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

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

T2-weighted imaging and dynamic contrast­enhanced imaging in predicting the prognosis in patients with acute-on-chronic liver failure.

BACKGROUND: Acute-on-chronic liver failure (ACLF) is a syndrome with high 28- and 90-day mortality rates. Magnetic resonance imaging (MRI) has been widely used to diagnose and evaluate liver disease. Our purpose is to determine the value of the imaging features derived from Gd-DTPA-enhanced MRI for predicting the poor outcome of patients with ACLF and develop a clinically practical radiological score. METHODS: This retrospective study comprised 175 ACLF patients who underwent Gd-DTPA-enhanced abdominal MRI from January 2017 to December 2021. The primary end-point was 90-day mortality. Imaging parameters, such as diffuse hyperintense of the liver on T2WI, patchy enhancement of the liver at the arterial phase, uneven enhancement of the liver at the portal vein phase, gallbladder wall edema, periportal edema, ascites, esophageal and gastric varix, umbilical vein patefac, portal vein thrombosis, and splenomegaly were screened. Cox proportional hazard regression models were used to evaluate prognostic factors and develop a prediction model. The accuracy of the model was evaluated by receiver operating characteristic (ROC) curves. RESULTS: During the follow-up period, 31 of the 175 ACLF patients died within 90 days. In the multivariate analysis, three imaging parameters were independently associated with survival: diffuse hyperintense on T2WI (p = 0.007; HR = 3.53 [1.40-8.89]), patchy enhancement at the arterial phase (p = 0.037; HR = 2.45 [1.06-5.69]), moderate ascites (vs. mild) (p = 0.006; HR = 4.12 [1.49-11.36]), and severe ascites (vs. mild) (p = 0.005; HR = 4.29 [1.57-11.71]). A practical radiological score was proposed, based on the presence of diffuse hyperintense (7 points), patchy enhancement (5 points), and ascites (6, 8, and 8 points for mild, moderate, and severe, respectively). Further analysis showed that a cut-off at 14 points was optimum to distinguish high-risk (score > 14) from the low-risk group (score ≤ 14) for 90-day survival and demonstrated a mean area under the ROC curve of 0.774 in ACLF patients. CONCLUSIONS: Gd-DTPA-enhanced MR imaging features can predict poor outcomes in patients with ACLF, based on which we proposed a clinically practical radiological score allowing stratification of the 90-day survival.

An Optimal Prognostic Model Based on Multiparameter Ultrasound for Acute-on-Chronic Liver Failure.

OBJECTIVE: Acute-on-chronic liver failure (ACLF) is associated with a considerably high mortality, and accurate prognosis prediction is critical to navigate intervention decisions and improve clinical outcomes. The objective of this study was to establish a better prognostic model for ACLF based on multiparameter ultrasound in combination with clinical features. METHODS: A total of 149 patients with ACLF were prospectively enrolled and underwent conventional ultrasound, 2-D shear wave elastography (SWE), attenuation imaging, color Doppler sonography, superb microvascular imaging and contrast-enhanced ultrasound (CEUS). Univariate and multivariate analyses were performed to identify independent ultrasound signatures for the prognosis of ACLF, which, when integrated with clinical characteristics, were used to establish a prognostic model. RESULTS: Hepatic perfusion features of CEUS differed significantly between the poor and good prognosis groups, among which the time interval (TI) between peak portal vein (PV) velocity and liver parenchyma (LP) enhancement, TI(PV, LP), was independently associated with the prognosis of ACLF. A prediction model comprising TI(PV, LP) and the international normalized ratio was established, and the area under the curve (AUC) was 0.851, which is greater than those of the Model for End-stage Liver Disease (0.785), fall time of LP model (0.754), 2-D SWE nomogram (0.708) and TI(PV, LP) (0.352). Furthermore, the performance of the model was verified in an independent validation cohort (AUC = 0.920). CONCLUSION: The newly developed model performs better than existing tested models; thus, it has potential as a better non-invasive model for predicting the prognosis of patients with ACLF. A future multicenter, large-sample study is required to validate the performance of this model.

Gd-BOPTA-enhanced hepatobiliary phase MR imaging can predict the prognosis of patients with acute-on-chronic liver failure.

OBJECTIVES: To determine the value of gadobenate dimeglumine (Gd-BOPTA)-enhanced magnetic resonance imaging (MRI) from the hepatobiliary phase for predicting poor outcome in acute-on-chronic liver failure (ACLF) patients. METHODS: In this single-center retrospective study, 74 patients diagnosed as ACLF who underwent Gd-BOPTA-enhanced hepatobiliary magnetic resonance imaging were collected. The quantitative liver-spleen contrast ratio (Q-LSC) and the relative enhancement ratio of the biliary system (REB) at the hepatobiliary phase were measured. Cox proportional hazards regression models were used to evaluate prognostic factors. The capacity of the Q-LSC and REB to predict the 90-day outcome was evaluated via receiver operating characteristic (ROC) curve. RESULTS: During the follow-up period, twenty-eight of 74 ACLF patients (38%) had a poor outcome. The Q-LSC and REB were significant predictive factors (hazard ratio [HR] = 0.03 [0.002-0.54], p < 0.05; HR = 0.07 [0.01-0.88], p < 0.05) for prognosis in patients with ACLF. Moreover, the areas under the ROC curves of Q-LSC and REB for predicting poor outcome in patients with ACLF were 0.81 and 0.80, respectively. The most appropriate cutoff values for the Q-LSC and REB were 1.09 and 0.57, respectively. The ACLF patients with the Q-LSC ≤ 1.09 or REB ≤ 0.57 had a low cumulative survival. CONCLUSIONS: Gd-BOPTA-enhanced hepatobiliary phase MR imaging can predict poor outcome in patients with acute-on-chronic liver failure. KEY POINTS: • The quantitative liver-spleen contrast ratio at the hepatobiliary phase was a significant predictive prognostic factor in patients with acute-on-chronic liver failure. • The relative enhancement ratio of the biliary system at the hepatobiliary phase was a significant prognostic factor in patients with acute-on-chronic liver failure. • Gadobenate dimeglumine contrast-enhanced MR imaging from the hepatobiliary phase can predict poor outcome in patients with acute-on-chronic liver failure.

Computed Tomography Image Features under Convolutional Neural Network Algorithm in Analysis of Inflammatory Factor Level and Prognosis of Patients with Hepatitis B Virus-Associated Acute-on-Chronic Liver Failure.

This study aimed to explore the application value of three-dimensional (3D) convolutional neural networks (3D-CNN)-based computed tomography (CT) image intelligent segmentation model in the identification of lesions of patients with hepatitis B virus-associated acute-on-chronic liver failure (HBV-ACLF). A total of 30 patients with HBV-ACLF, 30 patients with chronic HBV hospitalized in hospital, and 30 healthy volunteers were selected as subjects. Liver function and serum inflammatory factors were measured in each group, and the 3D-CNN algorithm model was applied to CT imaging. The results showed that the levels of interleukin (IL)-6, IL-26, and IL-37 in the HBV-ACLF group were the highest, which were 128.43 ± 45.16 pg/mL, 1237.47 ± 536.22 pg/mL, and 50.83 ± 7.62 pg/mL, respectively. Total bilirubin (TBIL) (P=0.035) and IL-26 (P=0.013) were independent predictors that affected the prognosis of HBV-ACLF patients. The results of lesion segmentation showed that the Dice coefficient of 3D-CNN low-density focus and enhanced focus segmentation was the highest (0.821 ± 0.07 and 0.773 ± 0.071), and the marked area was close to the area manually drawn by the doctor. 3D CNN was superior to other algorithms in the number of nodular lesions detected (533), sensitivity (97.5%), and missed detection rate (0.52%) (P < 0.05). In short, IL-26 may become a useful biomarker in the treatment of HBV-ACLF. The 3D-CNN model improved the segmentation performance of lesions in CT images of HBV-ACLF patients, which provided a reference for the diagnosis and prognosis of HBV-ACLF.

2D shear wave elastography combined with MELD improved prognostic accuracy in patients with acute-on-chronic hepatitis B liver failure.

OBJECTIVES: To evaluate accuracy of two-dimensional shear wave elastography (2D SWE) and develop and validate a new prognostic score in predicting prognosis of acute-on-chronic liver failure (ACLF) patients. METHODS: From 1 October 2013 to 30 September 2015, we consecutively enrolled 290 patients, sequentially collected data (including 2D SWE, ultrasound parameters, laboratory data and prognostic scores) and recorded patients' outcome (recovering/steady or worsening) during a 90-day follow-up period. We evaluated ability of 2D SWE to predict outcomes of acute-on-chronic hepatitis B liver failure (ACLF-HBV) patients. We developed a new score (MELD-SWE, combining MELD and SWE values) for predicting mortality risk of ACLF-HBV in 179 patients in a derivation group, and validated in 111 patients. RESULTS: 2D SWE values were higher in worsening patients than recovering/steady ones (p < 0.001). Accuracy of 2D SWE in predicting outcomes of ACLF-HBV was comparable to that of the MELD score (p = 0.441). MELD-SWE showed a significantly higher prognostic value than MELD in both derivation (AUROC, 0.80 vs. 0.76, p = 0.040) and validation (AUROC, 0.87 vs. 0.82, p = 0.018) group. CONCLUSIONS: The MELD-SWE score, combining MELD and SWE values, was superior to MELD alone for outcoming prediction in patients with ACLF-HBV. KEY POINTS: • 2D SWE is a simple prognostic evaluation tool in patients with ACLF-HBV. • MELD-SWE was created in this study: 1.3×MELD + 0.3×2D SWE (kPa). • MELD-SWE score was superior to MELD alone for outcoming prediction in ACLF-HBV. • In this study, 46.8 was the optimal cut-off value of MELD-SWE score.

Thromboelastography Parameters in Patients with Acute on Chronic Liver Failure.

INTRODUCTION AND AIM: Patients with acute on chronic liver failure (ACLF) have abnormal conventional coagulation tests- platelet count and international normalized ratio (INR). Thromboelastography (TEG) is a rapid, point-of-care assay, more comprehensive than platelet count and INR as it assesses for platelet adequacy (number and function), coagulation factors and clot retraction. The aim of the study was to evaluate the TEG parameters in patients with ACLF, chronic liver disease having acute decompensation (AD) and healthy subjects (HC). MATERIAL AND METHODS: TEG parameters were assessed in patients with ACLF and AD within 24 h of admission. Consecutive patients were included in the study over 12 months. Healthy subjects were recruited as controls. RESULTS: 179 patients were included- 68 ACLF, 53 AD and 58 HC. The mean values of INR in ACLF, AD and HC groups were 2.9 ± 1.4, 1.6 ± 0.4 and 1.1 ± 0.2; P < 0.001. Among TEG parameters - maximum amplitude (MA) was low in ACLF and AD patients as compared with HC (53.8 ± 15, 58.3 ± 13.9 mm and 67.2 ± 12.1 mm, respectively; P < 0.001). Lysis at 30 min (LY30) was high in ACLF patients, as compared to AD and HC (8.6 ± 14.1%, 5.0 ± 9.5% and 4.9 ± 9.8%, respectively; P = 0.060). There were no differences in r time, k time, and alpha angle between groups; normal in >90% patients. There was no difference in TEG parameters between different ACLF grades, whereas CCTs were more deranged with increasing grades of ACLF. CONCLUSION: Despite abnormal conventional coagulation tests, TEG parameters in ACLF patients are essentially normal, except reduced maximum amplitude. Future studies are needed to explore the utility of TEG in clinical management of ACLF patients.

The qualitative and quantitative image analysis of MR imaging in patients with acute-on-chronic liver failure.

PURPOSE: To evaluate the distinctive features of ACLF and chronic liver disease (CLD) on MR images using quantitative and qualitative analyses. METHODS: Twelve patients with ACLF and 36 patients with CLD who had undergone MR images were included. MR imaging findings from both groups were assessed. RESULTS: Gallbladder edema, esophageal varix, and ascites were significantly more prevalent in the ACLF group (all P-values <0.05). The liver to muscle SI ratio on T2-WI was significantly higher in the ACLF group (P=0.002). CONCLUSION: MR imaging findings could be helpful in differentiating between patients with ACLF and those with CLD.

Modification in CSF specific gravity in acutely decompensated cirrhosis and acute on chronic liver failure independent of encephalopathy, evidences for an early blood-CSF barrier dysfunction in cirrhosis.

Although hepatic encephalopathy (HE) on the background of acute on chronic liver failure (ACLF) is associated with high mortality rates, it is unknown whether this is due to increased blood-brain barrier permeability. Specific gravity of cerebrospinal fluid measured by CT is able to estimate blood-cerebrospinal fluid-barrier permeability. This study aimed to assess cerebrospinal fluid specific gravity in acutely decompensated cirrhosis and to compare it in patients with or without ACLF and with or without hepatic encephalopathy. We identified all the patients admitted for acute decompensation of cirrhosis who underwent a brain CT-scan. Those patients could present acute decompensation with or without ACLF. The presence of hepatic encephalopathy was noted. They were compared to a group of stable cirrhotic patients and healthy controls. Quantitative brain CT analysis used the Brainview software that gives the weight, the volume and the specific gravity of each determined brain regions. Results are given as median and interquartile ranges and as relative variation compared to the control/baseline group. 36 patients presented an acute decompensation of cirrhosis. Among them, 25 presented with ACLF and 11 without ACLF; 20 presented with hepatic encephalopathy grade ≥ 2. They were compared to 31 stable cirrhosis patients and 61 healthy controls. Cirrhotic patients had increased cerebrospinal fluid specific gravity (CSF-SG) compared to healthy controls (+0.4 %, p < 0.0001). Cirrhotic patients with ACLF have decreased CSF-SG as compared to cirrhotic patients without ACLF (-0.2 %, p = 0.0030) that remained higher than in healthy controls. The presence of hepatic encephalopathy did not modify CSF-SG (-0.09 %, p = 0.1757). Specific gravity did not differ between different brain regions according to the presence or absence of either ACLF or HE. In patients with acute decompensation of cirrhosis, and those with ACLF, CSF specific gravity is modified compared to both stable cirrhotic patients and healthy controls. This pattern is observed even in the absence of hepatic encephalopathy suggesting that blood-CSF barrier impairment is manifest even in absence of overt hepatic encephalopathy.