- Email: [email protected]
Performance of Upper Gastrointestinal Bleeding Risk Assessment Scores in Variceal Bleeding: A Prospective International Multicenter Study
Su1455
IMPACT OF INFLAMMATORY BOWEL DISEASE ON SURVIVAL OF PRIMARY SCLEROSING CHOLANGITIS PATIENTS FOLLOWING LIVER TRANSPLANTATION: UNOS DATA ANALYSIS Omar Y. Mousa, Neej J. Patel, Juan E. Corral, David D. Lee, Justin H. Nguyen, Kristopher P. Croome, Denise M. Harnois
PERFORMANCE OF UPPER GASTROINTESTINAL BLEEDING RISK ASSESSMENT SCORES IN VARICEAL BLEEDING: A PROSPECTIVE INTERNATIONAL MULTICENTER STUDY Jing Hieng Ngu, Stig B. Laursen, Yung Ka Chin, Loren Laine, Harry Dalton, Iain A. Murray, Michael Schultz, Nadkarni Nivedita, Adrian J. Stanley
Background: The effect of inflammatory bowel disease (IBD) on outcomes after liver transplantation (LT) for primary sclerosing cholangitis (PSC) has been inconclusive. Previous reports suggested that patients with IBD who undergo LT for PSC may have increased risk for adverse outcomes including retransplantation, requiring continuous attention. The impact of IBD on patient survival in the United Network for Organ Sharing (UNOS) database has not been performed. Objectives: To evaluate survival of patients who underwent LT for PSC, with and without inflammatory bowel disease (IBD). Methods: We examined the UNOS database and identified patients with PSC who underwent LT between 1988 and 2016. PSC patients greater than 18 years of age were included. Kaplan-Meier survival analysis and log-rank tests were performed. Results: In the UNOS database, 5% (7804/146,430) of patients underwent LT for PSC between Jan 1, 1988 and Oct 31, 2016. Mean age 45.3 years (SD±14.1), mean BMI 24.6 (SD± 4.8), males 5283 (68%), white 6406 (82%). 73% of PSC patients had IBD. 41% (N=3216) had ulcerative colitis (UC) and 13% (N=998) had crohn's disease. 39% (N=3,057) did not have IBD. Data regarding recurrence of PSC was available in 13% of PSC cases, and PSC recurrence occurred in 28.7% (299/1041). There was no statistical difference in patient survival or retransplant between PSC patients with UC, crohn's disease or other colitis (Log-rank test, p = 0.71). See figure 1. Conclusions: Analysis of the UNOS database showed that the presence of ulcerative colitis or crohn's disease or the absence of IBD in patients who underwent liver transplantation for PSC, did not have a significant impact on patient survival or the risk of retransplantation. PSC patients with or without IBD should receive equal attention and follow up following LT.
Background: Several risk assessment scores have been developed to stratify patients with upper gastrointestinal bleeding (UGIB). While they perform well in non-variceal bleeding, their discriminatory ability to predict outcomes in variceal bleeding remains uncertain. Variceal bleeding is a serious cause of UGIB that can be difficult to differentiate from nonvariceal bleeding at presentation. We performed a prospective, international multicenter study to compare the performance of five scoring systems in predicting clinical endpoints in patients with variceal bleeding and to assess their sensitivity in correctly identifying variceal bleeders as high risk. Methods: Consecutive patients with UGIB presenting to six large hospitals in Europe, North America, Asia and Oceania were prospectively included over a 12-month period. Glasgow Blatchford score (GBS), admission Rockall score (ARS), full Rockall score (FRS), AIMS65 and PNED were calculated for each patient. Low risk was defined using published thresholds such as GBS≤1, ARS≤1, FRS≤2, AIMS65≤1 and PNED≤4. Area under the receiver operating curve (AUROC) was used to assess the performance of the scores. Results: A total of 3012 patients were included, of which 153 patients had variceal bleeding. Table 1 summarizes the comparisons between variceal and non-variceal bleeders. Variceal bleeders had significantly higher mean risk scores than non-variceal bleeders. GBS had a high discriminative ability for predicting intervention (transfusion or hemostatic intervention) or death for non-variceal bleeders, but performed poorly on variceal bleeders (AUROC=0.87vs0.60; p<0.001). There were no significant differences in performance of the scores in predicting mortality between variceal and non-variceal bleeders. The proportions of variceal bleeders misclassified as low risk by GBS, ARS, FRS, AIMS65 and PNED were 1%, 18%, 19%, 56% and 42% respectively. Conclusion: While GBS performs well in predicting composite endpoints of intervention or death for non-variceal bleeders, its performance in variceal bleeders is poor. Apart from GBS, UGIB risk scores could misclassify a large proportion of variceal bleeders as low risk.
Su1454 PATIENTS TRANSPLANTED FOR METABOLIC AND VIRAL CAUSES OF CIRRHOSIS HAVE SIMILAR OUTCOMES AFTER FIVE YEARS Nikhilesh R. Mazumder, Behnam Saberi, James P. Hamilton, Andrew Cameron, Ahmet Gurakar Introduction: As the obesity epidemic unfolds, Non-alcoholic steatohepatitis (NASH) has become an increasingly common indication for liver transplant alongside alcoholic (ETOH) cirrhosis and viral hepatitidies. In this study we sought to determine the differences in baseline characteristics and post transplant outcomes between metabolic causes of cirrhosis (NASH and ETOH) and viral causes of cirrhosis (Hepatitis B and C virus infection). Methods: We retrospectively collected data on patients who underwent liver transplant for any indication during the period of 5/20/2008 to 12/31/2015 with a diagnosis in the medical record of NASH, (ETOH) cirrhosis, HCV, or HBV. We excluded patients under the age of 18, those who received liver grafts from live donors, and patients who had previously undergone transplant. If patients had both a metabolic and a viral cause, we assigned their case to the ‘viral' category. All patients underwent echocardiogram as a routine part of transplant workup. The primary composite outcome was time to death or re-transplant. Our survival analysis treated "time at risk" as time from date of transplant to date of outcome with censorship after last known follow up. Our secondary outcome was time to discharge from the ICU after transplant surgery. Sensitivity analysis for presence of hepatocellular carcinoma (HCC) at transplant was performed. Results: Of the 214 patients who met inclusion criteria, 134 had HCV, 17 had HBV, 54 ETOH, and 19 with NASH. These patients were sorted into 67 metabolic and 147 viral. Patients with viral cirrhosis were more likely to identify as Black (p=0.002), to be older (53.9 years vs. 57.3 years, p= 0.005), to have lower BMI at transplant (30.1 vs 28.1 p= 0.006), and to have a lower MELD at transplant (26.6 vs 19.5, p<0.001). There was no difference in pre-transplant echocardiogram between the groups. Metabolic patients were more likely to have long ICU stays immediately after transplant surgery on unadjusted analysis (12.7 days vs 3.9 days p =0.018) however univariate survival analysis demonstrated only a trend (daily HR 1.5 of ICU discharge of viral patients, p= 0.09). There was no difference in unadjusted rate of death or retransplant at five years between the groups. After sensitivity analysis, removal of patients with HCC (102 patients) from analysis equalized ICU length of stay between the two groups (5.8 days vs 6.0 days p =NS) but otherwise left the above relations unchanged. Discussion: Despite the cardiovascular comorbidities associated with metabolic causes of cirrhosis, these patients did not have differences in their pre-transplant echocardiographic function or in their unadjusted survival after five years. HCC should be taken into account when analyzing transplant outcomes, as these patients appear to be associated with HCV and may weight these groups towards 'less sick'.
Su1456 THE INFLUENCE OF TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT WITH CONCURRENT LEFT GASTRIC VEIN EMBOLIZATION ON THE LIVER FUNCTION OF PATIENTS WITH LIVER CIRRHOSIS Hui Huan, Huan Tong, Bo Wei, Hao Wu, Cheng-Wei Tang Background: Transjugular intrahepatic portosystemic shunt (TIPS) is more and more widely applied in the treatment for variceal bleeding and refractory ascites. However, it is highly concerned whether the liver function is deteriorated or not after TIPS. Theoretically, left gastric vein embolization (LGVE) might increase the blood supply of liver if it is performed in combination with TIPS. Objective: To investigate the influence of TIPS plus LGVE and TIPS alone on liver function before and after operation. Methods: 60 Patients with liver cirrhosis, who received TIPS + LGVE (n = 29) and TIPS alone (n = 31) in Department of Gastroenterology, West China Hospital between September 2014 and April 2015, were reviewed. The data of the liver function (before operation, and one week, one month, three months, six months and twelve months after operation) were obtained and analyzed. Results: Although there were no significant differences regarding to the liver function between the TIPS+LGVE group and the TIPS alone group before operation, TIPS +LGVE was significantly superior to TIPS alone in improving the liver function in 1 year after operation (Child-Pugh score: TIPS+LGVE 5.69 ± 1.19, TIPS 6.52 ± 1.54, P = 0.025; MELD score: TIPS+LGVE 8.38 ± 4.25, TIPS 10.90 ± 3.89, P = 0.020; Figure 1a, b). In addition, more patients with ChildPugh grade A liver cirrhosis were found in the TIPS+LGVE group in 1 year after operation (TIPS+LGVE 90%, TIPS 55%, P = 0.004; Figure 1c, d). Compared with preoperational liver function, the liver function in one year after operation in the TIPS+LGVE group improved with aspect to the Child-Pugh score significantly (before operation: 7.03±1.76, 1 year after operation 5.69±1.19, P = 0.001; Figure 1b), while no significant difference was observed in terms of MELD score (before operation 8.41±4.19, 1 year after operation 8.38±4.25, P = 0.975; Figure 1a). Moreover, no significant improvements of the liver function were found
S-1135
AASLD Abstracts
AASLD Abstracts
Su1453
IMPACT OF INFLAMMATORY BOWEL DISEASE ON SURVIVAL OF PRIMARY SCLEROSING CHOLANGITIS PATIENTS FOLLOWING LIVER TRANSPLANTATION: UNOS DATA ANALYSIS Omar Y. Mousa, Neej J. Patel, Juan E. Corral, David D. Lee, Justin H. Nguyen, Kristopher P. Croome, Denise M. Harnois
PERFORMANCE OF UPPER GASTROINTESTINAL BLEEDING RISK ASSESSMENT SCORES IN VARICEAL BLEEDING: A PROSPECTIVE INTERNATIONAL MULTICENTER STUDY Jing Hieng Ngu, Stig B. Laursen, Yung Ka Chin, Loren Laine, Harry Dalton, Iain A. Murray, Michael Schultz, Nadkarni Nivedita, Adrian J. Stanley
Background: The effect of inflammatory bowel disease (IBD) on outcomes after liver transplantation (LT) for primary sclerosing cholangitis (PSC) has been inconclusive. Previous reports suggested that patients with IBD who undergo LT for PSC may have increased risk for adverse outcomes including retransplantation, requiring continuous attention. The impact of IBD on patient survival in the United Network for Organ Sharing (UNOS) database has not been performed. Objectives: To evaluate survival of patients who underwent LT for PSC, with and without inflammatory bowel disease (IBD). Methods: We examined the UNOS database and identified patients with PSC who underwent LT between 1988 and 2016. PSC patients greater than 18 years of age were included. Kaplan-Meier survival analysis and log-rank tests were performed. Results: In the UNOS database, 5% (7804/146,430) of patients underwent LT for PSC between Jan 1, 1988 and Oct 31, 2016. Mean age 45.3 years (SD±14.1), mean BMI 24.6 (SD± 4.8), males 5283 (68%), white 6406 (82%). 73% of PSC patients had IBD. 41% (N=3216) had ulcerative colitis (UC) and 13% (N=998) had crohn's disease. 39% (N=3,057) did not have IBD. Data regarding recurrence of PSC was available in 13% of PSC cases, and PSC recurrence occurred in 28.7% (299/1041). There was no statistical difference in patient survival or retransplant between PSC patients with UC, crohn's disease or other colitis (Log-rank test, p = 0.71). See figure 1. Conclusions: Analysis of the UNOS database showed that the presence of ulcerative colitis or crohn's disease or the absence of IBD in patients who underwent liver transplantation for PSC, did not have a significant impact on patient survival or the risk of retransplantation. PSC patients with or without IBD should receive equal attention and follow up following LT.
Background: Several risk assessment scores have been developed to stratify patients with upper gastrointestinal bleeding (UGIB). While they perform well in non-variceal bleeding, their discriminatory ability to predict outcomes in variceal bleeding remains uncertain. Variceal bleeding is a serious cause of UGIB that can be difficult to differentiate from nonvariceal bleeding at presentation. We performed a prospective, international multicenter study to compare the performance of five scoring systems in predicting clinical endpoints in patients with variceal bleeding and to assess their sensitivity in correctly identifying variceal bleeders as high risk. Methods: Consecutive patients with UGIB presenting to six large hospitals in Europe, North America, Asia and Oceania were prospectively included over a 12-month period. Glasgow Blatchford score (GBS), admission Rockall score (ARS), full Rockall score (FRS), AIMS65 and PNED were calculated for each patient. Low risk was defined using published thresholds such as GBS≤1, ARS≤1, FRS≤2, AIMS65≤1 and PNED≤4. Area under the receiver operating curve (AUROC) was used to assess the performance of the scores. Results: A total of 3012 patients were included, of which 153 patients had variceal bleeding. Table 1 summarizes the comparisons between variceal and non-variceal bleeders. Variceal bleeders had significantly higher mean risk scores than non-variceal bleeders. GBS had a high discriminative ability for predicting intervention (transfusion or hemostatic intervention) or death for non-variceal bleeders, but performed poorly on variceal bleeders (AUROC=0.87vs0.60; p<0.001). There were no significant differences in performance of the scores in predicting mortality between variceal and non-variceal bleeders. The proportions of variceal bleeders misclassified as low risk by GBS, ARS, FRS, AIMS65 and PNED were 1%, 18%, 19%, 56% and 42% respectively. Conclusion: While GBS performs well in predicting composite endpoints of intervention or death for non-variceal bleeders, its performance in variceal bleeders is poor. Apart from GBS, UGIB risk scores could misclassify a large proportion of variceal bleeders as low risk.
Su1454 PATIENTS TRANSPLANTED FOR METABOLIC AND VIRAL CAUSES OF CIRRHOSIS HAVE SIMILAR OUTCOMES AFTER FIVE YEARS Nikhilesh R. Mazumder, Behnam Saberi, James P. Hamilton, Andrew Cameron, Ahmet Gurakar Introduction: As the obesity epidemic unfolds, Non-alcoholic steatohepatitis (NASH) has become an increasingly common indication for liver transplant alongside alcoholic (ETOH) cirrhosis and viral hepatitidies. In this study we sought to determine the differences in baseline characteristics and post transplant outcomes between metabolic causes of cirrhosis (NASH and ETOH) and viral causes of cirrhosis (Hepatitis B and C virus infection). Methods: We retrospectively collected data on patients who underwent liver transplant for any indication during the period of 5/20/2008 to 12/31/2015 with a diagnosis in the medical record of NASH, (ETOH) cirrhosis, HCV, or HBV. We excluded patients under the age of 18, those who received liver grafts from live donors, and patients who had previously undergone transplant. If patients had both a metabolic and a viral cause, we assigned their case to the ‘viral' category. All patients underwent echocardiogram as a routine part of transplant workup. The primary composite outcome was time to death or re-transplant. Our survival analysis treated "time at risk" as time from date of transplant to date of outcome with censorship after last known follow up. Our secondary outcome was time to discharge from the ICU after transplant surgery. Sensitivity analysis for presence of hepatocellular carcinoma (HCC) at transplant was performed. Results: Of the 214 patients who met inclusion criteria, 134 had HCV, 17 had HBV, 54 ETOH, and 19 with NASH. These patients were sorted into 67 metabolic and 147 viral. Patients with viral cirrhosis were more likely to identify as Black (p=0.002), to be older (53.9 years vs. 57.3 years, p= 0.005), to have lower BMI at transplant (30.1 vs 28.1 p= 0.006), and to have a lower MELD at transplant (26.6 vs 19.5, p<0.001). There was no difference in pre-transplant echocardiogram between the groups. Metabolic patients were more likely to have long ICU stays immediately after transplant surgery on unadjusted analysis (12.7 days vs 3.9 days p =0.018) however univariate survival analysis demonstrated only a trend (daily HR 1.5 of ICU discharge of viral patients, p= 0.09). There was no difference in unadjusted rate of death or retransplant at five years between the groups. After sensitivity analysis, removal of patients with HCC (102 patients) from analysis equalized ICU length of stay between the two groups (5.8 days vs 6.0 days p =NS) but otherwise left the above relations unchanged. Discussion: Despite the cardiovascular comorbidities associated with metabolic causes of cirrhosis, these patients did not have differences in their pre-transplant echocardiographic function or in their unadjusted survival after five years. HCC should be taken into account when analyzing transplant outcomes, as these patients appear to be associated with HCV and may weight these groups towards 'less sick'.
Su1456 THE INFLUENCE OF TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT WITH CONCURRENT LEFT GASTRIC VEIN EMBOLIZATION ON THE LIVER FUNCTION OF PATIENTS WITH LIVER CIRRHOSIS Hui Huan, Huan Tong, Bo Wei, Hao Wu, Cheng-Wei Tang Background: Transjugular intrahepatic portosystemic shunt (TIPS) is more and more widely applied in the treatment for variceal bleeding and refractory ascites. However, it is highly concerned whether the liver function is deteriorated or not after TIPS. Theoretically, left gastric vein embolization (LGVE) might increase the blood supply of liver if it is performed in combination with TIPS. Objective: To investigate the influence of TIPS plus LGVE and TIPS alone on liver function before and after operation. Methods: 60 Patients with liver cirrhosis, who received TIPS + LGVE (n = 29) and TIPS alone (n = 31) in Department of Gastroenterology, West China Hospital between September 2014 and April 2015, were reviewed. The data of the liver function (before operation, and one week, one month, three months, six months and twelve months after operation) were obtained and analyzed. Results: Although there were no significant differences regarding to the liver function between the TIPS+LGVE group and the TIPS alone group before operation, TIPS +LGVE was significantly superior to TIPS alone in improving the liver function in 1 year after operation (Child-Pugh score: TIPS+LGVE 5.69 ± 1.19, TIPS 6.52 ± 1.54, P = 0.025; MELD score: TIPS+LGVE 8.38 ± 4.25, TIPS 10.90 ± 3.89, P = 0.020; Figure 1a, b). In addition, more patients with ChildPugh grade A liver cirrhosis were found in the TIPS+LGVE group in 1 year after operation (TIPS+LGVE 90%, TIPS 55%, P = 0.004; Figure 1c, d). Compared with preoperational liver function, the liver function in one year after operation in the TIPS+LGVE group improved with aspect to the Child-Pugh score significantly (before operation: 7.03±1.76, 1 year after operation 5.69±1.19, P = 0.001; Figure 1b), while no significant difference was observed in terms of MELD score (before operation 8.41±4.19, 1 year after operation 8.38±4.25, P = 0.975; Figure 1a). Moreover, no significant improvements of the liver function were found
S-1135
AASLD Abstracts
AASLD Abstracts
Su1453