- Email: [email protected]
206 REPRODUCIBILITY AND RELIABILITY OF THE HEPATIC VENOUS PRESSURE GRADIENT (HVPG) MEASUREMENT IN PATIENTS WITH CIRRHOSIS IS HIGHER USING THE BALLOON COMPARED TO THE STRAIGHT CATHETER
POSTERS 204 SAFETY, EFFICACY AND PREDICTORS OF TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT IN REFRACTORY HEPATIC HYDROTHORAX R. Yellapu1 , A. Goldstein2 , S. Anondo3 , T. Schiano1 . 1 Liver Diseases, 2 Internal Medicine, 3 Radiology, Mount Sinai Medical Center, New York, NY, USA E-mail: [email protected] Background and Aims: Hepatic hydrothorax is an uncommon complication of portal hypertension. We sought to evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in these patients with symptomatic and refractory hepatic hydrothorax. Methods: Twenty four patients who underwent TIPS, between January 2001 and December 2009 for refractory hydrothorax were studied. Clinical, laboratory and procedural data were noted. Outcomes were recorded as responders or non-responders. Data patterns were examined by Chi-square test, t-test and Kaplan– Meier analysis. Results: Patients included 14 men and ten women; Child–Pugh class B, 16 patients; Child–Pugh class C, 8 patients. The mean age at TIPS creation was 60.4 years (s.d. 9.4). Mean pre-TIPS creatinine was 0.9 (s.d. 0.3) and mean model for end stage liver disease (MELD) score was 15.3 (s.d. 4.9). The mean pre- and post-TIPS portosystemic gradients were 17.7 (s.d. 5.2) mmHg and 7.4 (2.6) mmHg. There was technical success in all patients. In 19 patients covered stents were used and in 5 patients bare stents were used. Data was incomplete in one patient. Clinical response after TIPS was seen in 73.9% (17/23) patients. Median survival of the study group was 295 days (range 10–1280). The short term survival rates at 30 and 90 days were 95.6% and 82.6% respectively. The long term survival rates both at 1 and 3 years is 73.9%. Univariate and multivariate analysis showed clinical response (P = 0.01, HR 2.7 [95% CI 1.4–5.8]) was significantly and independently associated with overall survival. The 30 day mortality rate was 4.3%. Post TIPS new onset or worsening of encephalopathy was seen in 40 % of patients. Conclusion: TIPS is a relatively safe and effective method of controlling refractory hepatic hydrothorax. Clinical response after TIPS is associated with longer survival. Early mortality after TIPS may be minimized by proper selection of patients with low MELD and near normal renal functions. 205 HCV INFECTION AND ADVANCED LIVER CIRRHOSIS WERE ASSOCIATED INSULIN RESISTANCE Y.L. He1 , Z. Yan1 , K. Wang1 , T.Y. Chen2 , M. Liu2 , F. Ye2 , S.L. Zhang2 , S.M. Lin2 , Y.R. Zhao1 . 1 Hepatology Institution, Xian, 2 Infectious Diseases Department, XiAn JiaoTong University, Xian City, China E-mail: [email protected] Background and Aims: Several clinical studies have suggested a possible link between chronic hepatitis caused by hepatitis B virus (HBV)/Hepatitis C virus (HCV) and diabetes mellitus. We investigated the association between clinical data and glucose intolerance in HBV/HCV infected patients. Methods: A total 28 HCV infected patients and 61 HBV infected patients were recruited into this study. We evaluated insulin resistance (homeostasis model assessment of insulin resistance [HOMA-R]) and beta-cell function (homeostasis model assessment of beta0cell function [HOMA-b]) in a fasting state and after an oral 75 g glucose (whole-body insulin sensitivity index [WBISI]) and D-insulin 30/D-glucose 30). HBV/HCV infected patients divided into three sub-groups (chronic hepatitis [CH], liver cirrhosis with child-Pugh C stage [LC-C] and liver cirrhosis with child-Pugh B [LC-B]) according clinical data including biochemical parameter, CT scanning and gasrtoscopy. Serum virus load were quantified by real-time PCR. S88
Results: Multivariate analysis shows HCV infection and advanced liver cirrhosis the two keys independent factors associated with insulin resistance. HOMA-R was significant higher in HCV infected patients when compared with HBV infected patients. When patients were divided into CH, LC-C and LC-B sub-groups, HCV infected patients with child-Pugh stage C sub-group has the highest HOMA-R with 7.21.
Comparison of HOMA-R between CH, LC-B and LC-C subgroups. Conclusions: Our findings suggest that HCV infection and the advanced liver cirrhosis are associated insulin resistance. 206 REPRODUCIBILITY AND RELIABILITY OF THE HEPATIC VENOUS PRESSURE GRADIENT (HVPG) MEASUREMENT IN PATIENTS WITH CIRRHOSIS IS HIGHER USING THE BALLOON COMPARED TO THE STRAIGHT CATHETER A. Zipprich, M. Winkler, T. Seufferlein, M.M. Dollinger. First Department of Internal Medicine, Martin-Luther-University Halle, Halle, Germany E-mail: [email protected] HVPG (i.e. the difference between wedge hepatic [WHVP] and free hepatic venous pressure [FHVP]) is used as an estimation of portal pressure and of great importance in the management of patients with cirrhosis. Reduction of HVPG is correlated with a reduced risk of development of portal hypertension related complications, mainly variceal bleeding. Two different methods are available (straight and balloon catheter) and although the balloon catheter is considered more reproducible and reliable these two procedures were never compared directly. The aim of the study was to compare the two methods for HVPG assessment regarding reproducibility and reliability. Methods: In 47 patients with cirrhosis (alcoholic cirrhosis: n = 28; HVPG [mean±SD]: 14.7±7.2 mmHg) repeated measurements of HVPG was done using the straight (3 times) and the balloon catheter (3 times) during the same procedure to investigate the reproducibility. In another 29 patients (alcoholic cirrhosis: n = 25; WHVP [mean±SD]: 29.89±7.9 mmHg; portal pressure: 30.4±7.1 mmHg), WHVP was measured using the straight or the balloon catheter followed by a direct measurement of the portal pressure during TIPS insertion to investigate the reliability. For all measurements, variation coefficient and intraclass correlation coefficient were calculated.
Journal of Hepatology 2010 vol. 52 | S59–S182
POSTERS Results: Variation coefficients for the balloon catheter were 0.07, 0.02, and 0.06 for HVPG, WHVP, and FHVP, respectively. Variation coefficients for the straight catheter were 0.17 (HVPG), 0.06 (WHVP), and 0.07 (FHVP), and significantly higher for HVPG and WHVP (p < 0.001) compared with the balloon catheter. When comparing the WHVP measurements with the portal venous pressure, the calculated intraclass correlation coefficient was 0.72 (p = 0.004) using the balloon and 0.58 (p = 0.011) using the straight catheter. Conclusion: Reproducibility and reliability of the HVPG measurement was higher using the balloon catheter, which should be the preferred procedure to measure HVPG. The significant greater variation coefficient of the straight catheter may become clinically relevant, if this method is used to perform repeated measurements during the management of cirrhotic patients. 207 MELD VS CPS FOR PROGNOSIS IN CIRRHOSIS. RESULTS FROM A MULTICENTRE STUDY C. Triantos1 , K. Zisimopoulos1 , E. Tsochatzis2 , J. Vlachogiannakos3 , S. Manolakopoulos4 , C. Rigamonti2 , J. Goulis5 , E. Manesis4 , J. Anastasiou3 , F. Papalexi5 , K. Georgiou6 , A. Saveriadis3 , K. Thomopoulos1 , V. Margaritis1 , D. Tzourmakliotis6 , E. Akriviadis5 , A. Archimandritis4 , D. Karamanolis3 , V. Nikolopoulou1 , A.K. Buroughs2 . 1 University Hospital of Patras, Patras, Greece; 2 Royal Free Hospital, London, UK; 3 Evangelismos General Hospital, 4 Hippokration General Hospital of Athens, Athens, 5 Hippocration General Hospital of Thessaloniki, Thessaloniki, 6 Polyclinic General Hospital, Athens, Greece E-mail: [email protected] Background and Aim: The Model for end-stage (MELD) liver disease is used for allocation of recipients waiting for liver transplantation and models 3 month mortality. However the prognostic accuracy in other settings for cirrhosis is not clear, but despite this MELD is being used as a global prognostic index in substitution for Child–Pugh score (CPS). We evaluated both CPS and MELD for longer term survival. Patients and Methods: Six referral centres for liver diseases: 1243 consecutive cirrhotics diagnosed on biopsy or imaging – 1014 analyzed (229 lost to follow up). Men/women: 653/361, age median: 60 years (18–92), follow up: 26 months (1–217), CP (A/B/C): 52/36/12 %, CPS: mean: 7, median: 6 (5–13), MELD: mean: 13, median: 12 (6–39); HBV = 18%, HCV = 14%, alcohol = 31%, PBC = 12%, PSC = 0.5%, autoimmune = 2%, other: 22.5%. Individual components of CPS and MELD, as well CPS score, grade and MELD score were evaluated in different models. Cox regression was used to evaluate factors associated with survival. Results: 106 patients died during follow up (32 within 1 year). In Cox multivariate analysis independent variables associated with survival were: age (HR: 1.04, 95% CI: 1.02–1.06; P < 0.001), and CPS (HR: 1.19, 95% CI: 1.01–1.4; P = 0.031), or CP grade (HR = 1.51; 95% CI 1.03–2.23 P = 0.037), but MELD and sodium were not. At 1 year CP grade was significant (P = 0.03) but not MELD. Conclusions: Child Pugh score and grade are significant prognostic factors for medium and long term survival in cirrhosis. In this large cohort MELD was not independently predictive, and thus requires re-evaluation (and should not be used) as a prognostic model outside of transplant allocation settings.
03c. LIVER TUMORS: c. MANAGEMENT
208 MONOCENTRIC PROSPECTIVE EVALUATION OF CHEMOEMBOLISATION (TACE) FOR HEPATOCELLULAR CARCINOMA (HCC) SINCE THE DEVELOPMENT OF THE AASLD GUIDELINES K. Aziz1 , J. Auriol2 , C. Bureau1 , V. Lauwers-Cances3 , F. Muscari4 , N. Carrere4 , F. Pey2 , G. Canevet2 , L. Buscail5 , J.-P. Vinel1 , P. Otal2 , 1 1 J.-M. Peron ´ . Service d’H´epato-gastro-Ent´erologie, 2 Service de Radiologie, 3 CICT, 4 Service de Chirurgie Digestive, 5 Service de Gastro-ent´erologie et Nutrition, CHU Toulouse, Toulouse, France E-mail: [email protected] Background: TACE is the standard of care for intermediate stage HCC. It is also used as neoadjuvant therapy before curative strategies. The aim of this study was to prospectively assess TACE for HCC. Methods: Between November 2005 and December 2008, 453 patients were referred to our tertiary center and presented at our multidisciplinary committee. 372 patients were diagnosed for HCC according to AASLD guidelines. 72 patients were treated by TACE. 23 patients were treated before transplantation, resection, or RF. Tumor response was assessed by CTscan or MRI 4 to 8 weeks after each session. Treatment schedule was based on tumor response. OR was defined as a tumor necrosis >50%. Survival was evaluated by Kaplan-Meyer estimates. When receiving another treatment for HCC, patients were excluded from analysis at the date of the treatment. Results: 72 patients underwent 125 TACE sessions. Median number of TACE was 1.7. Median age was 65.2. 19% were older than 75. Main etiology of cirrhosis were alcohol in 57% and HCV in 26%. Child– Pugh score was A in 72%, B in 25% and C in 3%. BCLC tumor stage was A in 25% (neoadjuvant therapy group), B in 38%, C in 33% (14 due to partial portal vein thrombosis and 10 to altered performans status), and D in 4%. Median survival was 24.8 months. 1 and 2 years survival was 72 and 52%. OR was observed in 59.7%. No OR was observed in patients that needed more than 2 sessions. Univariate analysis identified OR, CP score, BCLC stage, baseline AFP, selective embolization and absence of post-embolization syndrome as prognostic factors. Using multivariate analysis, OR, AFP and gender were independent prognostic variables. Age was not associated with a poor prognosis. Grade III-IV adverse events were observed in 15 patients including 2 treatment related deaths. Conclusion: In a French population of HCC patients with predominantly alcohol related cirrhosis treated by TACE, the median survival was 24.8 months. OR and baseline AFP level were independent prognostic factors. Patients who do not reach OR after 2 TACE sessions should be evaluated for sorafenib. Advanced age is not a contra-indication for TACE. 209 FIBROSIS PROGRESSION DURING SUNITINIB THERAPY IN CIRRHOTIC PATIENTS WITH ADVANCED HEPATOCELLULAR CARCINOMA M. Biolato, M. Basso, A. Forgione, S. Racco, L. Miele, M. Pompili, G.L. Rapaccini, R. Landolfi, C. Barone, A. Grieco, G. Gasbarrini. Catholic University of Rome, Rome, Italy E-mail: [email protected] Background and Aims: In cirrhotic patients, serum hyaluronic acid (HA) concentration increases in proportion to the degree of liver fibrosis and is predictive of complications1 . Sunitinb, an oral multitargeted tyrosine kinase inhibitor of VEGF receptors, PDGF receptors, KIT and RET, has a promising activity against
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Results: Multivariate analysis shows HCV infection and advanced liver cirrhosis the two keys independent factors associated with insulin resistance. HOMA-R was significant higher in HCV infected patients when compared with HBV infected patients. When patients were divided into CH, LC-C and LC-B sub-groups, HCV infected patients with child-Pugh stage C sub-group has the highest HOMA-R with 7.21.
Comparison of HOMA-R between CH, LC-B and LC-C subgroups. Conclusions: Our findings suggest that HCV infection and the advanced liver cirrhosis are associated insulin resistance. 206 REPRODUCIBILITY AND RELIABILITY OF THE HEPATIC VENOUS PRESSURE GRADIENT (HVPG) MEASUREMENT IN PATIENTS WITH CIRRHOSIS IS HIGHER USING THE BALLOON COMPARED TO THE STRAIGHT CATHETER A. Zipprich, M. Winkler, T. Seufferlein, M.M. Dollinger. First Department of Internal Medicine, Martin-Luther-University Halle, Halle, Germany E-mail: [email protected] HVPG (i.e. the difference between wedge hepatic [WHVP] and free hepatic venous pressure [FHVP]) is used as an estimation of portal pressure and of great importance in the management of patients with cirrhosis. Reduction of HVPG is correlated with a reduced risk of development of portal hypertension related complications, mainly variceal bleeding. Two different methods are available (straight and balloon catheter) and although the balloon catheter is considered more reproducible and reliable these two procedures were never compared directly. The aim of the study was to compare the two methods for HVPG assessment regarding reproducibility and reliability. Methods: In 47 patients with cirrhosis (alcoholic cirrhosis: n = 28; HVPG [mean±SD]: 14.7±7.2 mmHg) repeated measurements of HVPG was done using the straight (3 times) and the balloon catheter (3 times) during the same procedure to investigate the reproducibility. In another 29 patients (alcoholic cirrhosis: n = 25; WHVP [mean±SD]: 29.89±7.9 mmHg; portal pressure: 30.4±7.1 mmHg), WHVP was measured using the straight or the balloon catheter followed by a direct measurement of the portal pressure during TIPS insertion to investigate the reliability. For all measurements, variation coefficient and intraclass correlation coefficient were calculated.
Journal of Hepatology 2010 vol. 52 | S59–S182
POSTERS Results: Variation coefficients for the balloon catheter were 0.07, 0.02, and 0.06 for HVPG, WHVP, and FHVP, respectively. Variation coefficients for the straight catheter were 0.17 (HVPG), 0.06 (WHVP), and 0.07 (FHVP), and significantly higher for HVPG and WHVP (p < 0.001) compared with the balloon catheter. When comparing the WHVP measurements with the portal venous pressure, the calculated intraclass correlation coefficient was 0.72 (p = 0.004) using the balloon and 0.58 (p = 0.011) using the straight catheter. Conclusion: Reproducibility and reliability of the HVPG measurement was higher using the balloon catheter, which should be the preferred procedure to measure HVPG. The significant greater variation coefficient of the straight catheter may become clinically relevant, if this method is used to perform repeated measurements during the management of cirrhotic patients. 207 MELD VS CPS FOR PROGNOSIS IN CIRRHOSIS. RESULTS FROM A MULTICENTRE STUDY C. Triantos1 , K. Zisimopoulos1 , E. Tsochatzis2 , J. Vlachogiannakos3 , S. Manolakopoulos4 , C. Rigamonti2 , J. Goulis5 , E. Manesis4 , J. Anastasiou3 , F. Papalexi5 , K. Georgiou6 , A. Saveriadis3 , K. Thomopoulos1 , V. Margaritis1 , D. Tzourmakliotis6 , E. Akriviadis5 , A. Archimandritis4 , D. Karamanolis3 , V. Nikolopoulou1 , A.K. Buroughs2 . 1 University Hospital of Patras, Patras, Greece; 2 Royal Free Hospital, London, UK; 3 Evangelismos General Hospital, 4 Hippokration General Hospital of Athens, Athens, 5 Hippocration General Hospital of Thessaloniki, Thessaloniki, 6 Polyclinic General Hospital, Athens, Greece E-mail: [email protected] Background and Aim: The Model for end-stage (MELD) liver disease is used for allocation of recipients waiting for liver transplantation and models 3 month mortality. However the prognostic accuracy in other settings for cirrhosis is not clear, but despite this MELD is being used as a global prognostic index in substitution for Child–Pugh score (CPS). We evaluated both CPS and MELD for longer term survival. Patients and Methods: Six referral centres for liver diseases: 1243 consecutive cirrhotics diagnosed on biopsy or imaging – 1014 analyzed (229 lost to follow up). Men/women: 653/361, age median: 60 years (18–92), follow up: 26 months (1–217), CP (A/B/C): 52/36/12 %, CPS: mean: 7, median: 6 (5–13), MELD: mean: 13, median: 12 (6–39); HBV = 18%, HCV = 14%, alcohol = 31%, PBC = 12%, PSC = 0.5%, autoimmune = 2%, other: 22.5%. Individual components of CPS and MELD, as well CPS score, grade and MELD score were evaluated in different models. Cox regression was used to evaluate factors associated with survival. Results: 106 patients died during follow up (32 within 1 year). In Cox multivariate analysis independent variables associated with survival were: age (HR: 1.04, 95% CI: 1.02–1.06; P < 0.001), and CPS (HR: 1.19, 95% CI: 1.01–1.4; P = 0.031), or CP grade (HR = 1.51; 95% CI 1.03–2.23 P = 0.037), but MELD and sodium were not. At 1 year CP grade was significant (P = 0.03) but not MELD. Conclusions: Child Pugh score and grade are significant prognostic factors for medium and long term survival in cirrhosis. In this large cohort MELD was not independently predictive, and thus requires re-evaluation (and should not be used) as a prognostic model outside of transplant allocation settings.
03c. LIVER TUMORS: c. MANAGEMENT
208 MONOCENTRIC PROSPECTIVE EVALUATION OF CHEMOEMBOLISATION (TACE) FOR HEPATOCELLULAR CARCINOMA (HCC) SINCE THE DEVELOPMENT OF THE AASLD GUIDELINES K. Aziz1 , J. Auriol2 , C. Bureau1 , V. Lauwers-Cances3 , F. Muscari4 , N. Carrere4 , F. Pey2 , G. Canevet2 , L. Buscail5 , J.-P. Vinel1 , P. Otal2 , 1 1 J.-M. Peron ´ . Service d’H´epato-gastro-Ent´erologie, 2 Service de Radiologie, 3 CICT, 4 Service de Chirurgie Digestive, 5 Service de Gastro-ent´erologie et Nutrition, CHU Toulouse, Toulouse, France E-mail: [email protected] Background: TACE is the standard of care for intermediate stage HCC. It is also used as neoadjuvant therapy before curative strategies. The aim of this study was to prospectively assess TACE for HCC. Methods: Between November 2005 and December 2008, 453 patients were referred to our tertiary center and presented at our multidisciplinary committee. 372 patients were diagnosed for HCC according to AASLD guidelines. 72 patients were treated by TACE. 23 patients were treated before transplantation, resection, or RF. Tumor response was assessed by CTscan or MRI 4 to 8 weeks after each session. Treatment schedule was based on tumor response. OR was defined as a tumor necrosis >50%. Survival was evaluated by Kaplan-Meyer estimates. When receiving another treatment for HCC, patients were excluded from analysis at the date of the treatment. Results: 72 patients underwent 125 TACE sessions. Median number of TACE was 1.7. Median age was 65.2. 19% were older than 75. Main etiology of cirrhosis were alcohol in 57% and HCV in 26%. Child– Pugh score was A in 72%, B in 25% and C in 3%. BCLC tumor stage was A in 25% (neoadjuvant therapy group), B in 38%, C in 33% (14 due to partial portal vein thrombosis and 10 to altered performans status), and D in 4%. Median survival was 24.8 months. 1 and 2 years survival was 72 and 52%. OR was observed in 59.7%. No OR was observed in patients that needed more than 2 sessions. Univariate analysis identified OR, CP score, BCLC stage, baseline AFP, selective embolization and absence of post-embolization syndrome as prognostic factors. Using multivariate analysis, OR, AFP and gender were independent prognostic variables. Age was not associated with a poor prognosis. Grade III-IV adverse events were observed in 15 patients including 2 treatment related deaths. Conclusion: In a French population of HCC patients with predominantly alcohol related cirrhosis treated by TACE, the median survival was 24.8 months. OR and baseline AFP level were independent prognostic factors. Patients who do not reach OR after 2 TACE sessions should be evaluated for sorafenib. Advanced age is not a contra-indication for TACE. 209 FIBROSIS PROGRESSION DURING SUNITINIB THERAPY IN CIRRHOTIC PATIENTS WITH ADVANCED HEPATOCELLULAR CARCINOMA M. Biolato, M. Basso, A. Forgione, S. Racco, L. Miele, M. Pompili, G.L. Rapaccini, R. Landolfi, C. Barone, A. Grieco, G. Gasbarrini. Catholic University of Rome, Rome, Italy E-mail: [email protected] Background and Aims: In cirrhotic patients, serum hyaluronic acid (HA) concentration increases in proportion to the degree of liver fibrosis and is predictive of complications1 . Sunitinb, an oral multitargeted tyrosine kinase inhibitor of VEGF receptors, PDGF receptors, KIT and RET, has a promising activity against
Journal of Hepatology 2010 vol. 52 | S59–S182
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