- Email: [email protected]
158 RELIABILITY OF SERUM CREATININE IN ASSESSING RENAL FUNCTION IS DIMINISHED IN PATIENTS WITH CIRRHOSIS AS COMPARED WITH PATIENTS WITH ORGANIC RENAL DISEASE
POSTERS hospitals-Cairo Egypt from the period of 26th of July till 30th of September 2010. Patients submitted to complete clinical, laboratory, ultrsonographic and endoscopic evaluation pre, during, and post Ramadan. Patients were divided into two groups fasting group and non fasting group and each group is subdivided into two subgroup Chronic hepatitis group and Cirrhotic group. Results: A total of 202 patients were included in the study, fasting group involved 103 (51%) and non fasting group 99 (49%) patients, both group were matched, non fasting group showed significantly good adherence to therapy (43.4%) compared to (27.2%) in fasting group (p = 0.16). Dyspeptic symptoms was significantly higher in fasting (53.4%) compared to (38.4%) in non fasting p = 0.032. G.I. bleeding during Ramadan was significantly higher in fasting group (17.5%) compared to (14.1%), in non fasting, bleeding due to o.v (1%) in fasting group compared to (9.1%) in non fasting group p = 0.004. Chronic hepatitis fasting group showed non significant changes pre, during and post Ramadan regarding liver function. Fasting cirrhotic group patients Child class C was increased to (13%) during and (32.6%) after Ramadan compared to (0%) before Ramadan p = 0.001. Conclusion: Ramadan fasting is prohibited for cirrhotic patients as it enhance the complication of liver cirrhosis. Patients with chronic hepatitis must be thoroughly investigated prior to Ramadan fasting. 157 CYSTATIN C IS AN INDEPENDENT PREDICTOR OF SURVIVAL IN PATIENTS WITH LIVER CIRRHOSIS, BUT DOES NOT IMPROVE THE PREDICTIVE POWER OF MELD A. Finkenstedt1 , L. Dorn1 , A. Griesmacher2 , W. Prokop2 , I. Graziadei1 , W. Vogel1 , H. Zoller1 . 1 Dept. of Gastroenterology and Hepatology, Medical University Innsbruck, 2 Central Institute for Medical and Chemical Laboratory Diagnosis, University Hospital Innsbruck, Innsbruck, Austria E-mail: armin.fi[email protected] Introduction: Cystatin C is considered to be a more reliable marker of renal function in patients with end stage liver disease, because serum creatinine overestimates renal function in patient with low muscle mass. The aim of this study was to investigate if a cystatin C based MELD score (MELD-Cys) more accurately predicts survival than the creatinine based UNOS MELD score. Methods: 259 cirrhotic patients (median age 57.5 years; 70 women) presenting to our unit between August 2007 and December 2009 were included in the analysis. Patients with malignancies, prior transplantation or renal replacement therapy were excluded. Most common underlying diseases were fatty liver disease (n = 142) and hepatitis B or C (n = 82). Cox proportional-hazards regression was used to test variables for prediction of survival. For calculation of MELD-Cys, we replaced creatinine and its regression coefficient by cystatin C with its regression coefficient, derived from our cohort. Predictive value of MELD and MELD-Cys for 30 and 90 day mortality were compared using receiver operating characteristic analysis. Additionally, actual survival was calculated with Kaplan–Meier procedure and compared with survival predicted from MELD and MELD-Cys. Results: During a median follow-up of 387 days, 45 patients underwent liver transplantation and 54 died. In univariate analysis, MELD parameters (creatinine, bilirubin and INR) and cystatin C were significantly associated with transplant free survival. In multivariate regression, bilirubin, INR and cystatin C, but not creatinine were independent predictors of survival. Median MELD score was 14.4 (range 6.4–50.3), median MELD-Cys score was significantly higher (16.8; range 6.4–47.2; p < 0.001). There was no significant difference in prediction of 30-day and 90-day mortality S68
and 30-day and 90-day transplant free survival between MELD and MELD-Cys. Survival at 30, 90, 360 and 730 days was 93%, 88%, 80% and 76%. Predicted survival at 30, 90, 360 and 730 days was 91%, 85%, 77% and 73% for MELD and 90%, 84%, 76% and 72% for MELD-Cys. Conclusion: Although cystatin C is an independent predictor of survival in patients with liver cirrhosis, a cystatin C based MELD score does not improve the predictive power of MELD. 158 RELIABILITY OF SERUM CREATININE IN ASSESSING RENAL FUNCTION IS DIMINISHED IN PATIENTS WITH CIRRHOSIS AS COMPARED WITH PATIENTS WITH ORGANIC RENAL DISEASE M. Garcovich1,2 , E. Tsochatzis1 , D. Georgadis1 , G. Germani1 , G. Fede1 , A. Davenport3 , A. Gasbarrini2 , A.K. Burroughs1 . 1 The Sheila Sherlock Liver Centre and Division of Surgery, Royal Free Hampstead NHS Trust, London, UK; 2 Universit` a Cattolica del Sacro Cuore Policlinico A. Gemelli, Roma, Italy; 3 Department of Nephrology, Royal Free Hampstead NHS Trust, London, UK E-mail: [email protected] Background and Aims: Although serum creatinine is a wellrecognized marker of prognosis in cirrhosis, it is an inaccurate marker of renal function being affected by various extra-renal factors. The measurement of glomerular filtration rate (GFR) by the plasma clearance Cr-EDTA is an acceptable substitute of the gold standard of inulin clearance. We assessed the correlations of serum creatinine with GFR measured by Cr-EDTA in patients with cirrhosis in comparison with patients with renal disease. Methods: We analysed data from 303 consecutive patients who underwent GFR assessment by Cr-EDTA as part of their liver transplant work-up. We collected similar data on 320 consecutive non-cirrhotic patients who attended the renal outpatient clinic. GFR was assessed by bolus infusion of Cr-EDTA and single or serial serum measurements after 2, 4, 6 and 24 hours. Spearman test was used to correlate serum creatinine and GFR in renal and liver patients. The differences in correlation coefficients were then compared by using the Fischer’s z score through the MedCalc statistical software. Results: Serum creatinine significantly and inversely correlated with GFR in patients with cirrhosis (r = −0.720, P < 0.001) and renal disease (r = −0.866, P < 0.001), however the difference of the correlation was significant between patients with renal disease and patients with cirrhosis (z = −4.8, P < 0.001). When analysis was performed according to gender, the difference of the correlation was again significant among male and female patients with renal disease and cirrhosis, and particularly in male compared to female patients with cirrhosis (P < 0.043). Therefore, for a given GFR, patients with cirrhosis had lower serum creatinine values than patients with renal disease (Liver patients . . . ). Moreover, female patients with cirrhosis had lower serum creatinine values than male patients with the same GFR.
Figure: Liver patients vs renal patients.
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POSTERS Conclusions: Serum creatinine underestimates renal function in patients with cirrhosis compared to patients with renal disease. Serum creatinine cut-offs used to define renal failure in the general population are not applicable to patients with cirrhosis and should be re-evaluated as they systematically underestimate renal function. 159 FREQUENCY AND CHARACTERISTICS OF HEPATOLENTICULAR DEGENERATION AND HEPATIC MYELOPATHY IN PATIENTS LISTED FOR LIVER TRANSPLANTATION – AN ONGOING PROSPECTIVE FOLLOW-UP STUDY 1,2 A. Goldbecker1,2 , A.B. Tryc1,2 , S. Rumke ¨ , K. Afshar1,2 , G. Hamidi Shahrezaei1,2 , G. Berding3 , H. Barg-Hock4 , C. Strassburg5 , K. Weissenborn1,2 . 1 Integrated Research and Treatment Center (IFB) Transplantation, 2 Neurology and Clinical Neurophysiology, 3 Nuclear Medicine, 4 Visceral and Transplantation Surgery, 5 Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany E-mail: [email protected] Background and Aims: Hepatolenticular degeneration (HLD) and hepatic myelopathy (HM) are rare complications of liver cirrhosis. Their prevalence, clinical course and outcome after liver transplantation (OLT) are unknown since prospective studies in representative samples are missing. The aim of our study is to evaluate the prevalence of HLD and HM in patients awaiting OLT, to characterize these syndromes clinically and via neuroimaging and to evaluate their outcome after OLT. Methods: So far 187 patients listed for OLT were recruited. They underwent a standardized neurological examination – repeatedly before and after OLT if applicable. Clinical diagnosis of HLD and HM was confirmed by application of standard work-up for Parkinson’s syndrome or myelopathy, respectively. In HLD patients the striatal D2-dopamine receptor and transporter availability was assessed using single photon emission computed tomography (SPECT). Results: HLD was diagnosed in 7, HM in 3, both in one patient. 7 of the 11 patients had overt hepatic encephalopathy according to West Haven Criteria. LabMELD ranged from 8.8 to 23.7. Cirrhosis was due to hepatitis (n = 4), alcohol abuse (n = 2), PBC (n = 1), and AIH (n = 1), or cryptogenic (n = 2). One patient suffered from transplant failure. Four patients died on the waiting list and one was transplanted before further examinations were performed. Four HLD cases underwent SPECT, revealing a reduction of the dopamine receptor availability in all cases, and reduced dopamine transporter availability in two. One patient with HM, who was bed-ridden due to spastic paraplegia and one patient with HLD underwent OLT so far. The HM patient is able to walk with a walking stick 18 months after OLT. The HLD patient showed a sudden but transient deterioration 8 weeks after OLT and has not yet improved compared to his pre-operative status 4 months after OLT. Conclusions: HLD and HM are rare but severely disabling complications of liver cirrhosis. HLD is accompanied with a pre-and postsynaptic alteration of the striatal dopaminergic neurotransmission explaining the poor effect of dopaminergic drug therapy. The benefit of OLT needs to be studied systematically. Acknowledgement: The IFB Transplantation of Hannover Medical School is funded by the German Federal Ministry of Education and Research.
160 HIGH RATE OF CARDIAC ABNORMALITIES IN A POST-MORTEM ANALYSIS OF PATIENTS SUFFERING FROM LIVER CIRRHOSIS 2 A.J. Heuer1 , A. Gehl2 , K. Puschel ¨ , K. Sydow3 , A.W. Lohse1 , S. Luth ¨ 1. 1 Department of Internal Medicine, 2 Department of Legal Medicine, 3 Department of General and Interventional Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany E-mail: [email protected] Background and Aims: Cirrhotic cardiomyopathy is a recently defined pathophysiological cardiac circumstance in patients with end-stage liver cirrhosis. The frequency of cirrhotic cardiomyopathy and other cardiac abnormalities, i.e. coronary heart disease, valvular disease, lipomatosis cordis and endocardial fibrosis associated with liver disease are poorly understood. Methods: Post-mortem autopsy data from 664 individuals with proven liver cirrhosis seen in the Department of Legal Medicine from 1995–2010 were analyzed. Mean age of the patients was 53 years with a range from 23 to 69 years. The individuals were classified into 4 groups according to the underlying etiology of cirrhosis: alcoholic steatohepatitis (ASH, 543 pts.), non-alcoholic steatohepatitis (NASH, 27 pts), viral hepatitis (VH, 39 pts), and cryptogenic (CRY, 55 pts.). Age, sex, cause of death, body mass index, and routine data of cardiac abnormalities, i.e. heart weight, heart chambers’ diameters, ventricular thickness, valvular changes, lipomatosis cordis, coronary heart disease and endocardial fibrosis were assessed in the 4 groups. Results: The mean heart weight was 428g, 643g, 404g, and 424g in the different groups of ASH, NASH, VH, and CRY, respectively, whereas left ventricular chamber dilatation was present in 28%, 74%, 26%, and 38%. Moreover, right ventricular chamber dilatation was present in 34%, 70%, 39%, and 45% in ASH, NASH, VH and CRY, respectively. Moderate (calcification and stenosis <50%) and severe (stenosis >50%) coronary heart disease occurred in 45%, 70%, 36%, and 55% in the 4 groups. No relevant differences in the presence of endocardial fibrosis were observed (22%, 26%, 23%, and 24%, respectively). Conclusions: Our results reveal a high rate of cardiac abnormalities in individuals previously suffering from liver cirrhosis regardless of the origin of liver cirrhosis. These data should be confirmed by prospective studies. 161 COLLAGEN PROPORTIONATE AREA: BEST INDEX TO PREDICT DECOMPENSATION IN PATIENTS WITH LIVER CIRRHOSIS OF DIFFERENT ETIOLOGIES G. Isgro1 , L. Andreana1 , M. Garcovich1 , T.V. Luong2 , A. Hall2 , P. Manousou1 , N. Goossens1 , J. O’Beirne1 , D. Patch1 , A.P. Dhillon2 , A.K. Burroughs1 . 1 The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery UCL, 2 Department of Cellular Pathology, Royal Free and University College Medical School, London, UK E-mail: [email protected] Background and Aims: Histological scoring systems classify liver cirrhosis as a “single stage” without evaluating the severity as they don’t measure the amount of fibrosis. Computer assisted digital image analysis (DIA) of Sirius red stained sections measures fibrosis morphologically, using segmentation of digital images to measure the relative areas of collagen and of tissue, producing a fibrosis ratio or collagen proportionate area (CPA) (Calvaruso, Hepatology 2009). CPA could have staging and prognostic value for histological cirrhosis. Aim of the study was to evaluate CPA in cirrhosis of different etiologies and its relationship with liver decompensation. Methods: 184 consecutive patients with histological cirrhosis of different etiologies (78 ALD, 37 HCV, 16 HBV, 11 AIH, 11 NASH, 3 PBC, 3 PCS, 25 miscellaneous): 115 males, mean age 52
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and 30-day and 90-day transplant free survival between MELD and MELD-Cys. Survival at 30, 90, 360 and 730 days was 93%, 88%, 80% and 76%. Predicted survival at 30, 90, 360 and 730 days was 91%, 85%, 77% and 73% for MELD and 90%, 84%, 76% and 72% for MELD-Cys. Conclusion: Although cystatin C is an independent predictor of survival in patients with liver cirrhosis, a cystatin C based MELD score does not improve the predictive power of MELD. 158 RELIABILITY OF SERUM CREATININE IN ASSESSING RENAL FUNCTION IS DIMINISHED IN PATIENTS WITH CIRRHOSIS AS COMPARED WITH PATIENTS WITH ORGANIC RENAL DISEASE M. Garcovich1,2 , E. Tsochatzis1 , D. Georgadis1 , G. Germani1 , G. Fede1 , A. Davenport3 , A. Gasbarrini2 , A.K. Burroughs1 . 1 The Sheila Sherlock Liver Centre and Division of Surgery, Royal Free Hampstead NHS Trust, London, UK; 2 Universit` a Cattolica del Sacro Cuore Policlinico A. Gemelli, Roma, Italy; 3 Department of Nephrology, Royal Free Hampstead NHS Trust, London, UK E-mail: [email protected] Background and Aims: Although serum creatinine is a wellrecognized marker of prognosis in cirrhosis, it is an inaccurate marker of renal function being affected by various extra-renal factors. The measurement of glomerular filtration rate (GFR) by the plasma clearance Cr-EDTA is an acceptable substitute of the gold standard of inulin clearance. We assessed the correlations of serum creatinine with GFR measured by Cr-EDTA in patients with cirrhosis in comparison with patients with renal disease. Methods: We analysed data from 303 consecutive patients who underwent GFR assessment by Cr-EDTA as part of their liver transplant work-up. We collected similar data on 320 consecutive non-cirrhotic patients who attended the renal outpatient clinic. GFR was assessed by bolus infusion of Cr-EDTA and single or serial serum measurements after 2, 4, 6 and 24 hours. Spearman test was used to correlate serum creatinine and GFR in renal and liver patients. The differences in correlation coefficients were then compared by using the Fischer’s z score through the MedCalc statistical software. Results: Serum creatinine significantly and inversely correlated with GFR in patients with cirrhosis (r = −0.720, P < 0.001) and renal disease (r = −0.866, P < 0.001), however the difference of the correlation was significant between patients with renal disease and patients with cirrhosis (z = −4.8, P < 0.001). When analysis was performed according to gender, the difference of the correlation was again significant among male and female patients with renal disease and cirrhosis, and particularly in male compared to female patients with cirrhosis (P < 0.043). Therefore, for a given GFR, patients with cirrhosis had lower serum creatinine values than patients with renal disease (Liver patients . . . ). Moreover, female patients with cirrhosis had lower serum creatinine values than male patients with the same GFR.
Figure: Liver patients vs renal patients.
Journal of Hepatology 2011 vol. 54 | S61–S208
POSTERS Conclusions: Serum creatinine underestimates renal function in patients with cirrhosis compared to patients with renal disease. Serum creatinine cut-offs used to define renal failure in the general population are not applicable to patients with cirrhosis and should be re-evaluated as they systematically underestimate renal function. 159 FREQUENCY AND CHARACTERISTICS OF HEPATOLENTICULAR DEGENERATION AND HEPATIC MYELOPATHY IN PATIENTS LISTED FOR LIVER TRANSPLANTATION – AN ONGOING PROSPECTIVE FOLLOW-UP STUDY 1,2 A. Goldbecker1,2 , A.B. Tryc1,2 , S. Rumke ¨ , K. Afshar1,2 , G. Hamidi Shahrezaei1,2 , G. Berding3 , H. Barg-Hock4 , C. Strassburg5 , K. Weissenborn1,2 . 1 Integrated Research and Treatment Center (IFB) Transplantation, 2 Neurology and Clinical Neurophysiology, 3 Nuclear Medicine, 4 Visceral and Transplantation Surgery, 5 Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany E-mail: [email protected] Background and Aims: Hepatolenticular degeneration (HLD) and hepatic myelopathy (HM) are rare complications of liver cirrhosis. Their prevalence, clinical course and outcome after liver transplantation (OLT) are unknown since prospective studies in representative samples are missing. The aim of our study is to evaluate the prevalence of HLD and HM in patients awaiting OLT, to characterize these syndromes clinically and via neuroimaging and to evaluate their outcome after OLT. Methods: So far 187 patients listed for OLT were recruited. They underwent a standardized neurological examination – repeatedly before and after OLT if applicable. Clinical diagnosis of HLD and HM was confirmed by application of standard work-up for Parkinson’s syndrome or myelopathy, respectively. In HLD patients the striatal D2-dopamine receptor and transporter availability was assessed using single photon emission computed tomography (SPECT). Results: HLD was diagnosed in 7, HM in 3, both in one patient. 7 of the 11 patients had overt hepatic encephalopathy according to West Haven Criteria. LabMELD ranged from 8.8 to 23.7. Cirrhosis was due to hepatitis (n = 4), alcohol abuse (n = 2), PBC (n = 1), and AIH (n = 1), or cryptogenic (n = 2). One patient suffered from transplant failure. Four patients died on the waiting list and one was transplanted before further examinations were performed. Four HLD cases underwent SPECT, revealing a reduction of the dopamine receptor availability in all cases, and reduced dopamine transporter availability in two. One patient with HM, who was bed-ridden due to spastic paraplegia and one patient with HLD underwent OLT so far. The HM patient is able to walk with a walking stick 18 months after OLT. The HLD patient showed a sudden but transient deterioration 8 weeks after OLT and has not yet improved compared to his pre-operative status 4 months after OLT. Conclusions: HLD and HM are rare but severely disabling complications of liver cirrhosis. HLD is accompanied with a pre-and postsynaptic alteration of the striatal dopaminergic neurotransmission explaining the poor effect of dopaminergic drug therapy. The benefit of OLT needs to be studied systematically. Acknowledgement: The IFB Transplantation of Hannover Medical School is funded by the German Federal Ministry of Education and Research.
160 HIGH RATE OF CARDIAC ABNORMALITIES IN A POST-MORTEM ANALYSIS OF PATIENTS SUFFERING FROM LIVER CIRRHOSIS 2 A.J. Heuer1 , A. Gehl2 , K. Puschel ¨ , K. Sydow3 , A.W. Lohse1 , S. Luth ¨ 1. 1 Department of Internal Medicine, 2 Department of Legal Medicine, 3 Department of General and Interventional Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany E-mail: [email protected] Background and Aims: Cirrhotic cardiomyopathy is a recently defined pathophysiological cardiac circumstance in patients with end-stage liver cirrhosis. The frequency of cirrhotic cardiomyopathy and other cardiac abnormalities, i.e. coronary heart disease, valvular disease, lipomatosis cordis and endocardial fibrosis associated with liver disease are poorly understood. Methods: Post-mortem autopsy data from 664 individuals with proven liver cirrhosis seen in the Department of Legal Medicine from 1995–2010 were analyzed. Mean age of the patients was 53 years with a range from 23 to 69 years. The individuals were classified into 4 groups according to the underlying etiology of cirrhosis: alcoholic steatohepatitis (ASH, 543 pts.), non-alcoholic steatohepatitis (NASH, 27 pts), viral hepatitis (VH, 39 pts), and cryptogenic (CRY, 55 pts.). Age, sex, cause of death, body mass index, and routine data of cardiac abnormalities, i.e. heart weight, heart chambers’ diameters, ventricular thickness, valvular changes, lipomatosis cordis, coronary heart disease and endocardial fibrosis were assessed in the 4 groups. Results: The mean heart weight was 428g, 643g, 404g, and 424g in the different groups of ASH, NASH, VH, and CRY, respectively, whereas left ventricular chamber dilatation was present in 28%, 74%, 26%, and 38%. Moreover, right ventricular chamber dilatation was present in 34%, 70%, 39%, and 45% in ASH, NASH, VH and CRY, respectively. Moderate (calcification and stenosis <50%) and severe (stenosis >50%) coronary heart disease occurred in 45%, 70%, 36%, and 55% in the 4 groups. No relevant differences in the presence of endocardial fibrosis were observed (22%, 26%, 23%, and 24%, respectively). Conclusions: Our results reveal a high rate of cardiac abnormalities in individuals previously suffering from liver cirrhosis regardless of the origin of liver cirrhosis. These data should be confirmed by prospective studies. 161 COLLAGEN PROPORTIONATE AREA: BEST INDEX TO PREDICT DECOMPENSATION IN PATIENTS WITH LIVER CIRRHOSIS OF DIFFERENT ETIOLOGIES G. Isgro1 , L. Andreana1 , M. Garcovich1 , T.V. Luong2 , A. Hall2 , P. Manousou1 , N. Goossens1 , J. O’Beirne1 , D. Patch1 , A.P. Dhillon2 , A.K. Burroughs1 . 1 The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery UCL, 2 Department of Cellular Pathology, Royal Free and University College Medical School, London, UK E-mail: [email protected] Background and Aims: Histological scoring systems classify liver cirrhosis as a “single stage” without evaluating the severity as they don’t measure the amount of fibrosis. Computer assisted digital image analysis (DIA) of Sirius red stained sections measures fibrosis morphologically, using segmentation of digital images to measure the relative areas of collagen and of tissue, producing a fibrosis ratio or collagen proportionate area (CPA) (Calvaruso, Hepatology 2009). CPA could have staging and prognostic value for histological cirrhosis. Aim of the study was to evaluate CPA in cirrhosis of different etiologies and its relationship with liver decompensation. Methods: 184 consecutive patients with histological cirrhosis of different etiologies (78 ALD, 37 HCV, 16 HBV, 11 AIH, 11 NASH, 3 PBC, 3 PCS, 25 miscellaneous): 115 males, mean age 52
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