Performance of eight predictive models for hepatocellular carcinoma recurrence after liver transplantation: A comparative study.

INTRODUCTION AND OBJECTIVES: Liver transplantation is the optimal treatment for patients with early hepatocellular carcinoma and cirrhosis. However, hepatocellular carcinoma recurs in approximately 15 % of individuals. This study aimed to assess the efficacy of predictive models for hepatocellular carcinoma recurrence after liver transplantation. PATIENTS AND METHODS: This retrospective study included 381 patients with HCC and evaluated the performance of the following models: R3-AFP score, alpha-fetoprotein (AFP) model, University of California, Los Angeles (UCLA) nomogram, Pre-Model of Recurrence after Liver Transplantation (MORAL), Post-MORAL, and Combo MORAL models, Risk Estimation of Tumor Recurrence (RETREAT) model and Platelet to Lymphocyte Ratio (PLR) model. RESULTS: The R3-AFP score, UCLA nomogram, AFP model, RETREAT, Combo MORAL, and Post-MORAL models exhibited comparable AUROCs, ranging from 0.785 to 0.733. The AUROCs for the R3-AFP model and AFP model were superior to those of the Pre-MORAL and PLR models. The UCLA nomogram, RETREAT score, Combo MORAL model, and Post-MORAL model performed similarly to the first two models, but were only superior to the PLR model. CONCLUSIONS: The R3-AFP model, UCLA nomogram, AFP model, RETREAT, Combo MORAL, and Post-MORAL models demonstrated a moderate predictive capacity for hepatocellular carcinoma recurrence following transplantation. No significant differences were observed among these models in their ability to predict recurrence.

Dobutamine stress echocardiography, myocardial perfusion scintigraphy, invasive coronary angiography, and post-liver transplantation events: Systematic review and meta-analysis.

The impact of coronary artery disease on the clinical course of patients enrolled for liver transplantation (LT) has changed over the years as these patients become older and sicker. The purpose of this systematic review and meta-analysis was to investigate the value of dobutamine stress echocardiography (DSE), myocardial perfusion scintigraphy (MPS), and invasive coronary angiography (ICA) in predicting cardiac events post-LT in cirrhotic patients. A literature search was conducted using Scopus, Web of Science, EMBASE, MEDLINE (via PubMed), BIREME (regional medical library of the Pan American Health Organization), LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Library for Systematic Reviews, and OpenGrey Repository (www.opengrey.eu) electronic databases. A total of 322 records were retrieved for DSE, 90 for MPS, and 149 for ICA. In the final analysis, 11 records for DSE, 7 for MPS, and 8 for ICA were included. The relative risk and confidence interval for major adverse cardiac events were 30.2 (2.8-325.4) for DSE, 2.6 (1.09-6.1) for MPS, and 2.1 (1.0-2.3) for ICA, while the relative risk and confidence interval for all-cause mortality was 4.7 for DSE (1.8-12.0), 2.7 (1.25-5.9) for MPS, and 1.5 (0.89-3.2) for ICA. In conclusion, this meta-analysis found that DSE, MPS, and ICA do not satisfactorily predict increased risk of perioperative MACE or all-cause mortality among cirrhotic patients listed for LT, among small and heterogenous studies.

Cultural Validation of the Transplanted Organ Questionnaire (TOQ) for the Brazilian Population.

BACKGROUND AND RATIONALE: The Transplanted Organ Questionnaire (TOQ), developed in France, is a disease-targeted instrument designed to evaluate what the transplanted organ represents to the recipient in patients who have undergone liver transplantation. The present study sought to validate a version of the TOQ for use in the Brazilian population. Translation and cross-cultural adaptation were carried out in accordance with international standard practices. Convergent validity was measured by correlations between TOQ domains and the Beck Depression Inventory (BDI), while reliability was assessed by measurement of internal consistency (Cronbach's alpha coefficient), reproducibility (intraclass correlation coefficient), sensitivity to change (effect size), and floor and ceiling effects. RESULTS: The study sample comprised 122 liver transplant recipients, with a mean age of 56.7 ± 9.9 years, treated at the outpatient clinic of a tertiary hospital in Southern Brazil. The sample was largely male (57.4%), and the predominant indication for liver transplant was hepatocellular carcinoma (34.4%). The mean total TOQ score was 32.9 ± 18.0. Cronbach's alpha for the total score was 0.89 (95%CI 0.86-0.92). Correlations between TOQ and BDI domains were acceptable, with the rejection domain correlating most strongly (r = 0.37; p ≤ 0.001). In conclusion, the Brazilian Portuguese version of the TOQ exhibited good psychometric performance, suggesting that it can be a useful tool in the Brazilian cultural context.

Cost-effectiveness of whole-body bone scans in the pre-liver transplant assessment of patients with hepatocellular carcinoma in Southern Brazil.

BACKGROUND: Bone metastases (BM) are rare in patients with early-stage hepatocellular carcinoma (HCC). In many centers, liver transplantation (LTx) policies require patients with HCC to undergo bone scans (BSs). METHODS: We retrospectively assessed the benefit of BS for patients with a diagnosis of HCC wait-listed for LTx. RESULTS: BS was performed in 259 of 328 patients (78.9%) and was suggestive of BM in only one (0.4%). At follow-up, 276 patients had received LTx, of whom 207 had undergone BS. Histopathological examination of explants failed to confirm the presence of HCC in 20 patients from the BS group. The survival and recurrence rates of the 187 patients with confirmed HCC in the explant who underwent BS as part of pre-LTx assessment and 69 patients who did not undergo BS were compared. The one- and five-yr post-transplant survival rates were 81% and 69%, respectively, in the BS group vs. 78% and 62%, respectively, in patients who did not undergo BS (p = 0.25). The one- and five-yr post-LTx recurrence rates were 4.8% and 10.7%, respectively, in the BS group vs. 2.9% and 10.1%, respectively, in patients who did not undergo BS (p = 0.46). CONCLUSIONS: BS generated expenditures of US$39 296 and was not cost-effective.

Cultural validation of the post-Liver transplant quality of life (pLTQ) questionnaire for the Brazilian population.

BACKGROUND AND RATIONALE: The post-Liver Transplant Quality of Life (pLTQ) questionnaire, developed in the United States, is a disease-targeted instrument designed to evaluate health-related quality of life (HRQoL) in liver transplant recipients. Our study sought to validate a version of the pLTQ for use in the Brazilian population. Translation and cross-cultural adaptation were carried out in accordance with international standard practices for questionnaire validation. Validity was measured by means of convergent validity (correlations between pLTQ domains and WHOQOL-Bref domains). Reliability was assessed by measurement of internal consistency (Cronbach's alpha coefficient), reproducibility (intraclass correlation coefficient), sensitivity to change (effect size), and floor and ceiling effects. RESULTS: The study sample comprised 160 liver transplant recipients, with a mean age of 56.9 ± 10.4 years, treated at a tertiary hospital in Southern Brazil. The sample was largely male (62.5%), and the predominant indication for liver transplant was hepatocellular carcinoma (49.4%). Only two questionnaire items were modified during the translation and cross-cultural validation stage. The mean total pLTQ score was 5.58 ± 0.9, with < 20% floor/ceiling effect. Correlations between pLTQ and WHOQOL-Bref domains were acceptable (r = 0.37-0.40). For similar dimensions, the correlations between WHOQOL-Bref and pLTQ were statistically significant (p ≤ 0.001). Cronbach's alpha for the total score was 0.91 (95% CI 0.89-0.93), with a range of 0.51 to 0.77 across domains. Reproducibility was 0.90, and sensitivity to change was 0.84. CONCLUSION: In conclusion, the Brazilian Portuguese versión of the pLTQ exhibited good psychometric performance, suggesting that it can be a useful tool in the Brazilian cultural context.

Biochemical non-invasive assessment of liver fibrosis cannot replace biopsy in HIV-HCV coinfected patients.

BACKGROUND AND RATIONALE: The liver biopsy has been considered the gold standard for the diagnosis and quantification of fibrosis. However, this method presents limitations. In addition, the non-invasive evaluation of liver fibrosis is a challenge. The aim of this study was to validate the fibrosis cirrhosis index (FCI) index in a cohort of human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfected patients, and compare to AST/ALT ratio (AAR), AST to platelet ratio index (APRI) and FIB-4 scores, as a tool for the assessment of liver fibrosis in coinfected patients. MATERIAL AND METHODS: Retrospective cross sectional study including 92 HIV-HCV coinfected patients evaluated in two reference centers for HIV treatment in the Public Health System in Southern Brazil. Patients who underwent liver biopsy for any indication and had concomitant laboratory data in the 3 months prior to liver biopsy, to allow the calculation of studied noninvasive markers (AAR, APRI, FIB-4 and FCI) were included. RESULTS: APRI < 0.5 presents the higher specificity to detect no or minimal fibrosis, whereas APRI > 1.5 presents the best negative predictive value and FCI > 1.25 the best specificity to detect significant fibrosis. The values of noninvasive markers for each Metavir fibrosis stage showed statistically significant differences only for APRI. In conclusion, until better noninvasive markers for liver fibrosis are developed and validated for HIV-HCV coinfected patients, noninvasive serum markers should be used carefully in this population.

Validation of the "Metroticket" model in a cohort of patients transplanted for hepatocellular carcinoma in southern Brazil.

This retrospective study evaluated the ability of the Metroticket model to predict five-yr post-transplant survival in patients with hepatocellular carcinoma (HCC) based only on explant data. Five-yr survival after transplant was estimated using the Metroticket Calculator, and observed survival was calculated using the Kaplan-Meier method. Metroticket-predicted survival was compared between deceased and surviving patients using the Mann-Whitney test. The accuracy of Metroticket estimates in discriminating between these two patient groups was assessed using the c-statistic. Median patient age (n = 109) was 55.7 yr, and 72.5% of the sample were men. Metroticket-predicted and observed post-transplant survival at five yr was 71.1% and 58.7%, respectively. Predictions were calculated using the explant data of the 64 survivors and 45 deceased patients. Median five-yr survival was 72.9% in the former and 69.7% in the latter. The c-statistic of the Metroticket model for distinguishing surviving from deceased patients was 0.55. In this cohort, the Metroticket model was unable to accurately predict five-yr post-transplant survival based only on explant data.

Exercise capacity of cirrhotic patients with hepatopulmonary syndrome.

INTRODUCTION: Hepatopulmonary syndrome (HPS) is characterized by a clinical triad of liver disease and/or portal hypertension, intrapulmonary vascular dilatation and abnormal arterial oxygenation. These conditions can worsen muscle strength, exercise capacity and functionality in the affected population. OBJECTIVE: The objective of this study was to compare exercise capacity, functional condition and respiratory muscle strength in cirrhotic patients diagnosed with HPS and cirrhotic patients without this diagnosis. MATERIAL AND METHODS: This cross-sectional study used a convenience sample consisting of 178 patients (92 patients with HPS and 86 patients without HPS) with a diagnosis of liver cirrhosis caused by either alcohol consumption or the hepatitis C virus (HCV). Peak oxygen consumption (VO2 peak) was used to verify exercise capacity, the six-minute walk test (6MWT) was used to test functionality, and manovacuometry was used to evaluate the strength of the respiratory muscles. The Kolmogorov-Smirnov test and Student's t-test were used for the statistical analysis. The data were analyzed using SPSS 16.00, and p < 0.05 was considered significant. RESULTS: The group of patients with the diagnosis of HPS exhibited a lower VO2 peak (14.2 ± 2.3 vs. 17.6 ± 2.6, p < 0.001), shorter distance walked in the 6MWT (340.8 ± 50.9 vs. 416.5 ± 91.4, p < 0.001), lower maximal inspiratory pressure (-49.1 ± 9.8 vs. -74.2 ± 13.9, p = 0.001) and lower maximum expiratory pressure (60.1 ± 12.2 vs. 76.8 ± 14.7, p = 0.001). CONCLUSION: The group of cirrhotic patients diagnosed with HPS exhibited lower values for VO2 peak, distance walked in the 6MWT and respiratory muscle strength than the cirrhotic patients not diagnosed with HPS.

D-MELD does not predict post-liver transplantation survival: a single-center experience from Brazil.

BACKGROUND: The D-MELD score was designed to prevent donor-recipient matches with a high risk of unfavorable outcome. The main objective of the present study was to assess the predictive value of the DMELD score for 1-month and 3-month post-transplant mortality in a cohort of patients who underwent deceased-donor liver transplantation in Southern Brazil. MATERIAL AND METHODS: A cohort study was conducted. Receiver operating characteristic c-statistics were used to determine the ability of the D-MELD score to predict mortality. The Kaplan-Meier method was used to analyze survival as a function of time regarding D-MELD scores, and the Cox model was employed to assess the association between D-MELD and mortality. RESULTS: Most recipients were male, with a mean age of 54.3 ± 9.6 years (n = 233 transplants). Mean donor age was 44.9 ± 16.8 years (19.3% of donors were aged ≥ 60 years). Mean MELD and D-MELD scores were 16.3 ± 7.1 and 733.1 ± 437.8 respectively. Overall survival at 1 and 3 months was 83.6%. The c-statistic value for 1- and 3-month mortality was < 0.5 for the D-MELD. Analysis of Kaplan-Meier curves for groups with D-MELD scores < 1,600 and ≥ 1,600 did not show statistically significant differences in survival (p = 0.722). CONCLUSION: D-MELD scores were unable to predict survival in this cohort of Brazilian liver transplant recipients.

Predicting major adverse cardiovascular events after orthotopic liver transplantation using a supervised machine learning model: A cohort study.

BACKGROUND: Liver transplant (LT) patients have become older and sicker. The rate of post-LT major adverse cardiovascular events (MACE) has increased, and this in turn raises 30-d post-LT mortality. Noninvasive cardiac stress testing loses accuracy when applied to pre-LT cirrhotic patients. AIM: To assess the feasibility and accuracy of a machine learning model used to predict post-LT MACE in a regional cohort. METHODS: This retrospective cohort study involved 575 LT patients from a Southern Brazilian academic center. We developed a predictive model for post-LT MACE (defined as a composite outcome of stroke, new-onset heart failure, severe arrhythmia, and myocardial infarction) using the extreme gradient boosting (XGBoost) machine learning model. We addressed missing data (below 20%) for relevant variables using the k-nearest neighbor imputation method, calculating the mean from the ten nearest neighbors for each case. The modeling dataset included 83 features, encompassing patient and laboratory data, cirrhosis complications, and pre-LT cardiac assessments. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC). We also employed Shapley additive explanations (SHAP) to interpret feature impacts. The dataset was split into training (75%) and testing (25%) sets. Calibration was evaluated using the Brier score. We followed Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines for reporting. Scikit-learn and SHAP in Python 3 were used for all analyses. The supplementary material includes code for model development and a user-friendly online MACE prediction calculator. RESULTS: Of the 537 included patients, 23 (4.46%) developed in-hospital MACE, with a mean age at transplantation of 52.9 years. The majority, 66.1%, were male. The XGBoost model achieved an impressive AUROC of 0.89 during the training stage. This model exhibited accuracy, precision, recall, and F1-score values of 0.84, 0.85, 0.80, and 0.79, respectively. Calibration, as assessed by the Brier score, indicated excellent model calibration with a score of 0.07. Furthermore, SHAP values highlighted the significance of certain variables in predicting postoperative MACE, with negative noninvasive cardiac stress testing, use of nonselective beta-blockers, direct bilirubin levels, blood type O, and dynamic alterations on myocardial perfusion scintigraphy being the most influential factors at the cohort-wide level. These results highlight the predictive capability of our XGBoost model in assessing the risk of post-LT MACE, making it a valuable tool for clinical practice. CONCLUSION: Our study successfully assessed the feasibility and accuracy of the XGBoost machine learning model in predicting post-LT MACE, using both cardiovascular and hepatic variables. The model demonstrated impressive performance, aligning with literature findings, and exhibited excellent calibration. Notably, our cautious approach to prevent overfitting and data leakage suggests the stability of results when applied to prospective data, reinforcing the model's value as a reliable tool for predicting post-LT MACE in clinical practice.

Liver retransplantation in adults: a 20-year experience of one center in southern Brazil.

INTRODUCTION: Liver retransplantation (LReTx) is the therapeutic option for hepatic graft failure. Survival after LReTx is poorer than after primary liver transplantation. Given the organ shortage, it is essential to optimize the use of this resource. OBJECTIVE: To evaluate rates, indications and patient survival after LReTx and identify factors associated with mortality following LReTx. MATERIAL AND METHODS: We conducted a retrospective cohort study of all adults undergoing LReTx based on registry data from the Liver Transplantation Group (Complexo Hospitalar Santa Casa de Porto Alegre), southern Brazil. RESULTS: Between June 16, 1991 and July 19, 2011, 824 patients underwent 866 liver transplants. Forty-two procedures corresponded to LReTx (4.8% of all liver transplants performed). Thirty-eight patients who underwent a single LReTx procedure were included in this study. The leading indication for LReTx was hepatic artery thrombosis (HAT) (31.6%), followed by primary nonfunction (PNF) (18.4%). The main indication for early LReTx was PNF (58.3%) and for late LReTx was HAT (38.5%). During the follow-up period, 26 patients (68.4%) died after LReTx. Patient survival at 1 and 3 years after LReTx was 44.7% and 44.7%, respectively. Patients infected with hepatitis C virus, serum albumin < 2.5 g/dL and receiving mechanical ventilation immediately before LReTx had a significantly lower survival rate than the other patients. CONCLUSION: Considering the increased mortality when the graft loss is delayed, it is necessary to define the minimum acceptable results to indicate LReTx and identify the patients who would most benefit from this treatment.

Impact of MELD score implementation on liver allocation: experience at a Brazilian center.

Introduction. Model for end-stage liver disease (MELD) is an accurate predictor of mortality in patients with cirrhosis, and has been used on liver allocation in Brazil since 2006. However, its impact on organ allocation, waiting list and post-transplant mortality is still poorly characterized. This study aimed to assess the impact of implementation of the MELD system on liver allocation and mortality after liver transplantation (LT) in Southern Brazil. Material and methods. Adult patients with chronic liver disease on the waiting list for primary deceased-donor LT were divided into two cohorts (pre- and post-MELD implementation) according to the date of waiting list placement. Disease severity, as assessed by MELD score at placement, was similar in both cohorts. Patients were followed for at least 18 months to assess the outcomes of interest (death/LT). Results. Higher MELD scores correlated with waiting list mortality, which increased 20% with each additional point (HR 1.2; 95%CI 1.14-2.26; p < 0.001). Waiting list mortality was 30.9% before and 21.7% after MELD implementation (nonsignificant). Transplant rate increased after MELD implementation (52 vs. 40%, p = 0.002). After excluding patients with hepatocellular carcinoma, mean MELD scores at LT were significantly higher in the MELD era (p < 0.01). There was no significant correlation between MELD scores at LT and post-LT survival. During 18-month follow-up, post-LT mortality rate was 25.4% before and 20% after MELD implementation (nonsignificant). Conclusion. MELD implementation was associated with a reduction in waiting list mortality. Although sicker patients received LT in the MELD era, post-transplant survival was similar in both periods.

Impact of creatinine values on MELD scores in male and female candidates for liver transplantation.

INTRODUCTION: A systematic bias against women, resulting from the use of creatinine as a measure of renal function, has been identified in Model for End-stage Liver Disease (MELD)-based liver allocation. Correction of this bias by calculation of female creatinine levels using the Modification of Diet in Renal Disease (MDRD) formula has been suggested. MATERIAL AND METHODS: A cohort of 639 cirrhotic candidates for first-time liver transplantation was studied. Creatinine levels were corrected for gender using the MDRD formula. The accuracy of MELD, with or without creatinine correction, to predict 3-and 6-month mortality after inclusion in a transplant waiting list was estimated. RESULTS: Women exhibited significantly lower creatinine levels, glomerular filtration rate, and MELD scores than men. After creatinine correction, female MELD scores had a mean increase of 1.1 points. Creatinine correction yielded an increase of 3 points in the MELD score in 15.2% of patients, 2 points in 22.4%, and 1 point in 17.6% of patients. The likelihood of death at 3 and 6 months after enrollment in the transplant waiting list was similar in males and females and the likelihood of receiving a transplant, as assessed by Kaplan-Meier survival curves, was also similar in males and females. CONCLUSION: The survival or the likelihood of receiving a transplant while on the waiting list were similar in men and women in both pre- and post-MELD eras and creatinine correction did not increase the accuracy of the MELD score in estimating 3- and 6-month mortality in female candidates for liver transplantation.

Association of blood pressure and hypertension with alcohol consumption in HIV-infected white and nonwhite patients.

INTRODUCTION: Although alcohol abuse is associated with hypertension in whites and nonwhites, it has been scarcely investigated in HIV-infected patients. OBJECTIVE: To investigate whether the association of alcohol abuse with hypertension is influenced by skin color in HIV-infected individuals. METHODS: Cross-sectional study in HIV-infected individuals aged 18 years or older. Demographic characteristics, lifestyle, and HIV infection were investigated. Alcohol abuse was defined as ≥ 15 (women) and ≥ 30 g/alcohol/day (men), and binge drinking by the intake of ≥ 5 drinks on a single occasion. Hypertension was defined by blood pressure ≥ 140/90 mmHg or use of blood pressure-lowering agents. RESULTS: We studied 1,240 individuals, with 39.1 ± 10 years, 51% males and 57% whites. Age and body mass index were associated with blood pressure, and there was an independent association of alcohol abuse with hypertension in whites (RR = 1.9, 95% CI 1.1-3.3) and nonwhites (RR = 2.4, 95% CI 1.4 to 4.0). Among nonwhite individuals who were alcohol abusers, systolic (9.3 ± 3.2; P = 0.001) and diastolic blood pressures (6.4 ± 2.1; P = 0.008) were higher than in nonabusers. CONCLUSION: Alcohol abuse is a risk factor for hypertension in white and nonwhite HIV-infected individuals. The association of ethanol consumption with blood pressure is not explained by AIDS-related conditions.

Risk of coronary heart disease among HIV-infected patients: a multicenter study in Brazil.

Cardiovascular disease has emerged as a crescent problem among HIV-infected population. This study aimed to determine the 10-year risk of coronary heart disease using the Framingham risk score among HIV-infected patients from three regions of Brazil. This is a pooled analysis of three cohort studies, which enrolled 3,829 individuals, 59% were men, 66% had white skin color, and mean age 39.0 ± 9.9 years. Comparisons among regions showed that there were marked differences in demographic, socioeconomic, clinical, and HIV-related characteristics. Prevalence of Framingham score ≥10 was 4.5% in the Southern, 4.2% in the Midwest, and 3.9% in the Northeast of Brazil. The Framingham score ≥10 was similar between regions for males, patients aged ≥60 years, with obesity, central obesity, hypertension, and diabetes mellitus. Women were three times more likely to have coronary heart disease in 10 years than men. Hypertension and diabetes increased more than four times the risk of coronary heart disease, followed by central obesity, obesity, and prehypertension. The use of antiretroviral agents and time since HIV diagnosis were not risk factors for coronary artery disease in 10 years. In conclusion, hypertension and diabetes are the strongest independent predictors of 10-year risk of coronary heart disease among HIV-infected population.

Correction: Propensity-matched analysis of patients with intrahepatic cholangiocarcinoma or mixed hepatocellular-cholangiocarcinoma and hepatocellular carcinoma undergoing a liver transplant.

[This corrects the article on p. 688 in vol. 13, PMID: 36160465.].

MELD scores with incorporation of serum sodium and death prediction in cirrhotic patients on the waiting list for liver transplantation: a single center experience in southern Brazil.

To compare the accuracy of standard model for end-stage liver disease (MELD) score with that of four MELD-based scores incorporating serum sodium (SNa) to predict three- and six-month mortality in cirrhotic patients after their placement on the waiting list for liver transplantation (LT). A cohort study was performed. Receiver operating characteristic (ROC) curves were generated for MELD, MELD incorporating SNa (MELD-Na, MELD-Na2), integrated MELD (iMELD), and MELD to SNa ratio (MESO) index to assess the predictive accuracy of these scores to determine three- and six-month mortality. The c-statistic (area under the ROC curve [AUC]) was used to determine predictive power and the Cox proportional-hazard ratio to estimate death risk. We studied 558 patients. There was a statistically significant difference in the predictive accuracy of scores at three months (AUCs: MELD = 0.79 [95% CI = 0.72-0.87]; MELD-Na = 0.84 [95% CI = 0.78-0.90]; MELD-Na2 = 0.85 [95% CI = 0.80-0.91]; iMELD = 0.85 [95% CI = 0.80-0.90]; MESO = 0.81 [95% CI = 0.80-0.91]) and at six months (MELD = 0.73 [95% CI = 0.67-0.80]; MELD-Na = 0.79 [95% CI = 0.73-0.84]; MELD-Na2 = 0.80 [95% CI = 0.74-0.85]; iMELD = 0.80 [95% CI = 0.75-0.85]; MESO = 0.75 [95% CI = 0.69-0.81]) (p < 0.001). Death risk was independent of age and sex. Sodium-modified MELD scores are able to more accurately predict three- and six-month mortality among cirrhotic patients awaiting LT.

Metabolic syndrome and population attributable risk among HIV/AIDS patients: comparison between NCEP-ATPIII, IDF and AHA/NHLBI definitions.

BACKGROUND: Metabolic Syndrome (MetS) is based on the same individual components, but has received several amendments to the original definition. In this study, we verified the prevalence of metabolic syndrome according to different criteria, and the impact of each component on the diagnostic. METHODS: This cross-sectional study enrolled HIV infected patients from a HIV/AIDS reference Center in southern Brazil. Metabolic syndrome was identified according to the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP-ATPIII), the International Diabetes Federation (IDF) and the American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI) criteria, and using a standardized questionnaire and blood testing. RESULTS: A sample of 1240, out of 1295, HIV-infected patients was enrolled. Males were on average older, more educated, and had shorter time since the HIV diagnosis. The population attributable risk (PAR) for waist circumference explained 80% of the prevalence among men and women (AHA/NHLBI criteria). Triglycerides had the highest impact on prevalence of metabolic syndrome according to all criteria, independently of age, skin color and HAART use, among men. CONCLUSIONS: In this large sample of HIV infected patients, the overall prevalence of metabolic syndrome, under either classification, was noticeable and the AHA/NHLBI definition accounted for the highest prevalence.

Prognostic factors associated with in-hospital mortality in patients with spontaneous bacterial peritonitis.

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is associated with a high in-hospital mortality rate ranging from 20-40%. The model for end-stage liver disease (MELD) has been suggested as a predictor of in-hospital mortality in patients with SBP. However, the accuracy of the MELD has been questioned, and the integrated MELD (iMELD) score, which incorporates age and serum sodium to the previous model, has been proposed to improve prognostic accuracy. The iMELD has not yet been evaluated in patients with SBP. AIM: To evaluate the accuracy of iMELD and MELD scores in predicting in-hospital mortality in patients with SBP and to identify other prognostic factors of mortality in this group of patients. RESULTS: Of 40 patients analyzed, 65% were male, 50% had hepatitis C, and 27.5% had hepatocellular carcinoma. Mean age was 55.6 years; 25.7% were classified as Child-Pugh class B, and 74.3% as class C. Mean scores were 46.0 and 19.9 for iMELD and MELD, respectively. In-hospital mortality was 40%. Univariate analysis showed that total bilirubin, creatinine, MELD and iMELD scores were significantly associated with in-hospital mortality. The prognostic accuracy was 80% and 77% for iMELD and MELD scores, respectively. CONCLUSION: In conclusion, bilirubin, creatinine, MELD and iMELD were predictors of in-hospital mortality in cirrhotic patients with SPB. iMELD was slightly more accurate than MELD in this group of patients.

Evaluation of the C3435T polymorphism in the MDR1 gene in patients with hepatocellular carcinoma.

INTRODUCTION: Considering the high prevalence of liver tumors and the impact on patient survival, a greater understanding of the biological behavior of those tumors if of great importance. The multidrug resistance gene (MDR1) may present as single nucleotide polymorphism (SNP) which can affect the expression and activity of P-glycoprotein (Pgp), and high expression of Pgp has been associated with a worse prognosis in affected patients. OBJECTIVE: To correlate the C3435T polymorphism in the MDR1 gene with the immunohistochemical expression of Pgp. MATERIAL AND METHODS: A total of 67 samples from patients with diagnosis of hepatocellular carcinoma (HCC), collected in the period from 2000 to 2009, were analyzed. The polymorphism in the MDR1 gene was determined by the technique of allele-specific real time PCR using TaqMan assay, and the expression of protein Pgp was evaluated by immunohistochemistry. RESULTS: Among the samples evaluated, 56 (83.6%) were from male patients and 11 (16.4%) from females. Mean age was 60.6 years (± 8.8), ranging from 37 to 85 years. The etiology of the HCC was related to hepatitis C virus infection (HCV) in 31 (46.3%) of cases, followed by hepatitis C virus infection + alcohol in 24 cases (35.8%), alcohol in 4 cases (6)%, hepatitis B virus (HBV) in 4 cases (6%) and other factors in 4 cases (6%). Liver transplantation was performed in 48 cases (71.6%) and hepatectomia in 19 cases (28.4%). The genotypes CC, CT and TT showed frequencies of 25.4%, 41.8% and 32.8%, respectively, and the allele frequencies were 46.3% for allele C and 53.7% for allele T. The expression of Pgp in over 75% of the cells was significantly more frequent in tumor tissue. On the other hand, a low expression of Pgp, in less than 25% of the cells, was significantly more frequent in non-tumor tissue. The Pgp expression in more than 50% of tumor cells of individuals with genotypes CC, CT and TT was 15.7%, 51.0% and 33.3%, respectively, and was significantly higher when in the presence of allele T (p = 0.002). CONCLUSION: The presence of the polymorphic allele T is related to increased expression of Pgp protein in patients with HCC.