An index based on deep learning-measured spleen volume on CT for the assessment of high-risk varix in B-viral compensated cirrhosis.

OBJECTIVES: Deep learning enables an automated liver and spleen volume measurements on CT. The purpose of this study was to develop an index combining liver and spleen volumes and clinical factors for detecting high-risk varices in B-viral compensated cirrhosis. METHODS: This retrospective study included 419 patients with B-viral compensated cirrhosis who underwent endoscopy and CT from 2007 to 2008 (derivation cohort, n = 239) and from 2009 to 2010 (validation cohort, n = 180). The liver and spleen volumes were measured on CT images using a deep learning algorithm. Multivariable logistic regression analysis of the derivation cohort developed an index to detect endoscopically confirmed high-risk varix. The cumulative 5-year risk of varix bleeding was evaluated with patients stratified by their index values. RESULTS: The index of spleen volume-to-platelet ratio was devised from the derivation cohort. In the validation cohort, the cutoff index value for balanced sensitivity and specificity (> 3.78) resulted in the sensitivity of 69.4% and the specificity of 78.5% for detecting high-risk varix, and the cutoff index value for high sensitivity (> 1.63) detected all high-risk varices. The index stratified all patients into the low (index value ≤ 1.63; n = 118), intermediate (n = 162), and high (index value > 3.78; n = 139) risk groups with cumulative 5-year incidences of varix bleeding of 0%, 1.0%, and 12.0%, respectively (p < .001). CONCLUSION: The spleen volume-to-platelet ratio obtained using deep learning-based CT analysis is useful to detect high-risk varices and to assess the risk of varix bleeding. KEY POINTS: • The criterion of spleen volume to platelet > 1.63 detected all high-risk varices in the validation cohort, while the absence of visible varix did not exclude all high-risk varices. • Visual varix grade ≥ 2 detected high-risk varix with a high specificity (96.5-100%). • Combining spleen volume-to-platelet ratio ≤ 1.63 and visual varix grade of 0 identified low-risk patients who had no high-risk varix and varix bleeding on 5-year follow-up.

Validation and reappraisal of the assessment for retreatment with transarterial chemoembolization score for unresectable non-metastatic hepatocellular carcinoma in a hepatitis b virus-endemic region.

OBJECTIVES: To validate and reappraise the Assessment for Retreatment with Transarterial chemoembolization (ART) score comprising three parameters (>25 % increase in aspartate aminotransferase [AST], increase in Child-Pugh score and tumour response), determined prior to subsequent transarterial chemoembolization (TACE). METHODS: Enrolled patients were diagnosed with unresectable non-metastatic hepatocellular carcinoma and underwent multiple TACEs between June 2006 and December 2007 (N = 153). Subgroupings were classified according to the established cut-off (≤1.5 vs. ≥2.5). Survival analysis using the Kaplan-Meier curve was performed. RESULTS: The original ART score dichotomized patients according to their overall survival (P = 0.004). We found several patients who actually survived longer than others were assigned to a poor prognostic group due to the AST component. Parameter estimates for AST obtained from our analysis were much lower than the original version (0.5 vs. 2.1). We adjusted the component according to the value of our parameter estimates, and patients with >25 % AST increase received 1.0 point. After this modification, patients assigned to the favourable prognostic group were more likely to have a better survival outcome (median 23.9 vs. 12.2 months, P < 0.001). CONCLUSIONS: In hepatitis B virus-endemic regions, the ART score is valid and can better predict post-TACE survival after the AST component is modified. KEY POINTS: • The ART score was validated in a HBV-endemic region. • The modified ART score improved prognostic performance by reappraising the AST component. • The modified ART score helps physicians make decisions for further TACE.

Assessment of current criteria for primary nonresponse in chronic hepatitis B patients receiving entecavir therapy.

UNLABELLED: A primary nonresponse to oral drugs against hepatitis B virus (HBV) is a generally accepted criterion for interrupting treatment. We investigated whether the concept of primary nonresponse suggested by current American (AASLD) and European (EASL) guidelines is appropriate for treatment with entecavir (ETV). The study included 1,254 treatment-naïve patients who had pretreatment HBV DNA levels of >2,000 IU/mL and received ETV 0.5 mg/day for over 6 months. "Primary nonresponse" was defined as a <2 log drop in HBV DNA after 6 months of therapy by AASLD and as a <1 log drop after 3 months by EASL. The cumulative probability of virological response (VR; HBV DNA of <15 IU/mL) was compared in patients with and without primary nonresponse. Median time to achieve VR was significantly shorter in primary responders by AASLD than nonresponders (12 versus 24 months; P = 0.004), but the cumulative probability of achieving a VR at 54 months was similar in the two groups (95.8% versus 100%). Time to achieve a VR and cumulative probability of VR over time did not differ between primary responders and nonresponders by EASL. On-treatment virological breakthrough occurred in 18 patients with a cumulative rate of 5.6% at 72 months. ETV resistance was detected in 13 of these 18 patients (72.2%), who were all classified as primary responder according to both guidelines. CONCLUSION: Long-term ETV therapy generally leads to a VR in treatment-naïve patients, although the time to achieve it is delayed in primary nonresponders. The current recommendation to change therapy in primary nonresponders needs to be modified to reflect drug differences in antiviral potency and resistance risk.

Non-invasive assessment of hepatic steatosis: prospective comparison of the accuracy of imaging examinations.

BACKGROUND & AIMS: Despite increasing use of various imaging examinations for non-invasive assessment of hepatic steatosis (HS), their relative accuracy is unknown. The objective of this study is to prospectively compare the accuracy of computed tomography (CT), dual gradient echo magnetic resonance imaging (DGE-MRI), proton magnetic resonance spectroscopy ((1)H-MRS), and ultrasonography (US) for the diagnosis and quantitative estimation of HS. METHODS: A total of 161 consecutive potential living liver donors underwent US (performed by two independent radiologists, US1 and US2), CT, DGE-MRI, (1)H-MRS, and liver biopsy on the same day. Using the histologic degree of HS as the reference standard, we compared the diagnostic performance of US1, US2, CT, DGE-MRI, and (1)H-MRS for diagnosing HS >or= 5% and HS >or= 30% and compared the accuracy of CT, DGE-MRI, and (1)H-MRS in the quantitative estimation of HS. RESULTS: DGE-MRI and (1)H-MRS significantly outperformed CT and US for the diagnosis of HS5%. DGE-MRI showed a tendency of higher accuracy than the other examinations for diagnosing HS >or= 30%. The cross-validated sensitivity and specificity of DGE-MRI at the optimal cut-off were 76.7% and 87.1%, respectively, for diagnosing HS >or= 5% and 90.9% and 94%, respectively, for diagnosing HS >or= 30%. The cross-validated Bland-Altman 95% limits of agreement between the estimated degree of HS on imaging examinations and the histologic degree of HS, were the narrowest with DGE-MRI, yielding -12.7% to 12.7%. CONCLUSIONS: Among CT, DGE-MRI, (1)H-MRS, and US, DGE-MRI is the most accurate method for the diagnosis and quantitative estimation of HS. Therefore, DGE-MRI may be the preferred imaging examination for the non-invasive assessment of HS.

Continuous peritransplant assessment of consciousness using bispectral index monitoring for patients with fulminant hepatic failure undergoing urgent liver transplantation.

BACKGROUND: Rapid deterioration of consciousness is a critical situation for patients with fulminant hepatic failure (FHF). Bispectral (BIS) index was derived from electroencephalography parameters, primarily to monitor the depth of unconsciousness. AIM: To assess the usability of peritransplant BIS monitoring in patients with FHF. METHODS: A prospective study using peritransplant BIS monitoring was performed in 26 patients with FHF undergoing urgent liver transplantation (LT). RESULTS: Pre-transplant Child-Pugh score was 12.2 +/- 1.0; model for end-stage liver disease score was 32.4 +/- 4.4; Glasgow coma score (GCS) was 9.9 +/- 1.3; and BIS index was 44.0 +/- 6.7. Pre-transplant sedation significantly decreased BIS index. After LT, all patients having endotracheal intubation recovered consciousness within one to three d and showed progressive increase in BIS index, which appeared slightly earlier and was more evident than the increase in derived GCS score. There was a significant correlation between BIS index and derived GCS scores (r(2) = 0.648). Timing of eye opening to voice was matched with BIS index of 66.3 +/- 10.4 and occurred 12.7 +/- 8.3 h after passing BIS index of 50. CONCLUSION: These results suggest that BIS monitoring is a non-invasive, simple, easy-to-interpret method, which is useful in assessing peritransplant state of consciousness. BIS monitoring may therefore be a useful tool during peritransplant intensive care for patients with FHF showing hepatic encephalopathy.