Outcome Of Cirrhotic Patients Research Articles

Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhosis.

Abdominal surgery is associated with high postoperative mortality and morbidity in cirrhotic patients. Despite improvements in surgical techniques, clinical management, and intensive care, the outcome could be influenced by the degree of portal hypertension, the severity of hepatopathy, or the type of surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement, in addition to medical therapy, plays an important role in managing the complications of portal hypertension such as ascites, hepatic encephalopathy, variceal bleeding or portal vein thrombosis. To date, the improvement of post-surgery outcomes in cirrhotic patients after TIPS placement remains unclear. Only observational data existing in the literature and prospective studies are urgently needed to evaluate the efficacy and safety of TIPS in this setting. This review aims to outline the role of TIPS as a tool in postoperative complications reduction in cirrhotic patients, both in the setting of emergency and elective surgery.

Clinical predictors of liver and diabetes outcomes in cirrhotic patients with type 2 diabetes

Clinical predictors of liver and diabetes outcomes in cirrhotic patients with type 2 diabetes

Thermal ablation versus liver resection for hepatocellular carcinoma in patients with cirrhosis: a systematic review and meta-analysis of propensity-score matched studies

The outcomes of cirrhotic patients with hepatocellular carcinoma (HCC) after thermal ablation (TA) versus liver resection (LR) are debated. We aimed to compare the overall survival (OS), disease-free survival (DFS), and operative outcomes after TA and LR for HCC in patients with cirrhosis. Until November 15, 2022, we searched PubMed, Embase, and Cochrane databases by using Medical Subject Heading terms and other terms, and used the Newcastle-Ottawa literature evaluation scale to assess the quality of selected studies. OS, DFS, and operative outcomes were extracted and analyzed. The meta-analysis showed that 5 propensity-score matched (PSM) studies including 933 patients (463 TA vs. 470 LR) were included. After analysis, TA and LR had similar results at 1-year OS (odds ratio [OR] 1.68; 95% confidence interval [CI] 1.01–2.78; P = 0.05) and 3-year OS (OR 0.76; 95% CI 0.56–1.04; P = 0.08), whereas LR increased 5-years OS (OR 0.37; 95% CI 0.18–0.74; P = 0.005). In addition to the DFS, the 1-year DFS was significantly higher in patients with LR. However, there were no obvious differences in 3-year and 5-year DFS when comparing TA and LR. The length of operative time and hospital stay were longer in the LR group. Besides, the LR group had significantly higher rate of perioperative blood transfusions and major complications. Our research proved that LR took advantage of OS and DFS for HCC patients with cirrhosis. Additional well-designed randomized controlled trials are needed.

Portal-hypertension features are associated with ascites occurrence and survival in patients with hepatocellular carcinoma treated by external radiotherapy.

We studied the impact of Portal hypertension (PHT) on ascites occurrence and on radiotherapy outcome in cirrhotic patients with hepatocellular carcinoma (HCC). All cirrhotic patients that received radiotherapy for HCC between 2012 and 2022 were included. Portal hypertension-Score was built using univariate analysis with the presence of esophageal varices (EV), platelet count, history of acute variceal bleeding (AVB) and spleen size. Time-to-events data were estimated using Kaplan-Meier method with log-rank and Cox-models. 60 patients were included (female 27%, age 67 years-old, Child-Pugh A 82%, alcoholic/non-alcoholic steatohepatitis/hepatitis C virus 55/40/32%). 38% and 15% presented history of ascites and AVB respectively, 25% had large EV, 53.5% presented PHT score ≥ 5. 92% were BCLC-0/A, median tumor size was 30mm. At 6months, ascites incidence was 19% and precluded access to further HCC treatment for all patients with HCC recurrence. All PHT parameters included in the score and PHT score ≥ 5 (hazard ratio (HR)=14.07, p=0.01) were associated with ascites occurrence. Transplantation free survival and recurrence free survival at 1year were 56% and 47% respectively. Albi grade 3 (HR=3.01; p=0.04) was independently associated with Transplantation free survival. Radiotherapy should be cautiously performed in patients with PHT score ≥ 5 because of ascites occurrence risk precluding access to further HCC treatments.

Predictive value of hematological parameters in cirrhotic patients with open umbilical hernia repair.

Patients with liver cirrhosis sometimes suffer from high recurrence rates and postoperative complications. We previously reported that platelet-related hematological parameters are associated with the outcomes after incisional herniorrhaphy, and aim to evaluate the predictive value of these criteria in cirrhotic patients undergoing open umbilical herniorrhaphy. This is a retrospective study. The data of 95 cirrhotic patients undergoing open umbilical herniorrhaphy were analyzed. Patients were grouped based on the recurrence and defined hematological values. Platelet-multiple-lymphocyte index (PLM), neutrophil-leukocyte ratio, lymphocyte-monocyte ratio, platelet-neutrophil ratio, systemic immune-inflammation index, and aspartate aminotransferase-leukocyte ratio values were calculated based on preoperative blood analyses. The outcomes were obtained from hospital records and follow-up calls to patients. Using cutoff values acquired by the Youden Index, we found a PLM value < 27.9, and the history of inguinal herniorrhaphy were revealed to be statistically significant in the recurrence based on univariant and multivariant analyses (p < 0.05). We further divided patients into two groups based on the cutoff value of PLM and found that a PLM value < 27.9 was significantly associated with the recurrence of incisional hernias (p = 0.018) and the occurrence of postoperative foreign sensation (p = 0.044), and tended to result in other postoperative complications such as cardiopathy, respiratory infection, hypoproteinemia, and hepatic diseases (p = 0.089). The preoperative hematological values, especially PLM, may indicate the outcomes in cirrhotic patients after open umbilical herniorrhaphy. Accurate identification of risks may alert the intraoperative and postoperative care for patients.

Prediction models combining zonulin, LPS, and LBP predict acute kidney injury and hepatorenal syndrome–acute kidney injury in cirrhotic patients

The development of acute kidney injury (AKI) and hepatorenal syndrome–acute kidney injury (HRS–AKI) in cirrhosis has been associated with intestinal barrier dysfunction and gut-kidney crosstalk. We use the related markers such as zonulin, lipopolysaccharides (LPS), and lipopolysaccharide-binding protein (LBP) to predict AKI and HRS–AKI in cirrhotic patients and evaluate their in vitro effects on intestinal (Caco-2) cells and renal tubular (HK-2) cells. From 2013 to 2020, we enrolled 70 cirrhotic patients and developed prediction models for AKI and HRS–AKI over a six-month period. There were 13 (18.6%) and 8 (11.4%) cirrhotic patients developed AKI and HRS–AKI. The prediction models incorporated zonulin, LPS, LBP, C-reactive protein, age, and history of hepatitis B for AKI, and zonulin, LPS, LBP, total bilirubin, and Child–Pugh score for HRS–AKI. The area under curve (AUC) for the prediction of AKI and HRS–AKI was 0.94 and 0.95, respectively. Furthermore, the conditioned medium of LPS+hrLBP pre-treated Caco-2 cells induced apoptosis, necrosis, and zonulin release in HK-2 cells, demonstrating the communication between them. This study found that zonulin, LPS, and LBP are potential practical markers for predicting AKI and HRS–AKI in cirrhotic patients, which may serve as potential targets for renal outcomes in cirrhotic patients.

A prospective study on the differential association of sarcopenia and frailty with health outcomes in cirrhotic patients

BackgroundTo investigate the joint impact of sarcopenia and frailty on mortality and the development of decompensation in cirrhosis. MethodsSarcopenia was assessed using the skeletal muscle mass index (SMI) by computed tomography, whereas frailty was measured using the Fried Frailty Phenotype (FFP). Cox proportional hazard regression and competing risks analysis were used to evaluate their association with adverse outcomes. ResultsThe prevalence of sarcopenia and frailty was 29.6% and 37.2%, respectively. Sarcopenia and frailty separately increased more than two times higher risk of all-cause mortality after adjustment for age, gender, Child-Turcotte-Pugh, and comorbidities. Co-occurrence of sarcopenia and frailty was associated with a higher incremental risk of mortality in patients with cirrhosis (HR = 4.16, 95% CI: 1.64–10.58, P = 0.003), but these two conditions didn't have significant interaction. Frailty, but not sarcopenia, was significantly associated with an increased cumulative incidence of liver-related mortality and decompensation after adjusting covariates. Subgroup analysis revealed that frailty shortened the liver-related survival of cirrhosis patients with male or higher liver severity based on MELD. ConclusionsCo-occurrence of sarcopenia and frailty increased the risk of death in cirrhosis, but these two conditions didn't have a significant interaction association. Frailty, but not sarcopenia, was associated with more adverse outcomes in cirrhotic patients.

Hematological Indices Are Useful in Predicting Complications of Liver Cirrhosis.

Liver cirrhosis is the final stage of chronic liver disease. We aimed to evaluate non-invasive scores as predictors of complications and outcome in cirrhotic patients. A total of 150 cirrhotic patients were included. Models for end-stage liver disease (MELD), albumin-bilirubin (ALBI) score, neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MoLR), and neutrophil-lymphocyte-albumin ratio (NLA) scores were tested in relation to the development of complications and mortality using receiver operating characteristic (ROC) curves. The ROC curve analysis showed (area under the curve) AUC values of NLR, NLA, ALBI, and MELD of 0.711, 0.730, 0.627, and 0.684, respectively, for short-term mortality. MELD, ALBI, and NLA scores showed a statistically significant correlation with hepatic encephalopathy (p = 0.000 vs. 0.014 vs. 0.040, respectively), and the MELD cut-off value of 16 had a sensitivity of 70% and a specificity of 52% (AUC: 0.671, 95% CI (0.577-0.765)). For the assessment of the presence of ascites, the AUC values for NLA and MoLR were 0.583 and 0.658, respectively, with cut-offs of 11.38 and 0.44. MELD, ALBI, and NLA are reliable predictors of hepatic encephalopathy. NLA and MoLR showed a significant correlation with the presence of ascites, and MELD, ALBI, NLR, and NLA have prognostic value to predict 30-day mortality in cirrhotic patients.

Predicting Post-Hepatectomy Liver Failure in HCC Patients: A Review of Liver Function Assessment Based on Laboratory Tests Scores.

The assessment of liver function is crucial in predicting the risk of post-hepatectomy liver failure (PHLF) in patients undergoing liver resection, especially in cases of hepatocellular carcinoma (HCC) which is often associated with cirrhosis. There are currently no standardized criteria for predicting the risk of PHLF. Blood tests are often the first- and least invasive expensive method for assessing hepatic function. The Child-Pugh score (CP score) and the Model for End Stage Liver Disease (MELD) score are widely used tools for predicting PHLF, but they have some limitations. The CP score does not consider renal function, and the evaluation of ascites and encephalopathy is subjective. The MELD score can accurately predict outcomes in cirrhotic patients, but its predictive capabilities diminish in non-cirrhotic patients. The albumin-bilirubin score (ALBI) is based on serum bilirubin and albumin levels and allows the most accurate prediction of PHLF for HCC patients. However, this score does not consider liver cirrhosis or portal hypertension. To overcome this limitation, researchers suggest combining the ALBI score with platelet count, a surrogate marker of portal hypertension, into the platelet-albumin-bilirubin (PALBI) grade. Non-invasive markers of fibrosis, such as FIB-4 and APRI, are also available for predicting PHLF but they focus only on cirrhosis related aspects and are potentially incomplete in assessing the global liver function. To improve the predictive power of the PHLF of these models, it has been proposed to combine them into a new score, such as the ALBI-APRI score. In conclusion, blood test scores may be combined to achieve a better predictive value of PHLF. However, even if combined, they may not be sufficient to evaluate liver function and to predict PHLF; thus, the inclusion of dynamic and imaging tests such as liver volumetry and ICG r15 may be helpful to potentially improve the predictive capacity of these models.

Pretransplant Functional Status Predicts Postoperative Morbidity and Mortality after Liver Transplantation in Patients with Cirrhosis.

This study aimed to investigate whether pretransplant frailty can predict postoperative morbidity and mortality after liver transplantation (LT) in patients with cirrhosis. We retrospectively reviewed 242 patients who underwent LT between 2018 and 2020 at a tertiary hospital in Korea. Among them, 189 patients (78.1%) received LT from a living donor. Physical frailty at baseline was assessed by the Short Physical Performance Battery (SPPB), by which patients were categorized into two groups: frail (SPPB <10) and non-frail (SPPB ≥10). Among the whole cohort (age, 55.0±9.2 years; male, 165 [68.2%]), 182 patients were classified as non-frail and 60 patients were classified as frail. Posttransplant survival was shorter in the frail group than the non-frail group (9.3 months vs 11.6 months). Postoperative intensive care unit stay was longer in the frail group than in the non-frail group (median, 6 days vs 4 days), and the 30-day complication rate was higher in the frail group than in the non-frail group (78.3% vs 59.3%). Frailty was an independent risk factor for posttransplant mortality (adjusted hazard ratio, 2.38; 95% confidence interval, 1.02 to 5.57). In subgroup analysis, frail patients showed lower posttransplant survival regardless of history of hepatocellular carcinoma and donor type. Assessment of pretransplant frailty, as measured by SPPB, provides important prognostic information for clinical outcomes in cirrhotic patients undergoing LT.

Analysis of the timing of endoscopic treatment for esophagogastric variceal bleeding in cirrhosis.

Existing guidelines recommend endoscopic treatment within 12 h or 12-24 h for patients with esophagogastric variceal bleeding (EGVB) in cirrhosis. In addition, research findings on the optimal time for endoscopy are inconsistent. The aim of this study was to investigate the relationship between the timing of endoscopy and clinical outcomes in cirrhotic patients with EGVB and to analyze the risk factors for the composite outcomes after endoscopic treatment. From January 2019 to June 2020, 456 patients with cirrhotic EGVB who underwent endoscopy were matched by a 1:1 propensity score. Finally, 266 patients were divided into two groups, including 133 patients within 12 h (urgent endoscopy group) of admission and after 12 h (non-urgent endoscopy group). Baseline data and clinical outcomes were compared. Logistic regression model analysis was used to determine risk factors for 30 days rebleeding and mortality. In 266 patients, the overall 30 days rebleeding rate and mortality were 10.9% (n = 29) and 3.4% (n = 9), respectively. Patients who underwent endoscopic treatment within 12 h had significantly higher 30 days rebleeding outcomes than those who underwent treatment beyond 12 h (15 vs. 6.8%, p = 0.003). However, 30 days mortality did not differ significantly between the two groups (3 vs. 3.8%, p = 0.736). Logistic regression analysis showed that age and shock on admission were independent risk factors for the composite outcome of 30 days rebleeding and mortality in patients with EGVB. The 30 days rebleeding rate in patients with cirrhotic EGVB treated with urgent endoscopy was significantly higher than that in patients treated with non-urgent endoscopy, but there was no significant difference in 30 days mortality.

Evaluation of right ventricular function during liver transplantation with transesophageal echocardiography.

The pathophysiology of advanced liver cirrhosis may induce alterations in the circulatory system that may be challenging for the anesthesiologist to manage intraoperatively, and perioperative cardiovascular events are associated with worse outcomes in cirrhotic patients undergoing liver transplantation. It remains controversial whether right ventricular function is impaired during this procedure. Studies using transesophageal echocardiography for quantitative analysis of the right ventricle remain scarce in this setting, yielding conflicting results. The aim of this study was to perform a quantitative assessment of right ventricular function with two parameters derived from transesophageal echocardiography during liver transplantation. Nineteen adult patients of both genders undergoing liver transplantation were evaluated in this observational study. The exclusion criteria were age under 18 or above 65 years old, fulminant hepatic failure, hepatopulmonary syndrome, portopulmonary hypertension, cardiopulmonary disease, and contraindications to the transesophageal echocardiogram. Right ventricular function was assessed at five stages during liver transplantation: baseline, hepatectomy, anhepatic, postreperfusion, and closure by measuring tricuspid annular plane systolic excursion and right ventricular fractional area change obtained with transesophageal echocardiography. Right ventricular function was found to be normal throughout the procedure. The tricuspid annular plane systolic excursion showed a trend toward a decrease in the anhepatic phase compared to baseline (2.0 ± 0.9 cm vs. 2.4 ± 0.7 cm; P = 0.24) but with full recovery after reperfusion. Right ventricular fractional area change remained nearly constant during all stages studied (minimum: 50% ± 10 at baseline and anhepatic phase; maximum: 56% ± 12 at postreperfusion; P = 0.24). Right ventricular function was preserved during liver transplantation at the time points evaluated by two quantitative parameters derived from transesophageal echocardiogram.

S1344 The Impact of Liver Cirrhosis on Patients Admitted With Candidemia: A Nationwide Analysis

Introduction: Cirrhosis has been identified as a risk factor for the development of candidemia, which is associated with high mortality rates. Although the current literature describes poor outcomes in cirrhotic patients with invasive candidiasis, factors contributing to worse outcomes are not well known. We aim to better understand the factors contributing to worse outcomes in cirrhotic patients with candidemia. Methods: Data were extracted from the National Inpatient Sample (NIS) database from 2016-2019. Using the ICD-10-CM codes, patients diagnosed with candidemia were identified. Baseline demographic data, comorbidities, in-hospital mortality, hospital charges, and hospital length of stay (LOS) were extracted and compared based on the presence or absence of a concurrent diagnosis of cirrhosis. Statistical analyses were done using t-test and Chi-squared analysis. A multivariate analysis for the mortality odds ratio (OR) was calculated to adjust for possible confounders. Results: A total of 49,130 patients diagnosed with candidemia, and 2,650 of them had a concurrent diagnosis of cirrhosis. There was no difference in the cost of hospitalization ($ 319,472 vs. $ 315,338; p = 0.86) or the LOS (21.6 vs 21.7 days; p = 0.91). Cirrhotic patients had a higher in-hospital mortality than those without cirrhosis (OR 2.43, CI 1.94-3.02; p = 0.01). Moreover, age >65, non-white race, alcoholism, and congestive heart failure were independently associated with a higher in-hospital mortality (Table). In patients with cirrhosis and candidemia, the presence of hepatic failure (OR 2.4, CI 1.63-3.53; p = 0.00) and ascites (OR 1.64, CI 1.11-2.45; p = 0.01) were associated with increased mortality. Other comorbidities such as hepatorenal syndrome, hepatopulmonary syndrome, spontaneous bacterial peritonitis, hepatocellular carcinoma, and esophageal varices did not have an association. Conclusion: A co-diagnosis of cirrhosis during hospitalization for candidemia may indicate a poor prognosis, especially in those with associated hepatic failure and ascites, and thus a careful clinical judgement should be practiced given the nature of cirrhosis may complicate the management of infection. Modifiable risk factors such as alcoholism and underlying socioeconomic factors may play key roles in disease outcomes and should be addressed to avoid excessively poor healthcare outcomes. Table 1. - Multivariate analysis of potential factors affecting in-hospital mortality in cirrhotic patients admitted with candidemia Variable Adjusted OR (CI 95%) P-value Cirrhosis 2.43 (1.94-3.02) < 0.01 Age >= 65 1.47 (1.3-1.65) < 0.01 Female 0.9 (0.81-1) 0.06 Non-White 1.4 (1.26-1.57) 0.02 Alcoholism 1.55 (1.22-1.96) < 0.01 Diabetes mellitus 0.65 (0.58-0.73) < 0.01 Hypertension 0.78 (0.69-0.87) < 0.01 Congestive heart failure 1.71 (1.53-1.92) < 0.01 Smoking 0.5 (0.43-0.56) < 0.01 Obesity (BMI > 30) 0.84 (0.72-0.99) 0.04

S1429 Outcomes of Pyogenic Liver Abscess (PLA) on Mortality and Hospitalization Cost Amongst Patients With and Without Cirrhosis: 4-Year Retrospective Study Using National Inpatient Sample (2016 – 2019)

Introduction: Liver abscesses are the most common type of intra-abdominal abscess. Risk factors for developing pyogenic liver abscess include diabetes mellitus, chronic hepatobiliary disease. Limited data is available comparing the clinical outcomes in cirrhotic patients who develop pyogenic liver abscess. Methods: Using National Inpatient Sample databases from 2016 to 2019, we identified patients presenting with pyogenic liver abscess, the population were then divided based on the presence and absence of cirrhosis using appropriate ICD-10-CM/PCS codes. STATA 17.0 software was used for the analysis. Pearson’s Chi-Square test was used to analyze categorical variable, whereas the student t-test was used to analyze continuous variables. Univariate and multivariate logistic regression was used to adjust for potential confounders. Primary outcome was in hospital mortality due to Pyogenic liver abscess in patients with cirrhosis vs without cirrhosis. Results: Amongst total of 19,830 patients admitted with pyogenic liver abscess, 1,770 patients had cirrhosis and 18,060 patients did not. Both groups consisted predominantly of white male patients. Mean LOS was 9.47+- 8.17 days in cirrhotic group and 7.18 +- 6.08 in non-cirrhotic group. This difference was statistically significant. Mean total hospitalization charges were $26,845 and $18,347 in the cirrhotic and non-cirrhotic groups respectively. There was no difference in the in-hospital mortality between the groups. (Table) Conclusion: Compared to those without cirrhosis, patients with cirrhosis who are admitted with pyogenic liver abscess showed had higher hospital resource utilization in terms of lenght of stay and charges. Though Mortality was higher in PLA with cirrhosis group, the result was not statistically significant Table 1. - In-patient outcome comparison of cirrhotic patients presenting with pyogenic liver abscess PLA with cirrhosis, N(%) PLA without Cirrhosis, N(%) P value Total 1770(8.92) 18060(91.70) Mean age (Years) 60.93±14.23 61.30±15.59 Female(%) 724(40.9) 7404(41) 0.946 Primary Outcome Odds Ratio 95% Confidence Interval P value Mortality(%) 1.673 0.213-13.088 0.624 Secondary Outcomes Mean Mean P Value Lenght of stay(days) 9.47+/-8.17 7.18+/-6.08 < 0.001 Charges (US$) 26845 18347 < 0.001

Elevated D-Dimer levels correlate with the development of hepatorenal syndrome and a poor outcome in patients with cirrhosis

Objectives Whether hemostatic status was correlated with the diverse types of acute kidney injury in cirrhotic patients is unclear. The present study aimed to investigate the relationship between hemostatic markers and the diverse types of acute kidney injury (AKI) in liver cirrhosis. Patients and methods Cirrhotic patients with consecutive treatment at the First Affiliated Hospital of Medicine School, Zhejiang University, were pooled in a cohort. Their demographic and clinical data, biochemistry parameters and hemostatic markers were assessed to identify risk factors for the development and prognosis of AKI. Results A total of 773 cirrhotic patients were included in this cohort. Patients with hepatorenal syndrome (HRS) had significantly higher D-Dimer than those with the other types of AKI. In univariate COX regression, APTT, TT, INR, D-Dimer and Fib were correlated with the development of AKI, HRS and acute tubular necrosis (ATN), however, only D-Dimer remained independently associated with the development of AKI and HRS in multivariate COX regression. The area under the ROC curve of D-Dimer was 0.755 (95%CI, 0.718–0.793) in predicting the development of AKI, 0.879 (95%CI, 0.791–0.967) in predicting the development of HRS, respectively. D-Dimer was used for diagnosis of HRS with a sensitivity of 87.3% and specificity of 72.9% at the cutoff of 3.7 (mg/L FEU). Survival rates differed significantly between groups by D-Dimer level. Conclusions Hemostatic markers were significantly associated with the diverse types of AKI. D-Dimer was an independent risk factor for HRS and correlated with a poor outcome in cirrhotic patients.

High risk of complications and acute-on-chronic liver failure in cirrhosis patients with acute pancreatitis

Background & aimsAcute pancreatitis (AP) is a frequent indication for hospitalization and may present with varying degrees of severity. AP often coincides with hepatic disease, yet the impact of liver cirrhosis (LC) on the course of AP is uncertain, and early identification of patients at risk for complications remains challenging. We aimed to assess the impact of LC on the development of pancreatic and extra-pancreatic complications of AP, and to identify predictors of adverse outcomes in cirrhotic patients. MethodsAll adult patients with LC and AP (LC-AP, n = 52) admitted to our institution between 01/2011–03/2020 were subjected to a 1:2 matched-pair analysis with patients with AP but without LC (NLC-AP, n = 104). ResultsAt hospital admission, Glasgow-Imrie and Ranson scores as well as markers of systemic inflammation were comparable in LC-AP and NLC-AP patients, and both groups had similar rates of necrotizing AP. Infectious complications were more prevalent, and medical interventions were performed more often and with higher complication rates in LC-AP patients. While only 12.5% of NLC-AP patients developed organ failures, 48% of LC-AP patients developed single (7.7%) or multiple organ failure (40.4%), resulting in 44% of LC-AP patients with acute-on-chronic liver failure (ACLF). Patients with overt portal hypertension were particularly prone for decompensation. Mortality was higher among LC-AP compared to NLC-AP patients (6-month mortality 25% vs. 1.9%, p < 0.001), and SOFA and MELD scores at admission most accurately predicted outcomes in LC-AP. ConclusionAmong AP patients, concomitant cirrhosis substantially increases the risk for infections, periprocedural complications, multiorgan failure and death.

Platelet-to-White Blood Cell Ratio Is Associated with Adverse Outcomes in Cirrhotic Patients with Acute Deterioration.

Background: The platelet-to-white blood cell ratio (PWR) is a hematologic marker of the systemic inflammatory response. Recently, the PWR was revealed to have a role as an independent prognostic factor for mortality in patients with hepatitis B virus (HBV)-related acute-on-chronic failure (ACLF) and HBV-related liver cirrhosis (LC) with acute decompensation (AD). However, the prognostic role of the PWR still needs to be investigated in LC patients with AD. In this study, we analyzed whether the PWR could stratify the risk of adverse outcomes (death or liver transplantation (LT)) in these patients. Methods: A prospective cohort of 1670 patients with AD of liver cirrhosis ((age: 55.2 ± 7.8, male = 1226 (73.4%)) was enrolled and evaluated for 28-day and overall adverse outcomes. Results: During a median follow-up of 8.0 months (range, 1.9–15.5 months), 424 (25.4%) patients had adverse outcomes (death = 377, LT = 47). The most common etiology of LC was alcohol use (69.7%). The adverse outcome rate was higher for patients with a PWR ≤ 12.1 than for those with a PWR > 12.1. A lower PWR level was a prognostic factor for 28-day adverse outcomes (PWR: hazard ratio 1.707, p = 0.034) when adjusted for the etiology of cirrhosis, infection, ACLF, and the MELD score. In the subgroup analysis, the PWR level stratified the risk of 28-day adverse outcomes regardless of the presence of ACLF or the main form of AD but not for those with bacterial infection. Conclusions: A lower PWR level was associated with 28-day adverse outcomes, indicating that the PWR level can be a useful and simple tool for stratifying the risk of 28-day adverse outcomes in LC patients with AD.

Diagnostic Value of Non-invasive Scoring Systems in the Prediction of Esophageal Varices in Patients with Liver Cirrhosis-Single Center Experience.

Background and Objectives: Upper endoscopy is considered the gold standard for screening and diagnosis of esophageal varices (EV). Non-invasive methods for predicting EV have become a research hotspot in recent years. The aim of this study was to assess the role of non-invasive scores in predicting the presence of EV in patients with liver cirrhosis, and to determine the value of these scores in predicting the outcome of patients with cirrhosis presenting with acute variceal bleeding. Materials and Methods: A total of 386 patients with liver cirrhosis were included. The model for end-stage liver disease (MELD), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT), AST to platelet ratio index (APRI), fibrosis-4-index (FIB-4), fibrosis index (FI), King’s Score, albumin-bilirubin (ALBI) score, and platelet-albumin-bilirubin (PALBI) score were calculated. The discriminatory capacities of the examined scores in predicting the presence of esophageal varices were tested using receiver operating characteristic (ROC) curves. Results: The ROC curve analysis showed (area under the curve) AUC values of ALBI and PALBI of 0.603, and 0.606, respectively, for the prediction of EV. APRI, MELD, PALBI, King’s, FIB-4, and ALBI scores showed statistically significant correlation with EV bleeding (p < 0.05). AUC of APRI and MELD for predicting EV bleeding were 0.662 and 0.637, respectively. The AUC value of MELD in short-term mortality was 0.761. Conclusions: ALBI and PALBI scores had modest diagnostic accuracy of EVs in liver cirrhosis. APRI and MELD can be used as a reference index for the EV bleeding, and MELD score is best associated with short-term outcome in cirrhotic patients.

Poor Oral Hygiene Predicts the Presence of Ascitic Fluid Infection in Patients with Decompensated Cirrhosis

Background: Ascitic fluid infection [AFI] is one of the important complications of cirrhosis which has poor prognosis. It may be classified as Spontaneous Bacterial Peritonitis (SBP), culture negative neutrocytic ascites (CNNA) or bacteriascites. Bacterial translocation from GI tract is considered to be the most important mechanism that leads to development of AFI. Poor oral hygiene may cause subclinical or persistent infections in cirrhotic patients may act as independent risk factor for adverse outcomes in cirrhotic patients including AFI. Aim:To assess the correlation between AFI in patients with decompensated cirrhosis having poor oral hygiene. Methods: All in patients of cirrhosis with ascites were examined for ascitic fluid analysis including total protein, albumin, glucose, PMN count. Fluid was also inoculated at bedside for cultures. Oral hygiene was examined for all patients by using the dental mirror. OHI-S was calculated after calculating calculus and Debris index to determine good /poor oral hygiene. Results: A total 200 patients of decompensated cirrhosis were enrolled in the study. With mean age of 50.9 + 9.85. There were 78 % males with a mean BMI of 18.9 + 1.9. Alcohol was the major cause of cirrhosis (72%). Mean MELD and CTP were 18.6+7.43 and 10.2 +1.28 . Mean OHI- S was 1.8+1.07. AFI was found in 28%, SBP and CNNA27% was found in 1% and 27 % respectively. On univariate analysis CTP, MELD, BMI, Haemoglobin, Serum protein and Albumin significantly associated with poor oral hygiene (P < 0.001). Poor oral hygiene was found in 59.6 % in patients with AFI compared to 16.9 % in patients without SBP/CNNA (P < 0.001). S – OHI so predicted presence of AFI with a AUROC of 0.83. Conclusion: We suggest screening for oral hygiene in all patients of decompensated cirrhosis as it may be a harbinger of ascitic fluid infection.

Presence of Underlying Cirrhosis Is Associated with Increased In-hospital Mortality and Length of Stay Following Pancreatoduodenectomy

Introduction: Patient- and system-level factors associated with outcomes following pancreatoduodenectomy (PD) are well established. However, despite theoretical disruption in hepatopetal flow, the impact of cirrhosis on in-hospital mortality following PD has not been assessed. The objective of this study was to evaluate post-operative outcomes in cirrhotic patients undergoing PD.