Yong Lv1, Zhengyu Wang1, Kai Li1, Qiuhe Wang1, Wei Bai1, Xulong Yuan1, Tianlei Yu1, Jing Niu1, Zhiping Yang2, Xuan Zhu3, Jianbo Zhao4, Hui Xue5, Zaibo Jiang6, Yuzheng Zhuge7, Chunqing Zhang8, Junhui Sun9, Pengxu Ding10, Weixin Ren11, Yingchun Li12, Kewei Zhang13, Wenguang Zhang14, Wengang Guo1, Bohan Luo1, Xiaomei Li1, Jie Yuan1, Na Han1, Ying Zhu1, Chuangye He1, Zhanxin Yin1, Daiming Fan2, Guohong Han1. 1. Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China. 2. State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China. 3. Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China. 4. Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China. 5. Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China. 6. Department of interventional Radiology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. 7. Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China. 8. Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China. 9. Hepatobiliaryand Pancreatic Intervention Center, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China. 10. Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China. 11. Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China. 12. Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China. 13. Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China. 14. Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
Abstract
BACKGROUND AND AIMS: Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB. APPROACH AND RESULTS: We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P < 0.001] and 0.556 [P < 0.001]) and other prognostic models. With X-tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF-C ADs <48), intermediate risk (CLIF-C ADs 48-56), and high risk (CLIF-C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). CONCLUSIONS: In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.
BACKGROUND AND AIMS: Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB. APPROACH AND RESULTS: We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P < 0.001] and 0.556 [P < 0.001]) and other prognostic models. With X-tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF-C ADs <48), intermediate risk (CLIF-C ADs 48-56), and high risk (CLIF-C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). CONCLUSIONS: In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.
Authors: Lukas Sturm; Michael Praktiknjo; Dominik Bettinger; Jan P Huber; Lara Volkwein; Arthur Schmidt; Rafael Kaeser; Johannes Chang; Christian Jansen; Carsten Meyer; Daniel Thomas; Robert Thimme; Jonel Trebicka; Michael Schultheiß Journal: Hepatol Commun Date: 2021-01-05