Relationship between platelet-to-lymphocyte ratio and early rebleeding after endoscopic variceal ligation: a bicenter retrospective study.

BACKGROUND: Endoscopic variceal ligation (EVL) is the primary treatment for esophageal variceal bleeding in patients with liver cirrhosis (LC). Postoperative rebleeding is a complication of EVL, contributing to over 20% of bleeding-related deaths. This study aims to examine the association between platelet-to-lymphocyte ratio (PLR) and rebleeding within 6 weeks after EVL in patients with LC. METHODS: The study included 145 eligible patients who underwent their first EVL procedure at Yijishan Hospital of Wannan Medical College between January 2016 and August 2022 (YJS cohort). An external validation cohort comprising 338 eligible patients from NO.2 People's Hospital of Fuyang City (FY cohort) between July 2018 and August 2022 was also utilized. RESULTS: In the YJS cohort, Multivariate logistic analysis indicated that high PLR is independently associated with early rebleeding after EVL. The restricted cubic spline analysis demonstrated that the risk of rebleeding increases with rising PLR, stabilizing at PLR values greater than 150. Similar findings were validated in the FY cohort. CONCLUSIONS: Our results have the potential to aid in the identification of high-risk patients for early rebleeding after EVL, thereby enabling improved clinical management and outcomes for these individuals.

This study is the first to report on the independent association between the platelet-to-lymphocyte ratio (PLR) and early rebleeding after endoscopic variceal ligation (EVL).The restricted cubic spline analysis showed a linear correlation between PLR and the risk of early rebleeding after EVL.An increase in PLR level is independently associated with a higher risk of early rebleeding after EVL.

Serum Prolactin as a Marker of the Severity of Liver Cirrhosis in a Tertiary Hospital in India: A Cross-Sectional Study.

BACKGROUND: In India, cirrhosis is becoming a growing concern, leading to an unmet need for new non-invasive markers to assess the severity of liver disease. Serum prolactin is one such marker. AIM: To determine the association between serum prolactin, the severity of liver cirrhosis, and its complications such as ascites, hepatic encephalopathy, and esophageal varices. METHODS: This cross-sectional study involved 117 patients with liver cirrhosis. They were evaluated for some complications such as ascites, esophageal varices, and hepatic encephalopathy, as well as for severity by using the Child-Turcotte-Pugh (CTP) score. Serum prolactin levels were measured, and their relationship with both the severity and complications of liver cirrhosis was determined. A P value of < 0.05 was considered significant. RESULTS: The mean age of the patients was 48.3 ± 12.08 years, and the majority (80.3%) were males. Seventy-one percent of the patients had elevated serum prolactin levels (>19.40 ng/mL). Elevated serum prolactin was found in approximately 95.0% and 86.8% of patients with hepatic encephalopathy and ascites, respectively. The median serum prolactin levels were significantly associated with esophageal varices grades (P = 0.043) and hepatic encephalopathy (P < 0.001). The sensitivity and specificity of serum prolactin for predicting severe CTP scores were 81.6% and 91.2%, respectively, with a diagnostic accuracy of 87.2%. On multivariate regression analysis, ascites (AOR = 3.8, 95%CI = 1.29-10.98, P = 0.015), hepatic encephalopathy (AOR = 6.1, 95%CI = 0.68-53.78, P = 0.012), CTP class B (AOR = 5.9, 95%CI = 1.39-24.68, P = 0.016), and CTP class C (AOR = 13.4, 95%CI = 2.25-82.21, P = 0.004) were significantly associated with elevated serum prolactin levels. CONCLUSION: There was a significant association between serum prolactin levels and CTP classes, esophageal varices, ascites, and hepatic encephalopathy in patients with liver cirrhosis.

Cystatin C/albumin ratio for early diagnosis of esophageal varices in liver cirrhosis.

The mortality rate related to variceal bleeding is high in patients with liver cirrhosis. Early detection and treatment of varices can reduce the risk of hemorrhage and thus decrease the mortality rate related to variceal bleeding. The study comprised 81 cirrhotic patients in training set, who were categorized into 2 groups: the patients with esophageal varices (EVs group) and the patients without esophageal varices (non-EVs group). The disparity in Cystatin C/albumin ratio (CAR) was assessed between these 2 groups. Subsequently, a regression model was constructed by generating a receiver operating characteristic (ROC) curve to calculate the area under the curve (AUC). Then an external validation was performed in 25 patients. Among patients with cirrhosis in training set, a statistically significant difference in CAR was observed between the EVs group and non-EVs group (P < .05). At the CAR cutoff value of 2.79*10-5, the AUC for diagnosing EVs were 0.666. Further, a multivariate logistic regression model was constructed, after adjusting the model, the AUC for EVs diagnosis were 0.855. And the external validation showed that the model could not be considered as a poor fit. CAR exhibits potential as an early detection marker for EVs in liver cirrhosis, and the regression model incorporating CAR demonstrates a strong capability for early EVs diagnosis.

Platelet count/spleen volume ratio has a good predictive value for esophageal varices in patients with hepatitis B liver cirrhosis.

BACKGROUND & AIMS: Platelet count/spleen longest diameter ratio (PSDR) is widely used in clinical practice due to its good performance in predicting esophageal varices (EV). We obtained spleen volume (SV) by magnetic resonance examination, the purpose of this study was to evaluate the clinical value of platelet count/spleen volume ratio (PSVR) and spleen volume in predicting EV in patients with hepatitis B cirrhosis. Methods: This study was a diagnostic accuracy experiment and retrospective, 199 patients with hepatitis B cirrhosis who met the criteria were selected as the research subjects. All patients were collected blood samples in the morning on an empty stomach within 2 days, and related indicators were tested. Within 10 days, they received electronic gastroscopy and abdominal magnetic resonance examination. According to the Child-Pugh score, the patients were divided into groups with or without EV and with or without high-risk esophageal varices (HRV), then statistical analysis of the two groups was performed. RESULTS: The area under the curve (AUC) of PSVR in predicting EV or HRV in each group (85.5%-92.6%) was higher than PSDR, SV, spleen diameter, and platelet count. The AUC of PSDR in diagnosing HRV was higher than SV, and the AUC of SV in diagnosing EV was higher than PSDR, but the difference was not significant (P>0.05). In Child-Pugh A patients, Multivariate logistic regression analysis showed PSVR could be a predictor of HRV (P<0.05), SV was a reliable predictor of EV (P<0.05). CONCLUSION: PSVR is better than PSDR, spleen diameter, platelet count in predicting EV; in the absence of serological results, SV could be used instead of PSDR. Both can predict EV or HRV of patients with hepatitis B cirrhosis.

Plasma YAP1 predicts esophageal varices and the risk of variceal bleeding in liver cirrhosis.

Aim: To explore the predictive value of plasma YAP1 for esophageal varices (EV) and high-risk EV (HRV) in patients with liver cirrhosis. Materials & methods: A total of 208 patients with liver cirrhosis were enrolled and categorized into four groups. Correlation analysis, logistic regression analysis and receiver operating characteristic curve analysis were performed to evaluate the diagnostic performance of plasma YAP1 for EV and HRV. Results: Plasma YAP1 levels were significantly elevated with the occurrence and progression of EV in cirrhotic patients. The multivariate logistic regression analysis revealed that plasma YAP1 is an independent predictor for EV and HRV. For predicting EV and HRV, the YAP1 cut-off values of 5.43 and 6.98 ng/ml yielded the area under the receiver operating characteristic curves of 0.944 and 0.955, respectively. Conclusion: Plasma YAP1 is a potential novel noninvasive biomarker for predicting EV and HRV in patients with liver cirrhosis.

The Combination of Shear Wave Elastography and Platelet Counts Can Effectively Predict High-Risk Varices in Patients with Hepatitis B-Related Cirrhosis.

BACKGROUND: Baveno VI criteria, based on liver stiffness (LS) measured by transient elastography and platelet counts (PLT), have been proposed to avoid unnecessary endoscopy screening for high-risk varices (HRVs). However, the cut-off value of LS measured by 2D-SWE and PLT to predict HRVs in compensated hepatitis B-related cirrhotic patients remains unknown. AIMS: To prospectively analyze the cut-off of the combination of LS measured by 2D-SWE and PLT in predicting HRVs and the influence of antiviral therapies in its efficacy. METHODS: Serum parameters, LS, and endoscopy results were obtained from 160 compensated hepatitis B-related cirrhotic patients. The accuracy of the combined algorithm was assessed in the whole cohort and subgroups with or without consecutive antiviral therapies in the past 6 months. RESULTS: In the whole cohort, the optimal cut-off value of LS for HRVs was 14.5 kPa. Patients with a LS value < 14.5 kPa with a PLT value > 110 × 109/L can be excluded from HRVs (NPV = 0.99, endoscopy saved rates = 0.68). Conversely, a LS value of ≥14.5 kPa and a PLT value of ≤110 × 109/L indicated HRVs, with accurate rates of 82.35%, and 10.63% of patients can avoid additional endoscopy screening. Moreover, antiviral therapy had no significant effect on the accuracy and rates saved from further endoscopy screening, when comparing patients with or without antiviral therapies (all p values > 0.05). CONCLUSIONS: The combination of LS (14.5 kPa) measured by 2D-SWE and PLT (110 × 109/L) can predict HRVs accurately in compensated hepatitis B-related cirrhotic patients without significant interference of antiviral therapy histories.

Novel albumin, bilirubin and platelet criteria for the exclusion of high-risk varices in compensated advanced chronic liver disease: A validation study.

BACKGROUND AND AIMS: Availability of transient elastography (TE) limits the application of Baveno-VI criteria. In a derivation study, the ABP criteria (Albumin >40 g/l, Bilirubin <22 µmol/l and Platelet >114,000/µl) had been shown to perform well in identifying compensated advanced chronic liver disease (cACLD) patients without high-risk varices (HRV). We aim to externally validate this novel ABP criteria for the exclusion of HRVs among cACLD patients. METHODS: Data was retrospectively collected from consecutive cACLD patients with paired TE and esophagogastroduodenoscopy (EGD) performed between 2011 and 2017 in Changi General Hospital, Singapore. We estimate the discriminative ability of ABP criteria in validation cohort using AUROC and calibration-in-the-large. We subsequently compare the performance between ABP and Baveno-VI criteria in the validation cohort. RESULTS: Among 314 patients included in our validation cohort, 32 (10.2%) had HRV on screening EGD. Application of ABP criteria within this validation cohort has increased discriminative ability than the derivation cohort. The AUROC of validation and derivation cohort were 0.68 (0.60-0.76) and 0.66 (0.60-0.76), respectively. The mean and standard error for calibration-in-the-large and calibration slope were -0.08 (0.22) and 0.93 (0.26) respectively. The ABP criteria had excellent performance in excluding HRV and will spare more screening EGDs than the Baveno-VI criteria (39.2% vs 27.4%, p < 0.001), without missing more HRVs. CONCLUSION: We validated the performance of ABP criteria for the exclusion of HRVs in cACLD patients. ABP criteria is superior to Baveno-VI criteria by sparing more screening EGD without the need of TE.

The value of platelet parameters and related scoring system in predicting esophageal varices and collateral veins in patients with liver cirrhosis.

OBJECTIVE: To explore the value of platelet parameters and related scoring system in predicting esophageal varices and collateral veins in patients with liver cirrhosis. METHOD: A total of 94 patients with liver cirrhosis diagnosed in our hospital from March 2017 to July 2018 were divided into without esophageal varices group (NEV) and esophageal varices group (EV) into mild, moderate, and severe subgroups according to the results of general gastroscopy. The differences of biological indexes among different degrees of esophageal varices and collateral veins were analyzed, and the related factors of esophageal varices and collateral veins were analyzed. RESULTS: PLT count and PCT decreased gradually with the increase of esophageal varices in EV group. There were significant differences in PLT count and PCT, which were negatively correlated with the degree of collateral vein in esophageal collateral vein group. The maximum cross-sectional diameter and mean diameter of esophageal collateral veins in EV group were wider than those in NEV group. Further study showed that the maximum cross-sectional total diameter and mean diameter of esophageal collateral veins in severe esophageal varices group were wider than those in NEV group and mild esophageal varices group. Sequential Logistic regression analysis showed that PCT could effectively predict the existence of esophageal varices. Platelet parameters had no significant diagnostic value in predicting peri-ECV and Para-ECV. For platelet-related FI, APRI, FIB-4, King, Lok, GUCI, and FibroQ scoring systems, multivariate Logistic regression showed that FI, FIB-4, Lok and FibroQ scoring systems could effectively predict the presence of EV and Para-ECV (P<0.05), and its Lok Index is better than other rating systems, with AUROC values of 0.773 and 0.747, respectively. There is no significant predictive value for above scoring systems of peri-ECV. CONCLUSIONS: PCT and LOK index can effectively predict the existence of esophageal varices and para-esophageal veins in patients with liver cirrhosis, and can be used as an effective filling method for common gastroscopy and endoscopic ultrasonography to detect EV and ECV in liver cirrhosis.

Transfusion with Cryoprecipitate for Very Low Fibrinogen Levels Does Not Affect Bleeding or Survival in Critically Ill Cirrhosis Patients.

BACKGROUND: Fibrinogen (FIB) levels less than 150 mg/dL have been associated with increased rates of bleeding and lower survival in critically ill cirrhosis patients. OBJECTIVE: We aimed to determine if treatment with cryoprecipitate (CRYO) for low FIB levels is associated with bleeding outcomes or survival. METHODS: A total of 237 cirrhosis patients admitted to an intensive care unit at a tertiary care liver transplant center with initial FIB levels less than 150 mg/dL were retrospectively assessed for CRYO transfusion, bleeding events, and survival outcomes. RESULTS: The mean MELD score was 27.2 (95% confidence interval [CI]: 26.0-28.3) and CLIF-C acute on chronic liver failure score was 53.4 (51.9-54.8). Ninety-nine (41.8%) were admitted for acute bleeding and the remainder were admitted for nonbleeding illnesses. FIB level on admission correlated strongly with disease severity. After adjusting for disease severity, FIB on admission was not an independent predictor of 30-day survival (hazard ratio [HR]: 0.99, 95% CI: 0.99-1.01, p = 0.68). CRYO transfusion increased FIB levels but had no independent effect on mortality or bleeding complications (HR: 1.10, 95% CI: 0.72-1.70, p = 0.65). CONCLUSION: In cirrhosis patients with critical illness, low FIB levels on presentation reflect severity of illness but are not independently associated with 30-day mortality. Treatment of low FIB with CRYO also does not affect survival or bleeding complications, suggesting FIB is an additional marker of severity of illness but is not itself a direct factor in the pathophysiology of bleeding in critically ill cirrhosis patients.

Porto-Sinusoidal Vascular Disease as the Cause of Portal Hypertension in Felty's Syndrome: A Case Report and Literature Review.

Felty's syndrome (FS) is a disorder wherein patients with rheumatoid arthritis develop splenomegaly, neutropenia, and in some cases, portal hypertension without underlying cirrhosis. Esophageal variceal bleeding is a complication of FS in patients with portal hypertension. In contrast to splenectomy, few reports exist on the management of variceal bleeding with endoscopic therapy. Moreover, the long-term outcome has not been reported. We present a patient with esophageal variceal bleeding due to portal hypertension secondary to Felty's syndrome. The patient was followed up for two years postendoscopy intervention. Literature review was performed and the histological features of portal hypertension in FS are discussed. The patient presented with a typical triad of rheumatoid arthritis (RA), splenomegaly, and neutropenia and was diagnosed as Felty's syndrome in 2012. She was admitted to our hospital in September 2017 for esophageal variceal bleeding. At the time of admission, her liver function test was normal. Abdominal CT showed no signs of cirrhosis and portal vein obstruction. Liver biopsy further excluded diagnosis of cirrhosis and supported the diagnosis of porto-sinusoidal vascular disease (PSVD), which was previously named as noncirrhotic idiopathic portal hypertension (NCIPH). An upper abdominal endoscopy revealed gastric and esophageal varices. A series of endoscopies was performed to ligate the esophageal varices. The patient was followed up for two years and did not show rebleeding. In conclusion, comorbid PSVD might be a cause of portal hypertension in FS patients. The present case had excellent outcome in two years, which supported the use of endoscopic therapy for the management of variceal bleeding in FS patients. Further large prospective study is needed to confirm the findings.

[Performance of the FIB-4 index in esophageal varices screening in patients with the diagnosis of liver cirrhosis]. / Desempeñ o del índice FIB-4 en el despistaje de vá rices esofá gicas en pacientes con el diagnóstico de cirrosis hepá tica.

INTRODUCTION: The diagnosis of esophageal varices in cirrhotic patients is made by the upper gastrointestinal endoscopy. Multiple non-invasive predictors have been studied for the diag-nosis of esophageal varices. The objective of this study is to testthe FIB4 index as screening of esophageal varices in patients with liver cirrhosis. MATERIALS AND METHODS: A cross-sectional analytic study was developed in four national hospital using hepatic cirrhosis patient's medi-cal files. We assessed the information using univariate and bivariate analysis, sensitivity, speci-ficity, predictive positive and negative value, the positive and negative likelihood ratio calcu-lation of the esophageal varices screening and its size. We built ROC curve for every analysis group. RESULTS: The study included 289 liver cirrhosis patients. Most of the patients were male (54.33%). 77.85% patients had esophageal varices. The distribution of varices was 19.03%, 35.99% and 22.84% for large, medium and small varices, respectively. In the FIB-4 index analysis for the presence of varices, it was found a sensitivity of 81.3%, specificity of 37.5% (AUC: 0.57). The calculation for variceal size showed a sensitivity of 81.8%, specificity of 23.9% (AUC: 0.50). In the analysis of FIB-4 index for prophylaxis groups was found a sensitivity of 81.8% and a specificity of 28.5% (AUC: 0.54). CONCLUSIONS: The FIB-4 index has no good performance in the screening for the presence of esophageal varices and its size in liver cirrhosis patients.

A study on two kinds of scoring models in predicting the degree of esophageal varices and bleeding.

OBJECTIVE: This study aims to investigate the value and determine the accuracy of two kinds of scoring models in predicting the degree of esophageal varices (EV) and esophageal variceal bleeding (EVB) in patients with liver cirrhosis (LC). PATIENTS AND METHODS: A total of 189 patients with LC, who underwent esophagogastroduodenoscopy (EGD), color Doppler ultrasound (CDU), and computed tomography (CT), were retrospectively analyzed. Then, the routine blood examination, liver function test, M-index of the spleen in CT, EGD, and CDU results were recorded. According to the EGD result, these patients were divided into five groups: varicose bleeding group, severe varices group, moderate varices group, mild varices group, and no varices group. Then, the receiver operating characteristic curves of all predicting parameters studied were respectively drawn, the area under the receiver operating characteristic curves were calculated, and the predictive value of EV and EVB was evaluated. RESULTS: The area under the receiver operating characteristic curve of the VAP score model and Plt/S-D score model was 0.901 and 0.835, respectively. The VAP score model cut-off value of 461.5 for predicting moderate esophageal varices (MoEV), severe esophageal varices (SEV), and EVB has a specificity and sensitivity of 100% and 68.7%, respectively, while the Plt/S-D score model cut-off value of 835.5 for predicting MoEV, SEV, and EVB has a specificity and sensitivity of 95.1% and 58.2%, respectively. CONCLUSIONS: These two kinds of scoring models can predict the degree of esophageal varices and bleeding in liver cirrhosis patients and has good predictive accuracy.

Course of oesophageal varices and performance of noninvasive predictors following Hepatitis C Virus clearance in compensated advanced chronic liver disease.

BACKGROUND: In patients with hepatitis C virus (HCV) and compensated advanced chronic liver disease (cACLD), there is evidence that sustained virological response (SVR) to direct-acting antivirals (DAA) may ameliorate portal hypertension, although both the course of oesophageal varices and the performance of their noninvasive predictors following DAA-induced SVR are less defined. In this study, our aim was to assess the variation in oesophageal varices status in HCV patients with cACLD who obtained an SVR to DAAs and to evaluate the diagnostic performance of noninvasive predictors of varices after HCV cure. MATERIAL AND METHODS: Sixty-three HCV patients with cACLD and SVR to DAAs were prospectively followed up, and oesophageal varices surveillance was carried out according to the Baveno VI indications. Appearance and disappearance of varices, accuracy performance of their noninvasive predictors (Baveno/expanded Baveno VI criteria, platelet count/spleen diameter ratio) and number of endoscopies spared with their application were calculated. RESULTS: Following SVR, varices developed or disappeared in 12.1% and 17.4% of patients, respectively. The negative predictive value for varices of the Baveno VI, expanded Baveno VI criteria and platelet count/spleen diameter ratio following SVR was 88.2% (65.6-96.7), 83.3% (66.3-92.7) and 80.7% (67.1-89.5), respectively. Their application would have saved 30.4%, 42.9% and 55.4% of endoscopies, with no varices needing treatment missed using both Baveno VI criteria. CONCLUSIONS: In HCV patients with cACLD, following SVR to DAA, the expanded Baveno VI criteria provide the best balance between utility (diagnostic accuracy and endoscopies avoided) and safety (varices needing treatment missed) for varices surveillance.

Desempeño del índice FIB-4 en el despistaje de várices esofágicas en pacientes con el diagnóstico de cirrosis hepática / Performance of the FIB-4 index in esophageal varices screening in patients with the diagnosis of liver cirrhosis

RESUMEN Introducción: El diagnóstico de várices esofágicas en pacientes cirróticos se realiza mediante la endoscopía digestiva alta. Se han estudiado predictores no invasivos para el diagnóstico de estas. Objetivo: El objetivo de este estudio es evaluar el desempeño del índice FIB-4 en el despistaje de várices esofágicas en pacientes con diagnóstico de cirrosis hepática. Materiales y métodos: Se realizó un estudio transversal analítico en cuatro hospitales nacionales utilizando historias clínicas de pacientes cirróticos. Se realizó el análisis univariado y bivariado, cálculo de sensibilidad, especificidad, valor predictivo positivo y negativo, razón de verosimilitud positiva y negativa del índice FIB-4 para el despistaje de várices esofágicas, tamaño de estas y profilaxis. Se construyeron curvas ROC para cada grupo de análisis. Resultados: Se incluyó 289 pacientes con diagnóstico de cirrosis hepática, la mayor parte fueron de sexo masculino (54,33%). 77,85% presentaron várices esofágicas. La distribución del tamaño de várices fue de 19,03%, 35,99% y 22,84% para várices grandes, medianas y pequeñas, respectivamente. En el análisis del índice FIB-4 con la presencia de várices se encontró una sensibilidad de 81,3% y una especificidad de 37,5% (AUC: 0,57). Para el tamaño de várices se encontró una sensibilidad 81,8% y una especificidad de 23,9% (AUC: 0,50). En el análisis de FIB-4 para grupos de profilaxis se encontró una sensibilidad de 81,8% y una especificidad de 28,5% (AUC: 0,54). Conclusiones: El índice FIB-4 no tiene un buen desempeño en el despistaje de la presencia várices esofágicas y su tamaño en pacientes con diagnóstico de cirrosis hepática.

ABSTRACT Introduction: The diagnosis of esophageal varices in cirrhotic patients is made by the upper gastrointestinal endoscopy. Multiple non-invasive predictors have been studied for the diag-nosis of esophageal varices. The objective of this study is to testthe FIB4 index as screening of esophageal varices in patients with liver cirrhosis. Materials and methods: A cross-sectional analytic study was developed in four national hospital using hepatic cirrhosis patient's medi-cal files. We assessed the information using univariate and bivariate analysis, sensitivity, speci-ficity, predictive positive and negative value, the positive and negative likelihood ratio calcu-lation of the esophageal varices screening and its size. We built ROC curve for every analysis group. Results: The study included 289 liver cirrhosis patients. Most of the patients were male (54.33%). 77.85% patients had esophageal varices. The distribution of varices was 19.03%, 35.99% and 22.84% for large, medium and small varices, respectively. In the FIB-4 index analysis for the presence of varices, it was found a sensitivity of 81.3%, specificity of 37.5% (AUC: 0.57). The calculation for variceal size showed a sensitivity of 81.8%, specificity of 23.9% (AUC: 0.50). In the analysis of FIB-4 index for prophylaxis groups was found a sensitivity of 81.8% and a specificity of 28.5% (AUC: 0.54). Conclusions: The FIB-4 index has no good performance in the screening for the presence of esophageal varices and its size in liver cirrhosis patients.

Influence of esophageal variceal bleeding on iron status in chronic hepatitis C patients.

BACKGROUND: Disorders of serum iron balance are frequently observed in chronic hepatitis C (CHC) patients. Iron overload as well as iron deficiency anemia are common clinical findings in these patients. Variceal bleeding is also a common complication. To date, no study has discussed the influence of esophageal bleeding on iron status in anemic CHC bleeders. OBJECTIVE: Was to study reticulocyte hemoglobin content (CHr) and serum hepcidin levels in anemic CHC and to evaluate the influence of variceal bleeding on patients' iron status. METHODS: Serum hepcidin levels and CHr were assessed in 65 early phase CHC patients (20 nonanemic, 23 anemic nonbleeders, and 22 anemic bleeders), and 20 healthy controls; and were compared with the conventional indices of iron deficiency including mean corpuscular volume, mean corpuscular hemoglobin, red cell distribution width, serum iron, total iron binding capacity, transferrin saturation and ferritin. RESULTS: Hepcidin levels were comparable in patients groups, but were significantly lower in patients than in controls (P = 0.01). Child-Pugh class B patients showed significantly lower hepcidin levels than class A patients. CHr levels were comparable in all groups as well as all iron deficiency indices. Patients with ferritin values or less 100 ng/ml and CHr or less 29 pg/cell or Tfsat or less 16% are more likely to have iron deficiency [odds ratio (OR = 3.93, 95% confidence interval (CI) = 2.54-6.08; OR = 10.50, 95% CI = 1.94-56.55, respectively). CONCLUSION: Esophageal bleeding has an almost no influence on iron status in CHC patients. Serum hepcidin content is influenced by CHC disease rather than by anemia associated with or without esophageal bleeding and it could be used as a marker of early hepatic insufficiency. Assessing CHr content could add a potential utility in the detection of iron deficiency in CHC patients.

Non-invasive assessment of large esophageal varices with liver cirrhosis ; a study conducted in Pakistan.

The assessment of non-invasive parameters for the prediction of large esophageal varices among patients with liver cirrhosisis is of utmost importance. In this study, non-invasive parameters for prediction of large esophageal varices were retrospectively evaluated. The presence of esophageal varices grade III and IV was classified as large esophageal varices positive while no varices or grade I and II were classified as large esophageal varices negative. There were 473 (90.09%) patients with ascites [mild 38 (8.03%), moderate 257 (54.33%) and severe 178 (37.63%)]. Frequency of esophageal varices was found to be higher (n=415, 79.04%). Whereas, large esophageal varices were found in 251 (47.81%) patients. The sensitivity, specificity, positive predicted value, negative predicted value and test accuracy of thrombocytopenia in predicting large esophageal varices were found to be 88.05%, 59.85%, 66.77%, 84.54% and 73.33% respectively. A significant association for large esophageal varices was observed for low platelet counts (AOR : 0.98, 95% CI : 0.97-0.99), high bilirubin level (AOR : 1.22, 95% CI : 1.07-1.39), ascites (AOR : 1.98, CI : 1.02-3.85) and Child score A (AOR : 0.26, 95% CI : 0.09-0.75) and Child Score B (AOR : 0.42, 95% CI : 0.28-0.61). In conclusion, low platelet count, high bilirubin level and ascites are found to be non-invasive predictive factor for large esophageal varices. J. Med. Invest. 66 : 248-251, August, 2019.

Percentage of small platelets on peripheral blood smear and Child-Turcott-Pugh class can predict the presence of oesophageal varices in newly diagnosed patients with cirrhosis: development of a prediction model for resource limited settings.

BACKGROUND: In cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence of OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class. METHODS: A prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka from April 2014-April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (full blood count with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed on admission. Linear logistic regression model was developed to predict OV using HP and CTP class. RESULTS: 54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P = 0.002), CTP-B (P = 0.003) and CTP-C (P = 0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = - 0.189 - (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on receiver operating characteristic (ROC) analysis, a model value > - 0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89%-positive predictive value and 76%-negative predictive value. CONCLUSIONS: We constructed a model using %SP on peripheral blood smear and CTP class. This model may be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with acceptable sensitivity and specificity, to prioritize the patients who deserve early UGIE in limited resource settings.

[Study on correlation between serum 25-hydroxyvitamin D3 level and esophageal variceal bleeding in cirrhotic patients].

Objective: To explore the correlation between serum 25-hydroxyvitamin D3 (25[OH]D(3)) levels and esophageal variceal bleeding (EVB) in cirrhotic patients. Methods: Eighty-three cases with liver cirrhosis hospitalized from November 2016 to January 2017 were collected. The patients were divided into bleeding group (51 cases) and non-bleeding group (32 cases) depending on the presence or absence of bleeding under gastroscopy. Serological tests were performed on both groups, including hemoglobin (Hb), albumin (ALB), alkaline phosphatase (ALP),γ-glutamyltransferase (GGT), interleukin-6 (IL-6), and 25-hydroxyvitamin D3 (25[OH]D(3)). Both groups were analyzed by univariate analysis. The differences between both groups were compared by t-test, after normality test. The other variables were compared by Mann-Whitney U test. The correlation between the relevant variables and EVB were analyzed by Spearman's rank correlation and a multivariate analysis. Cases with primary biliary cirrhosis were relatively low in number (four cases in bleeding group, accounting for 8%, 10 cases in non-bleeding group, accounting for 31%). The effects of ALP and GGT on serum 25(OH)D(3) level were analyzed by stratified analysis. Moreover, ALP and GGT levels were divided into two and three groups: < 140 U/L and >140 U/L and < 30 U/L, > 30 U/L, and ~≤60 U/L. Results: Bleeding group had low levels of hemoglobin (t= -2.827,P= 0.005), alkaline phosphatase (t= -3.097,P= 0.002), gamma-glutamyltransferase (t= -2.292,P= 0.022), and 25(OH)D(3) (t= -3.134,P= 0.002) than non-bleeding group. Both groups (P> 0.05) had similar levels of albumin, interleukin-6, AAR, and FIB-4. Logistic regression analysis showed that 25(OH)D(3), alkaline phosphatase and hemoglobin were independent risk factors for EVB. Spearman's correlation coefficient analysis showed that 25(OH)D(3)was significantly positively and negatively correlated with interleukin-6 (r= 0.306,P= 0.005) and albumin (r= -0.327,P= 0.003). Stratified analysis showed that serum 25(OH)D(3) level was lower in ALP≤140U/L group and the bleeding group, and the difference was statistically significant than non-bleeding group (P= 0.007), while the serum level of 25(OH)D(3)was decreased in both groups for alkaline phosphatase > 140 U/L group, and the difference was not statistically significant (P= 0.051). Furthermore, in the GGT > 60 U/L group, the serum level of 25(OH)D(3)was significantly lower in the bleeding group, and the difference was statistically significant in non-bleeding group (P= 0.003), while the difference between the two groups was not statistically significant (P> 0.05) in GGT≤30 U/ L, > 30 U/L, and ~≤60 U/L group. Conclusion: Serum 25(OH)D(3)level was significantly lower in EVB cirrhotic patients, and it was an independent risk factor for EVB. Serum 25(OH)D(3) low levels was more apparent with ALP normalization or GGT level > 60 U/L.

Prediction of Aspartate Aminotransferase to Platelet Ratio Index with Size of Esophageal Varices in Liver Cirrhosis.

BACKGROUND: Liver cirrhosis is one of the major causes of morbidity and mortality. The threatening complication of Liver cirrhosis is variceal bleeding. Early diagnosis and initiation of therapy can reduce mortality associated with variceal bleeding. This study is designed to predict the esophageal varices by non-invasive method using aspartate aminotransferase to platelet count ratio index (APRI). METHODS: A total of 100 patients were studied between March 2016 and February 2017 with the diagnosis of Liver cirrhosis admitted at Bir Hospital fulfilling the inclusion and exclusion criteria. Ethical approval was obtained from Institutional review board of National Academy of Medical Sciences. RESULTS: Out of one hundred patients, 80 were males and 20 females. On endoscopy, small varices were present in 28 (28%) patients and large varices in 51(51%) patients. APRI with a cutoff value of 0.908 has sensitivity of 87.3% and specificity of 71.4%, positive predictive value of 92% and negative predictive value of 60% (p=0.001) for the detection of varices. CONCLUSIONS: Aspartate aminotransferase to platelet count ratio index can be a useful tool to indirectly predict esophageal varices in a patient with Liver Cirrhosis.

Real-life experience of lusutrombopag for cirrhotic patients with low platelet counts being prepared for invasive procedures.

BACKGROUND AND AIMS: The present study aimed to report our real-life experience of the TPO receptor agonist lusutrombopag for cirrhotic patients with low platelet counts. METHODS: We studied platelet counts in 1,760 cirrhotic patients undergoing invasive procedures at our hospital between January 2014 and December 2017. In addition, we studied 25 patients who were administered lusutrombopag before invasive procedures between June 2017 and January 2018. Effectiveness of lusutrombopag to raise platelet counts and to avoid transfusion and treatment-related adverse events were analyzed. RESULTS: In 1,760 cirrhotic patients without lusutrombopag prior to invasive procedures, proportion of patients whose platelet counts <50,000/µL and needed platelet transfusions were 66% (n = 27/41) for radiofrequency ablation, 43% (n = 21/49) for transarterial chemoembolization, and 55% (n = 21/38) for endoscopic injection sclerotherapy / endoscopic variceal ligation, respectively. In 25 cirrhotic patients treated by lusutrombopag prior to the invasive procedures, platelet counts significantly increased compared with baseline (82,000 ± 26,000 vs. 41,000 ± 11,000/µL) (p < 0.01). Out of 25 patients, only 4 patients (16%) needed platelet transfusion before the invasive procedures. The proportion of patients with low platelet count and who needed platelet transfusions was significantly low in patients treated with lusutrombopag compared to those not treated with lusutrombopag (16% (4/25) vs. 54% (69/128), p = 0.001). Platelet counts after lusutrombopag treatment and prior to invasive procedures were lower in patients with a baseline platelet count ≤30,000/µL (n = 8) compared with those with a baseline platelet count >30,000/µL (n = 17) (50,000 ± 20,000 vs 86,000 ± 26,000/µL, p = 0.002). Patients with a baseline platelet count ≤30,000/µL with spleen index (calculated by multiplying the transverse diameter by the vertical diameter measured by ultrasonography) ≥40 cm2 (n = 3) had a lower response rate to lusutrombopag compared to those with spleen index <40 cm2 (n = 5) (0% vs. 100%, p = 0.02). Hemorrhagic complication was not observed. Recurrence of portal thrombosis was observed and thrombolysis therapy was required in one patient who had prior history of thrombosis. CONCLUSIONS: Lusutrombopag is an effective and safe drug for thrombocytopenia in cirrhotic patients, and can reduce the frequency of platelet transfusions.