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Continuing thrombocytopenia after TIPS-implantation is due to impaired platelet production
Category 2: Cirrhosis and its complications,
I235
MODEL
FOR END-STAGE
SURVIVAL
LIVER DISEASE
IN PATIENTS WITH VARICEAL
(MELD) PREDICTS BLEEDING
M. van IJperen3, K.M. Bambha’, M. Malinchoc2, W.K. Kremers2, W.R. Kim’,3, R.H. Wiesner’,3, P.S. Kamath’,3. ‘Gastroenterology And Hepatology; 2Health Sciences Research; 3Transplant Centec Mayo Clinic, Rochestes MN, USA Background: The Child-Turcotte-Pugh (CTP) score has traditionally been used to stratify patients at risk for mortality with variceal bleeding. Drawbacks of CTP include subjective assessment of ascites and encephalopathy and the lack of standardization of albumin and prothrombin time measurement. The Model for End-Stage Liver Disease (MELD) derived from serum creatinine, bilirubin, and prothrombin time INR has recently been found to be superior to CTP in stratifying patients at risk for mortality with cirrhosis of the liver. Aim: To determine whether MELD can stratify patients with variceal bleeding according to mortality risk. Methods: From a prospectively kept database, we identified 389 patients between 1998-2002 who fulfilled Baveno criteria for acute variceal bleeding. Of these, 299 (77%) patients had the requisite data for MELD score within 24 hours of the variceal bleed. Since 1993, treatment has been octreotide and endoscopic variceal ligation (n=205), while prior to 1993, treatment was vasopressin and either sclerotherapy or banding (n=94). Patient survival was analyzed using log rank test and Cox proportional hazards model with patients followed for a maximum of one year post bleeding. Results: The mortality for the cohort was 9.7% at 7 days, 25.7% at 42 days, and 39.1% at 1 year. When patients were grouped according to MELD score < 10, lo-20 and >20, the MELD score was a significant predictor of increased mortality (p
< 10
MELD
x4
lo-20
MELD
117
9x 22.4
% Mortality
7 days
9.6
% Mortality
42 days
9.5
21.7
52.5
% Mortality
365 days
19.9
34.5
71.5
> 20
Conclusions: MELD can accurately rank patients at risk of mortality following a variceal bleed irrespective of treatment and may be used in trials to stratify patients.
I
236
IMPACT OF THE PAlTERN HOSPITAL
MORTALITY
OF ORGAN
IN CRITICALLY
DYSFUNCTION
ON
ILL PATIENTS WITH
pathophysiology
and clinical aspects
73
(75%), Child-Pugh category (A, B, C) was n=lO, 76,189, hospitalmortality 44% After adjustment for age and gender, the relative risk of hospital death increased by 3.2 (95% confidence interval (CI) 2.0-5.1) for each point in the neurologic system, by 2.4/paint in the cardiovascular system (95%CI 1.7.3.4), by 1.7/paint in the hepatic system (95%CI 1.2.2.4), by 1.5/paint in the renal (95%CI 1.08-2.1) and the respiratory (95%CI 1.07. 2.1) system. Neurologic failure (Glasgow coma scale 9 or less, relative risk 25, 95%CI 6-105) and circulatory failure (vasopressors at least 0.1 kg/kg/min, relative risk 15,95%CI 5-45) had the highest impact on hospital death. Conclusion: In our population of critically ill cirrhotic patients the neurologic and cardiovascular organ system had the highest impact on short-term mortality.
I
237
CONTINUING IMPLANTATION
THROMBOCYTOPENIA IS DUE TO IMPAIRED
AFTER TIPSPLATELET
PRODUCTION
M. Wichlas’, .I. Pidlich’, S. Panzer2, A. Kreil’, M. Homoncik’, ‘Dept. of l? Ferenci’, A. Gangl’, M. Peck-Radosavljevic. Gastroenterology and Hepatology, Vienna, Austria; 2Dept. of Transfusion Medicine, Vienna, Austria Introduction: Thrombocytopenia in liver disease cannot be resolved by simple relief of portal hypertension. Methods: 24 patients with liver cirrhosis and thrombocytopenia were included. We studied platelet counts, thrombopoietin (TPO) serum levels, reticulated platelets (RP; markers of platelet production) as well as markers of coagulation activation (prothrombin fragment F1+2), thrombocyte activation (b-TG), and clotting factors before and for 1 year after TIPSimplantation. Results: No increase in thrombocyte count as well as in RP and persistently normal TPO-levels could be observed throughout the study period. F1+2 was mostly in the range of normal before TIPS, increased transiently at day 3 post TIPS returning to pre-treatment levels at day 10 until the end of the study period. b-TG was mostly in the range of normal before TIPS and did not change significantly throughout the study. The liver derived clotting factor V remained low, while factor VIII showed constantly high normal levels. Conclusion: Lack of increase in markers of thrombocyte activation and constant levels of clotting factors rule out platelet consumption and DIC after TIPS. Transient elevation of F1+2 cannot explain the persistently low platelet counts. Lack of elevated RP’s in thrombocytopenia point to an inadequate bone marrow production of platelets through low TPO serum levels due to impaired liver function in cirrhosis. Deficiency of this liver derived platelet-growth factor seems to be an important cause of thrombocytopenia in cirrhosis, which is not relieved by portal decompression.
CIRRHOSIS
M. Wehler’, D. Kern’, .I. Kokoska’, U. Reulbach2, E.G. Hahn’, R. Strauss’. ‘Department Of Medicine I University Of Erlangen-Nuremberg, Erlangen, Get-many; 2Department Of Medical Informatics, Biometry And Epidemiology, University Of Erlangen-Nuremberg, Erlangen, Get-many Introduction: Few studies have analyzed the impact of different organ system dysfunctions on short-term mortality in critically ill cirrhotic patients. Patients and Methods: All patients with hepatic cirrhosis admitted to our medical intensive care unit (ICU) were eligible. Organ function was evaluated by the Sequential Organ Failure Assessment (SOFA) 24 hours after ICU admission. The SOFA is composed of scores from six organ systems (respiratory, cardiovascular, hepatic, renal, coagulation, and neurologic) graded from 0 to 4 points according to normal function or the degree of dysfunction. Multiple logistic regression analysis was performed to evaluate the effect of the various organ systems on the risk of hospital death. Results: During 1997 and 2001, 275 consecutive patients were included: 66% male, median age 54 yrs. Etiology of cirrhosis was mainly alcoholic
I 238
BRAIN MRI CHANGES
AND OTHER DIAGNOSTIC
PATIENTS WITH SUBCLINICAL
TESTS
IN
HEPATIC ENCEPHALOPATHY
N. Yilmaz’,
C. Calli2, 0. Kitis2, Y. Colak’, A. Eryavuz3, N. Yunden3, S. Bilgin4, Y. Batur’. ‘Department Of Gastroenterology; 2Department Of Radiology; ‘Department Of Psychiatry; 4Department Of Neurology, Ege University Medical School, I&s Turkey Aim: The purpose of the study was to investigate MR changes and neuropsychological tests in patients with subclinical hepatic encephalopathy (SHE) and to investigate the accordance between the tests. Methods: 32 cirrhotic patients (9 female, 23 male, mean age 55) without any clinical signs of overt encephalopathy were included. Patients with concurrent use of alcohol, benzodiazepines or anti-epileptics were excluded. In order to diagnose SHE, the number connection tests part A (NCT-A), symbol digit test (SDT), electroencephalogram (EEG), and magnetic resonance imaging with MR spectroscopy were used. Findings were evaluated with t test and MC Nemar test.
I235
MODEL
FOR END-STAGE
SURVIVAL
LIVER DISEASE
IN PATIENTS WITH VARICEAL
(MELD) PREDICTS BLEEDING
M. van IJperen3, K.M. Bambha’, M. Malinchoc2, W.K. Kremers2, W.R. Kim’,3, R.H. Wiesner’,3, P.S. Kamath’,3. ‘Gastroenterology And Hepatology; 2Health Sciences Research; 3Transplant Centec Mayo Clinic, Rochestes MN, USA Background: The Child-Turcotte-Pugh (CTP) score has traditionally been used to stratify patients at risk for mortality with variceal bleeding. Drawbacks of CTP include subjective assessment of ascites and encephalopathy and the lack of standardization of albumin and prothrombin time measurement. The Model for End-Stage Liver Disease (MELD) derived from serum creatinine, bilirubin, and prothrombin time INR has recently been found to be superior to CTP in stratifying patients at risk for mortality with cirrhosis of the liver. Aim: To determine whether MELD can stratify patients with variceal bleeding according to mortality risk. Methods: From a prospectively kept database, we identified 389 patients between 1998-2002 who fulfilled Baveno criteria for acute variceal bleeding. Of these, 299 (77%) patients had the requisite data for MELD score within 24 hours of the variceal bleed. Since 1993, treatment has been octreotide and endoscopic variceal ligation (n=205), while prior to 1993, treatment was vasopressin and either sclerotherapy or banding (n=94). Patient survival was analyzed using log rank test and Cox proportional hazards model with patients followed for a maximum of one year post bleeding. Results: The mortality for the cohort was 9.7% at 7 days, 25.7% at 42 days, and 39.1% at 1 year. When patients were grouped according to MELD score < 10, lo-20 and >20, the MELD score was a significant predictor of increased mortality (p
< 10
MELD
x4
lo-20
MELD
117
9x 22.4
% Mortality
7 days
9.6
% Mortality
42 days
9.5
21.7
52.5
% Mortality
365 days
19.9
34.5
71.5
> 20
Conclusions: MELD can accurately rank patients at risk of mortality following a variceal bleed irrespective of treatment and may be used in trials to stratify patients.
I
236
IMPACT OF THE PAlTERN HOSPITAL
MORTALITY
OF ORGAN
IN CRITICALLY
DYSFUNCTION
ON
ILL PATIENTS WITH
pathophysiology
and clinical aspects
73
(75%), Child-Pugh category (A, B, C) was n=lO, 76,189, hospitalmortality 44% After adjustment for age and gender, the relative risk of hospital death increased by 3.2 (95% confidence interval (CI) 2.0-5.1) for each point in the neurologic system, by 2.4/paint in the cardiovascular system (95%CI 1.7.3.4), by 1.7/paint in the hepatic system (95%CI 1.2.2.4), by 1.5/paint in the renal (95%CI 1.08-2.1) and the respiratory (95%CI 1.07. 2.1) system. Neurologic failure (Glasgow coma scale 9 or less, relative risk 25, 95%CI 6-105) and circulatory failure (vasopressors at least 0.1 kg/kg/min, relative risk 15,95%CI 5-45) had the highest impact on hospital death. Conclusion: In our population of critically ill cirrhotic patients the neurologic and cardiovascular organ system had the highest impact on short-term mortality.
I
237
CONTINUING IMPLANTATION
THROMBOCYTOPENIA IS DUE TO IMPAIRED
AFTER TIPSPLATELET
PRODUCTION
M. Wichlas’, .I. Pidlich’, S. Panzer2, A. Kreil’, M. Homoncik’, ‘Dept. of l? Ferenci’, A. Gangl’, M. Peck-Radosavljevic. Gastroenterology and Hepatology, Vienna, Austria; 2Dept. of Transfusion Medicine, Vienna, Austria Introduction: Thrombocytopenia in liver disease cannot be resolved by simple relief of portal hypertension. Methods: 24 patients with liver cirrhosis and thrombocytopenia were included. We studied platelet counts, thrombopoietin (TPO) serum levels, reticulated platelets (RP; markers of platelet production) as well as markers of coagulation activation (prothrombin fragment F1+2), thrombocyte activation (b-TG), and clotting factors before and for 1 year after TIPSimplantation. Results: No increase in thrombocyte count as well as in RP and persistently normal TPO-levels could be observed throughout the study period. F1+2 was mostly in the range of normal before TIPS, increased transiently at day 3 post TIPS returning to pre-treatment levels at day 10 until the end of the study period. b-TG was mostly in the range of normal before TIPS and did not change significantly throughout the study. The liver derived clotting factor V remained low, while factor VIII showed constantly high normal levels. Conclusion: Lack of increase in markers of thrombocyte activation and constant levels of clotting factors rule out platelet consumption and DIC after TIPS. Transient elevation of F1+2 cannot explain the persistently low platelet counts. Lack of elevated RP’s in thrombocytopenia point to an inadequate bone marrow production of platelets through low TPO serum levels due to impaired liver function in cirrhosis. Deficiency of this liver derived platelet-growth factor seems to be an important cause of thrombocytopenia in cirrhosis, which is not relieved by portal decompression.
CIRRHOSIS
M. Wehler’, D. Kern’, .I. Kokoska’, U. Reulbach2, E.G. Hahn’, R. Strauss’. ‘Department Of Medicine I University Of Erlangen-Nuremberg, Erlangen, Get-many; 2Department Of Medical Informatics, Biometry And Epidemiology, University Of Erlangen-Nuremberg, Erlangen, Get-many Introduction: Few studies have analyzed the impact of different organ system dysfunctions on short-term mortality in critically ill cirrhotic patients. Patients and Methods: All patients with hepatic cirrhosis admitted to our medical intensive care unit (ICU) were eligible. Organ function was evaluated by the Sequential Organ Failure Assessment (SOFA) 24 hours after ICU admission. The SOFA is composed of scores from six organ systems (respiratory, cardiovascular, hepatic, renal, coagulation, and neurologic) graded from 0 to 4 points according to normal function or the degree of dysfunction. Multiple logistic regression analysis was performed to evaluate the effect of the various organ systems on the risk of hospital death. Results: During 1997 and 2001, 275 consecutive patients were included: 66% male, median age 54 yrs. Etiology of cirrhosis was mainly alcoholic
I 238
BRAIN MRI CHANGES
AND OTHER DIAGNOSTIC
PATIENTS WITH SUBCLINICAL
TESTS
IN
HEPATIC ENCEPHALOPATHY
N. Yilmaz’,
C. Calli2, 0. Kitis2, Y. Colak’, A. Eryavuz3, N. Yunden3, S. Bilgin4, Y. Batur’. ‘Department Of Gastroenterology; 2Department Of Radiology; ‘Department Of Psychiatry; 4Department Of Neurology, Ege University Medical School, I&s Turkey Aim: The purpose of the study was to investigate MR changes and neuropsychological tests in patients with subclinical hepatic encephalopathy (SHE) and to investigate the accordance between the tests. Methods: 32 cirrhotic patients (9 female, 23 male, mean age 55) without any clinical signs of overt encephalopathy were included. Patients with concurrent use of alcohol, benzodiazepines or anti-epileptics were excluded. In order to diagnose SHE, the number connection tests part A (NCT-A), symbol digit test (SDT), electroencephalogram (EEG), and magnetic resonance imaging with MR spectroscopy were used. Findings were evaluated with t test and MC Nemar test.