- Email: [email protected]
Rotational Thromboelastometry and Child can Predict 3-Month Mortality in Liver Cirrhosis
POSTER PRESENTATIONS hypertension. The data regarding the use of TE for predicting the response to NSBBs are weak. Our aim was to assess the performance of TE for predicting the achievement of response to NSBBs in cirrhotic patients. Methods: Our retrospective study included 194 cirrhotic patients and paired HVPG measurements, evaluated in our Hemodynamic Labor between 2008–2014. Response to NSBB was defined as decrease of HVPG ≥ 10% (in case of primary prophylaxis) or HVPG ≥ 20% (in case of secondary prophylaxis) or to absolute values <12 mmHg. TE was performed at the baseline HVPG measurements. According to the newly proposed TE quality criteria, ten valid measurements with a median liver stiffness value ≥7.1 kPa and IQR/median >30% were considered poorly reliable and not included into the analysis. TE cases without 10 valid measurements were also excluded. Results: The etiology of liver cirrhosis was: alcoholic −103 (53.1%) patients, viral −52 (26.8%) patients and other etiologies – 39 (20.1%) patients. According to the Child-Pugh classification 33.5% of patients were Child-Pugh A, 43.3% Child-Pugh B and 23.2% Child-Pugh C. Valid LS measurements by TE were obtained in 151/194 (77.8%) patients, which were included in the final analysis. A hemodynamic response to NSBBs was obtained in 97/151 (64.2%) patients. LS assessed by TE had 72.9% Se and 66.1% PPV for a cut-off <42 kPa in alcoholic cirrhosis for predicting the achievement of response to NSBBs, while in liver cirrhotic patients with viral etiology of liver disease for a cut-off value <48 kPa was obtained 75% PPV (Table). Etiology All Alcholic Viral
Cut-off (kPa) AUC <42 <72 <48
0.59 0.55 0.65
Se (%)
Sp (%)
PPV (%)
NPV (%)
Accuracy (%)
50.5 72.9 75
67.3 41.9 56.2
73.1 66.1 75
43.5 50 56.2
56.5 60.7 68.1
Conclusions: A single LS measurement at initiation of treatment with NSBB for predicting the hemodynamic response to NSBBs is not accurate enough to be use in routine clinical practice. THU-392 SODIUM PHENYLBUTYRATE ADMINISTRATION TO AVOID NEUROLOGICAL WORSENING IN CIRRHOTIC PATIENTS WITH HEPATIC ENCEPHALOPATHY ADMITTED IN ICU S. Tripon1, M. Mallet1, M. Lodey2, E. Guiller2, M. Rudler1, S. Mouri1, N. Weiss3, D. Thabut1, and Brain-Liver Pitie-Salpetriere Study Group. 1 Hepatology, Pitié-Salpêtrier̀ e Hospital; 2Pharmacology, La PitieSalpetriere Hospital; 3Neurological ICU, La Pitie-Salpetriere Hospital, APHP, Paris, France E-mail: [email protected] Background and Aims: Hepatic encephalopathy (HE) is a major clinical problem in patients with cirrhosis, which influences short and long-term prognosis. About one third of patient with overt HE will display altered consciousness needing ICU admission and sometimes mechanical ventilation. Recently, glycerol phenylbutyrate or sodium phenylbutyrate (PB), which lowers ammonia by providing an alternate pathway to urea for waste nitrogen excretion, has shown to be effective in preventing the occurrence of HE in RCT. Aim: To determine if sodium PB is effective to decrease ammonia and avoid neurological worsening in patients admitted in ICU for HE. Methods: We prospectively included cirrhotic patients with an ammonia level >100 μmol/L, who presented with HE and had no contra-indication to PB. This group was compared to a historical matched control group. Glasgow coma scale (GCS), FOUR score, WestHaven (WH), and critical flicker frequency (CFF) were assessed in each patient before and after treatment. Neurological improvement was defined as an improvement in either GCS or FOUR score in comatose patients, and as an improvement in WH or CFF in noncomatose patients. Side-effects were noted. Results: Between August 2014 and September 2015, 18 patients were included (age: 59 ± 3 years, male 80%; aetiology of cirrhosis: alcoholic S288
56%, viral 6%, other 38%; Child-Pugh 10 ± 1, MELD score 19 ± 2). They were compared to 18 matched control patients that did not differ in baseline characteristics. At admission, ammonia level was 160 ± 10 in PB group and 133 ± 10 in the control group ( p = 0.0514). GCS, FOUR score, WH (2 ± 0 in both groups) and CFF were not different at baseline between the 2 groups. At day-1, ammonia decrease was −61 [(−83)–(−27)] in the PB group compared to −12 [(−35)–(+34)] in the control group ( p = 0.0315), at day-2 −51 [(−79)–(−10)] vs −31 [(−39)– (+15)] (p = 0.0380) and at day-3 −43 [(−83)–(−26)] vs −34 [(−92)– (+165)] ( p = 0.1252). There was a trend to neurological improvement in PB group (56% vs 33% at day-1 ( p = 0.1797), 78% vs 56% at day-2 ( p = 0.1573) and 78% vs 56% at day-3 ( p = 0.1573)). At 6 months, 33% vs 44% died in the PB vs control group respectively. No major side-effects were reported under treatment. Conclusions: Sodium PB is effective in reducing rapidly ammonia levels and improves probably neurological status in HE patients with ammonia >100 μmol/L. THU-393 ROTATIONAL THROMBOELASTOMETRY AND CHILD CAN PREDICT 3-MONTH MORTALITY IN LIVER CIRRHOSIS S. Bedreli1, J.-P. Sowa1, S. Blomeyer1, S. Malek1, G. Kneiseler1, L. Bechmann1, A. Paul2, G. Gerken1, D. Heider3, F. Saner2, A. Canbay1. 1 Department of Gastroenterology and Hepatology; 2Department of General, Visceral and Transplantation Surgery, University Hospital, University Duisburg Essen, Essen; 3Department of Bioinformatics, University of Applied Science Weihenstephan-Triesdorf, Straubing, Germany E-mail: [email protected] Background and Aims: Patients with liver cirrhosis exhibit complex coagulation disorders. Classic coagulation parameters, such as INR, are commonly disturbed in cirrhotic patients, affecting the MELD score and organ allocation. However, INR does not precisely depict all changes of coagulation and anti-coagulative factors. Rotational thromboelastometry (ROTEM®) gains acceptance in evaluating hemostasis in liver disease, currently, due to more precise and exhaustive information on the actual coagulation status. The presented study aimed to identify the potential of ROTEM® to predict 3 month mortality in cirrhotic patients. Methods: 102 patients with liver cirrhosis were retrospectively evaluated. Common coagulation parameters, ROTEM®, clinical scores, and mortality were analyzed. Patients were grouped by 3 month survival into alive (A) and deceased (D). Results: Clotting Time in EXTEM (CTEXTEM) was significant shorter in the A group than in D ( p = 0.001). Alive patients exhibited significantly higher Maximum Lysis in EXTEM and APTEM compared to the D group ( p = 0.038; p = 0.005). Receiver operating characteristic curve analysis revealed a greater area under the curve (AUC) of CTEXTEM in comparison to MELD score for prediction of 3month mortality (AUC: 0.74 vs. 0.68) and a similar AUC as the CHILD score (AUC: 0.74). When logistic regression was performed for a combination of CTEXTEM and CHILD, a slightly lower AUC of 0.72 was reached. Though, at a cutoff with specificity of 90% to identify individuals who deceased 3 months after ROTEM, the combination of CHILD and CTEXTEM achieved significantly higher sensitivity than MELD, CHILD, or CTEXTEM alone (at identical specificity of 90%). Conclusions: ROTEM® is an up-to-date method for detailed and exact assessment of coagulation in cirrhotic patients. In addition the CTEXTEM value of ROTEM® could be a novel predictor of 3-month mortality in liver cirrhosis. Re-evaluation of the CHILD score by including CTEXTEM should be taken into consideration to achieve better specificity and sensitivity to identify patients under high mortality risk.
Journal of Hepatology 2016 vol. 64 | S213–S424
Cut-off (kPa) AUC <42 <72 <48
0.59 0.55 0.65
Se (%)
Sp (%)
PPV (%)
NPV (%)
Accuracy (%)
50.5 72.9 75
67.3 41.9 56.2
73.1 66.1 75
43.5 50 56.2
56.5 60.7 68.1
Conclusions: A single LS measurement at initiation of treatment with NSBB for predicting the hemodynamic response to NSBBs is not accurate enough to be use in routine clinical practice. THU-392 SODIUM PHENYLBUTYRATE ADMINISTRATION TO AVOID NEUROLOGICAL WORSENING IN CIRRHOTIC PATIENTS WITH HEPATIC ENCEPHALOPATHY ADMITTED IN ICU S. Tripon1, M. Mallet1, M. Lodey2, E. Guiller2, M. Rudler1, S. Mouri1, N. Weiss3, D. Thabut1, and Brain-Liver Pitie-Salpetriere Study Group. 1 Hepatology, Pitié-Salpêtrier̀ e Hospital; 2Pharmacology, La PitieSalpetriere Hospital; 3Neurological ICU, La Pitie-Salpetriere Hospital, APHP, Paris, France E-mail: [email protected] Background and Aims: Hepatic encephalopathy (HE) is a major clinical problem in patients with cirrhosis, which influences short and long-term prognosis. About one third of patient with overt HE will display altered consciousness needing ICU admission and sometimes mechanical ventilation. Recently, glycerol phenylbutyrate or sodium phenylbutyrate (PB), which lowers ammonia by providing an alternate pathway to urea for waste nitrogen excretion, has shown to be effective in preventing the occurrence of HE in RCT. Aim: To determine if sodium PB is effective to decrease ammonia and avoid neurological worsening in patients admitted in ICU for HE. Methods: We prospectively included cirrhotic patients with an ammonia level >100 μmol/L, who presented with HE and had no contra-indication to PB. This group was compared to a historical matched control group. Glasgow coma scale (GCS), FOUR score, WestHaven (WH), and critical flicker frequency (CFF) were assessed in each patient before and after treatment. Neurological improvement was defined as an improvement in either GCS or FOUR score in comatose patients, and as an improvement in WH or CFF in noncomatose patients. Side-effects were noted. Results: Between August 2014 and September 2015, 18 patients were included (age: 59 ± 3 years, male 80%; aetiology of cirrhosis: alcoholic S288
56%, viral 6%, other 38%; Child-Pugh 10 ± 1, MELD score 19 ± 2). They were compared to 18 matched control patients that did not differ in baseline characteristics. At admission, ammonia level was 160 ± 10 in PB group and 133 ± 10 in the control group ( p = 0.0514). GCS, FOUR score, WH (2 ± 0 in both groups) and CFF were not different at baseline between the 2 groups. At day-1, ammonia decrease was −61 [(−83)–(−27)] in the PB group compared to −12 [(−35)–(+34)] in the control group ( p = 0.0315), at day-2 −51 [(−79)–(−10)] vs −31 [(−39)– (+15)] (p = 0.0380) and at day-3 −43 [(−83)–(−26)] vs −34 [(−92)– (+165)] ( p = 0.1252). There was a trend to neurological improvement in PB group (56% vs 33% at day-1 ( p = 0.1797), 78% vs 56% at day-2 ( p = 0.1573) and 78% vs 56% at day-3 ( p = 0.1573)). At 6 months, 33% vs 44% died in the PB vs control group respectively. No major side-effects were reported under treatment. Conclusions: Sodium PB is effective in reducing rapidly ammonia levels and improves probably neurological status in HE patients with ammonia >100 μmol/L. THU-393 ROTATIONAL THROMBOELASTOMETRY AND CHILD CAN PREDICT 3-MONTH MORTALITY IN LIVER CIRRHOSIS S. Bedreli1, J.-P. Sowa1, S. Blomeyer1, S. Malek1, G. Kneiseler1, L. Bechmann1, A. Paul2, G. Gerken1, D. Heider3, F. Saner2, A. Canbay1. 1 Department of Gastroenterology and Hepatology; 2Department of General, Visceral and Transplantation Surgery, University Hospital, University Duisburg Essen, Essen; 3Department of Bioinformatics, University of Applied Science Weihenstephan-Triesdorf, Straubing, Germany E-mail: [email protected] Background and Aims: Patients with liver cirrhosis exhibit complex coagulation disorders. Classic coagulation parameters, such as INR, are commonly disturbed in cirrhotic patients, affecting the MELD score and organ allocation. However, INR does not precisely depict all changes of coagulation and anti-coagulative factors. Rotational thromboelastometry (ROTEM®) gains acceptance in evaluating hemostasis in liver disease, currently, due to more precise and exhaustive information on the actual coagulation status. The presented study aimed to identify the potential of ROTEM® to predict 3 month mortality in cirrhotic patients. Methods: 102 patients with liver cirrhosis were retrospectively evaluated. Common coagulation parameters, ROTEM®, clinical scores, and mortality were analyzed. Patients were grouped by 3 month survival into alive (A) and deceased (D). Results: Clotting Time in EXTEM (CTEXTEM) was significant shorter in the A group than in D ( p = 0.001). Alive patients exhibited significantly higher Maximum Lysis in EXTEM and APTEM compared to the D group ( p = 0.038; p = 0.005). Receiver operating characteristic curve analysis revealed a greater area under the curve (AUC) of CTEXTEM in comparison to MELD score for prediction of 3month mortality (AUC: 0.74 vs. 0.68) and a similar AUC as the CHILD score (AUC: 0.74). When logistic regression was performed for a combination of CTEXTEM and CHILD, a slightly lower AUC of 0.72 was reached. Though, at a cutoff with specificity of 90% to identify individuals who deceased 3 months after ROTEM, the combination of CHILD and CTEXTEM achieved significantly higher sensitivity than MELD, CHILD, or CTEXTEM alone (at identical specificity of 90%). Conclusions: ROTEM® is an up-to-date method for detailed and exact assessment of coagulation in cirrhotic patients. In addition the CTEXTEM value of ROTEM® could be a novel predictor of 3-month mortality in liver cirrhosis. Re-evaluation of the CHILD score by including CTEXTEM should be taken into consideration to achieve better specificity and sensitivity to identify patients under high mortality risk.
Journal of Hepatology 2016 vol. 64 | S213–S424