Journal of Clinical and Translational Hepatology

Journal of Clinical and Translational Hepatology

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Superior Performance of Teaching and Transplant Hospitals in the Management of Hepatic Encephalopathy from 2007 to 2014

Category: Vol 6 Issue 4 Published on 16 January 2019 Super User
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ORIGINAL ARTICLE

Superior Performance of Teaching and Transplant Hospitals in the Management of Hepatic Encephalopathy from 2007 to 2014

Daniel Bodek, Pavan Patel, Sushil Ahlawat, Evan Orosz, Thayer Nasereddin and Nikolaos Pyrsopoulos*

Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA

*Correspondence to: Nikolaos Pyrsopoulos, Rutgers New Jersey Medical School, University Hospital, MSB H538, 185 South Orange Avenue, Newark, NJ 07103, USA. Tel: +1-973-972-5252, Fax: +1-973-972-3144, E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Journal of Clinical and Translational Hepatology 2018;6(4):362-371 DOI: 10.14218/JCTH.2017.00078
Received: December 22, 2017 Accepted: October 3, 2018 Published online: November 27, 2018

Abstract

Background and Aims: Hepatic encephalopathy is a liver disease complication with significant mortality and costs. The aim of this study was to evaluate the relative performance of facilities based on their teaching status and transplant capability by correlating their connections to mortality, cost, and length of stay from 2007 to 2014.

Methods: The Nationwide Inpatient Sample database was utilized to collect information on (USA) American patients admitted with a primary diagnosis of hepatic encephalopathy from 2007–2014. Hospitals were placed into one of four categories using their teaching and transplant status. Using regression analysis, mortality, length of stay and cost adjusted rate ratios were calculated.

Results: The study revealed that teaching transplant centers had a mortality risk ratio of 0.783 (95% confidence interval (CI): 0.750–0.819, p < 0.001). Blacks had the highest mortality risk ratio, of 1.273 (95%CI: 1.217–1.331, p < 0.001). Furthermore, teaching transplant hospitals had a cost rate ratio of 1.226 (95%CI: 1.214–1.238, p < 0.001) and a length of stay rate ratio of 1.104 (95%CI: 1.093–1.115, p < 0.001).

Conclusions: It appears that admission to transplant facilities for hepatic encephalopathy is associated with reduced mortality but increased costs and longer stay independent of transplantation. Moreover, factors impacting black mortality should also be examined more closely.

Keywords

Disparities, Mortality, Cost, Length of stay, Hepatic encephalopathy

 

Journal of Clinical and Translational Hepatology 2018 vol. 6, 362-371  [ Html ] [ PDF Full-text ]

© The Authors 2018. This article is published under the terms of the Creative Commons Attribution-Noncommercial License (CC BY-NC 4.0), which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license.

2018 Reviewer Acknowledgement

Category: Vol 6 Issue 4 Published on 09 January 2019 Super User
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REVIEWER ACKNOWLEDGEMENT

2018 Reviewer Acknowledgement

Editorial Office of Journal of Clinical and Translational Hepatology

Journal of Clinical and Translational Hepatology 2018;6(4):449-451 DOI: 10.14218/JCTH.2018.000RA
Published online: December 20, 2018

We thank the following reviewers for their contribution and support in 2018.

Mai Ali Abd el Meguid

Egypt

Sherief Abd-Elsalam

Egypt

Avin Aggarwal

United States

Nobuhisa Akamatsu

Japan

Kawtar Alkhalloufi

United States

Khaled Amer

Egypt

Masahiro Arai

Japan

Leon Averbukh

United States

Gyorgy Baffy

United States

Mahmoud Mohamed Bahgat

Egypt

Jodie A Barkin

United States

Roopjeet Bath

United States

Mattia Bellan

Italy

Christian Benzing

Germany

Marina Berenguer

Spain

Ines Bilic-Curcic

Croatia

Timothy Billiar

United States

Han Bing

China

Ilka Bion

Brazil

John W Birk

United States

Claus Thomas Bock

Germany

Daniel Bodek

United States

Peter Buch

United States

Chalermrat Bunchorntavakul

Thailand

Wenqing Cao

United States

Naichaya Chamroonkul

Thailand

Roger W. Chapman

United Kingdom

Phunchai Charatcharoenwitthaya

Thailand

Limin Chen

Canada

Yongpeng Chen

China

Chunmei Chen

China

Jun Chen

China

John Chiang

United States

José Artur Chies

Brazil

Gourdas Choudhuri

India

Ashok Choudhury

India

S. Sylvester Darvin

India

Jianqiang Ding

China

Xingrong Du

United States

Atanu Kumar Dutta

India

Marko Duvnjak

Croatia

Cumali Efe

Turkey

Mostafa Kamel El-Awady

Egypt

Mohamed A. El-Guindi

Egypt

Gülsüm Ozlem Elpek

Turkey

Saleh Elwir

United States

Yuchen Fan

China

Jiangao Fan

China

Silvia Fargion

Italy

Fatemeh Farshadpour

Iran (Islamic Republic of)

Eduardo Fernández-Martínez

Mexico

Catherine Frenette

United States

Artin Galoosian

United States

Antonio Giorgio

Italy

Mohammad Mehdi Gouya

Iran (Islamic Republic of)

Severin O. Gudima

United States

Andrew John Gunn

United States

Birendra Prasad Gupta

Nepal

Ying Han

China

Kazuhiko Hayashi

Japan

Noha Helal

Egypt

Jeong Heo

Korea, Republic of

Cheng-Maw Ho

Taiwan

Yunyi Hong

China

Johannes Hov

Norway

Christine Hsu

United States

Yoshio Ijiri

Japan

Hartmut Jaeschke

United States

Abdurrahman Kadayifci

United States

Sandeep Kumar Karn

China

Lindsey Kennedy

United States

AM Khairy

Egypt

Tawfik khoury

Israel

Hyunseok Kim

United States

John Koskinas

Greece

Somashekar G Krishna

United States

Karen Krok

United States

Anand kulkarni

India

Ravikant Kumar

India

Ashish Kumar

India

Kwang-Ho Lee

Korea, Republic of

Xiaocong Liu

United States

Chenghai Liu

China

Bing Liu

China

Shuang Liu

China

Stephen Locarnini

Australia

Lungen Lu

China

Stefan Luth

Germany

Philipp Lutz

Germany

Shaina Lynch

United States

Michelle Ma

United States

Mojtaba mafi

Iran (Islamic Republic of)

Matthew McMillin

United States

Kamalika Moulick

United States

Pradeep Naik

India

Seyedehsan Navabi

United States

James S Park

United States

Yanyan Peng

China

M. Pokorska-Śpiewak

Poland

Xingshun Qi

China

Cristiano Quintini

United States

Atoosa Rabiee

United States

Alok Ranjan

United States

Ciro Romano

Italy

Manuel Romero-Gómez

Spain

Lionel Rostaing

France

Behnam Saberi

United States

Hidetsugu Saito

Japan

Ghada Salum

Egypt

Keisaku Sato

United States

Yehia M Shaker

Egypt

A. M. J. Shapiro

Canada

Hao Shi

United States

Shivaram Prasad Singh

India

Surajit Sinha

United States

Coleman Smith

United States

Martina Smolic

Croatia

Shanthi Srinivasan

United States

Eike Steinmann

Germany

Qingfeng Sun

China

Ashraf Tabll

Egypt

Mamoru Takenaka

Japan

Rahul Pundlik Talele

India

Giovanni Tarantino

Italy

Georgios Tsoulfas

Greece

Lucija Virovic-Jukic

Croatia

Lili Wang

United States

Benjamin l Woolbright

United States

Yongning Xin

China

Manfung Yuen

Hong Kong

Rong Zhang

United States

Peng Zhang

United States

Qingzhan Zhang

United States

Yuexin Zhang

China

Lanjing Zhang

United States

Hui Zhang

United States

Jingmin Zhao

China

Jianhong Zhong

China

CA-125 Significance in Cirrhosis and Correlation with Disease Severity and Portal Hypertension

Category: Vol 6 Issue 4 Published on 09 January 2019 Super User
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LETTERS TO THE EDITOR

CA-125 Significance in Cirrhosis and Correlation with Disease Severity and Portal Hypertension
Julio Collazos*

Infectious Diseases Unit, Hospital de Galdácano-Usánsolo, Vizcaya, Spain
*Correspondence to: Julio Collazos, Infectious Diseases Unit, Hospital de Galdácano-Usánsolo, Herriko Gudarien 11, Durango (Vizcaya) 48200, Spain. Tel/Fax: +34-94-603-2867, E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Journal of Clinical and Translational Hepatology 2018;6(4):447-448 DOI: 10.14218/JCTH.2018.00056
Published online: November 27, 2018

Edula et al.1 in their retrospective study of 172 patients concluded that serum concentrations of cancer antigen-125 (CA-125) are elevated in cirrhotic patients with ascites. This relationship has been well known for several decades,2–6 as well as the relationship of CA-125 with pleural and pericardial effusions, among many other non-malignant conditions,4,5,7 because CA-125 is expressed in the coelomic epithelium.8 In fact, ascitic fluid concentrations of CA-125 are even higher than in serum.2

Edula et al.1 said that cirrhotic patients without ascites had normal mean CA-125 concentrations, and define this observation as “a new finding”. However, these observations are not new. More than 25 years ago our group published a prospective and comprehensive study of 159 patients with liver diseases, including 85 cirrhotics with and without ascites.3 In this article, cited by Edula et al. as their reference 14, we found the same results as Edula et al.1 reported for ascitic and non-ascitic patients.1 Moreover, our group published other articles focused exclusively on patients without ascites.9,10 Like Edula et al.,1 we found that elevations of CA-125 concentrations in patients without ascites were uncommon, but also that these elevations were related to the degree of liver dysfunction.

Therefore, CA-125 increases markedly (even 100 times above the upper normal level) in patients with ascites, an increase that we previously found to be highly proportional to the amount of ascites as measured semiquantitatively in 5 degrees, and it decreases rapidly with the diminution of ascites. In fact, CA-125 proved to be a reliable marker of ascites (sensitivity 98.4%, specificity 95.9%, positive predictive value 93.8%, negative predictive value 98.9%, efficiency 96.9%).3

Although to a considerably lower degree, and much more infrequently, we also previously found increased CA-125 concentrations in some patients who did not have ascites, as evaluated ultrasonographically, as well as significant correlations between CA-125 and some liver function markers, such as albumin and prothrombin.9 Our findings suggested that, apart from the determinant role of ascites, liver dysfunction itself is also responsible for moderate increases in the serum concentrations of CA-125, probably due to a poor metabolization of this glycoprotein.9,10

On the other hand, the absence of statistical significance regarding portal hypertension (p = 0.1) reported by Edula et al.1 is surprising, considering that the differences in the CA-125 concentrations that they found were substantial (414 vs. 256 U/mL) and that portal hypertension is tightly related to ascites. The authors evaluated portal hypertension by a history of esophageal varices. Besides the limited sensitivity of this method to detect portal hypertension, perhaps the number of patients studied was too small (Type II error). Also, the parametric tests used by the authors for statistical calculations (t-test, ANOVA) might have been inappropriate, as we found that the distribution of CA-125 was markedly non-Gaussian, and the illustrations of Edula et al.1 suggest the same.

In our series, we found marked differences in CA-125 concentrations in patients with or without portal hypertension, as evaluated separately by three different methods: echography, esophageal varices and splenomegaly (p < 0.0001 for each).3 Even portal hypertension was associated with higher CA-125 concentrations in patients without ascites (p = 0.049).9

Conflict of interest
The author has no conflict of interest related to this publication.

 

References

[1] Edula RG, Muthukuru S, Moroianu S, Wang Y, Lingiah V, Fung P, et al. A-125 significance in cirrhosis and correlation with disease severity and portal hypertension: A retrospective study. J Clin Transl Hepatol 2018;6:241–246. doi: 10.14218/JCTH.2017.00070.
[2] Bergmann JF, Bidart JM, George M, Beaugrand M, Levy VG, Bohuon C. Elevation of CA 125 in patients with benign and malignant ascites. Cancer 1987;59:213–217. doi: 10.1002/1097-0142(19870115)59:2<213::AID-CNCR2820590206>3.0.CO;2-I.
[3] Collazos J, Genolla J, Ruibal A. CA 125 serum levels in patients with nonneoplastic liver diseases. A clinical and laboratory study. Scand J Clin Lab Invest 1992;52:201–206. doi: 10.3109/00365519209088786.
[4] Eerdekens MW, Nouwen EJ, Pollet DE, Briers TW, De Broe ME. Placental alkaline phosphatase and cancer antigen 125 in sera of patients with benign and malignant diseases. Clin Chem 1985;31:687–690.
[5] Mezger J, Wilmanns W, Lamerz R. Elevated serum CA 125 levels in patients with benign ascitic or pleural effusions. Tumour Biol 1988;9:47–52. doi: 10.1159/000217544.
[6] Bergmann JF, Beaugrand M, Labadie H, Bidart JM, Bohuon C. CA 125 (ovarian tumour-associated antigen) in ascitic liver diseases. Clin Chim Acta 1986;155:163–165. doi: 10.1016/0009-8981(86)90278-0.
[7] Touitou Y, Bogdan A. Tumor markers in non-malignant diseases. Eur J Cancer Clin Oncol 1988;24:1083–1091.
[8] Kabawat SE, Bast RC Jr, Bhan AK, Welch WR, Knapp RC, Colvin RB. Tissue distribution of a coelomic-epithelium-related antigen recognized by the monoclonal antibody OC125. Int J Gynecol Pathol 1983;2:275–285. doi: 10.1097/00004347-198303000-00005.
[9] Collazos J, Genolla J, Allende MT, Ruibal A. Serum CA 125 levels in patients with non-malignant liver diseases without ascites. Clin Investig 1993;71:239. doi: 10.1007/bf00180108.
[10] Ruibal A, Siuriana R. Evidence of a relationship between high serum Ca 125 and liver failure pattern in cirrhotic patients without ascitis and jaundice. Int J Biol Markers 1986;1:55–56. doi: 10.1177/172460088600100109.

 

The Author’s Reply

Raja GR Edula*

Gastroenterology Clinic, Valley Medical Center, Renton, WA, USA
*Correspondence to: Raja GR Edula, Gastroenterology Clinic, Valley Medical Center, M/S TAL-500, 4011 Talbot Road South, Suite 500, Renton, WA 98005, USA. Tel: +1-425-690-3488, Fax: +1-425-690-9088, E-mail: moc.liamtoh@41ydderjar>

Journal of Clinical and Translational Hepatology 2018;6(4):447-448 DOI: 10.14218/JCTH.2018.00056
Published online: November 27, 2018

We would like to thank Julio Collazos for taking the time to read and critique our study. While we understand that there were several studies done in the past on the same subject, our attempt was to revive interest in the same subject as CA-125 antigen is no longer recommended as part of the diagnostic work-up in patients with ascites as per the most recent American Association for the Study of Liver Diseases (AASLD) guidelines for ascites in cirrhosis.1 The findings of our study did lead us to comment that CA-125 could be a useful test, especially in patients with truncal obesity where clinical quantification of ascites could be challenging, and will require radiological imaging which may be more expensive and inconvenient for patients, especially when they are being followed for dose titration of diuretics.2

Our study did correlate CA-125 antigen with ascites and the model for end-stage liver disease (MELD) score in a linear regression model and concluded that there was a better statistically significant correlation with ascites as compared to the MELD score. Since the MELD score is currently used as the best objective marker for decompensation in patients with end-stage liver disease, we feel this is a significant finding in our study. This also applies to the albumin-bilirubin (ALBI) score, which is a relatively new ‘kid on the block’ in the evaluation of patients with cirrhosis. These findings are new and have not been reported from other previous studies.

Since our study was retrospective and relied on available data, we used esophageal varices as a marker of portal hypertension rather than other parameters. Moreover, the elevated total CA-125 in both groups of patients with and without esophageal varices (414 vs. 256 IU/mL) was significant, although the significance did not reach the threshold set for statistical significance; this finding was confounded by the fact that several of the patients in both groups had ascites from decompensated cirrhosis, which had the best correlation with elevated CA-125 antigen.

While we understand the limitations of a retrospective study and the probability of a Type 2 error, we were able to conclude that patients with cirrhosis but without ascites had normal values of CA-125 antigen, unlike in the study by Collazos et al.,3 who concluded that findings of elevated antigen were uncommon in the absence of ascites; moreover, their study concluded that CA-125 antigen was invalidate as a tumor marker. I would also like to highlight that our group of patients studied was homogenous and consisted of patients with cirrhosis exclusively.

References

1. Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57:1651–1653. doi: 10.1002/hep.26359.
2. Edula RG, Muthukuru S, Moroianu S, Wang Y, Lingiah V, Fung P, et al. CA-125 significance in cirrhosis and correlation with disease severity and portal hypertension: A retrospective study. J Clin Transl Hepatol. 2018;6:241–246. doi: 10.14218/JCTH.2017.00070. 
3. Collazos J, Genolla J, Ruibal A. CA 125 serum levels in patients with non-neoplastic liver diseases. A clinical and laboratory study. Scand J Clin Lab Invest. 1992;52:201–206. doi: 10.3109/00365519209088786. 

 

 

 

Journal of Clinical and Translational Hepatology 2018 vol. 6, 447-448  [ Html ] [ PDF Full-text ]

 

© The Authors 2018. This article is published under the terms of the Creative Commons Attribution-Noncommercial License (CC BY-NC 4.0), which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license.

 

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