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Rodríguez-Jacobo S, Jiménez-Castillo RA, Cortez-Hernández CA, Jaquez-Quintana JO, González-González JA, Maldonado-Garza HJ. MELD-Lactate as a predictor of in-hospital mortality in patients with variceal gastrointestinal bleeding. GASTROENTEROLOGIA Y HEPATOLOGIA 2025:502369. [PMID: 39892504 DOI: 10.1016/j.gastrohep.2025.502369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Revised: 01/20/2025] [Accepted: 01/28/2025] [Indexed: 02/03/2025]
Abstract
INTRODUCTION Variceal upper gastrointestinal bleeding is a common cause of decompensation in patients with liver cirrhosis. While mortality data, which are from 10 to 15%, are available, there are no validated scales to predict in-hospital mortality in this patient population. OBJECTIVE To determine whether the MELD-Lactate (MELD-LA) level is associated with in-hospital mortality in patients with chronic liver disease who are admitted for variceal bleeding. MATERIAL AND METHODS A prospective, observational, and analytical study was conducted that included 120 patients. The MELD-LA cut-off point was obtained, and in-hospital mortality was obtained using conventional prognostic scales that had the highest sensitivity and specificity for comparison purposes. Additionally, a survival analysis was performed using the MELD-LA cut-off point obtained. RESULTS In our cohort, 6 (5.0%) patients died during hospitalization. Patients who died had a mean MELD-LA value of 20.0 (±4.97) as opposed to those who did not die, 13.62 (±3.29), (p<0.001). The MELD-LA cut-off point of >14.0, with a sensitivity of 100%, a specificity of 71.0%, a positive predictive value of 15.4%, a negative predictive value of 100.0%, and an AUC (area under the curve) of 0.886, was most well correlated with higher in-hospital mortality. Survival was 71.1% in patients with MELD-LA levels>14.0 versus 100.0% in those with lower levels (p=0.001) during hospitalization. CONCLUSION The measurement of MELD-LA at admission seems to be a good complementary marker for the evaluation and prognosis of in-hospital mortality in patients with liver cirrhosis, and variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Sofía Rodríguez-Jacobo
- Gastroenterology Department, School of Medicine, and Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey N.L., Mexico
| | - Raúl A Jiménez-Castillo
- Gastroenterology Department, School of Medicine, and Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey N.L., Mexico
| | - Carlos A Cortez-Hernández
- Gastroenterology Department, School of Medicine, and Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey N.L., Mexico.
| | - Joel O Jaquez-Quintana
- Gastroenterology Department, School of Medicine, and Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey N.L., Mexico
| | - José A González-González
- Gastroenterology Department, School of Medicine, and Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey N.L., Mexico
| | - Héctor J Maldonado-Garza
- Gastroenterology Department, School of Medicine, and Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey N.L., Mexico
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He Y, Romeiro FG, Sun M, Ji F, Zhu Q, He Y, Ma D, Yuan S, Liu X, Philips CA, Basaranoglu M, Méndez-Sánchez N, Pinyopornpanish K, Li Y, Wu Y, Yang L, Shao L, Mancuso A, Chen Y, Tacke F, Lin S, Liu L, Li B, Qi X. Impact of thrombocytopenia on failure of endoscopic variceal treatment in cirrhotic patients with acute variceal bleeding. Therap Adv Gastroenterol 2025; 18:17562848241306934. [PMID: 39758964 PMCID: PMC11700413 DOI: 10.1177/17562848241306934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Accepted: 11/27/2024] [Indexed: 01/07/2025] Open
Abstract
Background Acute variceal bleeding (AVB), a life-threatening complication of liver cirrhosis, can be effectively treated by endoscopy, but there is a risk of early rebleeding after endoscopic variceal treatment (EVT). Thrombocytopenia is the most common hemostatic abnormality in liver cirrhosis. However, it is still unclear about whether thrombocytopenia increases the failure of EVT in cirrhotic patients with AVB. Objectives We investigated the association between thrombocytopenia and the failure of EVT in cirrhotic patients with AVB. Design International multicenter, retrospective study. Methods Overall, 2467 cirrhotic patients with acute gastrointestinal bleeding who were enrolled into an international multicenter study between September 30, 2020 and June 30, 2023 were retrospectively screened. Thrombocytopenia was defined as platelet count below 150 × 109/L and further classified as mild (100 × 109/L-150 × 109/L), moderate (50 × 109/L-100 × 109/L), and severe (<50 × 109/L). A 1:1 propensity score matching (PSM) analysis was performed. Five-day failure to control bleeding was evaluated. Results Overall, 1079 patients were included, of whom 923 (85.5%) had thrombocytopenia, including mild (n = 241), moderate (n = 445), and severe (n = 237) thrombocytopenia. PSM analysis demonstrated that the rate of 5-day failure to control bleeding was not significantly different between patients with and without thrombocytopenia (mild: (12/153) 7.8% vs (7/153) 4.6%, p = 0.236; moderate: (9/155) 5.8% vs (7/155) 4.5%, p = 0.608; or severe: (5/132) 3.8% vs (7/132) 5.3%, p = 0.555). Conclusion Thrombocytopenia may not influence the efficacy of EVT in cirrhotic patients with AVB.
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Affiliation(s)
- Yan He
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of China Medical University), Shenyang, China
| | | | - Mingyu Sun
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fanpu Ji
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Qiang Zhu
- Department of Infectious Disease, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Yingli He
- Department of Infectious Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Dapeng Ma
- Department of Critical Care Medicine, The Sixth People’s Hospital of Dalian, Dalian, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi’an Central Hospital, Xi’an, China
| | - Xiaofeng Liu
- Department of Gastroenterology, The 960th Hospital of Chinese PLA, Jinan, Shandong, China
| | - Cyriac Abby Philips
- Department of Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Kerala, India
| | - Metin Basaranoglu
- Gastroenterology and Hepatology, Bezmialem Vakif University, Istanbul, Turkey
| | - Nahum Méndez-Sánchez
- Medica Sur Clinic, National Autonomous University of Mexico, Mexico City, Mexico
| | - Kanokwan Pinyopornpanish
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Yiling Li
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, China
| | - Yunhai Wu
- Department of Critical Care Medicine, The Sixth People’s Hospital of Shenyang, Shenyang, China
| | - Ling Yang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force Hospital of Northern Theater Command, Shenyang, China
| | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Yu Chen
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You’an Hospital Affiliated to Capital Medical University, Beijing, China
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité—Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Su Lin
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Road, Fuzhou 350000, Fujian, Chin
| | - Lei Liu
- Department of Infectious Diseases, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi’an 710000, Shaanxi, China
| | - Bimin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zheng Street, Donghu District, Nanchang 330006, Jiangxi, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of China Medical University), No. 83 Wenhua Road, Shenyang 110840, Liaoning Province, China
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Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Centre for Liver and Digestive Diseases (CIBERehd). GASTROENTEROLOGIA Y HEPATOLOGIA 2025; 48:502208. [PMID: 39756832 DOI: 10.1016/j.gastrohep.2024.502208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 01/07/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of CSPH and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
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Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Universidad Complutense, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, España.
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4
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Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd). REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2025; 117:14-57. [PMID: 39350672 DOI: 10.17235/reed.2024.10805/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
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Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, España
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic. Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
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Elkrief L, Hernandez-Gea V, Senzolo M, Albillos A, Baiges A, Berzigotti A, Bureau C, Murad SD, De Gottardi A, Durand F, Garcia-Pagan JC, Lisman T, Mandorfer M, McLin V, Moga L, Nery F, Northup P, Nuzzo A, Paradis V, Patch D, Payancé A, Plaforet V, Plessier A, Poisson J, Roberts L, Salem R, Sarin S, Shukla A, Toso C, Tripathi D, Valla D, Ronot M, Rautou PE. Portal vein thrombosis: diagnosis, management, and endpoints for future clinical studies. Lancet Gastroenterol Hepatol 2024; 9:859-883. [PMID: 38996577 DOI: 10.1016/s2468-1253(24)00155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/27/2024] [Accepted: 05/08/2024] [Indexed: 07/14/2024]
Abstract
Portal vein thrombosis (PVT) refers to the development of a non-malignant obstruction of the portal vein, its branches, its radicles, or a combination. This Review first provides a comprehensive overview of all aspects of PVT, namely the specifics of the portal venous system, the risk factors for PVT, the pathophysiology of portal hypertension in PVT, the interest in non-invasive tests, as well as therapeutic approaches including the effect of treating risk factors for PVT or cause of cirrhosis, anticoagulation, portal vein recanalisation by interventional radiology, and prevention and management of variceal bleeding in patients with PVT. Specific issues are also addressed including portal cholangiopathy, mesenteric ischaemia and intestinal necrosis, quality of life, fertility, contraception and pregnancy, and PVT in children. This Review will then present endpoints for future clinical studies in PVT, both in patients with and without cirrhosis, agreed by a large panel of experts through a Delphi consensus process. These endpoints include classification of portal vein thrombus extension, classification of PVT evolution, timing of assessment of PVT, and global endpoints for studies on PVT including clinical outcomes. These endpoints will help homogenise studies on PVT and thus facilitate reporting, comparison between studies, and validation of future studies and trials on PVT.
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Affiliation(s)
- Laure Elkrief
- Faculté de médecine de Tours, et service d'hépato-gastroentérologie, Le Centre Hospitalier Régional Universitaire de Tours, Tours, France; Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Agustin Albillos
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departamento de Gastroenterología y Hepatología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Christophe Bureau
- Service d'Hépatologie Hôpital Rangueil, Université Paul Sabatier, Toulouse, France
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Andrea De Gottardi
- Gastroenterology and Hepatology Department, Ente Ospedaliero Cantonale Faculty of Biomedical Sciences of Università della Svizzera Italiana, Lugano, Switzerland
| | - François Durand
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Juan-Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Ton Lisman
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valérie McLin
- Swiss Pediatric Liver Center, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Lucile Moga
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Filipe Nery
- Immuno-Physiology and Pharmacology Department, School of Medicine and Biomedical Sciences, University of Porto, Portugal
| | - Patrick Northup
- Transplant Institute and Division of Gastroenterology, NYU Langone, New York, NY, USA
| | - Alexandre Nuzzo
- Intestinal Stroke Center, Department of Gastroenterology, IBD and Intestinal Failure, AP-HP Hôpital Beaujon, Clichy, France; Laboratory for Vascular and Translational Science, INSERM UMR 1148, Paris, France
| | - Valérie Paradis
- Department of Pathology, AP-HP Hôpital Beaujon, Clichy, France
| | - David Patch
- Department of Hepatology and Liver Transplantation, Royal Free Hospital, London, UK
| | - Audrey Payancé
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | | | - Aurélie Plessier
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Johanne Poisson
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service de Gériatrie, Hôpital Corentin Celton (AP-HP), Paris, France
| | - Lara Roberts
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Riad Salem
- Northwestern Memorial Hospital, Northwestern University, Chicago, IL, USA
| | - Shiv Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Christian Toso
- Service de Chirurgie Viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Dhiraj Tripathi
- Department of Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Dominique Valla
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Maxime Ronot
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service de Radiologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Pierre-Emmanuel Rautou
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France.
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Dong Y, Xu H, Zhang Z, Zhou Z, Zhao G, Cao H, Xiao S. A Novel Nomogram for Predicting Early Rebleeding After Endoscopic Treatment of Esophagogastric Variceal Hemorrhage. Dig Dis Sci 2024; 69:1852-1862. [PMID: 38514499 DOI: 10.1007/s10620-024-08382-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Early rebleeding is a significant complication of endoscopic treatment for esophagogastric variceal hemorrhage (EGVH). However, a reliable predictive model is currently lacking. AIMS To identify risk factors for rebleeding within 6 weeks and establish a nomogram for predicting early rebleeding after endoscopic treatment of EVGH. METHODS Demographic information, comorbidities, preoperative evaluation, endoscopic features, and laboratory tests were collected from 119 patients who were first endoscopic treatment for EGVH. Independent risk factors for early rebleeding were determined through least absolute shrinkage and selection operator logistic regression. The discrimination, calibration, and clinical utility of the nomogram were assessed and compared with the model for end-stage liver disease (MELD), Child-Pugh, and albumin-bilirubin (ALBI) scores using receiver-operating characteristic (ROC) curves, calibration plots, and decision curve analyses (DCA). RESULTS Early rebleeding occurred in 39 patients (32.8%) within 6 weeks after endoscopic treatment. Independent early rebleeding factors included gastric variceal hemorrhage (GVH), concomitant hepatocellular carcinoma (HCC), international normalized ratio (INR), and creatinine. The nomogram demonstrated exceptional calibration and discrimination capability. The area under the curve for the nomogram was 0.758 (95% CI 0.668-0.848), and it was validated at 0.71 through cross-validation and bootstrapping validation. The DCA and ROC curves demonstrated that the nomogram outperformed the MELD, Child-Pugh, and ALBI scores. CONCLUSIONS Compared with existing prediction scores, the nomogram demonstrated superior discrimination, calibration, and clinical applicability for predicting rebleeding in patients with EGVH after endoscopic treatment. Therefore, it may assist clinicians in the early implementation of aggressive treatment and follow-up.
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Affiliation(s)
- Yongqi Dong
- Department of Gastroenterology, Wushan County People's Hospital of Chongqing, No.168, Guangdongxi Road, Wushan County, Chongqing, 404700, People's Republic of China
| | - Hongyan Xu
- Department of Infectious Diseases, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Zhihuan Zhang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Zhihang Zhou
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Gang Zhao
- Department of Gastroenterology, Wushan County People's Hospital of Chongqing, No.168, Guangdongxi Road, Wushan County, Chongqing, 404700, People's Republic of China
| | - Haiyan Cao
- Department of Gastroenterology, Chengdu Second People's Hospital, NO.10, Yunnan Road, Chengdu, 610017, People's Republic of China
| | - Shiyong Xiao
- Department of Clinical Nutrition, Wushan County People's Hospital of Chongqing, No.168, Guangdongxi Road, Wushan County, Chongqing, 404700, People's Republic of China.
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Patel VC, McPhail MJ, Uddin R, Jafari H, Lawrence V, Le Boutillier C, Shearer J, Yaziji N, Cape A, Ahmed H, Ward C, Walsh P, Besly K, Zamalloa A, Kelly J, Carter B. Beta-blockers or Placebo for Primary Prophylaxis (BOPPP) of oesophageal varices: study protocol for a randomised controlled trial. Trials 2024; 25:265. [PMID: 38627804 PMCID: PMC11022376 DOI: 10.1186/s13063-024-08063-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Liver disease is within the top five causes of premature death in adults. Deaths caused by complications of cirrhosis continue to rise, whilst deaths related to other non-liver disease areas are declining. Portal hypertension is the primary sequelae of cirrhosis and is associated with the development of variceal haemorrhage, ascites, hepatic encephalopathy and infection, collectively termed hepatic decompensation, which leads to hospitalisation and mortality. It remains uncertain whether administering a non-selective beta-blocker (NSBB), specifically carvedilol, at an earlier stage, i.e. when oesophageal varices are small, can prevent VH and reduce all-cause decompensation (ACD). METHODS/DESIGN The BOPPP trial is a pragmatic, multicentre, placebo-controlled, triple-blinded, randomised controlled trial (RCT) in England, Scotland, Wales and Northern Ireland. Patients aged 18 years or older with cirrhosis and small oesophageal varices that have never bled will be recruited, subject to exclusion criteria. The trial aims to enrol 740 patients across 55 hospitals in the UK. Patients are allocated randomly on a 1:1 ratio to receive either carvedilol 6.25 mg (a NSBB) or a matched placebo, once or twice daily, for 36 months, to attain adequate power to determine the effectiveness of carvedilol in preventing or reducing ACD. The primary outcome is the time to first decompensating event. It is a composite primary outcome made up of variceal haemorrhage (VH, new or worsening ascites, new or worsening hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, an increase in Child-Pugh grade by 1 grade or MELD score by 5 points, and liver-related mortality. Secondary outcomes include progression to medium or large oesophageal varices, development of gastric, duodenal, or ectopic varices, participant quality of life, healthcare costs and transplant-free survival. DISCUSSION The BOPPP trial aims to investigate the clinical and cost-effectiveness of carvedilol in patients with cirrhosis and small oesophageal varices to determine whether this non-selective beta-blocker can prevent or reduce hepatic decompensation. There is clinical equipoise on whether intervening in cirrhosis, at an earlier stage of portal hypertension, with NSBB therapy is beneficial. Should the trial yield a positive result, we anticipate that the administration and use of carvedilol will become widespread with pathways developed to standardise the administration of the medication in primary care. ETHICS AND DISSEMINATION The trial has been approved by the National Health Service (NHS) Research Ethics Committee (REC) (reference number: 19/YH/0015). The results of the trial will be submitted for publication in a peer-reviewed scientific journal. Participants will be informed of the results via the BOPPP website ( www.boppp-trial.org ) and partners in the British Liver Trust (BLT) organisation. TRIAL REGISTRATION EUDRACT reference number: 2018-002509-78. ISRCTN reference number: ISRCTN10324656. Registered on April 24 2019.
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Affiliation(s)
- Vishal C Patel
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK.
- Institute of Liver Studies, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King's College London, London, UK.
- The Roger Williams Institute of Hepatology, Foundation for Liver Research, 111 Coldharbour Lane, London, SE5 9NT, UK.
| | - Mark J McPhail
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
- Institute of Liver Studies, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Ruhama Uddin
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Hassan Jafari
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Vanessa Lawrence
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Clair Le Boutillier
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Division of Methodologies, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - James Shearer
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nahel Yaziji
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Angela Cape
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Haroon Ahmed
- Cardiff University, Division of Population Medicine, Cardiff, UK
| | | | - Peter Walsh
- British Liver Trust, Venta Court, Winchester, UK
| | - Kevin Besly
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Ane Zamalloa
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
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8
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Vaishnav M, Biswas S, Shenoy A, Pathak P, Anand A, Swaroop S, Aggrawal A, Arora U, Elhence A, Jagannath S, Gunjan D, Kedia S, Mishra AK, Gamanagatti S, Nayak B, Garg P, Shalimar. Comparison of 1-day versus 3-day intravenous terlipressin in cirrhosis patients with variceal bleeding: A pilot randomised controlled trial. Aliment Pharmacol Ther 2024; 59:645-655. [PMID: 38186012 DOI: 10.1111/apt.17868] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/18/2023] [Accepted: 12/24/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND In cirrhosis patients with acute variceal bleeding (AVB), the optimal duration of vasoconstrictor therapy after endoscopic haemostasis is unclear. AIMS We aimed to compare efficacy of 1-day versus 3-day terlipressin therapy in cirrhosis patients with AVB post-endoscopic intervention. The primary objective was to compare rebleeding at 5 days between the two arms. Secondary objectives included rebleeding and mortality rates at 6 weeks. METHODS In this open-label, randomised controlled trial, cirrhosis patients with AVB were randomised to either 1-day or 3-day terlipressin therapy. RESULTS A total of 150 cirrhosis patients with AVB were recruited to receive either 1 day (n = 75) or 3 days (n = 75) of terlipressin therapy. One patient from 1-day arm was excluded. Modified intention-to-treat analysis included 149 patients. Baseline characteristics were comparable between the two groups. Rebleeding at 5 days: 3 (4.1%; 95% confidence interval [CI]: 0.4-9.0) versus 4 (5.3%; 95% CI: 2.0-10.0), risk difference (RD) p = 0.726 and 5-day mortality rates: 1 (1.4%; 95% CI: 0-7.3) versus 1 (1.3%; 95% CI: 0.2-7.0), RD p = 0.960 were similar. Rebleeding at 42 days: 9 (12.2%; 95% CI: 7.0-20.0) versus 10 (13.3%; 95% CI: 7.0-20.0), RD p = 0.842 and mortality at 42 days: 5 (6.8%; 95% CI: 3.0-10.0) versus 4 (5.3%; 95% CI: 2.0-10.0), RD p = 0.704 were also similar. Patients in the 1-day terlipressin therapy arm experienced significantly fewer adverse effects compared with those receiving 3 days of terlipressin therapy: 28 (37.8%) versus 42 (56%), p = 0.026. CONCLUSIONS Our results suggest that 1 day of terlipressin therapy is associated with similar 5-day and 42-day rebleeding rates, 42-day mortality and an overall superior safety profile compared with 3-day of terlipressin therapy. These findings require to be validated in double-blinded, larger, multiethnic and multicentre studies across the various stages of cirrhosis (CTRI/2019/10/021771).
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Affiliation(s)
- Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Piyush Pathak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhinav Anand
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Arnav Aggrawal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Soumya Jagannath
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ashwani Kumar Mishra
- National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences, Delhi, India
| | | | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Pramod Garg
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
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9
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Lv Y, Bai W, Zhu X, Xue H, Zhao J, Zhuge Y, Sun J, Zhang C, Ding P, Jiang Z, Zhu X, Ren W, Li Y, Zhang K, Zhang W, Li K, Wang Z, Luo B, Li X, Yang Z, Guo W, Xia D, Xie H, Pan Y, Yin Z, Fan D, Han G. Development and validation of a prognostic score to identify the optimal candidate for preemptive TIPS in patients with cirrhosis and acute variceal bleeding. Hepatology 2024; 79:118-134. [PMID: 37594323 DOI: 10.1097/hep.0000000000000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 06/12/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND AND AIM Baveno VII workshop recommends the use of preemptive TIPS (p-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) at high- risk of treatment failure. However, the criteria defining "high-risk" have low clinical accessibility or include subjective variables. We aimed to develop and externally validate a model for better identification of p-TIPS candidates. APPROACH AND RESULTS The derivation cohort included 1554 patients with cirrhosis and AVB who were treated with endoscopy plus drug (n = 1264) or p-TIPS (n = 290) from 12 hospitals in China between 2010 and 2017. We first used competing risk regression to develop a score for predicting 6-week and 1-year mortality in patients treated with endoscopy plus drugs, which included age, albumin, bilirubin, international normalized ratio, white blood cell, creatinine, and sodium. The score was internally validated with the bootstrap method, which showed good discrimination (6 wk/1 y concordance-index: 0.766/0.740) and calibration, and outperformed other currently available models. In the second stage, the developed score was combined with treatment and their interaction term to predicate the treatment effect of p-TIPS (mortality risk difference between treatment groups) in the whole derivation cohort. The estimated treatment effect of p-TIPS varied substantially among patients. The prediction model had good discriminative ability (6 wk/1 y c -for-benefit: 0.696/0.665) and was well calibrated. These results were confirmed in the validation dataset of 445 patients with cirrhosis with AVB from 6 hospitals in China between 2017 and 2019 (6-wk/1-y c-for-benefit: 0.675/0.672). CONCLUSIONS We developed and validated a clinical prediction model that can help to identify individuals who will benefit from p-TIPS, which may guide clinical decision-making.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Junhui Sun
- Hepatobiliary and Pancreatic Intervention Center, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zaibo Jiang
- Department of interventional Radiology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoli Zhu
- Department of interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Li
- Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kewei Zhang
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Huahong Xie
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
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10
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Cao J, Yao Z, Huo G, Liu Z, Tang Y, Huang J, Chen M, Ding R, Shen L, Zhou D. Analysis of transjugular intrahepatic portosystemic shunt by hemodynamic simulation. Biomed Mater Eng 2024; 35:27-37. [PMID: 37482973 DOI: 10.3233/bme-230020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS), which artificially creates a portocaval shunt to reduce portal venous pressure, has gradually become the primary treatment for portal hypertension (PH). However, there is no prefect shunting scheme in TIPS to balance the occurrence of postoperative complications and effective haemostasis. OBJECTIVE To construct cirrhotic PH models and compare different shunting schemes in TIPS. METHODS Three cases of cirrhotic PH with different liver volumes were selected for enhanced computed tomography scanning. The models for different shunting schemes were created using Mimics software, and following FLUENT calculation, all the models were imported into the software computational fluid dynamic-post for processing. In each shunting scheme, the differences in portal vein pressure, hepatic blood perfusion and blood flow from the superior mesenteric vein in the shunt tract were compared. The coefficient G was adapted to evaluate the advantages and disadvantages. RESULTS (1) Concerning the precise location of the shunt tract, the wider the diameter of the shunt tract, the lower the pressure of the portal vein and the lesser the hepatic blood perfusion. Meanwhile, the pressure drop objective was not achieved with the 6 mm-diameter shunting scheme. (2) The 8 mm-diameter shunting scheme through the left portal vein (LPV) had the highest coefficient G. CONCLUSION The 8 mm-diameter shunting scheme through the LPV may demonstrate a superior effect and prognosis in TIPS procedures.
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Affiliation(s)
- Junjie Cao
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Zhichao Yao
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Guijun Huo
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Zhanao Liu
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Yao Tang
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Jian Huang
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Minxin Chen
- Department of Mathematics, Soochow University, Suzhou, China
| | - Rui Ding
- Department of Mathematics, Soochow University, Suzhou, China
| | - Liming Shen
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Dayong Zhou
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
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11
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Lv Y, Bai W, Zhu X, Xue H, Zhao J, Zhuge Y, Sun J, Zhang C, Ding P, Jiang Z, Zhu X, Ren W, LiZhang YK, Zhang W, Li K, Wang Z, Luo B, Li X, Yuan J, Yang Z, Guo W, Xia D, Xie H, Yang C, Pan Y, Yin Z, Fan D, Han G. Association of nonmalignant portal vein thrombosis and clinical outcomes in patients with cirrhosis and acute variceal bleeding: a multicenter observational study. Hepatol Int 2023; 17:1192-1204. [PMID: 37258989 DOI: 10.1007/s12072-023-10493-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/20/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND AIM Baveno VII workshop recommends management of acute variceal bleeding (AVB) in cirrhotic patients with nonmalignant portal vein thrombosis (PVT) should be performed according to the guidelines for patients without PVT. Nevertheless, whether PVT affects the outcome of patients with cirrhosis and AVB remains unclear. The aim of this study was to assess the clinical impact of PVT on the outcomes in the pre-emptive TIPSS eligible patients with cirrhosis and AVB. METHODS From December 2010 to June 2016, 1219 consecutive cirrhotic patients admitted due to AVB with (n = 151; 12.4%) or without PVT (n = 1068; 87.6%), who received drug plus endoscopic treatment (a combination of vasoactive drugs, antibiotics, and endoscopic ligation for AVB, followed by beta-blockers plus variceal ligation for prevention of rebleeding) were retrospectively included. Fine and Gray competing risk regression models were taken to evaluate the impact of PVT on clinical outcomes after adjusting for potential confounders. RESULTS During follow-up, 211 patients (17.3%) died, 490 (40.2%) experienced further bleeding, and 78 (6.4%) experienced new or worsening ascites within 1 year. Compared with those without PVT, patients with PVT had a similar risk of mortality (PVT vs no-PVT: 19.9% vs 16.7% at 1 year; adjusted HR 0.88, 95%CI 0.51-1.52, p = 0.653), further bleeding (47.0% vs 39.2% at 1 year, adjusted HR 1.19, 95% CI 0.92-1.53, p = 183), and new or worsening ascites (7.9% vs 9.6%, adjusted HR 0.70, 95% CI 0.39-1.28, p = 0.253) after adjusting for confounders in multivariable models. These findings were consistent across different relevant subgroups and confirmed by propensity score matching analysis. CONCLUSIONS Our study showed no evidence that the PVT was associated with an improved or worsened outcome among cirrhotic patients with AVB who received standard treatment.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Junhui Sun
- Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Hepatobiliary and Pancreatic Intervention Center, Zhejiang University, Hangzhou, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zaibo Jiang
- Department of Interventional Radiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaoli Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Kewei LiZhang
- Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Huahong Xie
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Changbing Yang
- Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China.
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Abstract
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.
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Affiliation(s)
- Mahathi Avadhanam
- Department of Emergency Medicine, Queen Elizabeth hospital, London, UK
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Gachibowli, Hyderabad, India-500032.
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13
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Muacevic A, Adler JR, Awan SA, Shaikh AJ, Abbasi AA. Effectiveness of Proton Pump Inhibitor Therapy in the Prevention of Bleeding After Prophylactic Endoscopic Variceal Band Ligation. Cureus 2023; 15:e33932. [PMID: 36819375 PMCID: PMC9937675 DOI: 10.7759/cureus.33932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/19/2023] Open
Abstract
Background Endoscopic variceal ligation (EVL) is a surgical intervention that can work well to curb variceal bleeding in people with liver cirrhosis. However, it could make ulcer bleeding worse and be fatal in some cases. The widespread use of proton pump inhibitors (PPI) in cirrhotic individuals with variceal bleeding is empirical rather than based on scientific data. According to many studies, PPIs reduce the size of post-EVL ulcers. This study aimed to see if PPI use could reduce rebleeding after endoscopy therapy in cirrhotic patients with variceal bleeding. Methodology A retrospective cross-sectional study was conducted at a tertiary care hospital from August 2019 to September 2021. Cirrhotic patients with bleeding gastroesophageal varices (GEVs) who had undergone EVL at the same hospital were enrolled in the study. Medical records were organized, and the sample was divided into two groups based on whether or not PPI was given. Both PPI and non-PPI patients had their endoscopic findings, initial hemostasis outcomes, rebleeding rates, bleeding-related mortality rates, and treatment-related comorbidities compared. Results A total of 46 patients were selected for the study and divided into two groups (PPI group n=28 and non-PPI group n=18). The majority of the patients were males. The PPI group had a mean age of 58.6 ±7.8 years, whereas the non-PPI group had a mean age of 53.6 ±4.4 years. Hepatitis B virus (HBV) infection was the most prevalent cause of cirrhosis in both groups. After endoscopic treatment, three patients (16%) in the non-PPI group suffered a variceal hemorrhage. Bleeding-related fatalities and the time it took for the bleeding to stop varied significantly between the two groups. History of variceal bleeding (relative risk (RR)=1.45; 95% confidence interval (CI), 1.60-7.67; p=0.02), presence of gastric varices (RR=2.23; 95% CI, 2.56-9.832; p=0.035), and not administering PPIs (RR =7.542; 95% CI, 3.98-29.13; p=0.008) were linked with rebleeding. The presence of red concurrent esophageal varices (RR=6.37; 95% CI, 0.562-15.342; p=0.002) and failure to provide PPIs (RR=2.3; 95% CI, 1.621-25.64; p=0.04) were linked with post-EVL bleeding in a multivariate analysis. Conclusions Proton pump inhibitors reduce the occurrence of early bleeding and adverse events after EVL in cirrhotic patients. Not prescribing PPIs and the presence of GEVs were substantially related to a higher risk of bleeding during preventative EVL. Not initiating PPI medication immediately was the sole predictor of bleeding complications in patients who had undergone EVL without gastric varix treatment. To lower the risk of post-EVL ulcer bleeding, we recommend PPI use in patients undergoing EVL.
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14
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Yang J, Zeng Y, Zhang JW. Endoscopic ultrasound-guided diagnosis and treatment of gastric varices. World J Gastrointest Endosc 2022; 14:748-758. [PMID: 36567822 PMCID: PMC9782569 DOI: 10.4253/wjge.v14.i12.748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.
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Affiliation(s)
- Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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15
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La Mura V, Bitto N, Tripodi A. Rational hemostatic management in cirrhosis: from old paradigms to new clinical challenges. Expert Rev Hematol 2022; 15:1031-1044. [PMID: 36342412 DOI: 10.1080/17474086.2022.2144217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patients with cirrhosis are at risk of both thrombotic and hemorrhagic events. Traditional hemostatic tests are inadequate to assess the complex and fragile balance of hemostasis in this setting, especially in advanced stages of disease such as decompensated cirrhosis or acute on chronic liver failure (ACLF). Furthermore, the indiscriminate use of pro-hemostatic agents for prophylaxis and treatment of bleeding episodes is still debated and often contraindicated. Alongside, splanchnic, and peripheral thrombotic events are frequent in this population and require management that involves a careful balance between risks and benefits of antithrombotic therapy. AREAS COVERED This review aims to address the state of the art on the clinical management of the hemostatic balance of cirrhosis in terms of established knowledge and future challenges. EXPERT OPINION The old paradigm of cirrhosis as a naturally anticoagulated condition has been challenged by more sophisticated global tests of hemostasis. Integrating this information in the clinical decision-making is still challenging for physicians and experts in hemostasis.
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Affiliation(s)
- Vincenzo La Mura
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Niccolò Bitto
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Biomedical Sciences for Health, Università degli studi di Milano, Milan, Italy
| | - Armando Tripodi
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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16
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Lv Y, Bai W, Zhu X, Xue H, Zhao J, Zhuge Y, Sun J, Zhang C, Ding P, Jiang Z, Zhu X, Ren W, Li Y, Zhang K, Zhang W, Li K, Wang Z, Luo B, Li X, Yang Z, Wang Q, Guo W, Xia D, Yang C, Pan Y, Yin Z, Fan D, Han G. CLIF-C AD score predicts survival benefit from pre-emptive TIPS in individuals with Child-Pugh B cirrhosis and acute variceal bleeding. JHEP Rep 2022; 4:100621. [DOI: 10.1016/j.jhepr.2022.100621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/29/2022] [Indexed: 11/22/2022] Open
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17
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Le Boutillier C, Ahmed H, Patel VC, McPhail M, Carter B, Ward C, Lawrence V. General practitioner perspectives on factors that influence implementation of secondary care-initiated treatment in primary care: Exploring implementation beyond the context of a clinical trial. PLoS One 2022; 17:e0275668. [PMID: 36251653 PMCID: PMC9576064 DOI: 10.1371/journal.pone.0275668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Beta-blockers Or Placebo for Primary Prophylaxis of oesophageal varices (BOPPP) trial is a 3-year phase IV, multi-centre clinical trial of investigational medicinal product (CTIMP) that aims to determine the effectiveness of carvedilol in the prevention of variceal bleeding for small oesophageal varices in patients with cirrhosis. Early engagement of General Practitioners (GPs) in conversations about delivery of a potentially effective secondary care-initiated treatment in primary care provides insights for future implementation. The aim of this study was to understand the implementation of trial findings by exploring i) GP perspectives on factors that influence implementation beyond the context of the trial and ii) how dose titration and ongoing treatment with carvedilol is best delivered in primary care. METHODS This qualitative study was embedded within the BOPPP trial and was conducted alongside site opening. GP participants were purposively sampled and recruited from ten Clinical Commissioning Groups in England and three Health Boards across Wales. Semi-structured telephone individual interviews were conducted with GPs (n = 23) working in England and Wales. Data were analysed using reflexive thematic analysis. FINDINGS Five overarching themes were identified: i) primary care is best placed for oversight, ii) a shared approach led by secondary care, iii) empower the patient to take responsibility, iv) the need to go above and beyond and v) develop practice guidance. The focus on prevention, attention to holistic care, and existing and often long-standing relationships with patients provides an impetus for GP oversight. GPs spoke about the value of partnership working with secondary care and of prioritising patient-centred care and involving patients in taking responsibility for their own health. An agreed pathway of care, clear communication, and specific, accessible guidance on how to implement the proposed treatment strategy safely and effectively are important determinants in the success of implementation. CONCLUSIONS Our findings for implementing secondary care-initiated treatment in primary care are important to the specifics of the BOPPP trial but can also go some way in informing wider learning for other trials where work is shared across the primary-secondary care interface, and where findings will impact the primary care workload. We propose a systems research perspective for addressing implementation of CTIMP findings at the outset of research. The value of early stakeholder involvement is highlighted, and the need to consider complexity in terms of the interaction between the intervention and the context in which it is implemented is acknowledged. TRIAL REGISTRATION ISRCTN10324656.
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Affiliation(s)
- Clair Le Boutillier
- Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom,Division of Methodologies, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, United Kingdom,* E-mail:
| | - Haroon Ahmed
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Vishal C. Patel
- Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, United Kingdom,Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom,The Roger Williams Institute of Hepatology London, Foundation for Liver Research, London, United Kingdom
| | - Mark McPhail
- Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, United Kingdom,Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Christopher Ward
- NIHR Clinical Research Network South London, London, United Kingdom
| | - Vanessa Lawrence
- Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
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18
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Ji K, Li X, Zhu H, Zhao S, Zhan P, Shi Y, Ye S, Xie B, Zhang Y, Yu P, Ren Z, Ding J, Han X, Li Z. A creatinine-based model for predicting recurrent bleeding after modified percutaneous transhepatic variceal embolization in patients with cirrhosis. J Interv Med 2022; 5:95-102. [PMID: 35936666 PMCID: PMC9348999 DOI: 10.1016/j.jimed.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kun Ji
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xin Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Hanlong Zhu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Si Zhao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu Province, China
| | - Pengchao Zhan
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yang Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shuwen Ye
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Bingcan Xie
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yuyuan Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Peng Yu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhigang Ren
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Juan Ding
- Department of Quality Control, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhen Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- Corresponding author. Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, No.1 East Jian She Road, Zhengzhou 450052, Henan Province, China.
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19
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Hussain I, Wong YJ, Lohan R, Lin S, Kumar R. Does preemptive transjugular intrahepatic portosystemic shunt improve survival after acute variceal bleeding? Systematic review, meta-analysis, and trial sequential analysis of randomized trials. J Gastroenterol Hepatol 2022; 37:455-463. [PMID: 34665473 DOI: 10.1111/jgh.15714] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/20/2021] [Accepted: 10/12/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM A preemptive transjugular intrahepatic portosystemic shunt (p-TIPSS) after acute variceal bleeding (AVB) is advocated. However, when compared with the current standard of care, the survival benefit of p-TIPSS is questionable. We performed a systematic review, meta-analysis, and trial sequential analysis of randomized control trials (RCTs) to assess the survival benefit of p-TIPSS in patients with cirrhosis and AVB. METHODS Comprehensive literature search of three bibliographic databases (MEDLINE, Embase, and Cochrane) was conducted from inception till May 2021. All study types evaluating the survival benefit of p-TIPSS in AVB were considered for inclusion. The relative risk (RR) of mortality and rebleeding at 6 weeks and mortality at 1 year with a random-effects model was computed. Trial sequential analysis was performed for the primary outcome of 6-week mortality. RESULTS A total of nine studies (four RCTs and five cohort studies) comprising 2861 patients with AVB were included. The overall pooled risks of mortality at 6 weeks and 1 year were 17.9% (95% confidence interval [CI]: 16.5-19.3%) and 26.7% (95% CI: 25.0-28.3%), respectively. Although p-TIPSS was associated with lower 6-week rebleeding risk (RR = 0.20; 95% CI = 0.13-0.29, I2 = 0%), data from pooled RCTs showed no significant difference in mortality at 6 weeks (RR = 0.33; 95% CI = 0.08-1.36, I2 = 63%) or at 1 year (RR = 0.76; 95% CI = 0.51-1.14, I2 = 30%). Using trial sequential analysis, required sample size to detect a 20% relative risk reduction in mortality at 6 weeks with p-TIPSS was estimated to be 6317, which is beyond the total number of patients available for analysis. CONCLUSIONS This meta-analysis found that the available data from RCTs are insufficient to confer 6-week mortality benefit with p-TIPSS compared with standard of care; thus, adequately powered RCTs are required.
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Affiliation(s)
- Ikram Hussain
- Division of Gastroenterology, Department of Medicine, Woodlands Health Campus, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Centre, CGH Campus, Singapore.,Duke-NUS Medicine ACP, Singapore
| | - Rahul Lohan
- Department of Diagnostics Radiology, Khoo Teck Puat Hospital, Singapore
| | - Su Lin
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Centre, CGH Campus, Singapore
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20
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Le Boutillier C, Snowdon C, Patel V, McPhail M, Ward C, Carter B, Uddin R, Zamalloa A, Lawrence V. Using a theory-informed approach to explore patient and staff perspectives on factors that influence clinical trial recruitment for patients with cirrhosis and small oesophageal varices. PLoS One 2022; 17:e0263288. [PMID: 35113923 PMCID: PMC8812916 DOI: 10.1371/journal.pone.0263288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 01/17/2022] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE The success of pharmacological randomised controlled trials (RCTs) depends on the recruitment of the required number of participants. Recruitment to RCTs for patients with cirrhosis and small oesophageal varices raises specific additional challenges. The objectives of the study were 1) to explore patient perspectives on factors that influence RCT recruitment, 2) to understand factors that influence the success of recruitment from a staff perspective, and 3) to identify opportunities for tailored interventions to improve trial recruitment in this context. METHODS The qualitative study was embedded in a multi-centre blinded RCT (BOPPP trial) and was conducted alongside site opening. Semi-structured interviews were conducted with patients who enrolled to participate in the trial (n = 13), patients who declined to take part (n = 5), and staff who were responsible for recruiting participants to the trial (n = 18). An open approach to data collection and analysis was adopted and the Theoretical Domains Framework (TDF) was used to provide a theoretical lens through which to view influences on behaviour. Data was analysed using thematic analysis. RESULTS The findings consist of 5 overarching themes that outline trial recruitment influences at the patient, staff, team, organisational and trial levels: i) patient risks and benefits ii) staff attitudes, knowledge and capacity, iii) team-based approach, iv) organisational context and v) Trial collective. Patient-generated themes map onto thirteen of the fourteen TDF domains and staff-generated themes map onto all TDF domains. The overarching themes are not mutually exclusive; with evidence of direct interactions between patient and staff-level themes that influence recruitment behaviours. CONCLUSIONS This study uses a theory-informed approach to gain new insights into improving clinical trial recruitment for patients with cirrhosis and small oesophageal varices. Although people with cirrhosis often display decreased healthcare-seeking behaviours, we found that patients used research to empower themselves to improve their health. Pragmatic trials involving unpredictable populations require staff expertise in building trust, and a deep knowledge of the patient group and their vulnerabilities. RCT recruitment is also more successful when research visits align with what staff identified as the natural rhythm of care. TRIAL REGISTRATION ISRCTN10324656; https://clinicaltrials.gov/.
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Affiliation(s)
- Clair Le Boutillier
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Claire Snowdon
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Vishal Patel
- Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, United Kingdom
- Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
- The Roger Williams Institute of Hepatology London, Foundation for Liver Research, London, United Kingdom
| | - Mark McPhail
- Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, United Kingdom
- Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
| | - Christopher Ward
- NIHR Clinical Research Network South London, London, United Kingdom
| | - Ben Carter
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Ruhama Uddin
- Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ane Zamalloa
- Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Vanessa Lawrence
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
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21
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Romano J, Abdelfattah T, Manka PP, Fuchs M, Syn WK. Non-Invasive Risk Stratification in NAFLD/NASH Patients for Screening EGD. Clin Exp Gastroenterol 2022; 15:1-3. [PMID: 35046690 PMCID: PMC8759994 DOI: 10.2147/ceg.s339850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/24/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- John Romano
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Thaer Abdelfattah
- Division of Gastroenterology and Hepatology, Central Virginia VA Health Care System, Richmond, VA, USA
| | - Paul P Manka
- Department of Internal Medicine, University Hospital, Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Michael Fuchs
- Division of Gastroenterology and Hepatology, Central Virginia VA Health Care System, Richmond, VA, USA.,Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA, USA
| | - Wing-Kin Syn
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA.,Section of Gastroenterology, Ralph H Johnson VAMC, Charleston, SC, USA.,Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country, Universidad del Pa S Vasco/Euskal Herriko Univertsitatea (UPV/EHU), Leioa, Spain
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22
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Lee HL, Lee SW. The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: advantages and pitfalls. Clin Mol Hepatol 2021; 28:121-134. [PMID: 34571587 PMCID: PMC9013617 DOI: 10.3350/cmh.2021.0239] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/25/2021] [Indexed: 12/31/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.
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Affiliation(s)
- Hae Lim Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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23
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Mohanty A, Kapuria D, Canakis A, Lin H, Amat MJ, Rangel Paniz G, Placone NT, Thomasson R, Roy H, Chak E, Baffy G, Curry MP, Laine L, Rustagi T. Fresh frozen plasma transfusion in acute variceal haemorrhage: Results from a multicentre cohort study. Liver Int 2021; 41:1901-1908. [PMID: 33969607 DOI: 10.1111/liv.14936] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/25/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fresh frozen plasma (FFP) transfusion is often used in the management of acute variceal haemorrhage (AVH) despite best practice advice suggesting otherwise. OBJECTIVE We investigated if FFP transfusion affects clinical outcomes in AVH. DESIGN, SETTING AND PATIENTS We performed a retrospective cohort study of 244 consecutive, eligible patients admitted to five tertiary health care centres between 2013 and 2018 with AVH. MAIN OUTCOME MEASUREMENTS Multivariable regression analyses were used to study the association of FFP transfusion with mortality at 42 days (primary outcome) and failure to control bleeding at 5 days and length of stay (secondary outcomes). RESULTS Patients who received FFP transfusion (n = 100) had higher mean Model for End Stage Liver Disease (MELD) score and more severe variceal bleeding than those who did not received FFP transfusion (n = 144). Multivariable analysis showed that FFP transfusion was associated with increased odds of mortality at 42 days (odds ratio [OR] 9.41, 95% confidence interval [CI] 3.71-23.90). FFP transfusion was also associated with failure to control bleeding at 5 days (OR 3.87, 95% CI 1.28-11.70) and length of stay >7 days (adjusted OR 1.88, 95% CI 1.03-3.42). The independent association of FFP transfusion with mortality at 42 days persisted when the cohort was restricted to high-risk patients and in patients without active bleeding. LIMITATIONS AND CONCLUSIONS Fresh frozen plasma transfusion in AVH is independently associated with poor clinical outcomes. As this an observational study, there may be residual bias due to confounding; however, we demonstrate no benefit and potential harm with FFP transfusions in AVH.
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Affiliation(s)
- Arpan Mohanty
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Devika Kapuria
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
| | - Andrew Canakis
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Honghuang Lin
- Section of Computational Biomedicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Maelys J Amat
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Nicholas T Placone
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Reggie Thomasson
- Department of Pathology and Laboratory Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Hemant Roy
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Eric Chak
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Gyorgy Baffy
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Michael P Curry
- Division of Gastroenterology/Liver Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
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Kim JH, Park SW, Jung JH, Park DH, Bang CS, Park CH, Park JW, Park JG. Bedside risk-scoring model for predicting 6-week mortality in cirrhotic patients undergoing endoscopic band ligation for acute variceal bleeding. J Gastroenterol Hepatol 2021; 36:1935-1943. [PMID: 33538357 DOI: 10.1111/jgh.15426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/12/2021] [Accepted: 01/31/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM Acute variceal bleeding (AVB) is a fatal adverse event of cirrhosis, and endoscopic band ligation (EBL) is the standard treatment for AVB. We developed a novel bedside risk-scoring model to predict the 6-week mortality in cirrhotic patients undergoing EBL for AVB. METHODS Cox regression analysis was used to assess the relationship of clinical, biological, and endoscopic variables with the 6-week mortality risk after EBL in a derivation cohort (n = 1373). The primary outcome was the predictive accuracy of the new model for the 6-week mortality in the validation cohort. Moreover, we tested the adequacy of the mortality risk-based stratification and the discriminative performance of our new model in comparison with the Child-Turcotte-Pugh (CTP) and the model for end-stage liver disease scores in the validation cohort (n = 200). RESULTS On multivariate Cox regression analysis, five objective variables (use of beta-blockers, hepatocellular carcinoma, CTP class C, hypovolemic shock at initial presentation, and history of hepatic encephalopathy) were scored to generate a 12-point risk-prediction model. The model stratified the 6-week mortality risk in patients as low (3.5%), intermediate (21.1%), and high (53.4%) (P < 0.001). Time-dependent area under the receiver operating characteristic curve for 6-week mortality showed that this model was a better prognostic indicator than the CTP class alone in the derivation (P < 0.001) and validation (P < 0.001) cohorts. CONCLUSIONS A simplified scoring model with high potential for generalization refines the prediction of 6-week mortality in high-risk cirrhotic patients, thereby aiding the targeting and individualization of treatment strategies for decreasing the mortality rate.
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Affiliation(s)
- Jung Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, South Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, South Korea
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, South Korea
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, South Korea
| | - Chang Seok Bang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, South Korea
| | - Ji Won Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
| | - Jae Gun Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
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Chirapongsathorn S, Akkarachinores K, Chaiprasert A. Development and validation of prognostic model to predict mortality among cirrhotic patients with acute variceal bleeding: A retrospective study. JGH Open 2021; 5:658-663. [PMID: 34124382 PMCID: PMC8171152 DOI: 10.1002/jgh3.12550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 12/28/2022]
Abstract
Background and Aim Acute variceal bleeding (AVB) is a serious complication associated with high mortality. The aim of our study was to investigate mortality predictors and to develop a new simplified prognostic model among cirrhotic patients with AVB. Methods A simplified prognostic model was developed using multiple logistic regression after identifying significant predictors of 6‐week mortality. Results A total of 713 consecutive patients with AVB were enrolled. The 6‐week overall mortality rate was 18%. Multivariate analysis showed that shock, model for end‐stage liver disease (MELD) score, high‐risk stigmata of esophageal varices on endoscopic finding, and Glasgow Blatchford score were independent predictors of mortality. A new logistic model using these variables was developed. This model (cutoff value ≥ 4) area under the receiver operating characteristics (AUROC) was 0.93 and significantly higher than that of MELD score alone (0.74). Two validation analyses showed that the AUROC of our model was consistently high. The 6‐week rebleeding rate was 25.3%. Multivariate analysis showed that MELD score, Glasgow Blatchford score, history of upper GI bleeding, shock, and alcohol use were independent predictors of rebleeding. Conclusion Our new simplified model accurately and consistently predicted 6‐week mortality among patients with AVB using objective variables measured at admission. Patients with higher MELD scores should be closely monitored due to the higher probability of 6‐week rebleeding.
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Affiliation(s)
- Sakkarin Chirapongsathorn
- Division of Gastroenterology and Hepatology, Department of Medicine Phramongkutklao Hospital and College of Medicine Bangkok 10400 Thailand
| | - Kuntapon Akkarachinores
- Division of Gastroenterology and Hepatology, Department of Medicine Phramongkutklao Hospital and College of Medicine Bangkok 10400 Thailand
| | - Amnart Chaiprasert
- Division of Nephrology, Department of Medicine Phramongkutklao Hospital and College of Medicine Bangkok 10400 Thailand
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26
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Campos-Varela I, Villagrasa A, Simon-Talero M, Riveiro-Barciela M, Ventura-Cots M, Aguilera-Castro L, Alvarez-Lopez P, Nordahl EA, Anton A, Bañares J, Barber C, Barreira-Diaz A, Biagetti B, Camps-Relats L, Ciudin A, Cocera R, Dopazo C, Fernandez A, Jimenez C, Jimenez MM, Jofra M, Gil C, Gomez-Gavara C, Guanozzi D, Guevara JA, Lobo B, Malagelada C, Martinez-Camprecios J, Mayorga L, Miret E, Pando E, Pérez-Lopez A, Pigrau M, Prio A, Rivera-Esteban JM, Romero A, Tasayco S, Vidal-Gonzalez J, Vidal L, Minguez B, Augustin S, Genesca J. The role of liver steatosis as measured with transient elastography and transaminases on hard clinical outcomes in patients with COVID-19. Therap Adv Gastroenterol 2021; 14:17562848211016567. [PMID: 34104210 PMCID: PMC8170328 DOI: 10.1177/17562848211016567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 04/12/2021] [Indexed: 02/04/2023] Open
Abstract
Liver injury has been widely described in patients with Coronavirus disease 2019 (COVID-19). We aimed to study the effect of liver biochemistry alterations, previous liver disease, and the value of liver elastography on hard clinical outcomes in COVID-19 patients. We conducted a single-center prospective observational study in 370 consecutive patients admitted for polymerase chain reaction (PCR)-confirmed COVID-19 pneumonia. Clinical and laboratory data were collected at baseline and liver parameters and clinical events recorded during follow-up. Transient elastography [with Controlled Attenuation Parameter (CAP) measurements] was performed at admission in 98 patients. All patients were followed up until day 28 or death. The two main outcomes of the study were 28-day mortality and the occurrence of the composite endpoint intensive care unit (ICU) admission and/or death. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were elevated at admission in 130 patients (35%) and 167 (45%) patients, respectively. Overall, 14.6% of patients presented the composite endpoint ICU and/or death. Neither ALT elevations, prior liver disease, liver stiffness nor liver steatosis (assessed with CAP) had any effect on outcomes. However, patients with abnormal baseline AST had a higher occurrence of the composite ICU/death (21% versus 9.5%, p = 0.002). Patients ⩾65 years and with an AST level > 50 U/ml at admission had a significantly higher risk of ICU and/or death than those with AST ⩽ 50 U/ml (50% versus 13.3%, p < 0.001). In conclusion, mild liver damage is prevalent in COVID-19 patients, but neither ALT elevation nor liver steatosis influenced hard clinical outcomes. Elevated baseline AST is a strong predictor of hard outcomes, especially in patients ⩾65 years.
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Affiliation(s)
- Isabel Campos-Varela
- Liver Unit, Department of Internal Medicine,
Hospital Universitari Vall d’Hebron, Pg. Vall d’Hebron, 119-129, Barcelona,
08035, Spain
- Centro de Investigación Biomédica en Red de
Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos
III, Madrid, Spain
| | - Ares Villagrasa
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Macarena Simon-Talero
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de
Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos
III, Madrid, Spain
| | - Mar Riveiro-Barciela
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de
Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos
III, Madrid, Spain
| | - Meritxell Ventura-Cots
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de
Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos
III, Madrid, Spain
| | - Lara Aguilera-Castro
- Department of Gastroenterology, Vall d’Hebron
Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona,
Spain
| | - Patricia Alvarez-Lopez
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Emilie A Nordahl
- Department of Clinical Pharmacology, Vall
d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Adrian Anton
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Bañares
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Claudia Barber
- Department of Gastroenterology, Vall d’Hebron
Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona,
Spain
| | - Ana Barreira-Diaz
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Betina Biagetti
- Department of Endocrinology, Vall d’Hebron
Barcelona Hospital Campus, Barcelona, Spain
| | - Laura Camps-Relats
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrea Ciudin
- Department of Endocrinology, Vall d’Hebron
Barcelona Hospital Campus, Barcelona, Spain
| | - Raul Cocera
- Department of Urology, Vall d’Hebron Barcelona
Hospital Campus, Barcelona, Spain
| | - Cristina Dopazo
- Department of Hepatobiliar Surgery and Liver
Transplant, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Andrea Fernandez
- Department of Hepatobiliar Surgery and Liver
Transplant, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Cesar Jimenez
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria M Jimenez
- Department of Hematology, Vall d’Hebron
Barcelona Hospital Campus, Barcelona, Spain
| | - Mariona Jofra
- Department of Hepatobiliar Surgery and Liver
Transplant, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Clara Gil
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Concepción Gomez-Gavara
- Department of Hepatobiliar Surgery and Liver
Transplant, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Danila Guanozzi
- Department of Gastroenterology, Vall d’Hebron
Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona,
Spain
| | - Jorge A Guevara
- Department of Endoscopy, Vall d’Hebron
Barcelona Hospital Campus, Barcelona, Spain
| | - Beatriz Lobo
- Department of Gastroenterology, Vall d’Hebron
Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona,
Spain
| | - Carolina Malagelada
- Department of Gastroenterology, Vall d’Hebron
Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona,
Spain
| | - Joan Martinez-Camprecios
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Mayorga
- Department of Gastroenterology, Vall d’Hebron
Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona,
Spain
| | - Enric Miret
- Department of Urology, Vall d’Hebron Barcelona
Hospital Campus, Barcelona, Spain
| | - Elizabeth Pando
- Department of Hepatobiliar Surgery and Liver
Transplant, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ana Pérez-Lopez
- Department of Hematology, Vall d’Hebron
Barcelona Hospital Campus, Barcelona, Spain
| | - Marc Pigrau
- Department of Endoscopy, Vall d’Hebron
Barcelona Hospital Campus, Barcelona, Spain
| | - Alba Prio
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesus M Rivera-Esteban
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alba Romero
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stephanie Tasayco
- Department of Gastroenterology, Vall d’Hebron
Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona,
Spain
| | - Judit Vidal-Gonzalez
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Vidal
- Department of Hepatobiliar Surgery and Liver
Transplant, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Beatriz Minguez
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de
Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos
III, Madrid, Spain
| | - Salvador Augustin
- Liver Unit, Department of Internal Medicine,
Hospital Universitari Vall d’Hebron, Pg. Vall d’Hebron, 119-129, Barcelona,
08035, Spain
| | - Joan Genesca
- Liver Unit, Hospital Universitari Vall
d’Hebron, Vall d’Hebron Institut of Reseach (VHIR), Vall d’Hebron Barcelona
Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de
Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos
III, Madrid, Spain
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Pinchot JW, Kalva SP, Majdalany BS, Kim CY, Ahmed O, Asrani SK, Cash BD, Eldrup-Jorgensen J, Kendi AT, Scheidt MJ, Sella DM, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Radiologic Management of Portal Hypertension. J Am Coll Radiol 2021; 18:S153-S173. [PMID: 33958110 DOI: 10.1016/j.jacr.2021.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 12/17/2022]
Abstract
Cirrhosis is a heterogeneous disease that cannot be studied as a single entity and is classified in two main prognostic stages: compensated and decompensated cirrhosis. Portal hypertension, characterized by a pathological increase of the portal pressure and by the formation of portal-systemic collaterals that bypass the liver, is the initial and main consequence of cirrhosis and is responsible for the majority of its complications. A myriad of treatment options exists for appropriately managing the most common complications of portal hypertension, including acute variceal bleeding and refractory ascites. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts, Chief, Division of Interventional Radiology, Massachusetts General Hospital
| | | | - Charles Y Kim
- Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina, Chief, Division of Interventional Radiology, Duke University Medical Center
| | | | - Sumeet K Asrani
- Baylor University Medical Center, Dallas, Texas, American Association for the Study of Liver Diseases
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas, American Gastroenterological Association
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts, Society for Vascular Surgery
| | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapy at Mayo Clinic Rochester
| | | | | | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, Chair, FMLH credentials committee, Division chief of IR at Medical College of Wisconsin
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Rodríguez de Santiago E, Hernández-Tejero M, Rivero-Sánchez L, Ortiz O, García de la Filia-Molina I, Foruny-Olcina JR, Prieto HMM, García-Prada M, González-Cotorruelo A, De Jorge Turrión MA, Jiménez-Jurado A, Rodríguez-Escaja C, Castaño-García A, Outomuro AG, Ferre-Aracil C, de-Frutos-Rosa D, Pellisé M. Management and Outcomes of Bleeding Within 30 Days of Colonic Polypectomy in a Large, Real-Life, Multicenter Cohort Study. Clin Gastroenterol Hepatol 2021; 19:732-742.e6. [PMID: 32272252 DOI: 10.1016/j.cgh.2020.03.068] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/17/2020] [Accepted: 03/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Management of delayed (within 30 days) postpolypectomy bleeding (DPPB) has not been standardized. Patients often undergo colonoscopies that do not provide any benefit. We aimed to identify factors associated with therapeutic intervention and active bleeding after DPPB. METHODS We performed a retrospective study of 548 patients with bleeding within 30 days after an index polypectomy (DPPB; 71.9% underwent colonoscopy, 2.6% underwent primary angiographic embolization, and 25.5% were managed without intervention) at 6 tertiary centers in Spain, from January 2010 through September 2018. We collected demographic and medical data from patients. The primary outcomes were the need for therapeutic intervention and the presence of active bleeding during colonoscopy. RESULTS A need for therapeutic intervention was associated independently with the use of antithrombotic agents, hemoglobin decrease greater than 2 g/dL, hemodynamic instability, and comorbidities (P < .05). The bleeding point during colonoscopy was identified in 344 patients; 74 of these patients (21.5%) had active bleeding. Active use of anticoagulants (odds ratio [OR], 2.6; 95% CI, 1.5-4.5), left-sided polyps (OR, 1.95; 95% CI, 1-3.8), prior use of electrocautery (OR, 2.6; 95% CI, 1.1-6.1), and pedunculated polyp morphology (OR, 1.8, 95% CI, 1-3.2) significantly increased the risk of encountering active bleeding. We developed a visual nomogram to estimate the risk of active bleeding. Overall, 43% of the cohort did not require any hemostatic therapy. Rebleeding (<6%) and transfusion requirements were low in those managed without intervention. CONCLUSIONS In a study of patients with DPPB, we found that almost half do not warrant any therapeutic intervention. Colonoscopy often is overused for patients with DPPB. We identified independent risk factors for active bleeding that might be used to identify patients most likely to benefit from colonoscopy.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria Universidad de Alcalá, Madrid, Spain
| | - Maria Hernández-Tejero
- Department of Gastroenterology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universitat de Barcelona, Barcelona, Spain
| | - Liseth Rivero-Sánchez
- Department of Gastroenterology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universitat de Barcelona, Barcelona, Spain
| | - Oswaldo Ortiz
- Department of Gastroenterology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universitat de Barcelona, Barcelona, Spain
| | - Irene García de la Filia-Molina
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria Universidad de Alcalá, Madrid, Spain
| | - Jose Ramon Foruny-Olcina
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria Universidad de Alcalá, Madrid, Spain
| | - Hector Miguel Marcos Prieto
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Maria García-Prada
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Almudena González-Cotorruelo
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | | | | | - Carlos Rodríguez-Escaja
- Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Andres Castaño-García
- Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ana Gómez Outomuro
- Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Carlos Ferre-Aracil
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid
| | - Diego de-Frutos-Rosa
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid
| | - María Pellisé
- Department of Gastroenterology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universitat de Barcelona, Barcelona, Spain.
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Lv Y, Wang Z, Li K, Wang Q, Bai W, Yuan X, Yu T, Niu J, Yang Z, Zhu X, Zhao J, Xue H, Jiang Z, Zhuge Y, Zhang C, Sun J, Ding P, Ren W, Li Y, Zhang K, Zhang W, Guo W, Luo B, Li X, Yuan J, Han N, Zhu Y, He C, Yin Z, Fan D, Han G. Risk Stratification Based on Chronic Liver Failure Consortium Acute Decompensation Score in Patients With Child-Pugh B Cirrhosis and Acute Variceal Bleeding. Hepatology 2021; 73:1478-1493. [PMID: 32706906 DOI: 10.1002/hep.31478] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 04/29/2020] [Accepted: 06/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB. APPROACH AND RESULTS We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P < 0.001] and 0.556 [P < 0.001]) and other prognostic models. With X-tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF-C ADs <48), intermediate risk (CLIF-C ADs 48-56), and high risk (CLIF-C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). CONCLUSIONS In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xulong Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tianlei Yu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jing Niu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zaibo Jiang
- Department of interventional Radiology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Junhui Sun
- Hepatobiliaryand Pancreatic Intervention Center, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Li
- Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kewei Zhang
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Nicoară-Farcău O, Han G, Rudler M, Angrisani D, Monescillo A, Torres F, Casanovas G, Bosch J, Lv Y, Thabut D, Fan D, Hernández-Gea V, García-Pagán JC, Abraldes JG, Nevens F, Caca K, Laleman W, Appenrodt B, Luca A, Vinel JP, Mössner J, Di Pascoli M, Zipprich A, Sauerbruch T, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, Marrero JM, Buceta E, Sanchez J, Castellot A, Penate M, Cruz A, Pena E, Procopeț B, Giráldez Á, Amitrano L, Villanueva C, Ibañez-Samaniego L, Silva-Junior G, Martinez J, Genescà J, Trebicka J, Llop E, Palazon JM, Castellote J, Rodrigues S, Gluud LL, Ferreira CN, Barcelo R, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Gronbaek H, Hernández-Guerra M, Sassatelli R, Dell’Era A, Senzolo M, Romero-Gómez M, Casas M, Masnou H, Primignani M, Krag A, Calleja JL, Jansen C, Robic MA, Conejo I, Catalina MV, Albillos A, Alvarado E, Guardascione MA, Tanțău M, Zuo L, Zhu X, Zhao J, Xue H, Jiang Z, Zhuge Y, Zhang C, Sun J, Ding P, Ren W, Li Y, Zhang K, Zhang W, He C, Zhong J, Peng Q, Ma F, Luo J, Zhang M, Wang G, Sun M, Dong J, Bai W, Guo W, Wang Q, Yuan X, Wang Z, Yu T, Luo B, Li X, Yuan J, Han N, Zhu Y, Niu J, Li K, Yin Z, Nie Y, Fischer P, Horia Ștefănescu, Pop A, Laursen SB, Turon F, Baiges A, Ferrusquía-Acosta J, Magaz M, Cerda E, Tellez L, Allegretti G, Macedo G, Haldrup D, Santos P, Moura M, Reis D, Meireles L, Sousa P, Alexandrino P, Navascues C, Augustin S, La Mura V, Bañares R, Diaz R, Gómez ML, Ripoll C. Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient Data. Gastroenterology 2021; 160:193-205.e10. [PMID: 32980344 DOI: 10.1053/j.gastro.2020.09.026] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/25/2020] [Accepted: 09/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Compared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS. METHODS We searched publication databases for randomized controlled trials and observational studies comparing the effects of preemptive TIPS versus endoscopy plus nonselective beta-blockers in the specific population of high-risk patients with cirrhosis and acute variceal bleeding (CP-B+AB or Child-Pugh C, below 14 points), through December 31, 2019. We performed a meta-analysis of data from 7 studies (3 randomized controlled trials and 4 observational studies), comprising 1327 patients (310 received preemptive TIPS and 1017 received drugs plus endoscopy). We built adjusted models to evaluate risk using propensity score for baseline covariates. Multivariate Cox regression models were used to assess the factors associated with survival time. The primary endpoint was effects of preemptive TIPS versus drugs plus endoscopy on 1-year survival in the overall population as well as CP-B+AB and Child-Pugh C patients. RESULTS Overall, preemptive TIPS significantly increased the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survived for 1 year, compared with drugs plus endoscopy (hazard ratio [HR] 0.443; 95% CI 0.323-0.607; P < .001). This effect was observed in CP-B+AB patients (HR 0.524; 95% CI 0.307-0.896; P = .018) and in patients with Child-Pugh C scores below 14 points (HR 0.374; 95% CI 0.253-0.553; P < .001). Preemptive TIPS significantly improved control of bleeding and ascites without increasing risk of hepatic encephalopathy in Child-Pugh C and CP-B+AB patients, compared with drugs plus endoscopy. Cox analysis of patients who received preemptive TIPS showed that patients could be classified into 3 categories for risk of death, based on age, serum level of creatinine, and Child-Pugh score. In each of these risk categories, preemptive TIPS increased the proportion of patients who survived for 1 year, compared with drugs plus endoscopy. CONCLUSIONS In a meta-analysis of data from 1327 patients with cirrhosis, acute variceal bleeding, and Child-Pugh score between 10 and 13 points or CP-B+AB, preemptive TIPS increased the proportion who survived for 1 year, in both subgroups separately, compared with drugs plus endoscopy.
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Affiliation(s)
- Oana Nicoară-Farcău
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Marika Rudler
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Sorbonne University, Paris, France
| | - Debora Angrisani
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Alberto Monescillo
- Digestive Disease Department, Hospital Universitario Insular de Gran Canaria, Canary Islands
| | - Ferran Torres
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Hospital Clinic Barcelona, Barcelona, Spain; Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Georgina Casanovas
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Hospital Clinic Barcelona, Barcelona, Spain
| | - Jaime Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University, Bern, Switzerland
| | - Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Dominique Thabut
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Sorbonne University, Paris, France
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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Cheng R, Tan N, Kang Q, Luo H, Chen H, Pan J, Han Y, Yang Y, Xu X. High-density lipoprotein cholesterol is a predictor of survival in cirrhotic patients with acute gastrointestinal bleeding: a retrospective study. BMC Gastroenterol 2020; 20:381. [PMID: 33198637 PMCID: PMC7667781 DOI: 10.1186/s12876-020-01522-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/02/2020] [Indexed: 02/08/2023] Open
Abstract
Background Lipid profiles are declined in patients with viral liver cirrhosis and correlated with severity of liver disease. Hepatitis B virus (HBV) is the leading cause of liver cirrhosis in China. Our primary aim was to investigate whether serum lipids and lipoproteins associate with survival in patients with HBV-related cirrhosis and acute gastrointestinal bleeding, and develop a 6-week mortality risk score that incorporates it. Methods From January 2008 to December 2015, consecutive cirrhotic patients with acute gastrointestinal bleeding admitted to our hospital were evaluated and randomly divided into the derivation (n = 629) and validation (n = 314) cohorts. A logistic regression model was established to confirm the association between lipoprotein cholesterol and mortality. Accuracy to predict mortality were assessed by area under the receiver operating characteristic curves (AUROCs) and compared using the Hanley and McNeil test. Results Among study subjects, the 6-week mortality rate was 10.6%. High-density lipoprotein cholesterol (HDL-C) level was found to correlate most strongly with prognostic scores. On ROC analysis, HDL-C showed excellent diagnostic accuracy for 6-week mortality. Logistic regression analysis provided a simple algorithm based on the combined use of 4 variables (total bilirubin (TBIL), HDL-C, International normalized ratio, and hemoglobin), allowing accurate discrimination of 3 distinct prognostic subgroups with 1.7% (low risk), 12.3% (intermediate risk), and 56.9% (high risk) mortality. Its accuracy was significantly better than that of Child–Pugh, model of end-stage liver disease, albumin-bilirubin score, D’Amico model, Augustin model, AIMS65 score and Glasgow-Blatchford score. Baseline HDL-C values ≤ 0.54 mmol/L were associated with markedly lower 6-week survival. Comparable results were found in the validation set. Conclusion HDL-C is a potential indicator for the prognosis of patients with cirrhosis and acute gastrointestinal bleeding. The new algorithm based on HDL-C allowed an accurate predictive assessment of 6-week mortality after bleeding attack.
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Affiliation(s)
- Ran Cheng
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China
| | - Ning Tan
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China
| | - Qian Kang
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China
| | - Hao Luo
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China
| | - Hongyu Chen
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China
| | - Jiali Pan
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China
| | - Yifan Han
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China
| | - Yuqing Yang
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China
| | - Xiaoyuan Xu
- Department of Infectious Diseases, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China.
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A New Recalibrated Four-Category Child-Pugh Score Performs Better than the Original Child-Pugh and MELD Scores in Predicting In-Hospital Mortality in Decompensated Alcoholic Cirrhotic Patients with Acute Variceal Bleeding: a Real-World Cohort Analysis. World J Surg 2020; 44:241-246. [PMID: 31583458 DOI: 10.1007/s00268-019-05211-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There currently is no consensus on how to accurately predict early rebleeding and death after a major variceal bleed. This study investigated the relative predictive performances of the original Child-Pugh (CP), model for end-stage liver disease (MELD) and a four-category recalibrated Child-Pugh (rCP). METHODS This prospective study included all adult patients admitted to Groote Schuur Hospital with acute esophageal variceal bleeding secondary to alcoholic cirrhosis, between January 2000 and December 2017. CP and rCP grades and MELD score were calculated on admission, and the predictive ability in discriminating in-hospital rebleeding and death was compared by area under receiver-operating characteristic (AUROC) curves. RESULTS During the study period, 403 consecutive adult patients were treated for bleeding esophageal varices of whom 225 were secondary to alcoholic cirrhosis. Twenty-four (10.6%) patients were CP grade A, 88 (39.1%) grade B and 113 (50.2%) grade C on hospital admission. MELD scores ranged from 6 to 40. Thirty-one (13.8%) patients rebleed, and 41 (18.2%) patients died. There was no difference in the discriminatory capacity of the CP (AUROC 0.59, 95% CI 0.50-0.670) and MELD (AUROC 0.62, 95% CI 0.51-0.73) to predict rebleeding (p = 0.72), or between the Child-Pugh (AUROC 0.75, 95% CI 0.71-0.81) and MELD (AUROC 0.71, 95% CI 0.62-0.80) to predict death (p = 0.35). The rCP classification (A-D) had a significantly improved discriminatory capacity (AUROC 0.83 95% CI 0.77-0.89) compared to the CP score (A-C) and MELD to predict death (p = 0.004). CONCLUSION A recalibrated Child-Pugh score outperforms the original Child-Pugh grade and MELD score in predicting in-hospital death in patients with bleeding esophageal varices secondary to alcoholic cirrhosis.
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Shin J, Yu JH, Jin YJ, Yim HJ, Jung YK, Yang JM, Song DS, Kim YS, Kim SG, Kim DJ, Suk KT, Yoon EL, Lee SS, Kim CW, Kim HY, Jang JY, Jeong SW. Acute-on-chronic liver failure as a major predictive factor for mortality in patients with variceal bleeding. Clin Mol Hepatol 2020; 26:540-553. [PMID: 32937688 PMCID: PMC7641565 DOI: 10.3350/cmh.2020.0034] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND/AIMS This study examined the risk factors associated with mortality in cirrhotic patients hospitalized with variceal bleeding, and evaluated the effects of acute-on-chronic liver failure (ACLF) on the prognosis of these patients. METHODS This study was retrospectively conducted on patients registered in the Korean acute-on-chronic liver failure study cohort, and on 474 consecutive cirrhotic patients hospitalized with variceal bleeding from January 2013 to December 2013 at 21 university hospitals. ACLF was defined as described by the European Association for the Study of Liver-Chronic Liver Failure Consortium. RESULTS Among a total of 474 patients, 61 patients were diagnosed with ACLF. The cumulative overall survival (OS) rate was lower in the patients with ACLF than in those without (P<0.001), and patients with higher ACLF grades had a lower OS rate (P<0.001). The chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score was identified as a significant prognostic factor in patients hospitalized with variceal bleeding (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.30-1.50; P<0.001), even in ACLF patients with variceal bleeding (HR, 1.32; 95% CI, 1.19-1.46, P<0.001). Concerning the prediction of the mortality risk at 28- and 90-day using CLIF-SOFA scores, c-statistics were 0.895 (95% CI, 0.829-0.962) and 0.897 (95% CI, 0.842-0.951), respectively, and the optimal cut-off values were 6.5 and 6.5, respectively. CONCLUSION In cirrhotic patients hospitalized with variceal bleeding, the prognosis was poor when accompanied by ACLF, especially depending upon CLIF-SOFA score. CLIF-SOFA model well predicted the 28-day or 90-day mortality for cirrhotic patients who experienced variceal bleeding.
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Affiliation(s)
- Jongbeom Shin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jung Hwan Yu
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Young-Joo Jin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Hyung Joon Yim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Young Kul Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jin Mo Yang
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Seon Song
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Bucheon, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Bucheon, Korea
| | - Dong Joon Kim
- Institute of Liver and Digestive Diseases, Hallym University, Chuncheon, Korea.,Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Ki Tae Suk
- Institute of Liver and Digestive Diseases, Hallym University, Chuncheon, Korea.,Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Eileen L Yoon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Chang Wook Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Young Jang
- Institute for Digestive Research and Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Soung Won Jeong
- Institute for Digestive Research and Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Seoul, Korea
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Ardevol A, Alvarado-Tapias E, Garcia-Guix M, Brujats A, Gonzalez L, Hernández-Gea V, Aracil C, Pavel O, Cuyas B, Graupera I, Colomo A, Poca M, Torras X, Concepción M, Villanueva C. Early rebleeding increases mortality of variecal bleeders on secondary prophylaxis with β-blockers and ligation. Dig Liver Dis 2020; 52:1017-1025. [PMID: 32653417 DOI: 10.1016/j.dld.2020.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 05/14/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Despite secondary-prophylaxis with β-blockers and endoscopic-variceal-ligation rebleeding is frequent, particularly within the first-6-weeks. Early-rebleeding may have greater impact on death-risk than late rebleeding, which may affect therapy. We assessed whether the influence of rebleeding on long-term survival of patients on secondary-prophylaxis is greater in patients with early-rebleeding. METHODS 369 patients with cirrhosis were consecutively included once recovered from first variceal-bleeding. The impact of rebleeding on survival was investigated according to whether it occurred within 6-weeks (early-rebleeding) or later (late-rebleeding). RESULTS During 46-months of follow-up (IQR: 14-61), 45 patients (12%) had early-rebleeding, 74(20%) had late-rebleeding and 250(68%) had not rebleeding. Mortality risk was higher in early-rebleeding group vs. late-rebleeding (HR = 0.476, 95%CI = 0.318-0.712, p < 0.001) and was similar in late-rebleeding group vs. no-rebleeding (HR = 0.902, 95%CI = 0.749-1.086, p = 0.271). Adjusting for baseline risk-factors, early-rebleeding was independently associated with mortality-risk (HR = 1.58, 95%CI = 1.02-2.45; p = 0.04). Child-Pugh&MELD scores improved at 3rd-4th-week only in patients without early-rebleeding (p < 0.05). Presence of ascites or encephalopathy, MELD-score>12 and HVPG>20 mmHg identified patients at risk of early-rebleeding. CONCLUSIONS Patients with early-rebleeding have higher risk of death than patients without rebleeding and even than those rebleeding later. Our results suggest that patients at risk of early rebleeding might benefit from preemptive therapies such as early-TIPS.
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Affiliation(s)
- Alba Ardevol
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Edilmar Alvarado-Tapias
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Garcia-Guix
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Anna Brujats
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Laura Gonzalez
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Virginia Hernández-Gea
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, University of Barcelona, Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Carles Aracil
- Hospital Arnau de Vilanova,(IRBLleida), Lleida, Spain
| | - Oana Pavel
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Berta Cuyas
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Isabel Graupera
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Alan Colomo
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Xavier Torras
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Concepción
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Càndid Villanueva
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain.
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Lee YR, Park SY, Tak WY. Treatment Outcomes and Prognostic Factors of Acute Variceal Bleeding in Patients with Hepatocellular Carcinoma. Gut Liver 2020; 14:500-508. [PMID: 31816673 PMCID: PMC7366146 DOI: 10.5009/gnl19155] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/08/2019] [Accepted: 08/27/2019] [Indexed: 12/12/2022] Open
Abstract
Background/Aims The treatment outcomes and prognostic markers of acute variceal bleeding (AVB) in hepatocellular carcinoma (HCC) patients remain unclear. Therefore, we evaluated the clinical outcomes and prognostic factors of AVB in HCC patients. Methods Cirrhotic patients with endoscopically confirmed AVB between 2007 and 2013 were enrolled in this prospective study. Prognostic factors were identified by multivariate Cox proportional hazards regression analysis. Results Among the 329 enrolled patients, 125 patients (38.0%) were diagnosed with HCC. The 6-week mortality rates of all enrolled AVB patients and the HCC subgroup were 14.9% and 26.4%. The 5-day treatment failure, 6-week mortality, cirrhosis-related complications, and duration of hospitalization were greater in HCC patients than in non-HCC patients (all p<0.05). In the HCC subgroup, the Model for End-Stage Liver Disease (MELD) score (hazard ratio [HR], 1.145; p=0.001) and Barcelona Clinic Liver Cancer (BCLC) stage (C-D vs 0-B) (HR, 3.096; p=0.019) were independent predictors of 6-week mortality. Our study revealed that 85% of HCC patients with both a MELD score ≥15.5 and BCLC stage C-D died within 6 weeks, and the 6-week mortality risk was 21-fold higher in this group than in the group with a lower MELD score and earlier HCC stage (p<0.001). Conclusions The 5-day treatment failure and 6-week mortality rates were significantly higher among AVB patients with HCC than those without HCC. The MELD score and the presence and stage of HCC are strong predictors of 6-week mortality in patients with AVB.
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Affiliation(s)
- Yu Rim Lee
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Young Park
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Won Young Tak
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Mortality of Cirrhosis Induced Variceal Hemorrhage Is Declining: Can We Do More? Crit Care Med 2020; 47:1453-1455. [PMID: 31524694 DOI: 10.1097/ccm.0000000000003945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rout G, Sharma S, Gunjan D, Kedia S, Saraya A, Nayak B, Singh V, Kumar R. Development and Validation of a Novel Model for Outcomes in Patients with Cirrhosis and Acute Variceal Bleeding. Dig Dis Sci 2019; 64:2327-2337. [PMID: 30830520 DOI: 10.1007/s10620-019-05557-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 02/20/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute variceal bleeding (AVB) in patients with cirrhosis is associated with high mortality, ranging from 12 to 20% at 6 weeks. The existing prognostic models for AVB lack precision and require further validation. AIM In this prospective study, we aimed to develop and validate a new prognostic model for AVB, and compared it with the existing models. METHODS We included 285 patients from March 2017 to November 2017 in the derivation cohort and 238 patients from December 2017 to June 2018 in the validation cohort. Two prognostic models were developed from derivation cohort by logistic regression analysis. Discrimination was assessed using area under the receiver operator characteristic curve (AUROC). RESULTS The 6-week mortality was 22.1% in derivation cohort and 22.3% in validation cohort, P = 0.866. Model for end-stage liver disease (MELD) [odds ratio (OR) 1.106] and encephalopathy (E) (OR 4.658) in one analysis and Child-Pugh score (OR 1.379) and serum creatinine (OR 1.474) in another analysis were significantly associated with 6-week mortality. MELD-E model (AUROC 0.792) was superior to Child-creatinine model (AUROC) in terms of discrimination. The MELD-E model had highest AUROC; as compared to other models-MELD score (AUROC 0.751, P = 0.036), Child-Pugh score (AUROC 0.737, P = 0.037), D'Amico model (AUROC 0.716, P = 0.014) and Augustin model (AUROC 0.739, P = 0.018) in derivation cohort. In validation cohort, the discriminatory performance of MELD-E model (AUROC 0.805) was higher as compared to other models including MELD score (AUROC 0.771, P = 0.048), Child-Pugh score (AUROC 0.746, P = 0.011), Augustin model (AUROC 0.753, P = 0.039) and D'Amico model (AUROC 0.736, P = 0.021). CONCLUSION In cirrhotic patients with AVB, the novel MELD-Encephalopathy model predicts 6 weeks mortality with higher accuracy than the existing prognostic models.
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Affiliation(s)
- Gyanranjan Rout
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, 801507, India
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Lv Y, Zuo L, Zhu X, Zhao J, Xue H, Jiang Z, Zhuge Y, Zhang C, Sun J, Ding P, Ren W, Li Y, Zhang K, Zhang W, He C, Zhong J, Peng Q, Ma F, Luo J, Zhang M, Wang G, Sun M, Dong J, Bai W, Guo W, Wang Q, Yuan X, Wang Z, Yu T, Luo B, Li X, Yuan J, Han N, Zhu Y, Niu J, Li K, Yin Z, Nie Y, Fan D, Han G. Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut 2019; 68:1297-1310. [PMID: 30415233 DOI: 10.1136/gutjnl-2018-317057] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 09/20/2018] [Accepted: 09/29/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Early placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10-13) with cirrhosis and acute variceal bleeding (AVB). However, early TIPS criteria may overestimate the mortality risk in a significant proportion of patients, and the survival benefit conferred by early TIPS in such patients has been questioned. Alternative criteria have been proposed to refine the criteria used to identify candidates for early TIPS. Nevertheless, the true survival benefit provided (or not) by early TIPS compared with standard treatment in the different risk categories has not been investigated in specifically designed comparative studies. DESIGN We collected data on 1425 consecutive patients with cirrhosis and AVB who were admitted to 12 university hospitals in China between December 2010 and June 2016. Of these, 206 patients received early TIPS, and 1219 patients received standard treatment. The Fine and Gray competing risk regression model was used to compare the outcomes between the two groups that were stratified based on the currently available risk stratification systems after adjusting for liver disease severity and other potential confounders. RESULTS Overall, early TIPS was associated with an 80% relative risk reduction (RRR) in mortality at 6 weeks (adjusted HR=0.20; 95% CI: 0.10 to 044; p<0.001) and 51% RRR at 1 year (adjusted HR=0.49, 95% CI: 0.32 to 0.73; p<0.001) compared with standard treatment. In stratification analyses, the RRRs in mortality did not significantly differ among the risk categories. However, the absolute risk reductions (ARRs) of mortality were more pronounced in high-risk patients. The ARRs at 6 weeks were -2.1%, -10.2% and -32.4% in Model for End-stage Liver Disease (MELD) ≤11, 12-18 and ≥19 patients and were -1.5%, -9.1% and -23.2% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). The ARRs for mortality at 1 year were -1.7%, -5.4% and -32.7% in MELD ≤11, 12-18 and ≥19 patients, respectively, and -3.6%, -5.2% and -20.3% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). After adjusting for liver disease severity and other potential confounders, a survival benefit was observed in MELD ≥19 or Child-Pugh C patients but not in MELD ≤11 or Child-Pugh A patients. In MELD 12-18 patients, a survival benefit was observed within 6 weeks but not at 1 year. In Child-Pugh B patients, a survival benefit was observed in those with active bleeding but not those without active bleeding. However, the evaluation of active bleeding was associated with a high interobserver variability. Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding or rebleeding and new or worsening ascites, without increasing the risk of overt hepatic encephalopathy. CONCLUSIONS Early TIPS was associated with improved survival in patients with MELD ≥19 or Child-Pugh C cirrhosis but not in patients with MELD ≤11 or Child-Pugh A cirrhosis. For MELD 12-18 or Child-Pugh B patients, future studies addressing optimal selection criteria for early TIPS remain highly warranted.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Luo Zuo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, The Southern Medical University, Guangzhou, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zaibo Jiang
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Junhui Sun
- Hepatobiliaryand Pancreatic Intervention Center, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Li
- Department of Interventional Radiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kewei Zhang
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jiawei Zhong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qifeng Peng
- Department of Interventional Radiology, Nanfang Hospital, The Southern Medical University, Guangzhou, China
| | - Fuquan Ma
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Junyang Luo
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ming Zhang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Minhuang Sun
- Department of Interventional Radiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Junjiao Dong
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xulong Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tianlei Yu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jing Niu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yongzhan Nie
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Venous Collateral Pathways in Superior Thoracic Inlet Obstruction: A Systematic Analysis of Anatomy, Embryology, and Resulting Patterns. AJR Am J Roentgenol 2019; 213:200-210. [DOI: 10.2214/ajr.18.20172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Biselli M, Gramenzi A, Lenzi B, Dall'Agata M, Pierro ML, Perricone G, Tonon M, Bellettato L, D'Amico G, Angeli P, Boffelli S, Bonavita ME, Domenicali M, Caraceni P, Bernardi M, Trevisani F. Development and Validation of a Scoring System That Includes Corrected QT Interval for Risk Analysis of Patients With Cirrhosis and Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2019; 17:1388-1397.e1. [PMID: 30557740 DOI: 10.1016/j.cgh.2018.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/29/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The electrocardiographic QT interval frequently is prolonged in patients with cirrhosis. Acute gastrointestinal bleeding further prolongs corrected QT (QTc) in patients with cirrhosis, which has been associated with an increased risk of death within 6 weeks. We aimed to confirm these findings and develop a mortality risk index that incorporates QTc. METHODS We collected data from 274 patients with cirrhosis and acute gastrointestinal bleeding from any cause admitted to a hospital in Bologna, Italy, from January 2001 through December 2012 (training set). We used logistic regression analysis to identify patient factors associated with death within 6 weeks (6-week mortality). We validated our findings by using data from 200 patients with cirrhosis and gastrointestinal bleeding treated at 2 separate hospitals in Italy, from 2001 through 2016 and 2007 through 2012. Our primary aim was to confirm the prognostic effects of prolonged QTc in a large population of patients and develop a 6-week mortality risk score for acute gastrointestinal bleeding from any cause that incorporates the QTc interval. RESULTS In the training set, QTc greater than 456 ms, the model for end-stage liver disease-sodium (MELD-Na) score, previous bleeding, and serum albumin concentration were associated independently with 6-week mortality. We combined these parameters to create a risk scoring system that we named MELD-Na acute gastrointestinal bleeding (MELDNa-AGIB). In the validation set, the MELDNa-AGIB identified patients who died within 6 weeks with an area under the receiver operating characteristic curve (AUROC) of 0.888; this value was higher than that of the MELD score (AUROC, 0.838; P = .031), MELD score with updated calibration (AUROC, 0.837; P = .029), Child-Turcotte-Pugh score (AUROC, 0.789; P = .004), D'Amico score (AUROC, 0.761; P = .003), and Augustin score (AUROC, 0.792; P = .001), with a net reclassification improvement better than the MELD-Na score (0.266; P = .045). In calibration, the MELDNa-AGIB produced a high score in the Hosmer-Lemeshow test (P = .947), which was superior to that of MELD-Na (P = .146). In the training set, only 6.3% of patients with MELDNa-AGIB scores of 4 or less died within 6 weeks. Among patients with a scores of 9, 16, and 25 or higher, 15.5%, 41.5%, and 81% or more patients died within 6 weeks, respectively. The probability of survival progressively and significantly decreased with increasing scores in the training and validation sets. CONCLUSIONS We confirmed QTc as an independent predictor of 6-week mortality in a large population of patients with cirrhosis and acute gastrointestinal bleeding. The combination of QTc, MELD-Na, previous bleeding, and serum albumin (the MELDNa-AGIB score) accurately determines the risk of 6-week mortality, providing timely identification of patients at very high risk of death.
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Affiliation(s)
- Maurizio Biselli
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Annagiulia Gramenzi
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Barbara Lenzi
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marco Dall'Agata
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Monica Loreta Pierro
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giovanni Perricone
- Gastroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Gastroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Hepatology and Gastroenterology Unit, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marta Tonon
- Clinica Medica, Dipartimento di Medicina, University of Padua, Padua, Italy
| | - Luca Bellettato
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Gennaro D'Amico
- Gastroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Paolo Angeli
- Clinica Medica, Dipartimento di Medicina, University of Padua, Padua, Italy
| | - Silvia Boffelli
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maria Elena Bonavita
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marco Domenicali
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paolo Caraceni
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Mauro Bernardi
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Franco Trevisani
- Semeiotica Medica, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
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Wang XK, Wang P, Zhang Y, Qi SL, Chi K, Wang GC. A study on spleen transient elastography in predicting the degree of esophageal varices and bleeding. Medicine (Baltimore) 2019; 98:e14615. [PMID: 30817578 PMCID: PMC6831430 DOI: 10.1097/md.0000000000014615] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This study aims to investigate the value and determine the accuracy of spleen stiffness in predicting the degree of esophageal varices and bleeding in patients with liver cirrhosis.The age, gender, liver stiffness, spleen stiffness, and gastroscopy results of 124 inpatients or outpatients with liver cirrhosis and healthy volunteers, who underwent both gastroscopy and FibroScan testing in the fasting state, were retrospectively analyzed. According to the gastroscopy results, the patients and healthy volunteers were divided into six groups: varicose bleeding, severe varices, moderate varices, mild varices, no varices, and healthy control group. Then, the receiver operating characteristic curves were drawn, and the corresponding area under each curve was calculated and evaluated to predict the severity of varices based on the relevance of the area and its parameters.The area under the receiver operating characteristic curve of liver stiffness and spleen stiffness for predicting severe and moderate varices in the bleeding group was 0.955 and 0.989, respectively. The cut-off values were 29.6 kPa and 45.5 kPa, respectively. The area under the receiver operating characteristic curve of liver stiffness for predicting varicose bleeding was 0.860 (95% CI: 0.789-0.931). The liver stiffness cut-off value for predicting varicose bleeding was 33.2 kPa, with a specificity and sensitivity of 66.02% and 95.24%, respectively. The area under the receiver operating characteristic curve of spleen stiffness for predicting varicose bleeding was 0.923 (95% CI: 0.875-0.971). A spleen stiffness cut-off value of 55.2 kPa had a sensitivity and specificity of 90.48% and 86.41%, respectively.Spleen stiffness can predict the degree of esophageal varices and bleeding in liver cirrhosis patients, and has good predictive accuracy.
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Affiliation(s)
- Xie-Kui Wang
- First Clinical College of Liaoning University of Traditional Chinese Medicine, Shenyang 110032
- Department of Liver Disease, Dalian Sixth People Hospital, Dalian 116031
| | - Ping Wang
- Department of Liver Disease, Dalian Sixth People Hospital, Dalian 116031
- Department of Gastroenterology, Yantaishan Hospital, Yantai 264001, China
| | - Yong Zhang
- Department of Liver Disease, Dalian Sixth People Hospital, Dalian 116031
| | - Sheng-Lin Qi
- Department of Liver Disease, Dalian Sixth People Hospital, Dalian 116031
| | - Kun Chi
- Department of Liver Disease, Dalian Sixth People Hospital, Dalian 116031
| | - Gong-Chen Wang
- Department of Liver Disease, Dalian Sixth People Hospital, Dalian 116031
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Ichikawa T, Machida N, Kaneko H, Oi I, A Fujino M. C-reactive Protein Can Predict Patients with Cirrhosis at a High Risk of Early Mortality after Acute Esophageal Variceal Bleeding. Intern Med 2019; 58:487-495. [PMID: 30333404 PMCID: PMC6421136 DOI: 10.2169/internalmedicine.1447-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective The aim of this study was to identify patients with a high risk of early mortality after acute esophageal variceal bleeding by measuring the C-reactive protein (CRP) level. Methods We retrospectively evaluated 154 consecutive cirrhotic patients admitted with acute esophageal variceal bleeding. Differences between categorical variables were assessed by the chi-square test. Continuous variables were compared using the Mann-Whitney U-test. Multivariate logistic regression analyses consisting of clinical laboratory parameters were performed to identify risk factors associated with the 6-week mortality. The discriminative ability and the best cut-off value were assessed by a receiver-operating characteristic (ROC) curve analysis. Results Child-Pugh C patients showed a significantly higher 6-week mortality than Child-Pugh A or B patients (38% vs. 6%, p<0.0001). The 6-week mortality in Child-Pugh C patients was associated with the age (p<0.0001), etiology of cirrhosis (p=0.003), hepatocellular carcinoma (p=0.0003), portal vein thrombosis (p=0.005), baseline creatinine (p=0.0001), albumin (p=0.001), white blood cell count (p=0.038), baseline CRP [p=0.0004; area under the ROC (AUROC)=0.765; optimum cut-off value at 1.30 mg/dL] and bacterial infection (p=0.019). We determined that CRP ≥1.30 mg/dL was an independent predictor for 6-week mortality in Child-Pugh C patients [odds ratio (OR)=8.789; 95% confidence interval (CI): 2.080-47.496; p=0.003], along with a creatinine level of 0.71 mg/dL (OR=17.628; 95% CI: 2.349-384.426; p=0.004) (73% mortality if CRP ≥1.30 mg/dL vs. 19% if CRP<1.30 mg/dL, p<0.0001). Conclusion In Child-Pugh C patients with esophageal variceal bleeding, a baseline CRP ≥1.30 mg/dL can help identify patients with an increased risk of mortality.
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Affiliation(s)
- Takeshi Ichikawa
- Department of Gastroenterology and Hepatology, Nippon Koukan Hospital, Japan
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
| | - Nobuaki Machida
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
| | - Hiroaki Kaneko
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
| | - Itaru Oi
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
| | - Masayuki A Fujino
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
- Department of Internal Medicine, Hasune Royal Clinic, Japan
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Model for end-stage liver disease score and hemodynamic instability as a predictor of poor outcome in early transjugular intrahepatic portosystemic shunt treatment for acute variceal hemorrhage. Eur J Gastroenterol Hepatol 2018; 30:1441-1446. [PMID: 30048333 DOI: 10.1097/meg.0000000000001222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the outcome of early transjugular portosystemic shunt (TIPS) treatment in patients with a trial-compatible high-risk variceal bleeding and secondly to disclose other predictors of early mortality. MATERIALS AND METHODS A cohort study was conducted on patients referred for a TIPS procedure with or without combined variceal embolization to control acute esophageal variceal bleeding. A total of 32 patients with Child-Pugh C score less than 14 or Child-Pugh B plus active bleeding at endoscopy, admitted for early-TIPS treatment (<72 h), were included. RESULTS We noted one (3.7%) failure to control bleeding and no rebleeding during 1-year follow-up. Ten (31.3%) patients died within 6 weeks after TIPS placement. Early mortality was associated with model for end-stage liver disease (MELD) score (P=0.025), MELD score of at least 19 (P=0.008) and hemodynamic instability at time of admission (P=0.001). If hemodynamic instability is associated with a high MELD score, the 6-week mortality peaks at 77.8% (P=0.000). CONCLUSION This study confirms the excellent survival results of early-TIPS treatment for acute variceal bleeding in a selected patient group with a low MELD score. Poor survival in hemodynamically unstable patients with high MELD scores (≥19) contests the guidelines that patients with Child-Pugh class C cirrhosis or Child-Pugh class B with active bleeding on endoscopy should deliberately receive preemptive TIPS treatment after endoscopic haemostasis.
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Søgaard KK, Adelborg K, Darvalics B, Horváth-Puhó E, Beyer-Westendorf J, Ageno W, Sørensen HT. Risk of bleeding and arterial cardiovascular events in patients with splanchnic vein thrombosis in Denmark: a population-based cohort study. LANCET HAEMATOLOGY 2018; 5:e441-e449. [PMID: 30201587 DOI: 10.1016/s2352-3026(18)30133-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/21/2018] [Accepted: 07/21/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little is known about adverse events following splanchnic vein thrombosis. Venous thromboembolism has been associated with increased risks of bleeding and arterial cardiovascular events. To learn more about the clinical course of splanchnic vein thrombosis, we examined the risks of bleeding and arterial cardiovascular events in patients with the disease, and compared them with the risks in patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) and individuals from the general population. METHODS In this population-based cohort study, we used data for all patients with a diagnosis of splanchnic vein thrombosis recorded in the Danish National Patient Registry (DNPR) between Jan 1, 1994, and Nov 30, 2013 (cumulative source population 7 310 450 individuals). We created two comparison cohorts using data from the DNPR and the Civil Registration System for the same period: one of patients with DVT or PE and another of individuals from the general population. Comparison cohorts (ten comparators per patient with splanchnic vein thrombosis) were matched on sex, age, and calendar year of diagnosis. We calculated absolute risks and used proportional hazard regression to calculate adjusted hazard ratios (HRs) for the primary outcomes of bleeding and arterial cardiovascular events after splanchnic vein thrombosis diagnosis (or the index date for comparison cohorts). FINDINGS 1915 patients with splanchnic vein thrombosis, 18 373 patients with DVT or PE, and 19 150 individuals from the general population were included in the study. Patients with splanchnic vein thrombosis were followed up for a median of 1 year (IQR 0·1-3·9). These patients had a high risk of bleeding in the 30 days after diagnosis, both in absolute terms (4·3% [95% CI 3·5-5·3]) and in adjusted models (HR 9·64 [95% CI 6·46-14·40] vs DVT or PE; 39·79 [19·44-81·46] vs general population). Bleeding risk was still significantly increased in patients with splanchnic vein thrombosis up to 1 year after diagnosis (HR 3·01 [95% CI 2·28-3·97] vs DVT or PE; 6·83 [4·83-9·65] vs general population), and remained elevated for up to 10 years compared with patients with DVT or PE (1·93 [1·12-3·34]) and for up to 19 years compared with the general population (5·90 [2·22-15·64]). The risk of arterial cardiovascular events in patients with splanchnic vein thrombosis was high in the year after diagnosis (absolute risk 3·3% [95% CI 2·6-4·2] up to 30 days; 7·0% [5·8-8·4] up to 31-365 days), and in adjusted models was significantly higher than in patients with DVT or PE (HR 7·05 [95% CI 4·74-10·48] up to 30 days; 2·10 [1·62-2·72] up to 31-365 days) and individuals from the general population (15·75 [9·26-26·79] and 3·17 [2·34-4·27], respectively). However, this risk did not remain significantly elevated above that of patients with DVT or PE after 1 year or the general population after 5 years. INTERPRETATION Patients with splanchnic vein thrombosis are at increased risk of adverse outcomes, particularly bleeding but also arterial cardiovascular events, for years after diagnosis compared with patients with DVT or PE and the general population. Physicians should be cognisant of these risks in patients with splanchnic vein thrombosis. FUNDING The Program for Clinical Research Infrastructure (PROCRIN), established by the Lundbeck Foundation and the Novo Nordisk Foundation.
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Affiliation(s)
| | - Kasper Adelborg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Bianka Darvalics
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine 1, Division of Haematology, University Hospital Carl Gustav Carus, Dresden, Germany; King's Thrombosis Service, Department of Haematology, King's College London, London, UK
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. Concepts and Controversies in Haemostasis and Thrombosis Associated with Liver Disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118:1491-1506. [PMID: 30060258 PMCID: PMC6202935 DOI: 10.1055/s-0038-1666861] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- N. M. Intagliata
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - C. K. Argo
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - J. G. Stine
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - T. Lisman
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - S. H. Caldwell
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - F. Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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Angeli P, Bernardi M, Villanueva C, Francoz C, Mookerjee RP, Trebicka J, Krag A, Laleman W, Gines P. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1717] [Impact Index Per Article: 245.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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La Mura V, Braham S, Tosetti G, Branchi F, Bitto N, Moia M, Fracanzani AL, Colombo M, Tripodi A, Primignani M. Harmful and Beneficial Effects of Anticoagulants in Patients With Cirrhosis and Portal Vein Thrombosis. Clin Gastroenterol Hepatol 2018; 16:1146-1152.e4. [PMID: 29066371 DOI: 10.1016/j.cgh.2017.10.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Vitamin K antagonists (VKAs) promote recanalization of portal vein thrombosis (PVT) in patients with cirrhosis. However, the benefit of PVT recanalization might be offset by major and minor bleeding associated with use of anticoagulants. We evaluated harmful and beneficial effects of VKA in patients with PVT and cirrhosis. METHODS We performed a retrospective study of 63 consecutive patients with cirrhosis given anticoagulants for the first detection of non-neoplastic PVT from 2003 to 2015 in Italy. We collected data on bleeding events in these patients and compared them with those from patients without cirrhosis with venous thromboembolism (VTE) (n = 160) for up to 4 years. Time in the therapeutic range, based on the international normalized ratio, was used to determine the quality of anticoagulation. We also collected data from 139 patients with cirrhosis who did not receive VKAs (controls), to analyze portal hypertension-related events. We performed survival analyses to determine the effects of VKA in patients with PVT vs controls. RESULTS The group with VTE and the group with PVT were comparable in age, sex, and time in the therapeutic range, but patients with VTE received VKAs for a longer time period (31.1 ± 16.9 mo vs 23.3 ± 16.2 mo; P = .002). The incidence of major or minor bleeding was higher in patients with PVT than patients with VTE (major, 24% vs 7%; P = .012; minor, 29% vs 19%; P = .024). Patients with PVT had a higher rate of major bleeding from the upper-gastrointestinal tract than patients with VTE (P = .019), but there were no significant differences in other types of major bleeding (P = .376). Patients with PVT and controls had the same rate of upper-gastrointestinal bleeding. Complete recanalization in patients with PVT receiving VKA (n = 31) was independently associated with increased portal hypertension-related event-free and transplantation-free survival times. CONCLUSIONS In a retrospective analysis of 63 patients with cirrhosis given anticoagulants for PVT, we found VKA use to increase risk of minor bleeding, compared with patients without cirrhosis given VKA. However, this risk is offset by the ability of VKA to increase portal hypertension-related, event-free, and transplantation-free survival of patients with PVT recanalization. Portal hypertension, rather than anticoagulants, could account for the difference in risk of major bleeding between patients with PVT vs patients with VTE.
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Affiliation(s)
- Vincenzo La Mura
- A. M. and A. Migliavacca-Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy; Internal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Donato, Department of Biomedical Sciences for Health, University of Milan, San Donato Milanese, Italy.
| | - Simon Braham
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giulia Tosetti
- A. M. and A. Migliavacca-Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Federica Branchi
- A. M. and A. Migliavacca-Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Niccolò Bitto
- Internal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Donato, Department of Biomedical Sciences for Health, University of Milan, San Donato Milanese, Italy
| | - Marco Moia
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Anna Ludovica Fracanzani
- Internal Medicine, Department of Pathophysiology and Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Massimo Colombo
- Department of Internal Medicine, Humanitas Clinical and Research Center (MI), Rozzano, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Massimo Primignani
- A. M. and A. Migliavacca-Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Ardevol A, Ibañez-Sanz G, Profitos J, Aracil C, Castellvi JM, Alvarado E, Cachero A, Horta D, Miñana J, Gomez-Pastrana B, Pavel O, Dueñas E, Casas M, Planella M, Castellote J, Villanueva C. Survival of patients with cirrhosis and acute peptic ulcer bleeding compared with variceal bleeding using current first-line therapies. Hepatology 2018; 67:1458-1471. [PMID: 28714072 DOI: 10.1002/hep.29370] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/18/2017] [Accepted: 07/11/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED The presence of cirrhosis increases the mortality of patients with peptic ulcer bleeding (PUB). Both acute variceal bleeding (AVB) and PUB are associated with substantial mortality in cirrhosis. This multicenter cohort study was performed to assess whether the mortality of patients with cirrhosis with PUB is different from that of those with AVB. Patients with cirrhosis and acute gastrointestinal bleeding were consecutively included and treated with somatostatin and proton pump inhibitor infusion from admission and with antibiotic prophylaxis. Emergency endoscopy with endoscopic therapy was performed within the first 6 hours. 646 patients with AVB and 144 with PUB were included. There were baseline differences between groups, such as use of gastroerosive drugs or β-blockers. Child-Pugh and Model for End-Stage Liver Disease MELD scores were similar. Further bleeding was more frequent in the AVB group than those in the PUB group (18% vs. 10%; odds ratio [OR] = 0.50; 95% confidence interval [CI] = 0.29-0.88). However, mortality risk at 45 days was similar in both groups (19% in the AVB group vs. 17% in the PUB group; OR = 0.85; 95% CI = 0.55-1.33; P = 0.48). Different parameters, such as Child-Pugh score, acute kidney injury, acute on chronic liver failure, or presence of shock or bacterial infection, but not the cause of bleeding, were related to the risk of death. Only 2% of the PUB group versus 3% of the AVB group died with uncontrolled bleeding (P = 0.39), whereas the majority of patients in either group died from liver failure or attributed to other comorbidities. CONCLUSION Using current first-line therapy, patients with cirrhosis and acute peptic ulcer bleeding have a similar survival than those with variceal bleeding. The risk of further bleeding is higher in patients with variceal hemorrhage. However, few patients in both groups died from uncontrolled bleeding, rather the cause of death was usually related to liver failure or comorbidities. (Hepatology 2018;67:1458-1471).
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Affiliation(s)
- Alba Ardevol
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gemma Ibañez-Sanz
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joaquim Profitos
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | - Carles Aracil
- Department of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Josep M Castellvi
- Department of Gastroenterology, Hospital de Mataró, Barcelona, Spain
| | - Edilmar Alvarado
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alba Cachero
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Diana Horta
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | - Josep Miñana
- Department of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | | | - Oana Pavel
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Eva Dueñas
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Meritxell Casas
- Department of Gastroenterology, Corporació Sanitària Parc Tauli, Sabadell, Barcelona, Spain
| | | | - Jose Castellote
- Hepatology and Liver Transplant Unit, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Candid Villanueva
- Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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Lee HH, Park JM, Han S, Park SM, Kim HY, Oh JH, Kim CW, Yoon SK, Choi MG. A simplified prognostic model to predict mortality in patients with acute variceal bleeding. Dig Liver Dis 2018; 50:247-253. [PMID: 29208551 DOI: 10.1016/j.dld.2017.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/22/2017] [Accepted: 11/13/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute variceal bleeding (AVB) is a major cause of death in patients with liver cirrhosis. The aim of this study was to investigate mortality predictors and develop a new simple prognostic model using easily verified factors at admission in AVB patients. METHODS Between January 2009 and May 2015, 333 consecutive patients with AVB were included. A simplified prognostic model was developed using multiple logistic regression after identifying significant predictors of 6-week mortality. Mortality prediction accuracy was assessed with area under the receiver operating characteristic (AUROC) curve. We compared the new model to existing models of model for end-stage liver disease (MELD) and Child-Pugh scores. RESULTS The 6-week overall mortality rate was 12.9%. Multivariate analysis showed that C-reactive protein (CRP), total bilirubin, and the international normalized ratio were independent predictors of mortality. A new logistic model using these variables was developed. This model's AUROC was 0.834, which was significantly higher than that of MELD (0.764) or Child-Pugh scores (0.699). Two external validation studies showed that the AUROC of our model was consistently higher than 0.8. CONCLUSIONS Our new simplified model accurately and consistently predicted 6-week mortality in patients with AVB using objective variables measured at admission. Our system can be used to identify high risk AVB patients.
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Affiliation(s)
- Han Hee Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Jae Myung Park
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Republic of Korea.
| | - Seunghoon Han
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Sung Min Park
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Jung Hwan Oh
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Chang Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Seung Kew Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Myung-Gyu Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Republic of Korea
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D'Amico G, D'Amico M, Malizia G. Refining early-TIPS criteria requires good quality prognostic studies. Liver Int 2018; 38:412-414. [PMID: 29469210 DOI: 10.1111/liv.13671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Mario D'Amico
- Radiology Department, Ospedale Policlinico Maggiore, Milano, Italy
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