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Coverts and Overt Hepatic Encephalopathy
( Sang Gyune Kim ) 대한간학회 2019 Postgraduate Courses (PG) Vol.2019 No.1
Hepatic encephalopathy occurs in more than 10-20% of all cases of cirrhosis and is an important complication that degrades the quality of life. Overt hepatic encephalopathy is readily identifiable since it is apparently accompanied by disorientation or flapping tremor. On the other hand, covert hepatic encephalopathy means that only psychometric or neurophysiological abnormalities appear without signs of clinically obvious cognitive impairment. Covert hepatic encephalopathy includes minimal hepatic encephalopathy and West-Haven Criteria grade I hepatic encephalopathy (Table 1). Covert hepatic encephalopathy is being noticed more often and is regarded as an important disease that needs to be managed appropriately. It is identified up to 38-60% of cirrhosis tested. Recent studies revealed that covert hepatic encephalopathy significantly decrease the quality of life and diminish working ability in patients with compensated liver cirrhosis. Furthermore, it is strongly associated with increased risk of progression to overt hepatic encephalopathy.
( Sang Gyune Kim ),( Jeong-ju Yoo ),( Young Seok Kim ),( Bora Lee ),( Soung Won Jeong ),( Jae Young Jang ),( Sae Hwan Lee ),( Hong Soo Kim ),( Young Don Kim ),( Gab Jin Cheon ),( Boo Sung Kim ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1
Aims: Non-selective beta-blocker (NSBB) use has been established in the primary and secondary prevention of esophageal variceal hemorrhage. However, the use of beta-blockers in cirrhotic patients with ascites is still under debate. In this study, we compared overall survival (OS) in cirrhotic patients with ascites (≥grade 2) and esophageal varices according to their treatment strategies between endoscopic band ligation (EBL) and NSBB. Methods: This retrospective study included consecutive 269 patients who were diagnosed as liver cirrhosis complicated with esophageal varices and ascites (≥grade 2) in a tertiary single center in Korea. Patients were divided into 3 groups which were EBL only, NSBB, non-treatment group. A Cox-proportional hazard analysis was performed to compare overall survival between the groups. Results: The mean age was 53.8±10.9 years, and median follow-up duration was 37.7 months (IQR, 12.4-65.2). Overall survival was significantly shorter in the NSBB group followed by non-treatment group and EBL only group (median, 47.5 vs. 61.1 vs. 77.0 months; P=0.003). A multivariate analysis showed that the use of NSBB were an independent poor prognostic factor for shorter overall survival (adjusted hazard ratio, 1.98; 95% confidence interval, 1.31-2.98; P<0.001) after adjusted by Child-Pugh class. Conclusions: The use of NSBB worsens the prognosis of cirrhotic patients patients with significant ascites. These results suggest that EBL is a more appropriate treatment option of esophageal varices when complicated with ascites (≥grade 2).
Sarcopenia: Prognostic Impact on Cirrhosis
( Sang Gyune Kim ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1
Sarcopenia is a new clinical entity related to muscle decline, which has attracted a great deal of attention among clinicians because of its detrimental effect on clinical outcomes. Relevant pathways may vary depending on the underlying disease, but muscle depletion occurs due to imbalances in muscle formation and breakdown. According to recent meta-analysis, sarcopenia in patients with liver cirrhosis is an important prognostic factor, independent of MELD and CTP scores (Figure 1).1 In this study, the prevalence rate of sarcopenia among all cirrhotic patients was about 48%, and 2-fold more among men with a rate of 62% compared to that of 36% for women. Interestingly, Asians had a HR 2.45 (95% confidence interval (CI) = 1.44 ± 4.16, P = 0.001) of mortality whereas Westerners had a HR 1.45 (95% CI = 1.002 ± 2.09, P < 0.05). This might be due to discrepancy of muscle measurement and sarcopenia definition. Cirrhotic patients with sarcopenia suffered from poor quality of life and functional disability and increased infection and mortality.2 Recently, not only sarcopenia, but also combined obesity, which is called “sarcopenic obesity”, is known to be associated with higher rates of mortality and have a greater impact on physical function than either alone. The proposed mechanisms include increased pro-inflammatory cytokines, decreased physical activity, reduced protein synthesis, aging. Durand et al. suggested that MELD-sarcopenia scores combined with MELD and psoas muscle area scores were superior to MELD score alone in predicting prognosis of cirrhotic patients3. These results indicated that sarcopenia is an excellent predictor of organ allocation in liver transplant recipients. However, Tandon et al reported that the effect of Sarcopenia was significant in patients with low MELD scores (<15; P = 0.02), but not in patients with high MELD scores4. Therefore, sarcopenia seems to be an important prognostic factor and needs to be treated in early and intermediated stage rather than advanced liver cirrhosis. On the other hand, Van Vugt et al. reported that among patients with cirrhosis listed for liver transplantation in the Eurotransplant registry, MELD-sarcopenia combined scoring system had limited value in predicting waiting list mortality, although low skeletal muscle mass was significant related with mortality on the waiting list, particularly in patients who were listed with low priority based on a low MELD score5. In this competing risk analysis, mortality was significantly higher in patients with sarcopeniaM6 than in patients without sarcopeniaM (most frequently used for cancer patients), whereas no differences were observed for patients with and without sarcopeniaC (for liver transplant candidate)7. Since there are no universally accepted cut-off values to classify patients with sarcopenia, care should be taken when analyzing the effect of sarcopenia on prognosis in patients with cirrhosis.
( Sang Gyune Kim ),( Jeong Joo Yoo ),( Young Seok Kim ),( Bora Lee ),( Soung Won Jeong ),( Jae Young Jang ),( Sae Hwan Lee ),( Hong Soo Kim ),( Young Don Kim ),( Gab Jin Cheon ),( Boo Sung Kim ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1
Aims: The accuracy of detailed fibrosis stage classification assessed with transient elastography (fibroscan) was only 65% and, what is more, significant discrepancy rate (≥ 2 fibrosis stage) reached up to 13%. Several causative factors such as age, elevated liver enzyme, body mass index (BMI), skin to liver distance (SLD) are considered to contribute to this discrepancy, but there are few authentic evidences of what really works. In this study, we compared the discordance of fibrosis stage classification between fibroscan and two-dimensional shear wave ultrasound (2D-SWE) and looked for which variables are related with it. Methods: Patients who had a valid measurement and an adequate liver biopsy specimen were 291. The fibrosis stage classifications derived from the cumulated cut-offs calculated for different fibrosis stage by fibroscan as well as 2D-SWE. The discrepancy score took into account the size of error between fibrosis stage (Metavir) and fibrosis stage classification (fibroscan, 2D-SWE). This score was defined as follows: 0 for correct classification, then 1, 2, or 3 as per the misclassification in fibrosis stages. Results: Patients were male predominant (54.0%), their mean age was 48.9±13.5 years old. Liver fibrosis stage consisted of F0 (13.4%), F1 (22.0%), F2 (24.1%), F3 (16.8%) and F4 (23.7%). The optimal cut-off for each fibrosis stage observed by fibroscan was 6.9 (≥F2), 7.9 (≥F3), 10.4 (F4) and 6.7 (≥F2), 7.1 (≥F3), 10.0 (F4) by 2D-SWE. Accurate assessment of fibrosis stage classification by discrepancy score showed that the proportion of underestimation and overestimation was 19.6%, 22.0% in fibroscan, and 21.0%, 17.9% in 2D-SWE. The descrepancy score of fibroscan was higher than that of 2D-SWE (p=0.032). In multivariate analysis, viral liver disease, shorter SLD, lower prothrombin time were associated with underestimation in both fibroscan and 2D-SWE. Longer SLD and higher AST level significantly increased overestimation in fibroscan and, in 2D-SWE along with age. When a skin to liver distance is over 2.5cm, 80.0% (12/15) of fibroscan and 46.7% (7/15) of 2D-SWE were overestimated. Conclusions: Liver fibrosis stage in fairly large number of patients is misclassified by either fibroscan or 2D-SWE. Skin to liver distance rather than BMI was most important factor to affect the over and underestimation of liver fibrosis classification.
( Sang Gyune Kim ),( Jeong Joo Yoo ),( Young Seok Kim ),( Bora Lee ),( Soung Won Jeong ),( Jae Young Jang ),( Sae Hwan Lee ),( Hong Soo Kim ),( Young Don Kim ),( Gab Jin Cheon ),( Boo Sung Kim ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1
Aims: Several real-time two-dimensional shear wave elastography (2D-SWE) have been developed to assess liver fibrosis with readily use of combining elastography and traditional ultrasound imaging. However, compared with transient elastography (fibroscan), the diagnostic accuracy and clinical usefulness of these methods were not fully validated. In this study, newly developed 2D-SWE (LOGIQ E9, GE healthcare, UK) was evaluated for predicting liver fibrosis stage and compared with fibroscan. Methods: Out of 1,395 patients who received 2D-SWE during May 2015 to Apr 2016, seventy (5.0%) who failed to get available value of 2D-SWE due to obesity and 131 (9.4%) with high value of AST or ALT were excluded in the analysis. Liver biopsy was performed in 177 patients. 2D-SWE measurement was considered valid when homogenous color pattern in a region of interest of at least 10 mm was shown at 10 different sites. Diagnostic performance was calculated using area under the receiver operating characteristics curve (AUROC). Results: Patients were male predominant (60.8%), their mean age was 50.4±12.4 years old and most common etiology of liver disease was hepatitis B (40.3%) followed by alcohol (26.1%). Liver fibrosis stage consisted of F0 (14.1%), F1 (12.4%), F2 (28.8%), F3 (18.1%) and F4 (26.6%). Overall, 2D-SWE was well correlated with transient elastography (r=0.788, P<0.001). 2D-SWE median values (kPa) increased with increasing stage of liver fibrosis [ F0 (5.0±1.5), F1 (6.4±2.3), F2 (6.5±2.0), F3 (9.0±2.7), F4 (12.7±2.9)] (p for trend <0.001). For the diagnosis of liver cirrhosis, AUROCs and optimal cutoff of 2D-SWE were 0.928 (95% confidence interval [CI], 0.890-0.967) and 10.1 kPa. The sensitivity, specificity, positive predictive value and negative predictive value for predicting cirrhosis were 82.2%, 92.2%, 78.7% and 93.7% respectively. For diagnosing significant liver fibrosis (≥F2), AUROCs and optimal cutoff of 2D-SWE were 0.913 (95% CI, 0.870-0.956) and 7.99 kPa. Conclusions: With effective comparability to fibroscan and availability of a conventional ultrasound examination, 2D-SWE is an useful tool for stratifying liver fibrosis stage and diagnosing liver cirrhosis.