentages and their effect on NAFLD appears to be dissimilar. An elevated triglyceride (TG) level seems to have the strongest association with NAFLD. The latter is more prevalent in Hispanic patients; Blacks have lower TG levels and a lower NAFLD prevalence, compared to Caucasians or Hispanics. The severity of liver fibrosis is lower in some, but not all biopsy-based studies of Black patients. No study has evaluated the severity of liver disease controlling for the individual components of MetS, especially TG. Important racial differences in the prevalence of selected genetic polymorphisms, particularly PNPLA-3 and MBOAT7 have been documented, together with their effects on the prevalence of liver steatosis and fibrosis. Data on overall and liver mortality have found no significant differences according to race/ethnicity, with the possible exception of one paper reporting lower cirrhosis mortality in Black patients. We conclude that NAFLD is more prevalent in Hispanics and less in Blacks. This is supported by differences in key genetic polymorphisms associated with hepatic fat storage. However, there is presently insufficient evidence to firmly conclude that race, per se, plays a role in the development of liver fibrosis and its complications. Further studies, appropriately controlled for diet, exercise, and individual MetS parameters are needed.

Invasive aspergillosis is a critical determinant of mortality in cirrhosis: a systematic review with meta-analysis.

We report a high mortality rate of 81.8% in patients with liver cirrhosis and invasive aspergillosis. Higher odds (8.9 times) of death, especially in patients with ACLF or ICU admission were seen. Mortality was not affected by the country of study, site of infection, proven or probable nature of infection category, and quality of study.

Nutritional supplementation for nonalcohol-related fatty liver disease: a network meta-analysis.

Nutritional supplementation for nonalcohol-related fatty liver disease: a network meta-analysis.

The Effects of 12-Week Beta-Hydroxy-Beta-Methylbutyrate Supplementation in Patients with Liver Cirrhosis: Results from a Randomized Controlled Single-Blind Pilot Study.

Background and Aim: Sarcopenia is considered an important risk factor for morbidity and mortality in liver cirrhosis. Beta-hydroxy-beta-methylbutyrate (HMB) has the potential to increase muscle mass and performance by stimulating protein synthesis and reducing muscle catabolism. The present study aimed at evaluating the effect of HMB supplementation on muscle mass and function in patients with liver cirrhosis. Changes in frailty during the study were also estimated, and the safety of HMB supplementation was verified. Methods: This is a randomized, single-blind, placebo-controlled pilot trial. Twenty-four patients (14 HMB and 10 placebo) affected by liver cirrhosis were enrolled in the study. Each patient received dedicated counseling, which included nutrition and physical activity recommendations for chronic liver disease patients. Patients were randomized to receive 3 g/day of HMB or placebo (sorbitol powder) for 12 consecutive weeks. A diet interview, anthropometry, electrical bioimpedance analysis (BIA), quadriceps ultrasound, physical performance battery, Liver Frailty Index (LFI), and cognitive tests were completed at enrolment (T0), at 12 weeks (T1), and 24 weeks after enrolment (T2). Results: At baseline, the two groups were similar in demography, severity of liver disease, muscle mass, muscle function, and cognitive tests. LFI at baseline was higher in patients in the HMB group vs. those in the placebo group (4.1 ± 0.4 vs. 3.4 ± 0.6, p < 0.01). After treatment, a statistically significant increase in muscle function was seen in the HMB group (chair stand test: 14.2 ± 5 s vs. 11.7 ± 2.6 s, p < 0.05; six-minute walk test: 361.8 ± 68 m vs. 409.4 ± 58 m, p < 0.05). Quadriceps muscle mass measured by ultrasound also increased (4.9 ± 1.8 vs. 5.4 ± 1.8 mm, p < 0.05) after HMB, while LFI decreased (4.1 ± 0.4 vs. 3.7 ± 0.4, p < 0.05). HMB was well tolerated by patients, and no adverse events were documented. Conclusions: Our study suggests the efficacy of 12-week beta-hydroxy-beta-methylbutyrate supplementation in promoting improvements in muscle performance in compensated cirrhotic patients. LFI was also ameliorated. Further studies with a greater number of patients are required to reinforce this hypothesis.

Prevalence of clinically relevant liver fibrosis due to nonalcoholic fatty liver disease in Indian individuals with type 2 diabetes.

Background and AimType 2 diabetes (T2D) in associated with higher prevalence and worse outcomes of nonalcoholic fatty liver disease (NAFLD). However, data regarding the prevalence of clinically relevant liver fibrosis (CRLF) in Indian individuals with T2D are scarce. We investigated the prevalence of, and factors associated with, CRLF in Indians with T2D.MethodsWe conducted a prospective study of 601 consecutive adults with T2D. Steatosis was diagnosed using ultrasonography. Liver stiffness measurement (LSM) by transient elastography of ≥8.0 kPa was taken as cutoff suggesting CRLF. Individuals with LSM > 13.0 kPa underwent dynamic magnetic resonance imaging (MRI) of liver for detecting changes consistent with cirrhosis.ResultsThe prevalence of steatosis was 84.2%. Higher body mass index (BMI, P = 0.022), alanine aminotransferase (ALT; P = 0.001), and lower high‐density lipoprotein (HDL; P = 0.002) were independent factors associated with steatosis. The prevalence of CRLF was 28.2%. Higher BMI (P = 0.001), aspartate aminotransferase (AST; P < 0.0001), gamma‐glutamyl transpeptidase (GGT; P < 0.0001), and concomitant hypertension (P = 0.03) were independent factors associated with CRLF. Elevated ALT and AST (≥40 units/L) levels were present in 70.6 and 51.6% individuals with CRLF, respectively. Thirty‐one (7.2%) individuals had LSM > 13.0 kPa. Among them, 25 individuals underwent dynamic MRI of liver, which revealed features consistent with cirrhosis in 18 patients.ConclusionCRLF, an established risk factor for cirrhosis and overall mortality, affects at least one out of four (25%) Indians with T2D. These results support screening of all patients with T2D and NAFLD for liver fibrosis.

A predictive nomogram incorporating gait speed for all-cause mortality in hospitalized cirrhotics

ABSTRACT Objectives: No tailored model incorporating physical frailty for 2-year mortality in cirrhosis is available for practitioners in general practice. Thus we aimed to develop a model based on laboratory results and physical frailty allowing clinicians for stratifying cirrhotics by using individual estimate. Methods: One hundred and thirteen cases were assigned to the primary cohort, and all other 76 patients were regarded as the validation cohort. Multivariate Cox regression was performed, and a nomogram including five-meter gait speed (5MGS) were generated. The performance of the proposed model was assessed by C-index, calibration curve, and decision curve analysis (DCA). Results: On multivariate analysis, the Model for End-Stage Liver Disease-Sodium, albumin and 5MGS were independent predictors for 2-year mortality in cirrhosis. A nomogram incorporating all these parameters achieved a C-index of 0.804 (95%CI, 0.731–0.877). The calibration curve implied optimal correspondence between the predicted survival and actual outcomes. Our model is useful in the clinical settings based on DCA. Similar results were observed in the validation cohort with a C-index of 0.796 (95%CI, 0.689–0.899). Moreover, 5MGS, as a surrogate of physical performance, significantly correlated with multiple domains of general frailty according to Frailty Index (our published data), including instrumental activities of daily living, self-reported health, social activity and falls. Conclusion: In conclusion, the nomogram incorporating 5MGS may represent an individualized tool for predicting mortality in cirrhosis for primary care physicians.