POSTER PRESENTATIONS
THU-042
END-OF-LIFE HEALTHCARE COSTS AND UTILIZATION AMONG
PATIENTS WITH END-STAGE-LIVER-DISEASE IN ONTARIO: A
POPULATION-BASED STUDY
E.M. Kelly1, S. Murthy1, F. Wong2, T. Shaw-Stiffel1, L. Scully1,
M. Chalifoux3, P. Tanuseputro3, P. James1. 1The Ottawa Hospital,
Ottawa; 2University of Toronto, Toronto; 3OHRI, Ottawa, Canada
E-mail: ekelly@toh.on.ca
Background and Aims: Healthcare for patients with end stage liver
disease (ESLD) is often initiated in response to acute deterioration
from disease progression. Despite guarded prognoses, many ESLD
patients continue to receive expensive therapeutic interventions at
the end-of-life (EOL).
The aims of this study were to evaluate EOL costs and utilization in
patients with ESLD as compared to non-ESLD patients within the
province of Ontario, Canada.
Methods: Using the Ontario Health Administrative Database, we
performed population-based retrospective cohort study was
conducted of all decedents within the province of Ontario, between
April 1, 2010 and March 31, 2013. Patients with ESLD were defined
using international classification of disease codes (ICD-9) for cirrhosis
and decompensation (variceal bleeding, encephalopathy, ascites,
hepatorenal syndrome and peritonitis). Patients with ESLD were
compared to non-ESLD patients on direct health care costs in the last
year of life, including hospitalizations, outpatient services and long-
term care. Multivariate modelling was performed to compare the
total costs in the final 90 days of life, adjusting for individual
demographic (age and sex), co-morbidity burden.
Results: The study cohort consisted of 264,754 decedents, of which
ESLD patients comprised 2.1% (n = 5,575). Direct health care
expenditure for patients with ESLD increased more in the last 90
days of life compared to non-ESLD patients. The mean cost in the last
90 days of life was $35,008 for patients with ESLD and $21401 for
patients without ESLD ( p < 0.01), and this was predominantly
related to increased acute care utilization [ESLD = $30,667 (88%
of total costs) vs non-ESLD = $15,162 (71%)]. ESLD patients had
higher rates of acute care utilization in the last and 90 days of life [19
days vs 6 days, p < 0.01], longer hospitalization stays [additional 4.5
days [95% CI 4.2–4.9 days ( p < 0.001)], and increased odds of dying in
an institutional [OR 1.9 (95% CI 1.8–2.0; p < 0.001)]. ESLD patients
with peritonitis or hepatorenal syndrome incurred the highest mean
total costs in the last 90 days of life [$43,196 and $38,584,
respectively].
Conclusions: EOL care in ESLD patients is associated with
substantially higher costs than in the general population,
predominantly from increased acute care utilization including
hospitalization. Whether optimizing outpatient services for
patients and/or offering timely palliative services for patients
with ESLD can lead to more cost-effective EOL care warrants further
evaluation.
THU-043
COMPARISON OF CREATININE AND CYSTATIN C BASED
GLOMERULAR FILTRATION RATE FORMULAE WITH 51CHROMIUM-
EDTA CLEARANCE IN PATIENTS WITH DECOMPENSATED CIRRHOSIS
E. Cholongitas1, I. Goulis1, M. Ioannidou1, S. Soulaidopoulos1,
P. Chalevas1, E. Akriviadis1. 14th Department of Internal Medicine,
Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
E-mail: cholongitas@yahoo.gr
Background and Aims: The accurate assessment of glomerular
filtration rate (GFR) in cirrhosis has become very important. Serum
cystatin-C (CysC) and its derived GFR formulae estimates have been
proposed as superior predictors of renal function than those based
on serum creatinine (sCr). Our aim was to compare CysC and sCr
GFR formulae with 51Chromium-EDTA (“true GFR”) in patients with
decompensated cirrhosis and to derived a “new GFR” formula.
Journal of Hepatology 2016 vol. 64 | S213–S424
Methods: In 129 patients (72% male; age:53.9 ± 11.3years) we
estimated the following GFRs according to: a) sCr-based MDRD-4
and the CKD-EPI-sCr equations, b) cysC-based Hoek, Larsson and
CKD-EPI-CysC equations and c) mathematical formulae which
combined both sCr and cysC [i.e. CKD-EPI Cr-cysC and the equation
proposed recently (Mindikoglou et al., Clin GH. 2015) (Mindi-eGFR)].
All estimated GFRs were compared with “true GFR”. Multivariable
linear regression analysis was used for GFR predictors.
Results: The mean “true GFR” was 74.2 ± 27. The mean values of
MDRD, CKD-EPI-sCr, eGFR-Hoek, eGFR-Larsson, CKD-EPI-cysC,
CKD-EPI Cr-cysC and Mindi-eGFR were 79.4 ± 31, 76.1 ± 26, 44.6 ±
19, 42.2 ± 21, 41.4 ± 20, 54.6 ± 21 and 62 ± 20 mL/min, respectively.
The correlations between “true GFR” with MDRD, CKD-EPI-sCr, eGFR-
Hoek, eGFR-Larsson, CKD-EPI-cysC, CKD-EPIsCr-cysC and Mindi-
eGFR were good (Spearman r2:0.72, 0.71, 0.68, 0.68, 0.71, 0.75 and
0.76, respectively, p < 0.001). The factors independently associated
with the presence of “true” GFR < 60 mL/min were: sCr (OR: −0.56
95%C.I.: −0.87 to −0.41, p < 0.001) and 24 h urinary sodium excretion
(UNa24h) (OR:0.21, 95%C.I.: 0.0–0.003, p = 0.04). Based on the area
under the ROC curves, sCr had better discriminative ability for the
presence of “true” GFR <60 mL/min, compared to UNa24h (AUROC:
0.87 and 0.74, respectively). In multivariable linear regression
analysis, the factors independently associated with the “true GFR”
were age, cysC and sCr. These variables were included in the “new
GFR” equation, which had very good correlation (Spearman r2: 0.76)
with “true” GFR, it had lower bias, compared to the other eGFRs (0.89,
p < 0.05 for all comparisons with the other estimated GFRs) and
high discriminative ability to predict the presence of “true” GFR <
60 mL/min (AUC: 0.90).
Conclusions: In our study, we developed a new formula based on age,
sCr and cysC. This formula had a strong correlation with “true GFR”
and significantly lower bias, compared to the other conventional
GFRs (including Mindi-eGFR).
THU-044
URINE ALBUMIN-TO-CREATININE RATIO IS ASSOCIATED WITH THE
SEVERITY OF LIVER DISEASE, RENAL FUNCTION AND SURVIVAL IN
PATIENTS WITH DECOMPENSATED CIRRHOSIS
E. Cholongitas1, I. Goulis1, M. Ioannidou1, S. Soulaidopoulos1,
P. Chalevas1, E. Akriviadis1. 14th Department of Internal Medicine,
Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
E-mail: cholongitas@yahoo.gr
Background and Aims: Several studies have shown that urine
albumin-to-creatinine ratio (UACR) >30 mg/g is associated with the
presence of kidney damage. The aim of this prospective study was
to investigate if UACR is associated with the presence of renal
dysfunction (glomerular filtration rate, GFR < 60 mL/min), severity of
liver disease and survival in patients with decompensated cirrhosis.
Methods: We evaluated 220 patients (73% male; age 52.8 ± 12 years).
In each patient, assessment of GFR was based on 51Chromium-EDTA.
Collection of 24-hour urine for calculation of urine sodium (24UNa)
was done and random urine samples were obtained for measurement
of UACR.
Results: Thirty eight patients (17%, group 1) had UACR ≥ 30 mg/g and
182 (83%, group 2) had ACR < 30 mg/g. Group 1, compared to group 2
patients, had significantly lower levels of “true” GFR (61 vs 71 mL/
min, p = 0.035), but higher levels of INR (1.7 vs 1.4, p = 0.05), serum
creatinine (1.3 vs 1.0 mg/dL, p = 0.05) and MELD score (18.2 ± 5 vs
14.3 ± 6, p = 0.019). Patients with “true” GFR < 60 mL/min (n = 93),
compared to those with “true” GFR ≥ 60 mL/min (n = 127), had higher
levels of serum creatinine (1.4 vs 0.9 mg/dL, p < 0.001), cystatin-C (2.4
vs 1.4 mg/dL, p < 0.001), plasma renin activity (23 vs 11 ng/mL*h, p <
0.001), bilirubin (4.6 vs 2.8 mg/dL, p = 0.04), UACR (34 vs 19 mg/g, p =
0.028) and MELD score (18 vs 12, p < 0.001), but lower albumin (3.1
vs 3.5 g/dL, p = 0.01) and 24UNa (46 vs 74 mmol/24 h, p = 0.004).
In multivariable analysis, serum creatinine and UACR were
independently associated with the presence of GFR < 60 mL/min.
S259
POSTER PRESENTATIONS
Based on the area under the ROC curves, the best cut off point for
UACR was >16.51 mg/g giving a sensitivity 70%, specificity 49%, PPV
68% and NPV 51%. During the follow up period [17 (6–52) months],
the patients who died or underwent LT (n = 158), compared to
those who remained alive (n = 62), had higher levels of UACR (41 vs
13 mg/g, p = 0.025). Patients with UACR ≥ 30 mg/g had worse
outcome, compared to those with ACR < 30 mg/g (log rank p = 0.05).
UACR > 30 mg/g had specificity 92% and PPV 87.5% for mortality,
while the best cut off point for mortality was UACR > 2.49 giving
sensitivity, specificity, PPV and NPV were 97%, 29%, 78% και 79%,
respectively.
Conclusions: we showed for the first time that UACR ≥ 30 mg/g was
associated with more severe liver disease, lower GFR and worse LT-
free survival in patients with decompensated cirrhosis. However,
further studies are needed to confirm these findings.
THU-045
PORTAL VEIN THROMBOSIS IN PATIENTS WITH CIRRHOSIS.
INCIDENCE AND FACTORS ASSOCIATED WITH ITS
DEVELOPMENT
F. Turon1, A. Baiges1, A. Garcia-Criado2, I. Nuñez2, R. Gilabert2, C. Bru2,
A. Berzigotti1, J.C. Reverter3, S. Seijo1, J. Bosch1,4, V. Hernández-Gea1,4,
J.C. Garcia-Pagan1,4. 1Hepatic Hemodynamic Laboratory. Liver Unit.
IMDM. IDIBAPS.; 2Department of Radiology; 3Hemotherapy and
Hemostasis Unit, Hospital Clínic, Barcelona; 4Centro de Investigación
Biomedica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd,
Spain
E-mail: jcgarcia@clinic.ub.es
Background and Aims: Data on the incidence of portal vein
thrombosis (PVT) in patients with cirrhosis and its predictive
factors is scarce. The aim of this study is to determine the
prevalence and incidence of PVT in cirrhosis and to evaluate its
predictive factors.
Methods: Prospective single center study including consecutive
cirrhotic patients undergoing abdominal Doppler-Ultrasound (US)
for systematic screening of PVT between December 2010 and April
2013 and followed until August 2015 or until death, liver
transplantation, TIPS or evidence of tumoral thrombosis. PVT was
confirmed by angio-CT. Clinical, laboratory, US and coagulation data
were collected.
Results: 400 patients were included: 59% male, median age 59 ± 10
years, cirrhosis etiology: 56% HCV and 36% alcoholic, Child-Pugh A/B/
C 68/24/8%. Baseline US detected PVT in 23 (5.8%) patients (21 partial
and 2 occlusive). The presence of PVT was independently associated
with Child-Pugh score (OR 1.74; 95% CI = 1.40–2.16) and spleen
diameter (OR 1.505; 95% CI = 1.23–1.82). The 377 patients without
PVT at diagnosis were followed-up during a median of 41 months
(range 0–56). 26 (6.9%) patients developed PVT (24 partial and 2
occlusive). The incidence of PVT was 2, 4.3 and 7.6% at 1, 2 and 3 years.
Incidence of PVT stratifying by Child-Pugh A or B/C was 0.8, 2 and 4.7%
and 5.8, 11.7 and 18% at 1, 2 and 3 years respectively. Child-Pugh
score (OR 1.35; 95% CI = 1.06–1.71), spleen diameter (OR 1.22; 95%
CI = 1.05–1.4) and portal flow velocity (OR 0.92; 95% CI = 0.85–0.98)
were independently associated with development of PVT, suggesting
that the severity of portal hypertension and the degree of liver
failure are key factors in the development of PVT. A complete
coagulation study was done in 316 patients (including 20 developing
PVT). In this subgroup, portal flow velocity and low levels of the
procoagulant factor synthesized in liver, Factor X (OR 0.91: IC 95% =
0.88–0.95) were the only two independent predictors of the
development of PVT.
Conclusions: PVT in liver cirrhosis is a multifactorial event that
occurs preferentially in patients with more advanced liver disease
and more severe portal hypertension. The hemostatic disturbances of
cirrhosis do not seem to play an essential role.
S260 Journal of Hepatology 2016 vol. 64 | S213–S424
THU-046
CLINICAL TRIAL TO EVALUATE THE EFFICACY OF PRIMARY
PROPHYLAXIS WITH L-ORNITHINE L-ASPARTATE TO PREVENT THE
DEVELOPMENT OF OVERT HEPATIC ENCEPHALOPATHY IN
PATIENTS WITH CIRRHOSIS AND ACUTE VARICEAL BLEEDING
F. Higuera-de la Tijera1, A.I. Servín-Caamaño2, F. Salas-Gordillo1,
J.M. Abdo-Francis1, J. Camacho-Aguilera2, J.L. Pérez-Hernández1,
F. Jiménez-Ponce3. 1Gastroenterology/Hepatology; 2Internal Medicine,
Hospital General de México; 3Research Department, ISSSTE, Mexico City,
Mexico
E-mail: fatimahiguera@yahoo.com.mx
Background and Aims: Variceal bleeding (VB) is one of the most
important precipitating factors of overt hepatic encephalopathy
(OHE). L-ornithine L-aspartate (LOLA), an anti-ammonia therapy, has
never been evaluated as primary prophylaxis to prevent the
development of OHE in cirrhotic patients after an acute episode of
VB. The aim of this study was to evaluate if primary prophylaxis with
LOLA is effective to prevent the development of OHE after VB.
Methods: A randomized, double-blind, placebo-controlled clinical
trial, approved by Ethics and Research Committees from México’s
General Hospital, it included cirrhotic patients with VB and without
OHE according to West-Haven criteria (WHC), and without minimal
hepatic encephalopathy (MHE) assessed by the Psychometric Hepatic
Encephalopathy Score (PHES) and critical flicker fusion (CFF) at
admission-time. Sample size was calculated considering a one-
tailed 5% type I error, a statistic power of 80%, a difference between
groups of 26%, and considering an additional 20% of patients for
possible losses. Group 1 (22 patients) received a 24-hour intravenous
infusion of 500 mL of 0.9% saline solution containing 10 mg of LOLA
during 7 days. Group 2 (22 patients) received placebo. All patients
were daily evaluated searching for signs of OHE according with WHC.
Acute VB was treated according with recommendations from Baveno
V consensus.
Results: There were no differences between groups regard to
demographic, clinical and biochemical basal characteristics.
Patients in the placebo group had a greater frequency regard to the
development of OHE compared with LOLA group (54.5% vs. 22.7%, p =
0.03). In those who developed OHE, the grade according to WHC was
worst in the group receiving placebo (median 3, range 2-4) than in
those receiving LOLA (median 1, range 1–2), ( p = 0.004) The time in
days for the development of OHE has a median of 2 days (range 1–4)
and 3 days (range 1–3) for placebo and LOLA groups respectively ( p =
0.65). There were no adverse effects or deaths. One patient receiving
placebo developed spontaneous bacterial peritonitis despite
antibiotic prophylaxis, however, he had a good response when
antibiotic was adjusted according to the ascites culture result.
Conclusions: This is the first study that demonstrates that LOLA is
an effective therapy for primary prophylaxis in cirrhotic patients
with VB to prevent the development of OHE; this therapy also was
well tolerated and was free of adverse effects.
THU-325
INADEQUATE NUTRITION IN PATIENTS WITH CIRRHOSIS: THE
NEED OF A PERSONALIZED EDUCATIONAL PROGRAM
F.A. Giannone1, P. Caraceni1, M. Domenicali1, M. Baldassarre1, P. De
Pasquale1, S. Boffelli1, M. Laggetta1, M. Biselli1, M. Bernardi1.
1
Department of Surgical and Medical Sciences, U.O. Semeiotica Medica
and Center for Applied Biomedical Research (CRBA), Alma Mater
Studiorum University of Bologna, Bologna, Italy
E-mail: ferdinando.giannone@gmail.com
Background and Aims: Malnutrition and sarcopenia occur
frequently in patients with cirrhosis, contributing to excess
morbidity and mortality. Unfortunately, the management of
nutrition is often difficult, as these patients constitute a very
heterogeneous population in terms of needs of nutrients, due to
the various co-morbidities or complications, as well as motivation
and adherence to recommendations. This prospective observational