Presence Of Hepatic Encephalopathy Research Articles

Sleep disturbance in patients with cirrhosis and transjugular intrahepatic portosystemic shunt

BackgroundSleep disturbance (SD) is a common occurrence in individuals with cirrhosis and significantly impacts their quality of life. Datas regarding post transjugular intrahepatic portosystemic shunt (TIPS) SD are scarce. This study aimed to explore the incidence and outcomes of post-TIPS SD.MethodsFrom August 2018 to November 2019, 73 patients who underwent TIPS were prospectively recruited for the study. Sleep quality was evaluated via the Pittsburgh Sleep Quality Index (PSQI), and the presence of hepatic encephalopathy was evaluated according to the West Haven criteria before and after the TIPS procedure.ResultsNineteen patients (26%) experienced new-onset SD after TIPS, with a median latency of 67 (40–98) days from the procedure. The median time from TIPS creation to occurrence was 67 (40–98) days. Minimal hepatic encephalopathy (MHE) post-TIPS emerged as an independent predictor of SD, with an odds ratio of 3 (95% CI: 1.04–8.78, P = 0.046). Notably, five of the six (83%) patients with SD experienced improvement after being administered eszopiclone. Ten of the thirteen (77%) patients with SD improved spontaneously without treatment. Furthermore, the prevalence of MHE was significantly greater among patients with SD than among those without SD (58% vs. 31%, P = 0.04).ConclusionsSD is prevalent in patients who undergo TIPS. MHE is an independent risk factor for the development of SD post-TIPS. Eszopiclone may be a safe and effective treatment option for patients with SD after TIPS. The study was registered with ClinicalTrials.gov under the identifier NCT03685994, with a registration date of September 23, 2018.

Immediate and Long-Term Results of Portacaval Shunt Surgeries in Portal Hypertension: 10-Year Clinical Experience of a Regional Vascular Surgery Department

INTRODUCTION: The number of patients with liver cirrhosis (LC) makes 20–40 cases per 100 thousand populations and rises steadily. A five-year survival rate of patients with LC in the compensation stage is 50%–62%, in the decompensation stage — 11%–40%. In the overwhelming majority of patients (80%–90%), LC leads to the compensatory formation of esophageal and gastric varices (EV and GV, respectively), which is further complicated with a life-threatening bleeding in 30% of patients. AIM: To evaluate 5-year results of partial portacaval shunt surgeries. MATERIALS AND METHODS: The paper describes a 10-year clinical experience of the vascular surgery department of Yaroslavl Regional Clinical Hospital in surgical treatment of patients with LC with a clinical presentation of portal hypertension, with recorded esophageal and gastric variceal bleeding. The study included 26 patients (of them 11 men; the mean age 48 ± 7.3 years) with LC (A and B classes on Child-Pugh scale), who underwent planned reconstructive surgery on the portal system. By the type of anastomosis, the patients were divided into 3 groups: group 1 — mesocaval anastomosis (n = 6); group 2 — distal splenorenal anastomosis with preservation of spleen (n = 10); group 3 — splenorenal H-shaped shunt. The primary end points of the study were survival of the patients, rebleeding from EV, shunt patency. Secondary end points were dynamics of EV size, changes in the spleen size, dynamics of the portal and splenic veins size, blood flow directions in the portal system, the presence of hepatic encephalopathy. Postoperative mortality was 3.8%. RESULTS: Survival at 1, 3 and 5 years was 96%, 90% and 58, respectively, and patency of anastomoses was 96%, 96% and 91%, respectively. Rebleeding at 1 year made 4% (n = 1), at 3 years — 0, at 5 years — 17% (n = 2). Changes in the hemodynamics of the portal system were recorded after formation of all types of anastomoses: reduction of the diameter of the portal vein by on average 5 mm, of the splenic vein by 3 mm, of the spleen size by 210 cm3. Shunt thrombosis occurred in two of 26 patients (7.7%) at 1 year (splenorenal H-shaped shunt with use of prosthesis) and 4 years (splenorenal autovenous shunt), respectively. CONCLUSION: The formation of partial portacaval anastomoses in patients with portal hypertension and episodes of bleeding from esophageal varices is a reliable prevention of rebleeding. The first bleeding episode is an indication for an open surgery in case the transjugular intrahepatic stenting is impossible. Survival rate of patients after portacaval shunt surgeries is determined by the initial degree of hepatic failure and patency of the formed anastomoses.

Variants of Ascitic Fluid Bacterial Infections and Clinical Outcomes in Patients with Liver Cirrhosis

Background: Ascitic fluid infection (AFI) is the most common bacterial infection in patients with cirrhosis and has several variants, including spontaneous bacterial peritonitis (SBP), bacterascites (BA), and culture-negative neutrocytic ascites (CNNA). Objectives: To date, there has been disagreement about the differences in clinical features and outcomes of these variants of AFI, and there are still few studies in this area. Methods: A cross-sectional study was conducted at a referral hospital from June 2018 to September 2022. All cirrhotic patients with ascites were evaluated for the presence of AFI. Patients with AFI were divided into SBP, BA, and CNNA variants. Non-AFI participants were also evaluated as a comparison group. The outcomes, as well as the clinical and laboratory characteristics of the variants of AFI, were compared. Kaplan-Meier curves and Cox regression analysis were used for survival analysis. Results: A total of 466 patients were studied, of which 132 (28.33%) were in the AFI group and 334 (71.67%) were in the non-AFI group. In the AFI group, 64 (48.48%) had SBP, 43 (32.58%) had CNNA, and 25 (18.94%) had BA. The most common bacteria causing AFI was Escherichia coli. SBP (HR 2.43; 95% CI 1.36 - 4.36; P = 0.003) significantly increased the risk of mortality, while CNNA and BA did not significantly increase this risk. The presence of hepatic encephalopathy and female gender also significantly increased the risk of mortality. Conclusions: The mortality risk was higher in patients with SBP compared to other types of AFI. This study also showed differences in clinical characteristics and laboratory parameters among the three types of AFI. Further research is recommended.

Risk factors and predictive nomograms for bedside emergency endoscopic treatment following endotracheal intubation in cirrhotic patients with esophagogastric variceal bleeding

Data on emergency endoscopic treatment following endotracheal intubation in patients with esophagogastric variceal bleeding (EGVB) remain limited. This retrospective study aimed to explore the efficacy and risk factors of bedside emergency endoscopic treatment following endotracheal intubation in severe EGVB patients admitted in Intensive Care Unit. A total of 165 EGVB patients were enrolled and allocated to training and validation sets in a randomly stratified manner. Univariate and multivariate logistic regression analyses were used to identify independent risk factors to construct nomograms for predicting the prognosis related to endoscopic hemostasis failure rate and 6-week mortality. In result, white blood cell counts (p = 0.03), Child-Turcotte-Pugh (CTP) score (p = 0.001) and comorbid shock (p = 0.005) were selected as independent clinical predictors of endoscopic hemostasis failure. High CTP score (p = 0.003) and the presence of gastric varices (p = 0.009) were related to early rebleeding after emergency endoscopic treatment. Furthermore, the 6-week mortality was significantly associated with MELD scores (p = 0.002), the presence of hepatic encephalopathy (p = 0.045) and postoperative rebleeding (p < 0.001). Finally, we developed practical nomograms to discern the risk of the emergency endoscopic hemostasis failure and 6-week mortality for EGVB patients. In conclusion, our study may help identify severe EGVB patients with higher hemostasis failure rate or 6-week mortality for earlier implementation of salvage treatments.

A novel imaging index for predicting adverse progression in acute-on-chronic liver failure related to hepatitis B virus: the low erector spine index

BackgroundIt is widely known that muscle mass influences the outcomes of many chronic diseases. Erector spine mass is a convenient parameter obtained from routine abdominal computed tomography (CT). The clinical application value of erector spine mass, and whether erector spine mass could predict the outcome of disease has not been studied.AimTo evaluate the role of the erector spine index (ESI) calculated based on abdominal CT imaging in the progression of acute-on-chronic liver failure related to the hepatitis B virus (HBV-ACLF).MethodsWe performed a retrospective study of 118 HBV-ACLF patients and calculated the ESI (the total erector spine area normalized for height2 in meters) for each patient through abdominal CT. The findings were analyzed regarding the progression of HBV-ACLF and the ESI at baseline, including mortality and the development of complications.ResultsThe ESI level was associated with mortality and the development of complications. During the 90-day follow-up period, patients with a low ESI (<12.05 cm2/m2) had higher mortality than those with a high ESI (≥ 12.05 cm2/m2) (51.7% vs. 26.7%), and the cumulative survival rates were 71.0%±4.6 and 85.8%±3.9, respectively (log-rank P = 0.003). The hazard ratios (HRs) calculated using univariable and multivariable analyses were 2.23(95% confidence interval (CI): 1.25–4.21, P = 0.005) and 2.52 (95% CI: 1.34–9.24, P = 0.011), respectively. Patients with a low ESI (<12.05 cm2/m2) had higher incidences of kidney dysfunction (43.5% vs. 23.2%, P = 0.029; log-rank P = 0.017) and hepatic encephalopathy (39.6% vs. 14.0%, P = 0.003; log-rank P = 0.010) than those with a high ESI. A low ESI was an independent risk factor for kidney dysfunction (adjusted HR = 1.36, 95% CI: 1.05–2.93, P = 0.043) and the development of hepatic encephalopathy (adjusted HR = 2.26; 95% CI: 2.05–3.13, P = 0.036). In addition, the presence of hepatic encephalopathy (the odds ratio (OR) = 2.26, 95% CI: 2.05–3.18, P = 0.006), spontaneous bacterial peritonitis (OR = 3.95, 95% CI: 1.01–5.46, P = 0.037), and kidney dysfunction (OR = 4.47, 95% CI: 1.02–9.64, P = 0.032) was independently associated with a low ESI in patients.ConclusionA low ESI is an independent risk factor for mortality in patients with HBV-ACLF, as well as the development of kidney dysfunction and hepatic encephalopathy.

Predictors of clinical trajectories of patients with acutely decompensated cirrhosis. An external validation of the PREDICT study.

The PREDICT study recently showed that acutely decompensated (AD) patients with cirrhosis can present three different clinical phenotypes in the 90 days after admission: (1) pre-ACLF, developing acute-on-chronic liver failure (ACLF); (2) unstable decompensated cirrhosis (UDC), being re-admitted for AD without ACLF and (3) stable decompensated cirrhosis (SDC), not presenting readmission or ACLF. This study aimed to externally validate the existence of these three distinct trajectories and to identify predictors for the occurrence of each trajectory. Baseline data, 3-month ACLF and readmission incidence and 1-year survival were analysed in a prospective cohort of patients admitted for AD. A multinomial multivariable model was used to evaluate the association between baseline features and clinical trajectories. Of the 311 patients enrolled, 55% met the criteria for SDC, 18% for UDC and 27% for pre-ACLF, presenting a significantly different 1-year mortality: pre-ACLF 65%, UDC 46%, SDC 21% (p < .001). The presence of hepatic encephalopathy (HE) was associated with UDC (p = .043), while the absence of ascites to SDC (p = .017). Among laboratory parameters, an increase in MELD-Na (p = .001) and C-reactive protein (p = .009) and a decrease in haemoglobin (p = .004) and albumin (p = .008) levels were associated with pre-ACLF. The present study confirms that AD patients have three different clinical trajectories with different mortality rates. Besides the severity of cirrhosis, the association with C-reactive protein supports the predominant role of systemic inflammation in ACLF pathophysiology. Finally, HE is associated with the UDC phenotype highlighting the need for better management of this complication after discharge.

Healthcare Costs for Medicare Patients With Hepatocellular Carcinoma in the United States

Hepatocellular carcinoma (HCC) has an increasing mortality in the United States and is a leading cause of morbidity and mortality in patients with cirrhosis. We aimed to estimate the financial burden related to HCC in a large nationally representative United States cohort. We used the Surveillance, Epidemiology, and End Results program (SEER)-Medicare database to identify 4525 adult patients who were diagnosed with HCC between 2011 and 2015. We generated a 1:1 propensity score-matched cohort of patients with cirrhosis but no HCC as a comparator group to define incremental HCC-specific costs beyond costs related to underlying cirrhosis. Our main outcomes were patient liabilities and Medicare payments in the first year after HCC diagnosis. Compared with patients with cirrhosis, those with HCC had higher incremental patient liabilities (median+$7166; interquartile range, $2401-$16,099) and Medicare payments (+$50,110; interquartile range, $142,42-$136,239; P < .001 for both) in the first year after diagnosis. Patients with HCC had significantly higher inpatient, outpatient, and physician service costs compared with the matched cohort with cirrhosis (P < .001 for all). Patients with early-stage HCC had lower incremental patient liabilities (median, $4195 vs $8238; P < .001) and Medicare payments (median, $28,207 vs $59,509; P < .001) than those with larger tumor burden. In multivariable median regression analysis, incremental patient liabilities and Medicare payments were significantly associated with the National Cancer Institute comorbidity index, nonalcoholic fatty liver disease etiology, presence of ascites, and presence of hepatic encephalopathy. Patients with HCC suffer from cancer-related financial burden, highlighting a need for policy interventions and financial support systems.

Therapeutic plasma-exchange improves short-term, but not long-term, outcomes in patients with acute-on-chronic liver failure: A propensity score-matched analysis.

Acute-on-chronic liver failure (ACLF) is associated with a high short-term mortality rate in the absence of liver transplantation. The role of therapeutic plasma exchange (TPE) in improving the outcomes of ACLF and acute decompensation (AD) is unclear. In this retrospective analysis, we aimed to determine the impact of TPE on mortality in patients with ACLF. ACLF patients receiving TPE with standard medical treatment (SMT) were propensity score matched (PSM) with those receiving SMT alone (1:1) for sex, grades of ACLF, CLIF C ACLF scores, and the presence of hepatic encephalopathy. The primary outcomes assessed were mortality at 30 and 90 days. Survival analysis was performed using Kaplan Meier survival curves. A total of 1151 patients (ACLF n=864 [75%], AD [without organ failure] n=287 [25%]) were included. Of the patients with ACLF (n=864), grade 1, 2, and 3 ACLF was present in 167 (19.3%), 325 (37.6%), and 372 (43.0%) patients, respectively. Thirty-nine patients received TPE and SMT, and 1112 patients received only SMT. On PSM analysis, there were 38 patients in each group (SMT plus TPE vs SMT alone). In the matched cohort, the 30-days mortality was lower in the TPE arm compared to SMT (21% vs 50%, P=.008), however, the 90-day mortality was not significantly different between the two groups (36.8% vs 52.6%, P=.166); HR, 0.82 (0.44-1.52), P=.549. TPE improves short-term survival in patients with ACLF, but has no significant impact on long-term outcomes. Randomized control trials are needed to obtain a robust conclusion in this regard.

S1319 Etiologies for In-Hospital Mortality in Patients With Compensated and Decompensated Hepatic Cirrhosis

Introduction: Cirrhosis is the end-stage of chronic liver disease and is generally associated with poor outcome, increased hospitalizations, and mortality. The occurrence of decompensated cirrhosis further markedly increases mortality. Knowledge regarding the causes of mortality and hospitalization can help risk stratify hospitalized patients with cirrhosis. Methods: Using the US Nationwide readmissions database 2014, we identified hospitalized patients who had cirrhosis and died during their hospitalization. In this cohort, we identified rates of cirrhotic and non-cirrhotic complications and etiologies for hospitalization. Causes of death were identified by the primary discharge diagnosis. Decompensated cirrhosis was defined as the presence of hepatic encephalopathy (HE), ascites, jaundice, variceal bleeding (VB), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), or hepatocellular carcinoma (HCC). Appropriate ICD-9 codes were used to identify all diagnoses and procedures. Results: We studied 291,368 patients with cirrhosis of whom 38,394 patients (13.2%) died in-hospital. Around 19% of patients who had decompensation (53% of all patients) and 6.7% of patients who had compensated cirrhosis (47%) died during a hospitalization. Decompensated cirrhosis was present in 76.1% (N=29,212) of patients with mortality. Ascites was present in 50.3%, HE in 32.1%, VB in 23.2%, HRS in 19.4%, SBP in 9.1%, jaundice in 5.6% and HCC in 8.7%. In the overall cohort, the most common causes of death were sepsis (31.2%) followed by decompensated cirrhosis (13.6%), viral hepatitis (3.9%), respiratory failure (3.8%), and gastrointestinal bleeding (non-variceal) (3.8%). In patients with compensated cirrhosis, major causes of death were sepsis (33.8%), respiratory failure (6.3%), stroke (5.1%), congestive heart failure (3.4%), and traumatic intracranial injury (3.3%). When decompensation was present, major causes of death were sepsis (30.4%), decompensated cirrhosis (17.9%), gastrointestinal bleeding (4.6%), viral hepatitis (4.5%), and respiratory failure (3.1%). Conclusion: In the US, 1 in 7 hospitalized patients with cirrhosis, 1 in 5 with decompensated cirrhosis, and 1 in 14 with compensated cirrhosis had in-hospital mortality. Sepsis is the most common cause of death (1/3rd) in cirrhotic patients, in both compensated and decompensated cirrhosis. These data can help risk stratify and improve management strategies of hospitalized patients with cirrhosis.

Development and validation of a nomogram for predicting overall survival in cirrhotic patients with acute kidney injury.

BACKGROUNDAcute kidney injury (AKI) is a common and severe complication in patients with cirrhosis, and is associated with poor prognosis. Therefore, identifying cirrhotic patients with AKI who are at high risk of mortality is very important and may be helpful for providing timely medical interventions to improve the prognosis of these patients. However, studies focused on investigating the risk factors for the mortality of cirrhotic patients with AKI were scarce.AIMTo identify risk factors for mortality and establish a nomogram for predicting the prognosis of these patients.METHODSTwo hundred fifty consecutive patients with cirrhosis and AKI were recruited and randomly divided into training cohort (n = 173) and validation cohort (n = 77). In the training cohort, potential risk factors for death were identified by performing a Cox regression analysis, and a nomogram was established. The predictive performance of the nomogram was internally and externally validated by calculating the area under the receiver operating characteristic curve (AUROC), constructing a calibration curve and performing decision curve analysis.RESULTSThe serum sodium level, international normalized ratio, peak serum creatinine level > 1.5 mg/dL, the presence of hepatic encephalopathy and diabetes were potential risk factors for mortality of cirrhotic patients with AKI in the training dataset. A prognostic nomogram incorporating these variables was established for predicting the overall survival of these patients. Compared with Child-Turcotte-Pugh, the model for end-stage liver disease (MELD) and the MELD-Na scores, the nomogram in predicting 90- and 180-d mortality exhibited better discriminatory power with AUROCs of 0.792 and 0.801 for the training dataset and 0.817 and 0.862 for the validation dataset, respectively. With a nomogram score of 98, patients were divided into low- and high-risk groups, and high-risk patients had a higher mortality rate.CONCLUSIONA prognostic nomogram displayed good performance for predicting the overall survival of cirrhotic patients with AKI, and will assist clinicians in evaluating the prognosis of these patients.

Gastrointestinal hemorrhage as an acute-on-chronic liver failure trigger in cirrhotic patients.

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of chronic liver disease associated with organ failures and very high short-term mortality. To assess the incidence and factors predisposing to ACLF in patients with liver cirrhosis hospitalized due to acute gastrointestinal bleeding (GIB). We collected and retrospectively analyzed the data of 89 consecutive patients (59 males (66.2%), median age 53 years (range: 44-62 years), mean Model for End-Stage Liver Disease (MELD) score 14.42 ±6.5, median Child-Turcotte-Pugh score 10 (range: 8-11), and acute GIB (72 variceal bleeding and 17 non-variceal bleeding cases). Acute-on-chronic liver failure was diagnosed based on European Association for the Study of the Liver - Chronic Liver Failure Consortium definition. Twenty-seven (30.33%) patients met the criteria of ACLF during hospitalization: 8 (30%) had ACLF grade 1, 13 (48%) had ACLF grade 2 and 6 (22%) had ACLF grade 3. The most frequent organ failures were respiratory (22 (25%)), kidney (18 (20.23%)) and brain (17 (19.1%)) failure. The MELD score value, creatinine level and presence of hepatic encephalopathy (HE) on admission were significant predictors of ACLF in the multivariate logistic regression model with optimal cutoff point for MELD score of 18.313 and optimal cutoff point for creatinine level of 1.35 mg/dL. In-hospital risk of ACLF in cirrhotic patients hospitalized for acute gastrointestinal hemorrhage is high despite successful arrest of bleeding. Elevated creatinine level, MELD score and the presence of HE on admission are the best predictors of ACLF during hospitalization in such patients.

CORRELATION BETWEEN SARCOPENIA AND HEPATIC ENCEPHALOPATHY IN PATIENTS WITH CIRRHOSIS

Malnutrition is a frequent complication in patients with cirrhosis, associated with greater disease progression, complication rate, and mortality. Sarcopenia is one of the main indicators of malnutrition, characterized by a general decrease in muscle mass and functional deterioration. CT determination of muscle mass is not easily accessible in routine clinical practice, so practical measurement tools are essential. It has been proposed to classify sarcopenia as severe when decreased muscle strength, muscle mass, and low physical performance coexist. The impact of severe sarcopenia on the risk of developing hepatic encephalopathy is currently unknown. Primary outcome: Determine if there is a significant correlation between the degree of sarcopenia and hepatic encephalopathy. Secondary outcomes: to determine the prevalence of sarcopenia in patients with cirrhosis, the association between sarcopenia and liver decompensation events, to determine the correlation between individual tests (battery of functional physical performance tests [SPPB], grip strength, and skeletal muscle mass) with hepatic encephalopathy. Prospective, cross-sectional, observational, descriptive, and analytical study in patients with liver cirrhosis evaluated by outpatient consultation, with diagnosis confirmed by transitional elastography (Fibroscan® 502 ECHOSENS® equipment). The presence of sarcopenia was determined by measurement of grip strength with a hand-held hydraulic dynamometer (JAMAR® B001D7QDJG) and determination of muscle mass by tetrapolar electrical bioimpedance (OMRON® HBF 500). A positive case was considered when coexisting force ≤27 kg / ≤16 kg and skeletal muscle mass ≤20 kg / ≤15kg in men and women respectively, classifying it as severe sarcopenia with a score of ≤8 pts in SPPB. The presence of hepatic encephalopathy was determined by clinical evaluation and critical flicker rate (cut-off <39 Hz). Logistic regression analysis and Chi-square test were performed. 96 patients were included, of which 35 (36.4%) had sarcopenia and 21 (60%) were classified as severe sarcopenia. The demographic characteristics and severity of cirrhosis were comparable in patients with and without sarcopenia. In multivariate logistic regression analysis, a significant correlation was demonstrated between the presence of sarcopenia and manifest hepatic encephalopathy p = 0.014, HR 9.05, 95% CI (1.54-52). No significant correlation was shown with ascites (p = 0.08) or recent variceal bleeding (p = 0.53). A significant correlation was demonstrated between previous events of encephalopathy (p = 0.021) and ascites (p = 0.032) with the presence of sarcopenia. Regarding individual tests, a SPPB score ≤8 was independently associated with overt encephalopathy (0.009, HR 19.7, 95% CI (2.1-182). Handgrip strength, chair stand, and muscle mass were not statistically significant. This pilot study suggests that the presence of sarcopenia is significantly correlated with the risk of developing overt hepatic encephalopathy, and the presence of previous ascites could increase the risk of developing sarcopenia. Evaluation of physical performance by SPPB could be independently correlated with the development of hepatic encephalopathy. The authors declare that there is no conflict of interest

Predictors of survival in portopulmonary hypertension: a 20-year experience.

Portopulmonary hypertension (PoPH) is a rare complication of portal hypertension associated with poor survival. Scarce data is available on predictors of survival in PoPH with conflicting results. We sought to characterize the outcomes and variables associated with survival in a large cohort of patients with PoPH in an American population of patients. We identified PoPH patients from the Cleveland Clinic Pulmonary Hypertension Registry between 1998 and 2019. We collected prespecified data, particularly focusing on hepatic and cardiopulmonary assessments and tested their effect on long-term survival. Eighty patients with PoPH with a mean ± SD age of 54 ± 10 years, (54% females) were included in the analysis. The median Model for End-Stage Liver Disease with sodium (MELD-Na) score was 13.0 (10.0-18.0) at PoPH diagnosis. World Health Association functional class III-IV was noted in 57%. Mean pulmonary arterial pressure was 47 ± 10 mmHg and pulmonary vascular resistance 6.0 ± 2.8 Woods units. A total of 63 (78.5%) patients were started on pulmonary arterial hypertension (PAH)-specific treatment during the first 6 months of diagnosis. Survival rates at 1-, 3- and 5-year were 77, 52 and 34%, respectively. Cardiopulmonary hemodynamics as well as PAH-specific treatment did not affect survival. In the multivariable model, MELD-Na, resting heart rate and the presence of hepatic encephalopathy were independent predictors of survival. PoPH patients have poor 5-year survival which is strongly associated to the severity of underlying liver disease and not to the hemodynamic severity of PoPH; therefore efforts should be focused in facilitating liver transplantation for these patients.

Особливості діагностики енцефалопатії у хворих з синдромом портальної гіпертензії

Актуальність. Печінкова енцефалопатія — патологічні зміни функцій головного мозку незапального генезу, що проявляються синдромом вторинних неврологічних і когнітивних розладів, спричинених комплексом глибоких метаболічних порушень, в результаті гострої печінкової недостатності, хронічних захворювань печінки або портосистемного шунтування крові. Початкова стадія енцефалопатії не має клінічних неврологічних симптомів, але визначається у 20–80 % хворих на цироз печінки і на відміну від кінцевих стадій є оборотною. Мета дослідження: оцінити ефективність тесту зв’язку чисел, флікер-тесту та електроенцефалографії в діагностиці енцефалопатії у хворих з печінковою та позапечінковою формою портальної гіпертензії. Матеріали та методи. Синдром печінкової енцефалопатії вивчено у 50 хворих з печінковою формою портальної гіпертензії, 30 хворих з позапечінковою формою портальної гіпертензії та 25 осіб без ознак портальної гіпертензії. Для діагностики використовували тест зв’язку чисел, флікер-тест та електроенцефалографію. Результати. Тест зв’язку чисел дозволив встановити ознаки печінкової енцефалопатії майже в усіх хворих незалежно від наявності та форми портальної гіпертензії. Однак прояви печінкової енцефалопатії за частотою і за вираженістю переважали у хворих з печінковою портальною гіпертензією. Проведення флікер-тесту дозволило діагностувати мінімальну печінкову енцефалопатію у 96 % хворих з печінковою портальною гіпертензією та 60 % хворих з позапечінковою портальною гіпертензією. Виконання електроенцефалографії визначило наявність печінкової енцефалопатії у 60 % хворих з печінковою портальною гіпертензією, 50 % хворих з позапечінковою портальною гіпертензією та 12 % хворих без портальної гіпертензії. Висновки. Зіставлення ефективності діагностичних тестів показало, що простий у виконанні і доступний тест зв’язку чисел є найбільш ефективним, однак і інші тести мають свої позитивні сторони в клінічній оцінці печінкової енцефалопатії у хворих з портальною гіпертензією.

Acute severe autoimmune hepatitis with anti-rods and rings autoantibodies; literature first evidence.

Autoimmune hepatitis (AIH) was defined as a progressive, chronic inflammatory autoimmune liver disease (ALD). The diagnosis of AIH requires the presence of characteristic clinical and laboratory features, and the exclusion of other clinical conditions that cause chronic hepatitis and cirrhosis. AIH can have an acute onset that mimics an acute viral or toxic hepatitis or an acute severe (fulminant, ASF) presentation that satisfies criteria for acute liver. Guidelines from the European Association for the Study of Liver Diseases define ALF with absence of pre-existing liver disease, acute onset of ≤ 26 weeks, coagulopathy (international normalised ratio (INR) ≥ 1.5), and presence of hepatic encephalopathy (HE). In recent years, autoantibodies (Aab) targeting subcellular structures described as the rods and rings (R&R) pattern in HEp-2 ANA have been presented as a unique and particular case of Aab generation. These R&R structures are composed of inosine monophosphate dehydrogenase type 2 (IMPDH2), and their formation can be induced in vitro by several small-molecule inhibitors. Aab targeting these relatively unknown structures has been observed in Hepatitis C virus (HCV) patients who have undergone treatment with pegylated interferona/ ribavirin (IFN/RBV) therapy. We presented and characterized a case patient with R&R and SMA Aab in AIH (ASF, fatal, without liver transplantation). To the best of our knowledge, this is the first evidence described in the Literature. Our early experience showed the R&R circulating Aab in one patient with Primary Biliary Cholangitis. This work now demonstrates that R&R Aab can also be present in AIH case.

Association Between Serum IL-6, IL-10, IL-12, and IL-23 Levels and Severity of Liver Cirrhosis.

Background:Liver cirrhosis contributes to high liver-related mortality globally. Systemic inflammation mediated by immune cells contributes to the progression of liver cirrhosis. Growing evidence shows that several pro- and anti-inflammatory cytokines might have an important role in liver cirrhosis.Objective:To evaluate the association between serum IL-6, IL-10, IL-12, and IL-23 levels and severity of liver cirrhosis.Methods:This observational study was carried out at the Department of Internal Medicine, Universitas Sumatera Utara, Indonesia from March 2018 to August 2019. The severity of liver cirrhosis was assessed by using the Child-Pugh score. IL-6, IL-10, IL-12, and IL-23 levels, hepatitis and renal function were measured in all study subjects. Independent t-test and Mann-Whitney tests were conducted to observe differences between groups.Results:A total of 78 liver cirrhosis patients were enrolled, mean age was 50.6±11.4. Median serum IL-6, IL-10, IL-12, and IL-23 levels were 24.5(2.6-46.4)pg/ml, 2.1(0.4-9.3)pg/ml, 3.5(1.4-20.8)pg/ml and 20.3(9.2-218)pg/ml, respectively. A higher IL-6 level was associated with more severe liver cirrhosis (p=0.001) and the presence of hepatic encephalopathy (p=0.018). Higher IL-23 level was found in patients with no hepatic encephalopathy (p=0.049). There was no association between serum cytokines levels and hepatitis viral infection status.Conclusion:IL-6 is associated with the severity of liver cirrhosis.

Pre and post-liver transplant outcome of cirrhotic patients with acute on chronic liver failure.

Acute on chronic liver failure (ACLF) is a dynamic syndrome, but frequently associated with a high 1 month mortality rate. This is the first study applying the new European Association for the Study of the Liver- chronic liver failure consortium criteria to explore mortality on the waiting list (WL) and early after liver transplantation (LT) in a cohort of Romanian cirrhotic patients that improved or recovered after an episode of ACLF.To assess frequency and waitlist mortality for different grades of ACLF.An observational study was conducted; 257 patients with liver cirrhosis included on the WL between 2015 and 2017 were analyzed. The cumulative incidence of waitlist mortality or removal was calculated for combination of competing events using multivariable competing risks regression.ACLF-1 occurred in 12.07%, ACLF-2 in 7.39% and ACLF-3 in 8.56% of patients. Median Model for End Stage Liver Diseases (MELD) score at the moment of ACLF was 29. The main event while on the WL was death, followed by ACLF; patients with ACLF-3 had a significantly greater subhazard ratio for mortality of 2.25 (1.55–3.26) compared to patients with ACLF-1 or 2. LT proved to be associated with a significantly lower risk of death on the WL at 6 months after inclusion. One and 12 months post-transplant survival of patients with or without ACLF was similar (P = .77).Occurrence of an ACLF episode while on the WL is associated with a significantly high mortality rate, as well as MELD score at inclusion on the WL, renal and liver failure, presence of hepatic encephalopathy. Overall patient short and long term survival after LT is similar to non-ACLF patients in good selected cases.

Early identification using the referral system prolonged the time to onset for hepatic encephalopathy after diagnosing severe acute liver injury

In 2004, we implemented a referral system for patients with acute liver injury (ALI) based on an established formula that estimates the risk of progression to acute live failure (ALF); however, the benefits of the system for patients with severe acute liver injury (SLI) remain unclear. We have evaluated the clinical significance of the referral system for SLI patients. Patients with ALI/SLI who were consecutively and prospectively listed on the system between 2004 and 2018 were analyzed. Of the 371 ALI/SLI/ALF patients on the system, 124 satisfied the criteria for SLI; 34 of these 124 progressed to SLI after registration. Multivariate analysis using age, sex, AST, ALT, creatinine, total bilirubin, prothrombin, presence of hepatic encephalopathy (HE), and SLI at registration revealed that HE was associated with high mortality. Among the 23 patients who developed HE, five who progressed to SLI after registration showed an increased time to HE development compared with patients who had SLI at the time of registration. However, there was no significant difference in survival time after HE development. We concluded that early identification of SLI patients using the referral system increased the time from SLI diagnosis to HE development.

Clinical Considerations of Coagulopathy in Acute Liver Failure.

Acute liver failure (ALF) is the rapid onset of severe liver dysfunction, defined by the presence of hepatic encephalopathy and impaired synthetic function (international normalized ratio of ≥1.5) in the absence of underlying liver disease. The elevated international normalized ratio value in ALF is often misinterpreted as an increased hemorrhagic tendency, which can lead to inappropriate, prophylactic transfusions of blood products. However, global assessments of coagulopathy via viscoelastic tests or thrombin generation assay suggest a reestablished hemostatic, or even hypercoagulable, status in patients with ALF. Although the current versions of global assays are not perfect, they can provide more nuanced insights into the hemostatic system in ALF than the conventional measures of coagulopathy.

S1030 The Clinical Impact of Cirrhosis on the Postoperative Outcomes of Patients Undergoing Splenectomy

INTRODUCTION: Splenectomy may be required in patients with cirrhosis due to severe hypersplenism from portal hypertension or due to non-cirrhosis causes including traumatic injury or laceration of the spleen. In this study, we evaluate the effects of cirrhosis on the postoperative outcomes of patients undergoing splenectomy. METHODS: Inpatient splenectomy cases isolated from the 2011 to 2017 National Inpatient Sample were stratified by the presence of cirrhosis. The cirrhosis and non-cirrhosis cohorts were compared using mortality, length of stay, hospitalization costs, and postoperative complications. A subgroup analysis was performed on the cirrhosis cohort to evaluate the effect of decompensated cirrhosis (presence of hepatic encephalopathy, ascites, variceal bleeding, hepatorenal syndrome, and SBP) on the study endpoints. RESULTS: Of the 28596 splenectomy cases selected from the database, 619 cases (2.16%) included cirrhosis. There was no difference in age (55.8 vs 52.9y P = 0.11) between cohorts, but the cirrhosis cohort was more likely to be male (62.7 vs 50.9% P < 0.01). The mortality was higher in the cirrhosis cohort (18.6 vs 5.65% P < 0.01, OR 3.81 95%CI 3.09–4.69), as were the LOS (12.1 vs 10.9d P < 0.01) and hospitalization costs ($214,275 vs $164,792 P < 0.01). The cirrhosis cohort had higher incidences of bleeding complications (7.27 vs 4.65% P < 0.01, OR 1.61 95%CI 1.18–2.19) and sepsis (12.1 vs 8.20% P < 0.01, OR 1.54 95%CI 1.21–1.97). However, there was no difference between cohorts in the incidences of the bowel perforation (0.49 vs 1.05% P = 0.23 OR 0.46 95%CI 0.09-1.36), bowel obstruction (3.55 vs 4.89% P = 0.15, OR 0.72 95%CI 0.47–1.10), wound complication (2.26 vs 1.58% P = 0.24, OR 1.44 95%CI 0.84–2.47), and postoperative infection (1.94 vs 2.24% P = 0.71, OR 0.86 95%CI 0.48–1.53). In a multivariate analysis, cirrhosis was associated with increased hospital mortality (P < 0.01, aOR 2.83 95%CI 2.09–3.78). In a subgroup analysis of cirrhosis patients, the presence of hepatic decompensation was associated with increased hospital mortality (24.4 vs 16.6% P = 0.04, OR 1.62 95%CI 1.05–2.51) as well as increased LOS (17.2 vs 10.4d P < 0.01) and hospitalization costs ($308,616 vs $181,390 P < 0.01). CONCLUSION: The presence of cirrhosis is associated with increased hospital mortality in patients undergoing splenectomy. Therefore, these patients require preoperative risk-assessment and multidisciplinary management of both cirrhosis and post-splenectomy complications.Figure 1.: Multivariate model: cirrhosis is associated with increased postoperative mortality in patients undergoing splenectomy.