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170 DIASTOLIC DYSFUNCTION PREDICTS MORTALITY AFTER TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) CREATION
POSTERS 169 DIFFERENT PATTERN OF DECOMPENSATION IN ALCOHOLIC VERSUS NON-ALCOHOLIC LIVER CIRRHOSIS M. Kuehne1 , J. Wiegand1 , P. Pradat2 , J. Moessner1 , F. Zoulim2 , C. Trepo2 , H.L. Tillmann1,3 . 1 Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany; 2 Department of Hepatogastroenterology, Hˆ otel Dieu Hospital University, Lyon, France; 3 Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA E-mail: [email protected] Background: The clinical course of alcoholic versus non-alcoholic liver cirrhosis has not been well described yet. However, hepatic decompensation may be differentiated either in consequences of fibrosis (i.e. jaundice, variceal bleeding) or in lack of function (i.e. ascites) resulting in variable morbidity and mortality. We therefore evaluated the pattern of decompensation in relation to the etiology of liver cirrhosis. Patients and Methods: 220 cirrhotic German patients hospitalized between 2002 and 2006 were retrospectively evaluated (cohort A). Results were confirmed in a second cohort of German and French patients (cohort B: n = 217) and in an overall analysis. Hepatic decompensation was defined as presence of either ascites, jaundice, encephalopathy, variceal bleeding, hepatorenal syndrome, spontaneous bacterial peritonitis, or hepatocellular carcinoma. Results: In cohort A and B, alcoholic cirrhosis was present in 76.4% and 73.7% of cases. 8.9% of cases were in Child status A, 30.2% status B, and 44.6% status C (p = n.s.). Compared to non-alcoholic cirrhosis (cryptogen n = 37, HCV n = 30, HBV n = 11, other n = 31), alcoholics (n = 328) were significantly younger (55.6±11.5 y vs. 62.4±12.8 y, p = 0.000), more often male (75.9% vs. 53.2%; p = 0.000) and smokers (60.8% vs. 28.8%; p = 0.000). Alcoholics were significantly more frequently hospitalized for ascites (cohort A: 56.5% vs. 38.5%, p = 0.023; cohort B 53.2% vs. 36.8%, p = 0.042; total: 54.6% vs. 37.6%; p = 0.002) and showed a higher incidence of spontaneous bacterial peritonitis (total: 8.9% vs. 2.8%; p = 0.033) compared to non-alcoholics. Non-alcoholics presented with significantly higher rates of hepatocellular carcinoma (31.2% vs. 17.2%; p = 0.002). There were no significant differences in jaundice, variceal bleeding, hepatorenal syndrome, or encephalopathy. A subgroup analysis of alcoholic vs. viral hepatitis confirmed ascites as dominant decompensation in alcoholics (54.6% vs. 36.6%; p = 0.03). In alcoholic cirrhosis, survival did not differ between cases with or without ascites (p = 0.957). However, it was significantly impaired once ascites occurred in non-alcoholic disease (p < 0.001). Conclusions: Ascites is the leading initial pattern of decompensation in alcoholic cirrhosis whereas hepatocellular carcinoma dominates in non-alcoholics. Non-Alcoholics developing ascites show a poor survival. 170 DIASTOLIC DYSFUNCTION PREDICTS MORTALITY AFTER TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) CREATION G. Lang1 , S. Banerjee1 , T. Van Ha2 , N. Reau3 , H. Te3 , D. Jensen3 . 1 Internal Medicine, 2 Radiology, 3 Gastroenterology, Hepatology, and Nutrition, The University of Chicago, Chicago, IL, USA E-mail: [email protected] Introduction: Cirrhotic patients with diastolic dysfunction appear to be extremely sensitive to the increased preload that occurs after TIPS placement and liver transplantation. Unfortunately, many of the specific clinical variables that predict the high rate of mortality following TIPS remain undocumented. Our goal was to examine the
relationship between patients with abnormal left ventricular (LV) diastolic function and mortality following TIPS. Methods: A retrospective chart review of patients who had undergone TIPS placement between 2005 and 2009 was performed. Of the 80 patients identified, 43 patients (39%) had a two dimensional echocardiogram performed within the 6 months prior to TIPS. These patients were subsequently divided into 2 groups based on the presence or absence of diastolic dysfunction based on the American Society of Echocardiography’s guidelines. Patients with septal e < 8 (measured by tissue Doppler) and LA volumes >34 ml/m2 were classified as having abnormal LV diastolic function. Subsequently, through the social security death index data base, we identified which patients survived to the 3 month time point after TIPS creation. Analysis of potential predictors of response including presence of diastolic dysfunction, etiology of cirrhosis, age, indication for TIPS, MELD score, and Child–Pugh score were performed with Chi-squared analyses to determine their association with mortality at three months. Results: Of the 43 patients with echocardiographic data, the mean age was 56 years old, with 56% being male. 20 patients (47%) were identified as having diastolic dysfunction. Overall, 14 (33%) patients died within 3 months of TIPS. There were no intergroup differences with regard to cause of cirrhosis or TIPS indication. Of the patients with diastolic dysfunction, 11 (55%) died within 3 months compared with only 3 (13%) patients without diastolic dysfunction. Based on our analysis, diastolic dysfunction assessed 6 months prior to TIPS procedure is a significant predictor of mortality (p = 0.003). Conclusion: Our results indicate that diastolic dysfunction diagnosed by echocardiographic criteria within 6 months of TIPS creation predicts mortality at 3 months. The categorization of diastolic dysfunction by using LA volumes and septal e provides clinicians with important information regarding patient outcomes prior to TIPS placement. 171 INDOCYANINE GREEN AS A PREDICTOR OF CLINICALLY SIGNIFICANT PORTAL HYPERTENSION IN A PROSPECTIVE COHORT STUDY OF PATIENTS WITH CHRONIC LIVER DISEASE A. Lisotti1 , F. Azzaroli1 , L. Turco1 , F. Buonfiglioli1 , P. Ceciinato1 , C. Calvanese1 , F. Lodato2 , M. Montagnani1 , R. Golfieri3 , A. Colecchia3 , D. Festi1 , G. Mazzella1 . 1 Clinical Medicine, University of Bologna and S Orsola-Malpighi Hospital, 2 Internal Medicine, Aging and Nephrological Disease, 3 Digestive Diseases and Internal Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy E-mail: [email protected] Introduction: Measurement of hepatic venous pressure gradient (HVPG) is the gold standard for the assessment of portal hypertension (PH) and the prediction of clinical decompensation in patients with cirrhosis and PH. The development of non-invasive methodologies able to identify clinically significant PH and predict disease progression is needed. Indocyanine green clearance at 15 minutes (IcgR15) is an index of liver blood flow, functioning hepatocyte mass and energy status of the liver. In this ongoing study, we evaluate the ability of IcgR15 and other non-invasive tests to predict PH in patients with chronic liver disease of various etiology. Methods: Sixty-seven consecutive patients (43M/34F, mean age 61.09±12.57; age range 33–84 years) with chronic liver disease underwent HVPG measurement in our radiological unit between January and November 2010. All patients underwent laboratory tests, EGDS, abdominal ultrasound and IcgR15. Mann-Whitney test and multiple regression analysis has been performed in order to identify variables independently associated with HVPG > 10 mmHg, HVPG > 12 and gastro-esophageal varices (GEV). ROC curves were used to define the best cut-off (Medcalc software v11.4).
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relationship between patients with abnormal left ventricular (LV) diastolic function and mortality following TIPS. Methods: A retrospective chart review of patients who had undergone TIPS placement between 2005 and 2009 was performed. Of the 80 patients identified, 43 patients (39%) had a two dimensional echocardiogram performed within the 6 months prior to TIPS. These patients were subsequently divided into 2 groups based on the presence or absence of diastolic dysfunction based on the American Society of Echocardiography’s guidelines. Patients with septal e < 8 (measured by tissue Doppler) and LA volumes >34 ml/m2 were classified as having abnormal LV diastolic function. Subsequently, through the social security death index data base, we identified which patients survived to the 3 month time point after TIPS creation. Analysis of potential predictors of response including presence of diastolic dysfunction, etiology of cirrhosis, age, indication for TIPS, MELD score, and Child–Pugh score were performed with Chi-squared analyses to determine their association with mortality at three months. Results: Of the 43 patients with echocardiographic data, the mean age was 56 years old, with 56% being male. 20 patients (47%) were identified as having diastolic dysfunction. Overall, 14 (33%) patients died within 3 months of TIPS. There were no intergroup differences with regard to cause of cirrhosis or TIPS indication. Of the patients with diastolic dysfunction, 11 (55%) died within 3 months compared with only 3 (13%) patients without diastolic dysfunction. Based on our analysis, diastolic dysfunction assessed 6 months prior to TIPS procedure is a significant predictor of mortality (p = 0.003). Conclusion: Our results indicate that diastolic dysfunction diagnosed by echocardiographic criteria within 6 months of TIPS creation predicts mortality at 3 months. The categorization of diastolic dysfunction by using LA volumes and septal e provides clinicians with important information regarding patient outcomes prior to TIPS placement. 171 INDOCYANINE GREEN AS A PREDICTOR OF CLINICALLY SIGNIFICANT PORTAL HYPERTENSION IN A PROSPECTIVE COHORT STUDY OF PATIENTS WITH CHRONIC LIVER DISEASE A. Lisotti1 , F. Azzaroli1 , L. Turco1 , F. Buonfiglioli1 , P. Ceciinato1 , C. Calvanese1 , F. Lodato2 , M. Montagnani1 , R. Golfieri3 , A. Colecchia3 , D. Festi1 , G. Mazzella1 . 1 Clinical Medicine, University of Bologna and S Orsola-Malpighi Hospital, 2 Internal Medicine, Aging and Nephrological Disease, 3 Digestive Diseases and Internal Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy E-mail: [email protected] Introduction: Measurement of hepatic venous pressure gradient (HVPG) is the gold standard for the assessment of portal hypertension (PH) and the prediction of clinical decompensation in patients with cirrhosis and PH. The development of non-invasive methodologies able to identify clinically significant PH and predict disease progression is needed. Indocyanine green clearance at 15 minutes (IcgR15) is an index of liver blood flow, functioning hepatocyte mass and energy status of the liver. In this ongoing study, we evaluate the ability of IcgR15 and other non-invasive tests to predict PH in patients with chronic liver disease of various etiology. Methods: Sixty-seven consecutive patients (43M/34F, mean age 61.09±12.57; age range 33–84 years) with chronic liver disease underwent HVPG measurement in our radiological unit between January and November 2010. All patients underwent laboratory tests, EGDS, abdominal ultrasound and IcgR15. Mann-Whitney test and multiple regression analysis has been performed in order to identify variables independently associated with HVPG > 10 mmHg, HVPG > 12 and gastro-esophageal varices (GEV). ROC curves were used to define the best cut-off (Medcalc software v11.4).
Journal of Hepatology 2011 vol. 54 | S61–S208
S73