Malnutrition is common in patients with end-stage liver disease (ESLD) and is an independent risk factor for survival, therefore it should be treated as the same important guideline as ascites and hepatic encephalopathy. However, up to now, there is no clinical nutrition guideline for patients with ESLD in China. In order to standardize the nutrition treatment, Chinese Society of Hepatology (CSH) and Chinese Society of Gastroenterology (CSGE), Chinese Medical Association(CMA) co-organized and co-developed this guideline. Recommendations on nutritional screening and assessment as well as principles of intervention and management in patients with ESLD were provided to help clinicians make rational decisions on clinical malnutrition.
Ascites ; China ; End Stage Liver Disease/physiopathology* ; Enteral Nutrition/standards* ; Gastroenterology/standards* ; Hepatic Encephalopathy ; Humans ; Liver Cirrhosis/complications* ; Malnutrition/physiopathology* ; Nutrition Assessment ; Nutritional Status ; Practice Guidelines as Topic

INTRODUCTIONHepatic venous pressure gradient (HVPG) measurement is recommended for prognostic and therapeutic indications in centres with adequate resources and expertise. Our study aimed to evaluate the quality of HVPG measurements at our centre before and after introduction of a standardised protocol, and the clinical relevance of the HVPG to variceal bleeding in cirrhotics.

METHODSHVPG measurements performed at Singapore General Hospital from 2005-2013 were retrospectively reviewed. Criteria for quality HVPG readings were triplicate readings, absence of negative pressure values and variability of ≤ 2 mmHg. The rate of variceal bleeding was compared in cirrhotics who achieved a HVPG response to pharmacotherapy (reduction of the HVPG to < 12 mmHg or by ≥ 20% of baseline) and those who did not.

RESULTS126 HVPG measurements were performed in 105 patients (mean age 54.7 ± 11.4 years; 55.2% men). 80% had liver cirrhosis and 20% had non-cirrhotic portal hypertension (NCPH). The mean overall HVPG was 13.5 ± 7.2 mmHg, with a significant difference between the cirrhosis and NCPH groups (p < 0.001). The proportion of quality readings significantly improved after the protocol was introduced. HVPG response was achieved in 28 (33.3%, n = 84) cirrhotics. Nine had variceal bleeding over a median follow-up of 29 months. The rate of variceal bleeding was significantly lower in HVPG responders compared to nonresponders (p = 0.025).

CONCLUSIONThe quality of HVPG measurements in our centre improved after the introduction of a standardised protocol. A HVPG response can prognosticate the risk of variceal bleeding in cirrhotics.

Esophageal and Gastric Varices ; complications ; physiopathology ; Female ; Follow-Up Studies ; Gastrointestinal Hemorrhage ; etiology ; physiopathology ; prevention & control ; Humans ; Hypertension, Portal ; complications ; physiopathology ; Liver Cirrhosis ; complications ; physiopathology ; Male ; Middle Aged ; Portal Pressure ; physiology ; Prognosis ; Retrospective Studies

INTRODUCTIONLarge, recent population-based data for evaluating the predictors of oesophageal variceal bleeding (OVB) among cirrhotic patients is still lacking. This study aimed to determine the cumulative incidence of OVB among cirrhotic patients and identify the predictors of OVB occurrence.

METHODSPatient information on 38,172 cirrhotic patients without a history of OVB, who were discharged between 1 January 2007 and 31 December 2007, was obtained from the Taiwan National Health Insurance Database for this study. All patients were followed up for three years. Death was the competing risk when calculating the cumulative incidences and hazard ratios (HRs) of OVB.

RESULTSOVB was present in 2,609 patients (OVB group) and absent in 35,563 patients (non-OVB group) at hospitalisation. During the three-year follow-up period, the cumulative incidence of OVB was 44.5% and 11.3% in the OVB and non-OVB group, respectively (p < 0.001). Modified Cox regression analysis showed that the HR of OVB history was 4.42 for OVB occurrence (95% confidence interval [CI] 4.13-4.74). Other predictors for OVB occurrence included hepatocellular carcinoma (HR 1.16, 95% CI 1.09-1.24), young age (HR 0.98, 95% CI 0.98-0.98), ascites (HR 1.46, 95% CI 1.37-1.56), alcohol-related disorders (HR 1.20, 95% CI 1.12-1.28), peptic ulcer bleeding (HR 1.26, 95% CI 1.13-1.41) and diabetes mellitus (HR 1.14, 95% CI 1.06-1.23).

CONCLUSIONCirrhotic patients have a fourfold increased risk of future OVB following the first incidence of OVB.

Adult ; Aged ; Alcoholism ; complications ; Ascites ; complications ; Carcinoma, Hepatocellular ; complications ; Databases, Factual ; Diabetes Complications ; Esophageal and Gastric Varices ; epidemiology ; etiology ; Female ; Gastrointestinal Hemorrhage ; epidemiology ; etiology ; Humans ; Incidence ; Liver Cirrhosis ; complications ; physiopathology ; Liver Neoplasms ; complications ; Male ; Middle Aged ; Peptic Ulcer ; complications ; Proportional Hazards Models ; Recurrence ; Retrospective Studies ; Risk ; Taiwan

PURPOSE: The present study aimed to investigate the role of hepatic venous pressure gradient (HVPG) for prediction of long-term mortality in patients with decompensated cirrhosis. MATERIALS AND METHODS: Clinical data from 97 non-critically-ill cirrhotic patients with HVPG measurements were retrospectively and consecutively collected between 2009 and 2012. Patients were classified according to clinical stages and presence of ascites. The prognostic accuracy of HVPG for death, survival curves, and hazard ratios were analyzed. RESULTS: During a median follow-up of 24 (interquartile range, 13-36) months, 22 patients (22.7%) died. The area under the receiver operating characteristics curves of HVPG for predicting 1-year, 2-year, and overall mortality were 0.801, 0.737, and 0.687, respectively (all p<0.01). The best cut-off value of HVPG for predicting long-term overall mortality in all patients was 17 mm Hg. The mortality rates at 1 and 2 years were 8.9% and 19.2%, respectively: 1.9% and 11.9% with HVPG < or =17 mm Hg and 16.2% and 29.4% with HVPG >17 mm Hg, respectively (p=0.015). In the ascites group, the mortality rates at 1 and 2 years were 3.9% and 17.6% with HVPG < or =17 mm Hg and 17.5% and 35.2% with HVPG >17 mm Hg, respectively (p=0.044). Regarding the risk factors for mortality, both HVPG and model for end-stage liver disease were positively related with long-term mortality in all patients. Particularly, for the patients with ascites, both prothrombin time and HVPG were independent risk factors for predicting poor outcomes. CONCLUSION: HVPG is useful for predicting the long-term mortality in patients with decompensated cirrhosis, especially in the presence of ascites.
Adult ; Aged ; Ascites/mortality ; Female ; Hepatic Veins/*physiopathology ; Humans ; Kaplan-Meier Estimate ; Liver Cirrhosis/blood/complications/diagnosis/*mortality/*physiopathology ; Liver Failure/diagnosis/*mortality/physiopathology ; Male ; Middle Aged ; Predictive Value of Tests ; Prognosis ; Proportional Hazards Models ; ROC Curve ; Retrospective Studies ; Risk Factors ; Severity of Illness Index ; Venous Pressure

According to the increasing need for accurate staging of hepatic fibrosis, the ultrasound (US) elastography techniques have evolved significantly over the past two decades. Currently, US elastography is increasingly used in clinical practice. Previously published studies have demonstrated the excellent diagnostic performance of US elastography for the detection and staging of liver fibrosis. Although US elastography may seem easy to perform and interpret, there are many technical and clinical factors which can affect the results of US elastography. Therefore, clinicians who are involved with US elastography should be aware of these factors. The purpose of this article is to present a brief overview of US techniques with the relevant technology, the clinical indications, diagnostic performance, and technical and biological factors which should be considered in order to avoid misinterpretation of US elastography results.
Disease Progression ; Elasticity Imaging Techniques/instrumentation/*methods ; Fatty Liver/complications/diagnostic imaging ; Humans ; Hypertension, Portal/complications ; Liver/*diagnostic imaging/physiopathology ; Liver Cirrhosis/diagnostic imaging/pathology

Portal hypertension is a severe consequence of chronic liver diseases and is responsible for the main clinical complications of liver cirrhosis. Hepatic venous pressure gradient (HVPG) measurement is the best available method to evaluate the presence and severity of portal hypertension. Clinically significant portal hypertension is defined as an increase in HVPG to >10 mmHg. In this condition, the complications of portal hypertension might begin to appear. HVPG measurement is increasingly used in the clinical fields, and the HVPG is a robust surrogate marker in many clinical applications such as diagnosis, risk stratification, identification of patients with hepatocellular carcinoma who are candidates for liver resection, monitoring of the efficacy of medical treatment, and assessment of progression of portal hypertension. Patients who had a reduction in HVPG of > or =20% or to < or =12 mmHg in response to drug therapy are defined as responders. Responders have a markedly decreased risk of bleeding/rebleeding, ascites, and spontaneous bacterial peritonitis, which results in improved survival. This review provides clinical use of HVPG measurement in the field of liver disease.
Chronic Disease ; Hemodynamics ; Hemorrhage/etiology ; Hepatic Veins/physiology ; Humans ; Hypertension, Portal/complications ; Liver Cirrhosis/diagnosis ; Liver Diseases/complications/*physiopathology ; Portal Pressure

OBJECTIVETo determine the levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and evaluate their relationships with cardiac structure and function and liver function in patients with cirrhosis.

METHODSFifty patients with cirrhosis underwent two-dimensional Doppler echocardiography. The cirrhotic patients were divided into groups according to Child-Pugh score:Child-Pugh class A, n=15; Child-Pugh class B, n=20; Child-Pugh class C, n=15. Cardiac dimensions and left and right ventricular functions were evaluated. In addition, the plasma NT-proBNP was detected in the 50 cirrhotic patients and 11 healthy controls.

RESULTSThe levels of plasma NT-proBNP was significantly higher in cirrhotic patients than in healthy controls (240.15+/-80.87 pg/mL vs.55.86+/-20.13 pg/mL, P=0.000).The Child-Pugh class A, B and C groups showed no differences for left ventricular diameter, right ventricular diameter, septal thickness, left ventricular wall thickness, E wave, A wave, aortic annulus diameter, and the value of E/A.However, the left atrial diameter was significantly lower in the A group than in the C group (29.83+/-3.76 mm vs.35.08+/-3.68 mm, P=0.015) and in the B group than in the C group (31.78+/-4.05 mm vs.35.08+/-3.68 mm, P=0.000); there was no significant difference between the A and B groups. The plasma NT-proBNP was significantly lower in the A group than the C group (189.20+/-20.25 pg/mL vs.300.13+/-34.96 pg/mL, P=0.000) and in the B group than in the C group (202.34+/-31.20 pg/mL vs.300.13+/-34.96 pg/mL, P=0.000); there was no significant difference between the A and B groups (P=0.302).The NT-proBNP level was positively correlated with the left atrial diameter and the left ventricular wall thickness (r=0.540, P=0.000 andr=0.309, P=0.029 respectively).In addition, the NT-proBNP showed correlation with Child-Turcotte-Pugh score (r=0.454, P=0.001), albumin level (r=-0.376, P=0.007) and total bilirubin level (r=0.283, P=0.047).

CONCLUSIONs Increased levels of plasma NT-proBNP are related to disease severity in patients with cirrhosis.Furthermore, cardiac dysfunction in patients with cirrhosis may be related to increased plasma levels of NT-proBNP.

Heart Diseases ; complications ; Humans ; Liver Cirrhosis ; complications ; physiopathology ; Natriuretic Peptide, Brain ; blood ; Peptide Fragments ; blood

OBJECTIVEEndogenous hydrophobic bile acids may be a pathogenetic factor of biliary complications after orthotopic liver transplantation (OLT).This study was designed to investigate the effects of hydrophilic ursodeoxycholic acid (UDCA), when administered early after OLT, on serum liver tests and on the incidence of biliary complications.

METHODSA total of 112 adult patients undergoing OLT were randomly assigned to one of two groups for receipt of UDCA (13 to 15 mg/kg/d for 4 weeks, n=56) or a placebo (n=56). All patients underwent serum liver testing and measurement of serum bile acids during the 4 weeks following OLT.Patients with T-tube underwent measurement of biliary bile acids during the 4 weeks following OLT.Biliary complications, as well as patient and graft survival rates, were analyzed during the follow-up period (mean of 65.6 months).

RESULTSAt post-OLT days 7, 21 and 28, the UDCA-treated patients showed significantly lower levels of alanine aminotransferase, aspartate aminotransferase and gamma glutamyl transpeptidase (all P less than 0.05).In addition, the UDCA-treated patients showed significantly lower incidence of biliary sludge and casts within the first year post-OLT (3.6% vs.14.3%; x2=3.953, P=0.047). However, there were no significant differences for the incidence of other biliary complications at post-OLT years 1, 3 and 5.The graft and patient survival rates were also similar between the two groups.

CONCLUSIONUDCA, when administered early after OLT, improves results from serum liver tests and decreases the incidence of biliary sludge and casts within the first postoperative year.

Alanine Transaminase ; Aspartate Aminotransferases ; Bile ; Bile Acids and Salts ; Biliary Tract Diseases ; drug therapy ; physiopathology ; Humans ; Liver ; physiopathology ; Liver Cirrhosis, Biliary ; Liver Function Tests ; Liver Transplantation ; Postoperative Complications ; physiopathology ; Ursodeoxycholic Acid ; therapeutic use ; gamma-Glutamyltransferase

OBJECTIVETo investigate the risk factors for and the prognosis of acute kidney injury (AKI) in decompensated cirrhotic patients.

METHODSA total of 126 patients with decompensated cirrhosis and with (n =60) or without (n =66, control group) AKI were enrolled in this retrospective analysis. Follow-up was carried out on all patients, with durations ranging from less than 1 year to up to 4 years. Blood biochemistry, liver and renal functional parameters and prognosis of these patients were recorded. Logistic regression analysis was used to evaluate possible risk factors for decompensated cirrhotic patients developing AKI.

RESULTSThe patients with AKI had a significantly lower survival rate than the patients without AKI (55.0% vs.83.3%, x2 =13.270, p =0.001). Unconditional multivariate logistic regression analysis identified risk factors of AKI development in decompensated cirrhotic patients as increased serum creatinine (odds ratio (OR):1034), increased total bilirubin (OR:1.005), increased international normalized ratio (INR; OR:2.471), decreased plasma sodium concentration (OR:0.910), decreased serum cholinesterase (OR:0.999), and decreased glomerular filtration rate (GFR; OR:0.972) (all P less than 0.05).

CONCLUSIONThe development of acute kidney injury represents an adverse prognosis in decompensated cirrhotic patients. An increase in serum creatinine, total bilirubin or INR or a decrease in plasma sodium concentration, serum cholinesterase or GFR may be early-warning factors of development of AKI in decompensated cirrhotic patients.

Acute Kidney Injury ; diagnosis ; etiology ; Adult ; Case-Control Studies ; Female ; Humans ; Kidney Function Tests ; Liver Cirrhosis ; complications ; physiopathology ; Male ; Middle Aged ; Prognosis ; Retrospective Studies ; Risk Factors

INTRODUCTIONNecrotising fasciitis (NF) is often found in patients with diabetes mellitus, chronic renal failure, alcoholism, malignancy or liver cirrhosis. However, it remains unknown whether liver cirrhosis is an independent risk factor for the occurrence of NF. This study aimed to determine whether liver cirrhosis is an independent risk factor for the occurrence of NF, and to identify the relationship between severity of liver cirrhosis and occurrence of NF.

METHODSThe National Health Insurance Research Database, maintained by Taiwan's National Health Insurance programme, was retrospectively analysed, and the hospitalisation data of 40,802 cirrhotic patients and 40,865 randomly selected, age‑ and gender‑matched non‑cirrhotic control patients was collected. The medical records of all patients were individually followed for a three‑year period from the patients' first hospitalisation in 2004.

RESULTSDuring the three‑year follow‑up period, there were 299 (0.7%) cirrhotic patients with NF and 160 (0.4%) non‑cirrhotic patients with NF. Cox regression analysis showed that liver cirrhosis was a risk factor for the occurrence of NF during the study period (hazard ratio 1.982; p < 0.001). Among cirrhotic patients, those with complicated liver cirrhosis had a higher risk for the occurrence of NF than patients with non‑complicated liver cirrhosis (hazard ratio 1.320; p = 0.028).

CONCLUSIONCirrhotic patients had a higher risk for the occurrence of NF than non‑cirrhotic patients, and the risk for NF was especially high among patients with complicated liver cirrhosis.

Adult ; Age Factors ; Aged ; Alcoholism ; complications ; Comorbidity ; Fasciitis, Necrotizing ; complications ; physiopathology ; Female ; Follow-Up Studies ; Hospitalization ; Humans ; Incidence ; Liver Cirrhosis ; complications ; physiopathology ; Male ; Middle Aged ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors ; Sex Factors ; Taiwan ; Treatment Outcome