Survival In Cirrhotic Patients Research Articles

Rifaximin improves survival in cirrhotic patients with refractory ascites: A real-world study.

BACKGROUNDRifaximin has been shown to reduce the incidence of hepatic encephalopathy and other complications in patients with cirrhosis. However, few studies have investigated the effect of rifaximin in cirrhotic patients with refractory ascites.AIMTo evaluate the effects of rifaximin in the treatment of refractory ascites and to preliminarily explore its possible mechanism.METHODSA total of 75 cirrhotic patients with refractory ascites were enrolled in the study (50 in a rifaximin and 25 in a control group). Patients in the rifaximin group were divided into two subgroups according to the presence of spontaneous bacterial peritonitis and treatment with or without other antibiotics (19 patients treated with rifaximin and 31 patients treated with rifaximin plus intravenous antibiotics). All patients received conventional treatment for refractory ascites, while patients in the rifaximin group received oral rifaximin-α 200 mg four times daily for at least 2 wk. The ascites grade, fasting weight, liver and kidney function, and inflammatory factors in the plasma were evaluated before and after treatment. In addition, the gut microbiota was determined by metagenomics sequencing to analyse the changes in the characteristics of the gut microbiota before and after rifaximin treatment. The patients were followed for 6 mo.RESULTSCompared with the control group, the fasting weight of patients significantly decreased and the ascites significantly subsided after treatment with rifaximin (P = 0.011 and 0.009, respectively). The 6-mo survival rate of patients in the rifaximin group was significantly higher than that in the control group (P = 0.048). The concentration of interferon-inducible protein 10 decreased significantly in the rifaximin group compared with that in the control group (P = 0.024). The abundance of Roseburia, Haemophilus, and Prevotella was significantly reduced after rifaximin treatment, while the abundance of Lachnospiraceae_noname, Subdoligranulum, and Dorea decreased and the abundance of Coprobacillus increased after treatment with rifaximin plus intravenous antibiotics. The gene expression of virulence factors was significantly reduced after treatment in both subgroups treated with rifaximin or rifaximin plus intravenous antibiotics.CONCLUSIONRifaximin mitigates ascites and improves survival of cirrhotic patients with refractory ascites. A possible mechanism is that rifaximin regulates the structure and function of intestinal bacteria, thus improving the systemic inflammatory state.

P: 48 Nonselective Beta-blocker Use Is Associated With Increased Hepatic Encephalopathy-Related Readmissions in Patients With Cirrhosis

BACKGROUND: Hepatic Encephalopathy (HE) is a reversible syndrome of impaired brain function that is associated with frequent hospitalizations and decreased survival in cirrhotic patients. Nonselective beta-blockers (NSBB) are the mainstay of pharmacologic treatment for portal hypertension and prevention of variceal bleeding. Due to their effects on hepatic blood flow, we hypothesized that NSBB use would decrease portal flow, leading to increased HE related hospitalizations independent of liver disease severity. This study was done to assess the effect of NSBB use on HE-related readmissions. METHODS: We examined all the patients with cirrhosis admitted at Baylor University Medical Center between January 2013 and July 2018. The outcome measure of HE-related readmissions was analyzed in patients taking NSBB vs. patients not taking NSBB using cox proportional hazard regression model. The model was adjusted for age, sex, Model for End-Stage Liver Disease (MELD) score, selective beta-blocker (SBB) use, ascites, and history of esophageal varices (EV) and transjugular intrahepatic portosystemic shunt (TIPS). The Kaplan-Meier method and log-rank test were used to compare the cumulative incidence of HE-related readmissions between the aforementioned groups. RESULTS: There were 393 patients in this study with a mean age of 58.1 ± 10.2 years and a male predominance. The mean MELD score was 19.6 ± 7.7. The median time between the first admission and future readmission was 1.9 months with interquartile range of 4.8 months. The cumulative incidence of HE-related readmissions was significantly higher in patients taking NSBB compared with patients who were never prescribed NSBB (P < 0.001) (Figure 1). This effect was not seen for patients who were taking SSBs. In multivariate analysis, after adjusting for age, sex, MELD score, SBB use, ascites, history of EV and TIPS, NSBB use was independently associated with increased risk of HE-related re-hospitalizations; Hazard ratio was 2.82 (95% confidence interval: 1.81–4.41). CONCLUSIONS: NSBB use is independently associated with increased HE-related readmissions in patients with cirrhosis, regardless of liver disease severity. Thus, NSBBs should be used cautiously in patients who have experienced a prior HE episode. However, further prospective studies are needed to determine the impact of NSBB on portal hypertension complications.

Outpatient telephonic transitional care after hospital discharge improves survival in cirrhotic patients.

BACKGROUNDIntervention to improve outcomes in cirrhotic patients (CP) after hospital discharge often focus on 30 d readmission rate (RR). However, recent studies suggest dissociation between RR and survival. At our center, CP are now offered outpatient telephonic transitional care (OTTC) by a care coordinator for 30 d after hospital discharge.AIMTo determine the effect of OTTC on survival in CP.METHODSIn this cohort study from a tertiary center, CP who received OTTC formed the intervention group. They were compared with a control group discharged during the same period. Mortality and RR were compared between the groups.RESULTSAfter OTTC introduction, 194 CP were discharged. After applying exclusion criteria, 169 CP (51% male, mean age 58 years ± 12 years) were included. OTTC group comprised 76 patients and was compared with 93 controls. Baseline disease and index admission related characteristics were not significantly different between the groups. The intervention group showed significantly higher 6 mo survival compared to controls (84.2% vs 68.8%; P = 0.03), while RR at 1, 3, and 6 mo were comparable. On multivariable analysis, the intervention group showed lower odds for mortality compared to the controls (hazard ratio: 0.4; 95% confidence interval: 0.2-0.82; P = 0.012), while higher model for end-stage liver disease scores were associated with higher mortality (hazard ratio: 1.05; 95% confidence interval: 1.01-1.1; P = 0.024).CONCLUSIONCP provided OTTC had higher 6 mo survival compared to controls without a difference in RR. Use of RR to gauge quality of care provided during hospitalization or subsequent transitional care programs should be revisited.

SUN-PO067: Prevalence of Malnutrition by GLIM Criteria and of Sarcopenia by the New Definition and Their Associations with 1-Year Survival in Cirrhotic Patients

SUN-PO067: Prevalence of Malnutrition by GLIM Criteria and of Sarcopenia by the New Definition and Their Associations with 1-Year Survival in Cirrhotic Patients

Can we perform esophagectomy for esophageal cancer patients with concomitant liver cirrhosis? A comprehensive systematic review and meta-analysis.

Liver cirrhosis is sometimes encountered in esophageal cancer patients intended for surgery. However, the impact of liver cirrhosis on patients with surgically treated esophageal cancer remains unclear. Therefore, we conducted the first meta-analysis focusing on current topic. We comprehensively searched relevant studies in Pubmed, Embase, and Web of Science on September 3, 2018. Data for analysis included both short-term (including morbidity and mortality rates) and long-term (5-year survival rate) outcomes. Our meta-analysis was conducted by using the STATA 12.0 package. We finally included a total of six cohort studies involving a total of 1426 patients (161 cirrhotic patients and 1265 noncirrhotic patients). Meta-analysis showed that cirrhotic patients had a significantly higher morbidity rate (risk ratio (RR)=1.226; 95% Confidence interval (CI)=[1.043, 1.442]; P=0.014) than noncirrhotic patients. For specific complications, cirrhotic patients had a significantly higher rate of pulmonary complications (RR=2.354; 95%CI=[1.376, 4.026]; P=0.002) and pleural effusion (RR=2.414; 95%CI=[1.482, 3.613]; P<0.001) than noncirrhotic patients and there was a trend toward a higher rate of anastomotic leak (RR=1.759; 95%CI=[0.945, 3.274]; P=0.075) in cirrhotic patients. Moreover, cirrhotic patients also had a significantly higher mortality rate (RR=2.529; 95%CI=[1.480, 4.324]; P=0.001) than noncirrhotic patients. Cirrhotic patients tended to yield a lower 5-year survival rate than those noncirrhotic patients after surgical resection of esophageal cancer (RR=0.715; 95%CI=[0.492, 1.039]; P=0.079). In conclusion, liver cirrhosis was significantly correlated with high morbidity and mortality rates. However, there was no sufficient evidence of unfavorable survival in cirrhotic patients. Esophagectomy can be performed for certain esophageal cancer patients with concomitant liver cirrhosis with acceptable operative risks, providing that careful preoperative evaluation and patient selection have been achieved.

Early-Recurrent Overt Hepatic Encephalopathy Is Associated with Reduced Survival in Cirrhotic Patients after Transjugular Intrahepatic Portosystemic Shunt Creation

PurposeTo investigate the role of early overt hepatic encephalopathy (OHE) as a clinical marker of prognosis in cirrhosis with a transjugular intrahepatic portosystemic shunt (TIPS) and to assess the relationship between recurrence of OHE and survival after TIPS. MethodsFrom January 2012 to December 2013, a retrospective study of consecutive patients with cirrhosis and a TIPS was performed at a single institution. A total of 304 patients (196 males; mean age, 52 years) were enrolled during the study period. The mean Model for End-Stage Liver Disease (MELD) score was 11.6. Time-dependent Cox regression was applied to estimate the predictive ability of early OHE (within 3 months after TIPS) and the effect of its frequency on survival. ResultsDuring a median follow-up of 28.3 months, 115 patients experienced OHE after the TIPS procedure; of these, 54 had at least 2 OHE episodes. Long-term survival worsened in patients with early OHE (hazard ratio [HR] = 2.75; 95% confidence interval [CI]: 1.75–4.32; P < .001). When early OHE was further divided into early-recurrent and single OHE, death was more common in patients with early-recurrent OHE (P < .001) than in patients with early-single OHE (P = .24). After adjustment by MELD score, ascites, serum albumin, indication for TIPS, and age, patients with early-recurrent OHE had a lower probability of survival (HR = 2.91; 95% CI: 1.04–4.89; P < .001). Furthermore, landmark and propensity score analyses confirmed the predictive value of early-recurrent OHE. ConclusionsEarly recurrence of OHE was associated with an increased risk of mortality for patients with cirrhosis who underwent TIPS.

Screening for Hepatopulmonary Syndrome in Cirrhotic Patients Using Technetium 99m-macroaggregated Albumin Perfusion Lung Scan (Tc-MAA): Diagnostic Approach and Clinical Correlations.

The aims of this study were to prospectively screen cirrhotic patients with arterial blood gas test and albumin perfusion scan, identify those fulfilling the classic hepatopulmonary syndrome (HPS) criteria, correlate with clinical parameters, and evaluate the survival of patients with HPS compared with those without HPS in a genetically homogenous Cretan cirrhotic population. Data on consecutive 102 patients within 1 year were collected and analyzed. All patients underwent a technetium 99m-macroaggregated albumin perfusion lung scan (Tc-MAA). Diagnosis of HPS was based on the presence of the quantitative index Tc-MAA≥6% and a [P(A-a)O2]≥15 mm Hg (≥20 mm Hg for patients over >64 y). In 94/102 patients, complete scintigraphic data were available. In total, 24 (26%) patients fulfilled the diagnostic criteria of HPS; 95.8% of them had mild-to-moderate HPS. In 8 patients the Tc-MAA scintigraphy could not be interpreted. There was no difference in HPS between decompensated (24.6%) and compensated cirrhosis (27.3%). In the multivariate analysis only the quantitative index was significant for the diagnosis of HPS (P=0.001, odds ratio; 95% confidence interval, 7.05; 2.27-21.87). Kaplan- Meier survival curves indicated a similar overall prognosis for patients diagnosed with HPS (P=0.105). HPS is a frequent complication of cirrhosis. Mild-to-moderate HPS has no significant effect on survival of cirrhotic patients. The quantitative Tc-MAA test is a reliable tool for diagnosis.

Prognostic significance of vitamin D receptor (VDR) gene polymorphisms in liver cirrhosis

Several polymorphisms in the vitamin D receptor (VDR) are associated with the occurrence of chronic liver disease. Here, we investigated the association between BsmI, ApaI, TaqI and FokI VDR polymorphisms and the severity of liver cirrhosis in relation to serum cytokine and lipopolysaccharide binding protein (LBP) levels and their role on survival in cirrhotic patients. We found that patients harboring the BB genotype had higher MELD score, and they were mainly at CP stage C; patients harboring the AA genotype had increased LBP, IL-1β and IL-8 levels, and they were mostly at CP stage C; TT genotype carriers had higher MELD score and they were mainly at CP stage C and FF genotype carriers had lower IL-1β levels when compared to Bb/bb, Aa/aa, Tt/tt and Ff/ff genotypes respectively. In the multivariate analysis ApaI, BsmI and TaqI polymorphisms were independently associated with liver cirrhosis severity. In the survival analysis, the independent prognostic factors were CP score, MELD and the FF genotype. Our results indicate that the ApaI, TaqI and BsmI polymorphisms are associated with the severity of liver cirrhosis, through the immunoregulatory process. Survival is related to the FF genotype of FokI polymorphism, imparting a possible protective role in liver cirrhosis.

Left Ventricular Diastolic Dysfunction is Associated with Renal Dysfunction, Poor Survival and Low Health Related Quality of Life in Cirrhosis

The presence of left ventricular diastolic dysfunction (LVDD) in patients with cirrhosis leads to a restriction of activities and a poor health related quality of life (HRQoL), which should be taken into consideration when treating them for liver and cardiac complications. The prevalence, complications, predictors of HRQoL and survival in cirrhotic patients with LVDD were studied. We report a prospective cohort study of 145 consecutive cirrhotic patients with LVDD who were evaluated for cardiac functional status at enrollment and followed up for hepatic complications, cardiac events, outcome and HRQoL using the Minnesota Living With Heart Failure Questionnaire (MLHFQ) over a period of 2 years. In total, 145 (mean age 61 years, 59% male) patients were included. Seventeen patients died with 10.5%, 22.5% and 40% mortality rates in patients with Grades 1, 2 and 3 LVDD respectively over 24 months. The parameters that were significant for predicting mortality on bivariate analysis were MELD, MELDNa, hepatic venous pressure gradient, MLHFQ, and left ventricular (LV) diastolic function (e' and E/e' ratio), but only MELD, MELDNa and E/e' remained significant on multivariate analysis. The E/e' ratio (8.7±3.3 in survivors vs. 9.1±2.3 in non-survivors) predicted outcome. On univariate analysis, the predictors of poor HRQoL were the Child-Pugh score ≥9.8 (OR 2.6; 95% confidence intervals (CI) 2.3-9.1, P=0.041), MELD score≥15.7 (OR 2.48; 95% CI 1.4-3.9, P=0.029), refractory ascites (OR 1.9; 95% CI 1.1-6.1, P=0.050), and E/e' ratio ≥7.6 (OR 1.9; 95% CI 1.8-7.1, P=0.036) The presence of Class II/III (P=0.046) symptoms of heart failure and MLHFQ≥ 45 (P=0.042) were predictors of mortality at 24 months. The grade of LVDD correlates with liver function, clinical events, risk of renal dysfunction and HRQoL. Evaluation of novel therapies which target symptomatic improvement in LVDD, should be done with suitable outcome measures, including HRQoL assessment.

Evaluation of two nutrition screening tools in predicting malnutrition, sarcopenia and one-year survival In cirrhotic patients

Evaluation of two nutrition screening tools in predicting malnutrition, sarcopenia and one-year survival In cirrhotic patients

Adjusted Intensive Care Infection Score (ICISΔ)—A new approach for prediction of ascitic fluid infection in patients with cirrhosis

BackgroundEarly and accurate diagnosis is the key to improving survival in cirrhotic patients with ascitic fluid infection. AimsTo investigate the usefulness of adjusted Intensive Care Infection Score (ICISΔ) for diagnosis of ascites infection in cirrhotic patients. MethodsCirrhotic patients with ascites (n = 125) were enrolled, and the efficacy of ICIS and ICISΔ for predicting ascites infection was evaluated. ICISΔ was created by using the weighted variation of each ICIS parameter. ResultsThe area under the curves (AUCs) of ICIS for the diagnosis of ascites infection were 0.90 (95% CI: 0.84–0.95), 0.85 (95% CI: 0.79–0.90), and 0.87 (95% CI: 0.81–0.93), for SBP, culture-negative SBP, and combined SBP/culture-negative SBP, respectively. ICIS was optimized and diagnostic accuracy was obviously improved. ICISΔ had high AUCs of 0.99 (95% CI: 0.93–1.00) for SBP, 0.98 (95% CI: 0.83–1.00) for culture-negative SBP, and 0.98 (95% CI: 0.94–1.00) for the combination group. The optimal cutoff was identified as ICISΔ > 2, which had >97.8% sensitivity and 100% specificity for diagnosis of both SBP and culture-negative SBP. The ICISΔ had significantly higher AUCs than PCT and CPR in both groups (P = 0.002–0.008). ICISΔ kinetics could differentiate between SBP and culture-negative SBP patients. From sterile ascites, through culture-negative SBP to SBP, three ICISΔ parameters showed an increasing trend. ConclusionsICIS and ICISΔ are simple, rapid, accurate and cost-effective methods for the diagnosis of ascites infection in cirrhotic patients.

Transjugular intrahepatic portosystemic shunt creation for cirrhotic portal hypertension is well tolerated among patients with portal vein thrombosis.

Portal vein thrombosis (PVT) develops in cirrhotic patients because of stagnation of blood flow. Transjugular intrahepatic portosystemic shunt (TIPS) creates a low-resistance conduit that restores portal venous patency and blood flow. The effect of PVT on transplant-free survival in cirrhotic patients undergoing TIPS creation was evaluated. A multicenter, retrospective cohort study of patients who underwent TIPS creation for cirrhotic portal hypertension was carried out. A Cox model with propensity score adjustment was developed to evaluate the effect of PVT on 90-day and 3-year transplant-free survival. A subgroup analysis examining mortality of those with superior and inferior PVT was also carried out. A total of 252 consecutive TIPS creations were assessed, including 65 in patients with PVT. Survival of patients with high Model for End-stage Liver Disease scores (≥18) and PVT was not statistically different compared with patients with low Model for End-stage Liver Disease scores (<18) and no PVT at 90 days (P=0.46) and 3 years (P=0.42). Those with superior PVT had improved 90-day and 3-year survival both compared with patients with a inferior PVT and those without a PVT (P<0.01, all cases). The presence of PVT does not impair the prognosis of patients following TIPS creation, particularly in patients with superior portal occlusion.

Nonselective Beta-Blockers Do Not Affect Survival in Cirrhotic Patients with Ascites.

The role of nonselective beta-blockers in cirrhotic patients with ascites has been recently questioned; however, definitive evidence in this regard is still lacking. To analyze published data on the influence of nonselective beta-blockers as compared to control group on survival of cirrhotic patients with ascites. Computerized bibliographic search on the main databases was performed. Hazard ratios from Kaplan-Meier curves were extracted in order to perform an unbiased comparison of survival estimates. Secondary outcomes were mortality in patients with refractory ascites, pooled rate of nonselective beta-blockers interruption, spontaneous bacterial peritonitis and hepato-renal syndrome incidence. Three randomized controlled trials and 13 observational studies with 8279 patients were included. Overall survival was comparable between the two groups (hazard ratio = 0.86, 0.71-1.03, p = 0.11). Study design resulted as the main source of heterogeneity in sensitivity analysis and meta-regression. Mortality in refractory ascites patients was similar in the two groups (odds ratio = 0.90, 0.45-1.79; p = 0.76). No difference in spontaneous bacterial peritonitis (odds ratio = 0.78, 0.47-1.29, p = 0.33) and hepato-renal syndrome incidence (odds ratio = 1.22, 0.48-3.09; p = 0.67) was observed. Pooled rate of nonselective beta-blockers interruption was 18.6% (5.2-32.1%). Based on our findings, nonselective beta-blockers should not be routinely withheld in patients with cirrhosis and ascites, even if refractory.

Early-TIPS improves survival in cirrhotic patients with high-risk varical bleeding: Results of a China multicenter observational study

Early-TIPS improves survival in cirrhotic patients with high-risk varical bleeding: Results of a China multicenter observational study

SAT-219 - High-dose but not low-dose enoxaparin substantially improves survival in cirrhotic patients with portal vein thrombosis

SAT-219 - High-dose but not low-dose enoxaparin substantially improves survival in cirrhotic patients with portal vein thrombosis

Impact of spider nevus and subcutaneous collateral vessel of chest/abdominal wall on outcomes of liver cirrhosis.

IntroductionSpider nevus and subcutaneous collateral vessel of the chest/abdominal wall are common in liver cirrhosis. This prospective study aimed to evaluate the impact of spider nevus and subcutaneous collateral vessel of the chest/abdominal wall on the outcomes of cirrhotic patients.Material and methodsWe prospectively enrolled patients with a diagnosis of liver cirrhosis consecutively admitted to our department. We recorded the number and location of spider nevi and subcutaneous collateral vessels of the chest/abdominal wall. Clinical profiles and survival were compared according to the presence of spider nevus and subcutaneous collateral vessel of the chest/abdominal wall. The study was registered (NCT02468479).ResultsOverall, 198 patients were enrolled between June 2015 and May 2016. The median follow-up duration was 350 days. The prevalence of spider nevus and subcutaneous collateral vessel of the chest/abdominal wall was 47% and 29.8%, respectively. Patients with spider nevi had a significantly higher proportion of alcohol abuse (54.84% vs. 26.67%, p < 0.001). Both spider nevus and subcutaneous collateral vessel of the chest/abdominal wall were significantly associated with higher Child-Pugh (8.35 ±2.19 vs. 7.47 ±1.91, p = 0.005; 8.57 ±2.20 vs. 7.60 ±1.98, p = 0.002) and MELD scores (9.91 ±6.41 vs. 7.43 ±5.40, p = 0.008; 10.77 ±6.76 vs. 7.68 ±5.42, p = 0.003). The cumulative survival was not significantly different between patients with and without spider nevi of the chest/abdominal wall (p = 0.951). Patients with subcutaneous collateral vessels of the chest/abdominal wall had significantly worse cumulative survival (p = 0.018).ConclusionsPresence of spider nevus and subcutaneous collateral vessel of the chest/abdominal wall indicated more severe liver dysfunction. Subcutaneous collateral vessel of the chest/abdominal wall should be a simple and important predictor for the overall survival of cirrhotic patients.

4:12 PM Abstract No. 290 Changes in kidney function and model of end-stage liver disease score in diabetic patients undergoing the transjugular intrahepatic portosystemic shunt procedure

Diabetes is an important comorbidity present in up to 30% of patients with liver cirrhosis. The purpose of our study was to determine the impact of diabetes on the renal function and survival after transjugular intrahepatic portosystemic shunt (TIPS) procedure. We reviewed the medical records of 387 patients who had successful TIPS between September 2004 and September 2016. The patients were divided into two groups; group A (diabetics, n = 186) and group B (non-diabetics, n = 201). The glomerular filtration rate (GFR) and model for end-stage liver disease (MELD) score before and within 1 month after TIPS placement were recorded in each group. A threshold GFR and MELD score associated with mortality was estimated in each group. The study included 261 (62%) males, 373 (88%) whites, and 186 (45%) diabetics, with an average age of 59 (SD = 9.7) for diabetics and 54.7 (SD = 9.6) for non-diabetics. Before TIPS, there was a statistically significant difference between diabetics and non-diabetics in mean GFR (63.3 versus 80.9 respectively, p<0.0001) and in MELD score (13.3 versus 12.3 respectively, p = 0.0123). In spite of the significant change in MELD score after TIPS in diabetics and non-diabetics (p<0.0001), there was no significant change in the GFR after TIPS in either diabetics (p = 0.3345) or non-diabetics (p = 0.5065). Lower pre-TIPS GFR was significantly associated with mortality in diabetics [HR = 0.989,CI (0.98-0.99),p = 0.039), while higher pre-TIPS MELD score was associated with mortality in both diabetics [HR = 1.07,CI (1.00-1.14),p = 0.0398] and non-diabetics [HR = 1.08,CI (1.03-1.14),p = 0.001]. The threshold of pre-TIPS GFR and MELD score in discriminating survival in diabetics was 54 (p = 0.039) and 12 (p = 0.0398). Non-diabetic status was a significant contributor to survival [HR = 0.74,CI (0.55-0.99),p = 0.043]. TIPS does not significantly change the GFR in diabetics. However, pre-TIPS lower GFR and higher MELD score were associated with mortality after TIPS in diabetic patients. The best survival outcome was seen in patients with GFR > 54 and MELD < 12, and the absence of diabetes was a significant contributor to survival in cirrhotic patients undergoing TIPS.

EPTFE‐TIPS vs repetitive LVP plus albumin for the treatment of refractory ascites in patients with cirrhosis

Reduction in portal pressure by self-expandable polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunts (TIPS) is a treatment option for refractory ascites. Data on clinical outcomes after ePTFE-TIPS vs repetitive large-volume paracentesis (LVP) plus albumin (A) administration for the treatment of patients with refractory ascites are limited. Retrospective comparison of ePTFE-TIPS vs LVP+A in terms of (i) control of ascites, (ii) occurrence of overt hepatic encephalopathy (HE) and (iii) transplant-free survival in cirrhotic patients with refractory ascites. Among n=221 patients with cirrhosis and refractory ascites, n=140 received ePTFE-TIPS and were compared to n=71 patients undergoing repetitive LVP+A. After ePTFE-TIPS, ascites was controlled without any further need for paracentesis in n=76 (54%; n=7 without and n=69 with diuretics). The need for frequent large-volume paracentesis was significantly higher in the LVP+A group than with ePTFE-TIPS (median 0.67 (IQR: 0.23-2.63) months vs 49.5 (IQR: 5.07-102.60) months until paracentesis, log-rank P<.001). De-novo incidence of HE was similar in ePTFE-TIPS and LVP+A patients (log-rank P=.361). Implantation of ePTFE-TIPS was associated with improved 1-year survival as compared to LVP+A (65.6% vs 48.4%, log-rank P=.033). Age (odds ratio (OR):1.05; 95% confidence interval (95% CI):1.03-1.07; P<.001), serum albumin (OR: 0.95; 95% CI: 0.92-0.99; P=.013) and hepatocellular carcinoma (OR: 1.66; 95% CI: 1.06-2.58; P=.026) emerged as independent predictors of survival. ePTFE-TIPS results in superior control of ascites without increasing the risk for overt HE as compared to LVP+A. Although ePTFE-TIPS improved 1-year survival in cirrhotic patients with refractory ascites, its use was not independently associated with transplant-free survival.

Duration of the acute hepatic encephalopathy episode determines survival in cirrhotic patients.

Background:Episodes of hepatic encephalopathy (HE) have been related to low survival rate. However, the relation between its clinical evolution and mortality has not been assessed.Methods:A retrospective analysis of 245 cirrhotic patients admitted for an acute episode of HE (⩾grade 2) or who developed an HE episode after an upper gastrointestinal bleeding (UGIB) event was performed to assess the relation between time in HE and transplant-free survival.Results:Median (IQR25–75) time in HE was 48 h (24–96 h) in the whole cohort. Patients who presented a longer time in HE (>48 h; n = 89) exhibited a lower transplant-free survival at 28 days (67.2% versus 88.9%, p < 0.001), 90 days (48.7% versus 73.8%, p < 0.001) and 365 days (30.3% versus 53.2%, p < 0.001), as compared to those with less time in HE (⩽48 h; n = 156). Survival rates remained significantly different, with lower percentages in the group with time in HE >48 h, when comparing patients according to baseline HE grade (2 versus ⩾3) or model for end-stage liver disease (MELD) function (⩽15 versus >15). Time in HE was also an independent risk factor for mortality at each time point, hazard ratio (HR) (95 CI%) 28 days 2.59 (1.39–4.84); 90 days 1.98 (1.28–3.1) and 365 days 1.5 (1.08–2.19).Conclusions:The duration of the acute HE episode determines survival in cirrhotic patients independently of liver function and baseline HE grade.

Von Willebrand factor and alkaline phosphatase predict re-transplantation-free survival after the first liver transplantation.

After liver transplantation (LT), there are liver-related, infectious and cardiovascular complications that contribute to reduced graft survival. These conditions are associated with an increase in the Von Willebrand factor antigen (VWF-Ag), which was previously correlated with survival in cirrhotic patients. Evaluate VWF-Ag as a predictive marker of re-transplantation-free survival in patients after LT. We measured VWF-Ag in patients after first LT and then followed them prospectively with regard to the primary endpoint, namely re-transplantation-free survival. There were 6 out of 80 patients who died or received re-LT during follow-up. In these patients, the median VWF-Ag was 510.6%, which was significantly higher (p = 0.001) than in the patients who were alive at the end of follow-up (with a median VWF-Ag = 186.8%). At a cut-off of 286.8%, VWF-Ag was significantly correlated with re-transplantation-free survival (p < 0.001). VWF-Ag was independently associated with re-transplantation-free survival in a multivariate analysis; as was alkaline phosphatase (ALP), but not the model of end-stage liver disease (MELD) score, donor age, nor cold ischemia time. A score combining VWF-Ag and ALP showed an impressive capability in the receiver operating characteristic (ROC) analysis (with area under the curve (AUC) = 0.958) to distinguish between patients with regard to the primary endpoint. VWF-Ag is a non-invasive marker that can predict outcome in patients after LT. Its diagnostic performance increased when combined with ALP in a newly developed scoring system.