Disparities in Mortality and Health Care Utilization for 460,851 Hospitalized Patients with Cirrhosis and Hepatic Encephalopathy.

BACKGROUND AND AIMS: Hepatic encephalopathy (HE) is a common cause of hospitalizations and readmissions for patients with decompensated cirrhosis. In this study, we proposed to investigate recent trends in in-hospital mortality and utilization for patients with cirrhosis and HE and to explore the effect of various sociodemographic, hospital, and clinical factors on mortality. METHODS: We performed an observational study using serial cross-sectional data from the 2009-2013 National Inpatient Sample to examine hospitalizations of patients with cirrhosis and HE. We collected data on in-hospital mortality, length of stay, and total hospital costs. We used negative binomial regression and logistic regression to investigate trends in utilization and multilevel modeling to examine the association between sociodemographic, hospital, and clinical factors and in-hospital mortality. RESULTS: The annual total number of hospitalizations from HE has steadily risen from 75,475 in 2009 to 106,915 in 2013 (P < 0.001). Annual in-hospital mortality (11.9-10.2%, P < 0.001) and length of stay (7.5-7.1 days, P = 0.015) have significantly decreased over this timeframe. The presence of septicemia, GI bleeding, and being uninsured were associated with 29.6%, 16.7%, and 15.7% of in-hospital death, respectively. Patients hospitalized in the South, Medicare beneficiaries, and patients hospitalized in the Midwest had a 9.8%, 9.2%, and 8.9% chance of dying in the hospital. CONCLUSION: The number of hospitalizations from HE has increased while in-hospital mortality has concomitantly decreased from 2009 to 2013. Both traditional risk factors (sepsis and GI bleeding) strongly influence the probability of in-hospital death. However, disparities in mortality by sociodemographic factors (insurance status and geography) also exist.

Cost-Effectiveness of Rifaximin Treatment in Patients with Hepatic Encephalopathy.

BACKGROUND: Hepatic encephalopathy (HE) is a complication of cirrhosis of the liver causing neuropsychiatric abnormalities. Clinical manifestations of overt HE result in increased health care resource utilization and effects on patient quality of life. While lactulose has historically been the mainstay of treatment for acute HE and maintenance of remission, there is an unmet need for additional therapeutic options with a favorable adverse event profile. Compared with lactulose alone, rifaximin has demonstrated proven efficacy in complete reversal of HE and reduction in the incidence of HE recurrence, mortality, and hospitalizations. Evidence suggests the benefit of long-term prophylactic therapy with rifaximin; however, there is a need to assess the economic impact of rifaximin treatment in patients with HE. OBJECTIVE: To assess the incremental cost-effectiveness of rifaximin ± lactulose versus lactulose monotherapy in patients with overt HE. METHODS: A Markov model was developed in Excel with 4 health states (remission, overt HE, liver transplantation, and death) to predict costs and outcomes of patients with HE after initiation of maintenance therapy with rifaximin ± lactulose to avoid recurrent HE episodes. Cost-effectiveness of rifaximin was evaluated through estimation of incremental cost per quality-adjusted life-year (QALY) or life-year (LY) gained. Analyses were conducted over a lifetime horizon. One-way deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty in results. RESULTS: The rifaximin ± lactulose regimen provided added health benefits despite an additional cost versus lactulose monotherapy. Model results showed an incremental benefit of $29,161 per QALY gained and $27,762 per LY gained with rifaximin ± lactulose versus lactulose monotherapy. Probabilistic sensitivity analyses demonstrated that the rifaximin ± lactulose regimen was cost-effective ~99% of the time at a threshold of $50,000 per QALY/LY gained, which falls within the commonly accepted threshold for incremental cost-effectiveness. CONCLUSIONS: The clinical benefit of rifaximin, combined with an acceptable economic profile, demonstrates the advantages of rifaximin maintenance therapy as an important option to consider for patients at risk of recurrent HE. DISCLOSURES: This analysis was funded by Salix Pharmaceuticals, a division of Bausch Health US. Salix and Xcenda collaborated on the methods, and Salix, Xcenda, Jesudian, and Ahmad collaborated on the writing of the manuscript and interpretation of results. Bozkaya and Migliaccio-Walle are employees of Xcenda. Ahmad reports speaker fees from Salix Pharmaceuticals, unrelated to this study. Jesudian reports consulting and speaker fees from Salix Pharmaceuticals, unrelated to this study. The results from this model were presented at AASLD: The Liver Meeting 2014; November 7-11; Boston, MA.

Outcomes after hepatic encephalopathy in population-based cohorts of patients with cirrhosis.

BACKGROUND: Hepatic encephalopathy is a devastating complication of cirrhosis. AIM: To describe the outcomes after developing hepatic encephalopathy among contemporary, aging patients. METHODS: We examined data for a 20% random sample of United States Medicare enrolees with cirrhosis and Part D prescription coverage from 2008 to 2014. Among 49 164 persons with hepatic encephalopathy, we evaluated the associations with transplant-free survival using Cox proportional hazard models with time-varying covariates (hazard ratios, HR) and incidence rate ratios (IRR) for healthcare utilisation measured in hospital-days and 30-day readmissions per person-year. We validated our findings in an external cohort of 2184 privately insured patients with complete laboratory values. RESULTS: Hepatic encephalopathy was associated with median survivals of 0.95 and 2.5 years for those ≥65 or <65 years old and 1.1 versus 3.9 years for those with and without ascites. Non-alcoholic fatty-liver disease posed the highest adjusted risk of death among aetiologies, HR 1.07 95% CI (1.02, 1.12). Both gastroenterology consultation and rifaximin utilisation were associated with lower mortality, respective adjusted-HR 0.73 95% CI (0.67, 0.80) and 0.40 95% CI (0.39, 0.42). Thirty-day readmissions were fewer for patients seen by gastroenterologists (0.71 95% CI [0.57-0.88]) and taking rifaximin (0.18 95% CI [0.08-0.40]). Lactulose alone was associated with fewer hospital-days, IRR 0.31 95% CI (0.30-0.32), than rifaximin alone, 0.49 95% CI (0.45-0.53), but the optimal therapy combination was lactulose/rifaximin, IRR 0.28 95% CI (0.27-0.30). These findings were validated in the privately insured cohort adjusting for model for endstage liver disease-sodium score and serum albumin. CONCLUSIONS: Hepatic encephalopathy remains morbid and associated with poor outcomes among contemporary patients. Gastroenterology consultation and combination lactulose-rifaximin are both associated with improved outcomes. These data inform the development of care coordination efforts for subjects with cirrhosis.

[Prognostic significance and economic burden of hepatic encephalopathy in liver cirrhosis in German hospitals based on G-DRG data]. / Mortalität und ökonomische Auswirkungen der hepatischen Enzephalopathie bei Leberzirrhose in deutschen Krankenhäusern auf der Basis von G-DRG-Kostendaten.

INTRODUCTION: Hepatic encephalopathy (HE) represents a frequent complication of liver cirrhosis with negative effects on patients' lives. The prevalence of clinical HE is estimated to be between 30-45 %. Regardless of its clinical and prognostic relevance HE is considered to be underdiagnosed. METHODS: Beyond a systematic analysis of mortality of HE, we investigated the economic impact and reimbursement situation for HE in patients with liver cirrhosis in Germany. For the retrospective analysis, anonymized data (2011-2015) concerning expenses and diagnoses (§â€Š21-4 KHEntgG) were obtained from 74 participating hospitals of the Diagnosis Related Groups (DRG) Project of the German Gastroenterological Association (DGVS). Furthermore, results were compared with case data from all German hospitals provided by the German Federal Authority on Statistics (Statistische Bundesamt (Destatis), Wiesbaden). RESULTS: In participating hospitals 59 093 cases with liver cirrhosis were identified of which 14.6 % were coded as having HE. Hospital mortality was threefold increased compared to cirrhosis-patients without HE (20.9 versus 7.5 %). Cases with cirrhosis as well as the proportion with HE increased over time. Compared to all patients with cirrhosis, reimbursement for HE patients produced a deficit (of up to 634 € for HE grade 4). DISCUSSION: Mortality is threefold increased in patients with cirrhosis when an additional HE is diagnosed. Hospitals participating in the DGVS-DRG-project coded 2 % more HE cases among their cirrhosis cases than the rest of hospitals either because of a selection bias for greater disease severity or because of better coding quality. At present, reimbursement for HE patients on the basis of F-DRG-system produced a deficit.

Serial assessment of hepatic encephalopathy in patients hospitalised for acute decompensation of cirrhosis.

INTRODUCTION AND AIM: Hepatic encephalopathy (HE) is a frequent complication of cirrhosis, but the clinical and prognostic significance of the progression of mental status in hospitalised cirrhotics is unknown. We aimed to investigate the prognostic significance of serial evaluation of HE in patients hospitalised for acute decompensation (AD) of cirrhosis. MATERIALS AND METHODS: Patients (n=293) were evaluated for HE (West-Haven criteria) at admission and at day-3 and classified in two groups: (1) Absent or improved HE: HE absent at admission and at day-3, or any improvement at day-3; (2) Unfavourable progression: Development of HE or HE present at admission and stable/worse at day-3. RESULTS: Unfavourable progression of HE was observed in 31% of patients and it was independently associated with previous HE, Child-Pugh C and acute-on-chronic liver failure (ACLF). MELD score and unfavourable progression of HE were independently associated with 90-day mortality. The 90-day Kaplan-Meier survival probability was 91% in patients with MELD<18 and absent or improved HE and only 31% in subjects with both MELD≥18 and unfavourable progression of HE. Unfavourable progression of HE was also related to lower survival in patients with or without ACLF. Worsening of GCS at day-3 was observed in 11% of the sample and was related with significantly high mortality (69% vs. 27%, P<0.001). CONCLUSION: Among cirrhotics hospitalised for AD, unfavourable progression of HE was associated with high short-term mortality and therefore can be used for prognostication and to individualise clinical care.

A validated risk model for prediction of early readmission in patients with hepatic encephalopathy.

INTRODUCTION AND AIM: Hepatic encephalopathy (HE) is a common complication in cirrhotics and is associated with an increased healthcare burden. Our aim was to study independent predictors of 30-day readmission and develop a readmission risk model in patients with HE. Secondary aims included studying readmission rates, cost, and the impact of readmission on mortality. MATERIALS AND METHODS: We utilized the 2013 Nationwide Readmission Database (NRD) for hospitalized patients with HE. A risk assessment model based on index hospitalization variables for predicting 30-day readmission was developed using multivariate logistic regression and validated with the 2014 NRD. Patients were stratified into Low Risk and High Risk groups. Cox regression models were fit to identify predictors of calendar-year mortality. RESULTS: Of 24,473 cirrhosis patients hospitalized with HE, 32.4% were readmitted within 30 days. Predictors of readmission included presence of ascites (OR: 1.19; 95% CI: 1.06-1.33), receiving paracentesis (OR: 1.43; 95% CI: 1.26-1.62) and acute kidney injury (OR: 1.11; 95% CI: 1.00-1.22). Our validated model stratified patients into Low Risk and High Risk of 30-day readmissions (29% and 40%, respectively). The cost of the first readmission was higher than index admission in the 30-day readmission cohort ($14,198 vs. $10,386; p-value <0.001). Thirty-day readmission was the strongest predictor of calendar-year mortality (HR: 4.03; 95% CI: 3.49-4.65). CONCLUSIONS: Nearly one-third of patients with HE were readmitted within 30 days, and early readmission adversely impacted healthcare utilization and calendar-year mortality. With our proposed simple risk assessment model, patients at high risk for early readmissions can be identified to potentially avert poor outcomes.

Increasing Burden of Hepatic Encephalopathy Among Hospitalized Adults: An Analysis of the 2010-2014 National Inpatient Sample.

BACKGROUND: Hepatic encephalopathy (HE) is associated with substantial morbidity and mortality, contributing significant burden on healthcare systems. AIM: We aim to evaluate trends in clinical and economic burden of HE among hospitalized adults in the USA. METHODS: Using the 2010-2014 National Inpatient Sample, we identified adults hospitalized with HE using ICD-9-CM codes. Annual trends in hospitalizations with HE, in-hospital mortality, and hospital charges were stratified by the presence of acute liver failure (ALF) or cirrhosis. Adjusted multivariable regression models were evaluated for predictors of in-hospital mortality and hospitalization charges. RESULTS: Among 142,860 hospitalizations with HE (mean age 59.3 years, 57.8% male), 67.7% had cirrhosis and 3.9% ALF. From 2010 to 2014, total number of hospitalizations with HE increased by 24.4% (25,059 in 2010 to 31,182 in 2014, p < 0.001). Similar increases were seen when stratified by ALF (29.7% increase) and cirrhosis (29.7% increase). Overall in-hospital mortality decreased from 13.4% (2010) to 12.3% (2014) (p = 0.001), with similar decreases observed in ALF and cirrhosis. Total inpatient charges increased by 46.0% ($8.15 billion, 2010 to $11.9 billion, 2014). On multivariable analyses, ALF was associated with significantly higher odds of in-hospital mortality (OR 5.37; 95% CI 4.97-5.80; p < 0.001) as well as higher mean inpatient charges (122.6% higher; 95% CI + 115.0-130.3%; p < 0.001) compared to cirrhosis. The presence of ascites, hepatocellular carcinoma, and hepatorenal syndrome was associated with increased mortality. CONCLUSIONS: The clinical and economic burden of hospitalizations with HE in the USA continues to rise. In 2014, estimated national economic burden of hospitalizations with HE reached $11.9 billion.

[Clinical outcomes and hospital costs of hepatic encephalopathy: an analysis of "real life" data from Marche Region.] / Valutazione degli outcome clinici e dei costi ospedalieri dell'encefalopatia epatica conclamata: un'analisi sui dati "real life" della Regione Marche.

Hepatic encephalopathy (HE) describes a spectrum of potentially reversible neuropsychiatric changes observed in patients with hepatic dysfunction and/or portosystemic shunt. The aim of this study is to compare data from clinical trials and observational studies with Italian real-world (RW) data as for clinical outcomes; other aim is to evaluate economic burden of hepatic encephalopathy related to hospitalization for overt HE. The work is based on data from the Health Information Systems (SIS) of Marche Region, Italy (about 1.5 million patients) available for the period 2008-2014. 450 subjects were identified (62% men, mean age 68 years) with a first episode of overt HE (OHE) in the three-year period 2010-2012. The mortality in the index hospitalization was equal to 32.2%; the 2-year mortality rate for a specific cause was 24.3% while that for all cases was 33.1%. The proportion of patients discharged alive from the hospitalization index that in the following two years incurs in rehospitalization, correlated with OHE is on average 66.6%. These figures largely exceed those identified in clinical trials or observational studies. Assuming that the incidence of OHE cases observed in the Marche region is representative of the national one we could estimate a charge to the NHS equal to about € 200 million for hospital assistance in the first year from the OHE event.

Natural history of covert hepatic encephalopathy: An observational study of 366 cirrhotic patients.

AIM: To explore the natural history of covert hepatic encephalopathy (CHE) in absence of medication intervention. METHODS: Consecutive outpatient cirrhotic patients in a Chinese tertiary care hospital were enrolled and evaluated for CHE diagnosis. They were followed up for a mean of 11.2 ± 1.3 mo. Time to the first cirrhosis-related complications requiring hospitalization, including overt HE (OHE), resolution of CHE and death/transplantation, were compared between CHE and no-CHE patients. Predictors for complication(s) and death/transplantation were also analyzed. RESULTS: A total of 366 patients (age: 47.2 ± 8.6 years, male: 73.0%) were enrolled. CHE was identified in 131 patients (35.8%). CHE patients had higher rates of death and incidence of complications requiring hospitalization, including OHE, compared to unimpaired patients. Moreover, 17.6% of CHE patients developed OHE, 42.0% suffered persistent CHE, and 19.8% of CHE spontaneously resolved. In CHE patients, serum albumin < 30 g/L (HR = 5.22, P = 0.03) was the sole predictor for developing OHE, and blood creatinine > 133 µmol/L (HR = 4.75, P = 0.036) predicted mortality. Child-Pugh B/C (HR = 0.084, P < 0.001) and OHE history (HR = 0.15, P = 0.014) were predictors of spontaneous resolution of CHE. CONCLUSION: CHE exacerbates, persists or resolves without medication intervention in clinically stable cirrhosis. Triage of patients based on these predictors will allow for more cost-effect management of CHE.

Risk factors for mortality in patients with alcoholic hepatitis and assessment of prognostic models: A population-based study.

BACKGROUND: Severe alcoholic hepatitis (AH) is associated with a substantial risk for short-term mortality. OBJECTIVES: To identify prognostic factors and validate well-known prognostic models in a Canadian population of patients hospitalized for AH. METHODS: In the present retrospective study, patients hospitalized for AH in Calgary, Alberta, between January 2008 and August 2012 were included. Stepwise logistic regression models identified independent risk factors for 90-day mortality, and the discrimination of prognostic models (Model for End-stage Liver Disease [MELD] and Maddrey discriminant function [DF]) were examined using areas under the ROC curves. RESULTS: A total of 122 patients with AH were hospitalized during the study period; the median age was 49 years (interquartile range [IQR] 42 to 55 years) and 60% were men. Median MELD score and Maddrey DF on admission were 21 (IQR 18 to 24) and 45 (IQR 26 to 62), respectively. Seventy-three percent of patients received corticosteroids and/or pentoxifylline, and the 90-day mortality was 17%. Independent predictors of mortality included older age, female sex, international normalized ratio, MELD score and Maddrey DF (all P<0.05). For discrimination of 90-day mortality, the areas under the ROC curves of the prognostic models (MELD 0.64; Maddrey DF 0.68) were similar (P>0.05). At optimal cut-offs of ≥22 for MELD score and ≥37 for Maddrey DF, both models excluded death with high certainty (negative predictive values 90% and 96%, respectively). CONCLUSIONS: In patients hospitalized for AH, well-known prognostic models can be used to predict 90-day mortality, particularly to identify patients with a low risk for death.

Rehabilitation for cirrhotic patients discharged after hepatic encephalopathy improves survival.

INTRODUCTION: The 1-year mortality of cirrhotic patients with hepatic encephalopathy (HE) is approximately 60-80% in recent studies. We aimed to establish a rehabilitation out-patient clinic (RC) for alcoholic cirrhotic patients sur-viving HE. MATERIAL AND METHODS: Prospectively, patients surviving HE were offered participation in the RC and were seen by a nurse for a one-hour interview with 1-3 weeks' interval after discharge and by a physician, if needed. Clinical, psychological and social problems were identified and addressed. Alcohol consumption was recorded and alcohol cessation was encouraged at each visit. Minimal or overt HE prompted referral to the Liver Unit. The patients were compared with HE patients discharged in 2008 (the control group). RESULTS: A total of 19 patients were included in the RC group and compared with the 14 patients of the control group. The Child-Pugh score was higher in the RC group (median 13; range 8-14) than in the control group (median 11; range 7-13) (p = 0.033), whereas other clinical, demographic and biochemical parameters did not differ between the two groups. One-year survival was higher in the RC group (16/19; 84%) than in the control group versus (5/14; 36%) (p = 0.012). The log-rank test confirmed an improved survival for the RC group (p = 0.008). The economic costs of subsequent hospital admissions did not differ between the two groups. In the RC group, alcohol consumption was reduced in all but two patients. CONCLUSION: Survival was significantly improved for patients in the rehabilitation clinic. The improved survival did not subsequently cause higher hospital admission costs. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

In-hospital mortality and economic burden associated with hepatic encephalopathy in the United States from 2005 to 2009.

BACKGROUND & AIMS: Hepatic encephalopathy (HE) is a major complication of cirrhosis that causes substantial mortality and utilization of resources. METHODS: We analyzed 5 cycles of the Nationwide Inpatient Sample, conducted between 2005 and 2009, to determine national estimates of incidence, prevalence, inpatient mortality, severity of illness, and resource utilization for inpatients with HE. RESULTS: The yearly inpatient incidence of HE ranged from 20,918 (2005) to 22,931 (2009) (P = .2226), comprising approximately 0.33% of all hospitalizations in the United States. Over the 5-year period of analysis, mortality of inpatients with HE remained relatively stable, at 14.13%-15.61% (P = .062); however, the proportion of patients with major and extreme severity of illness increased (P < .0001). The average length of inpatient stay increased from 8.1 to 8.5 days (P = .019). The average total inpatient charges increased from $46,663 to $63,108 per case (P < .0001). Furthermore, total national charges related to HE increased from $4676.7 million (2005) to $7244.7 million (2009). In multivariate analysis, independent predictors of inpatient mortality included the number of diagnoses per admission (odds ratio [OR] = 1.022; 95% confidence interval [CI], 1.016-1.029 per diagnosis), number of procedures per admission (OR = 1.192 per procedure; 95% CI, 1.177-1.208), and major or extreme severity of illness (OR = 3.16; 95% CI, 2.84-3.50). The most important predictors of cost, charge, and length of stay were admission to a large, urban hospital; use of Medicaid or Medicaid as the payer; major or extreme severity of illness; number of diagnoses at discharge; and procedures per admission (P < .05). CONCLUSIONS: Resource utilization increased from 2005 to 2009 for patients discharged from US hospitals with the diagnosis of HE. The inpatient mortality rate, however, remained stable, despite a trend toward more severe disease.

Algorithm to determine the outcome of patients with acute liver failure: a data-mining analysis using decision trees.

BACKGROUND: We established algorithms to predict the prognosis of acute liver failure (ALF) patients through a data-mining analysis, in order to improve the indication criteria for liver transplantation. METHODS: The subjects were 1,022 ALF patients seen between 1998 and 2007 and enrolled in a nationwide survey. Patients older than 65 years, and those who had undergone liver transplantation and received blood products before the onset of hepatic encephalopathy were excluded. Two data sets were used: patients seen between 1998 and 2003 (n=698), whose data were used for the formation of the algorithm, and those seen between 2004 and 2007 (n=324), whose data were used for the validation of the algorithm. Data on a total of 73 items, at the onset of encephalopathy and 5 days later, were collected from 371 of the 698 patients seen between 1998 and 2003, and their outcome was analyzed to establish decision trees. The obtained algorithm was validated using the data of 160 of the 324 patients seen between 2004 and 2007. RESULTS: The outcome of the patients at the onset of encephalopathy was predicted through 5 items, and the patients were classified into 6 categories with mortality rates between 23% and89%. When the prognosis of the patients in the categories with mortality rates greater than 50% was predicted as "death", the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the algorithm were 79, 78, 81, 83, and 75%, respectively. Similar high values were obtained when the algorithm was employed in the patients for validation. The outcome of the patients 5 days after the onset of encephalopathy was predicted through 7 items, and a similar high accuracy was found for both sets of patients. CONCLUSIONS: Novel algorithms for predicting the outcome of ALF patients may be useful to determine the indication for liver transplantation.

Prognostic assessment in patients with hepatic encephalopathy.

Hepatic encephalopathy (HE) is a common complication of liver failure that is associated with poor prognosis. However, the prognosis is not uniform and depends on the underlying liver disease. Acute liver failure is an uncommon cause of HE that carries bad prognosis but is potentially reversible. There are several prognostic systems that have been specifically developed for selecting patients for liver transplantation. In patients with cirrhosis the prognosis of the episode of HE is usually dictated by the underlying precipitating factor. Acute-on-chronic liver failure is the most severe form of decompensation of cirrhosis, the prognosis depends on the number of associated organ failures. Patients with cirrhosis that have experienced an episode of HE should be considered candidates for liver transplant. The selection depends on the underlying liver function assessed by the Model for End-stage Liver Disease (MELD) index. There is a subgroup that exhibits low MELD and recurrent HE, usually due to the coexistence of large portosystemic shunts. The recurrence of HE is more common in patients that develop progressive deterioration of liver function and hyponatremia. The bouts of HE may cause sequels that have been shown to persist after liver transplant.

Assessment of a modified Child-Pugh-Turcotte score to predict early mortality after liver transplantation.

OBJECTIVE: The Model for End-Stage Liver Disease (MELD) predicts mortality on the transplant list; however, it has not been of much use to predict posttransplant outcomes. Several prognostic models have been tested among patients with cirrhosis; nevertheless, their predictive value has not been established in the posttransplant setting. We recently modified the Child-Pugh-Turcotte (CPT) score by adding creatinine levels (CPT + Cr), which has proven useful for patients with alcoholic cirrhosis. This retrospective analysis sought to predict early (1 month) mortality using CPT + Cr versus 5 other prognostic models in patients who underwent orthotopic liver transplantation (OLT) at our center. MATERIALS AND METHODS: We included 48 consecutive patients (30 males, 18 females, median age 51 years). The predictive values of CPT + Cr were compared with CPT scores without or with the Huo modification, CPT + Na, MELD, and MESO, which is the MELD to serum Na ratio. Pearson correlations and ROC curves as evidenced by the area under the curve (AUC) were determined for each index. P < .05 was considered to be significant. RESULTS: CPT + Cr showed the highest correlation with the risk of death (r = .368, P = .01); MELD and MESO were the lowest (r = .204, P = NS; and r = .254, P = NS, respectively). ROC analysis showed the best predictive value of CPT and CPT-Crea with AUC of 0.758 (P = .010) and 0.748 (P = .011) respectively, as compared to 0.689 for MESO and 0.659 for MELD (both NS). CONCLUSIONS: A modified CPT score with creatinine levels may be of value to predict early death after OLT. Its usefulness must be validated in a prospective study of a large patient cohort.

The EEG assessment of low-grade hepatic encephalopathy: comparison of an artificial neural network-expert system (ANNES) based evaluation with visual EEG readings and EEG spectral analysis.

OBJECTIVE: The EEG provides an objective staging of hepatic encephalopathy (HE), but its interpretation may be biased by inter-observer variability. This study aims at comparing an entirely automatic EEG classification of HE based on an artificial neural network-expert system procedure (ANNES) with visual and spectral analysis based EEG classifications. METHODS: Two hundred and thirty-eight consecutive cirrhotic patients underwent closed-eye EEG. They were followed up for up to one-year to detect bouts of overt HE and death. The EEG was classified by ANNES, qualitative visual reading, main basic rhythm frequency and spectral analysis. The classifications were assessed on the basis of: (i) match with liver function, (ii) prognostic value and (iii) repeatability. RESULTS: All classifications were found to be related to the severity of liver failure, with cognitive findings and a history of previous bouts of HE. All of them had prognostic value on the occurrence of overt HE and on survival. The ANNES based classification was more repeatable than the qualitative visual one, and had the advantage of detecting low power EEG, but its efficiency in analyzing low-grade alterations was questionable. CONCLUSIONS: An entirely automatic - ANNES based - EEG classification of HE can improve the repeatability of EEG assessment, but further improvement of the device is required to classify mild alterations. SIGNIFICANCE: The ANNES based EEG grading of HE needs further improvements to be recommended in clinical practice, but it is already sufficient for detecting normal and clearly altered EEG tracings.

Prognostic assessment of fulminant hepatitis from indication criteria for liver transplantation.

The clinical outcome in 15 patients with fulminant hepatitis was predicted by the indication criteria for liver transplantation used in five different transplantation centers. Fifty-four to 100% of 13 fulminant hepatitis patients died who were fulfilled with these criteria for transplantation. Most of the patients died within five to nine days after the decision of liver transplantation was made. Takahashi's score of prognostic assessment for fulminant hepatitis decreased rapidly during the time when all the different criteria in transplantation centers were fulfilled. However, two survival cases with the acute type of fulminant hepatitis were incorrectly judged to be transplanted by the two criteria. The Cambridge's criterion for liver transplantation predicted the prognosis of fulminant hepatitis most correctly; sensitivity was 84.6% and specificity 100%.