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DOI: 10.1055/a-2039-1575
Assessing the Short-Term Prognosis of Patients with Cirrhosis Using the DIC Scores
Funding None.
Prediction of prognosis in patients with chronic liver disease is an art which is seldom supported by objective, reliable, and reproducible tools.[1] In patients with liver cirrhosis, the Model for End-stage Liver Disease (MELD) score was devised more than 20 years ago to assess the suitability of patients to transjugular intrahepatic portosystemic shunt, and its use soon became popular to assess the short-term prognosis of patients with cirrhosis and their candidacy to liver transplantation.[2] [3] [4] Despite some adjustments, such as the inclusion of sodium, the MELD score is used worldwide to assess the prognosis of patients with cirrhosis.[5] In these patients also coagulation indexes and degree of thrombocytopenia are associated with liver function derangement, as the majority of coagulation factors and thrombopoietin are synthesized by the liver, while platelets are also cleared from the circulation by the spleen due to increased portal pressure, and thus also these parameters are often used to indirectly evaluate the degree of liver dysfunction and portal hypertension.[6] [7] [8] Hypofibrinogenemia is often observed in patients with end-stage liver disease, and its presence—besides being variably associated with spontaneous or provoked bleeding—harbors an ominous prognosis.[9] [10] [11]
Recently, Grafeneder et al observed that the disseminated intravascular coagulation (DIC) score is able to predict 30-day mortality in a heterogeneous group of patients with very low fibrinogen levels and at least two pathological DIC parameters, with a statistically significant improved accuracy as compared with the MELD-Na score, although they observed that in the sub-group of patients with cirrhosis this prognostic improvement—though meaningful—was not statistically significant.[12] [13] [14] These results underscore the complexity of the relationship between coagulation indexes, liver dysfunction, and prognostic assessment of patients with liver disease, although they fell short to support the use of the DIC scores for the prediction of very short-term survival in patients with end-stage liver disease. The reasons behind this missed opportunity may either reside in the retrospective setting of the study, in the identification of patients by means of International Classification of Diseases coding, and in the inclusion of patients with heterogeneous conditions, or with the fact that in patients with very low fibrinogen (i.e., <150 mg/dL) and elevated MELD score, the DIC scores may truly fail to add further granularity to prognostication.
To verify whether the (partially negative) results of the study by Grafeneder et al might have been secondary to this bias, we prospectively assessed the prognosis of a series of consecutive patients with liver cirrhosis using the inclusion criteria set forth in their study, with the exclusion of a fibrinogen level <150 mg/dL, and compared the accuracy of the MELD-Na and DIC scores in assessing their prognosis. To this end, we studied 33 patients with liver cirrhosis at admission in our clinical ward, between August and November 2022, whose main characteristics are shown in [Table 1]. Most patients had decompensated liver disease and the 30-day mortality rate was 36.3%, with this figure mainly related to a high incidence of sepsis (27.3%) and bleeding (33.3%) in this population. [Fig. 1A] shows the receiver operating characteristics (ROC) curves for 30-day mortality of the MELD-Na, the International Society on Thrombosis and Haemostasis (ISTH) DIC-2001, and the ISTH DIC-2018 scores together with their accuracy figures. While all the scores adequately predicted the 30-day prognosis, we observed a numerically greater accuracy of the DIC scores over the MELD-Na score, although this difference did not reach statistical significance likely due to the small series. [Fig. 1B] shows the ROC curves for 90-day mortality of the MELD-Na, the ISTH DIC-2001, and the ISTH DIC-2018 scores together with their accuracy figures. This analysis shows similar accuracy of the ISTH DIC-scores and of the MELD-Na score, although the latter performed numerically better than both the ISTH DIC scores, without a statistically significant difference.[13] [14] This finding may be due to a better sensitivity of the MELD score in the setting where it was originally devised (i.e., 90 day). Lastly, the mortality rates at 30 and 90 days for the various DIC scores are reported in [Table 2].
Abbreviations: DIC, disseminated intravascular coagulation; INR, international normalized ratio; MELD, Model for End-stage Liver Disease; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Note: Data are shown as absolute number and (proportion) or median and (interquartile range).
Abbreviations: DIC, disseminated intravascular coagulation; ISTH, International Society on Thrombosis and Haemostasis.
Note: Data are shown as number of death/total of patients for each DIC score values and (proportion).
To summarize, we feel that the results of the study by Grafeneder et al and our own seem to suggest that the DIC scores can be considered useful tools to predict short-term mortality of patients with cirrhosis, and once again underscore the complex interplay between liver disease and alteration in coagulation parameters. These data, due to the limitation related to the small sample size, are considered preliminary, and we feel that only future studies on larger series may be able to assess whether use of these scores may be preferred over traditional ones for the assessment of very short-term prognosis in patients with cirrhosis.
Publikationsverlauf
Eingereicht: 02. Dezember 2022
Angenommen: 17. Februar 2023
Accepted Manuscript online:
20. Februar 2023
Artikel online veröffentlicht:
24. März 2023
© 2023. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
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References
- 1 O'Leary JG, Friedman LS. Predicting surgical risk in patients with cirrhosis: from art to science. Gastroenterology 2007; 132 (04) 1609-1611
- 2 Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31 (04) 864-871
- 3 Kamath PS, Wiesner RH, Malinchoc M. et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33 (02) 464-470
- 4 Giannini E, Botta F, Testa E. et al. The 1-year and 3-month prognostic utility of the AST/ALT ratio and model for end-stage liver disease score in patients with viral liver cirrhosis. Am J Gastroenterol 2002; 97 (11) 2855-2860
- 5 Biggins SW, Kim WR, Terrault NA. et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology 2006; 130 (06) 1652-1660
- 6 European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, European Association for the Study of the Liver. EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76 (05) 1151-1184
- 7 Eidelberg A, Kirubakaran R, Nair SC, Eapen CE, Elias E, Goel A. Systematic review: role of elevated plasma von-Willebrand factor as predictor of mortality in patients with chronic liver disease. Eur J Gastroenterol Hepatol 2019; 31 (10) 1184-1191
- 8 Giannini EG, Savarino V. Thrombocytopenia in liver disease. Curr Opin Hematol 2008; 15 (05) 473-480
- 9 Violi F, Leo R, Vezza E, Basili S, Cordova C, Balsano F. C.A.L.C. Group. Coagulation Abnormalities in Cirrhosis Study Group. Bleeding time in patients with cirrhosis: relation with degree of liver failure and clotting abnormalities. J Hepatol 1994; 20 (04) 531-536
- 10 Giannini EG, Giambruno E, Brunacci M. et al. Low fibrinogen levels are associated with bleeding after varices ligation in thrombocytopenic cirrhotic patients. Ann Hepatol 2018; 17 (05) 830-835
- 11 Under the auspices of the Italian Association for the Study of Liver Diseases (AISF) and the Italian Society of Internal Medicine (SIMI). Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference. Dig Liver Dis 2016; 48: 455-467
- 12 Grafeneder J, Buchtele N, Egger D. et al. Disseminated intravascular coagulation score predicts mortality in patients with liver disease and low fibrinogen level. Thromb Haemost 2022; 122 (12) 1980-1987
- 13 Taylor Jr FB, Toh CH, Hoots WK, Wada H, Levi M. Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 2001; 86 (05) 1327-1330
- 14 Suzuki K, Wada H, Imai H, Iba T, Thachil J, Toh CH. Subcommittee on Disseminated Intravascular Coagulation. A re-evaluation of the D-dimer cut-off value for making a diagnosis according to the ISTH overt-DIC diagnostic criteria: communication from the SSC of the ISTH. J Thromb Haemost 2018; 16 (07) 1442-1444