Comparison of Prognostic Value of Predictors of Mortality in Patients with Cirrhosis and Refractory Ascites: Prognostic Predictors in Cirrhosis

Muhammad Muzammil; Nadeem Ullah; Shahid Mukhtar; Muhammad Adnan; Hassan Aziz; Mumtaz Athar

doi:10.54393/pjhs.v5i08.1808

Authors

Muhammad Muzammil Department of Nephrology, Bakhtawar Amin Medical and Dental College, Multan, Pakistan
Nadeem Ullah Department of Medicine, Bakhtawar Amin Medical and Dental College, Multan, Pakistan
Shahid Mukhtar Department of Medicine, Bakhtawar Amin Medical and Dental College, Multan, Pakistan
Muhammad Adnan Department of Urology, Bakhtawar Amin Medical and Dental College, Multan, Pakistan
Hassan Aziz Department of Medicine, Bakhtawar Amin Medical and Dental College, Multan, Pakistan
Mumtaz Athar Department of Gastroenterology, Bakhtawar Amin Medical and Dental College, Multan, Pakistan

DOI:

https://doi.org/10.54393/pjhs.v5i08.1808

Keywords:

Child-Pugh Score, Hyponatremia, Cirrhosis, Refractory Ascites

Abstract

The Model for End-Stage Liver Disease-Sodium score (MELDNa) has been developed that has a better prognostic value to predict early mortality but has not been frequently used in cirrhotic and refractory ascites patients with recurrent incidences of severe hyponatremia. Objective: To compare the prognostic value of severe hyponatremia, Child-Pugh score, and the model for end-stage liver disease-sodium score in cirrhotic and refractory ascitic patients. Methods: A prospective, observational study was conducted at the Hepatology Department, Bakhtawar Amin Trust Hospital, Multan from March 2023 to March 2024. A total of 200 patients with cirrhosis and refractory ascites undergoing albumin paracentesis twice a month were selected for the study. The 135 patients (after exclusion of preexisting ascites patients) were administered diuretics symmetrically; 50 mg spironolactone and 40 mg furosemide in patients who did not have renal failure and severe hyponatremia. Prognostic scores were recorded and patients were followed up for minimum 3 months. Results: The area under the curve of the Child-Pugh score (0.90, 95% CI: 0.87-0.96) was significantly higher than the MELD score (0.60, 95 CI: 0.51-0.70) and MELDNa (0.75, 95% CI: 0.65-0.79) as a predictor of mortality (p<0.0001). With respect to the etiology of refractory ascites being an independent risk factor of mortality, the cumulative incidence function was highest in patients with hyponatremia (79%; 95% CI: 79-80%) followed by renal failure patients (55%; 95 CI: 54-56%) and patients receiving maximum dose of treatment (28%; 95% CI: 27-29%) (p<0.001). Conclusions: Severe hyponatremia, ineffective diuretic treatment, and Child-Pugh score were risk factors of death in cirrhotic and refractory ascitic patients.

References

Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM et al. Guidelines on the management of ascites in cirrhosis. Gut. 2021 Jan; 70(1) :9-29. doi: 10.1136/gutjnl-2020-321790.

Neong SF, Adebayo D, Wong F. An update on the pathogenesis and clinical management of cirrhosis with refractory ascites. Expert Review of Gastroenterology & Hepatology. 2019 Apr; 13(4): 293-305. doi: 10.1080/17474124.2018.1555469.

Kim KM, Shim SG, Sinn DH, Song JE, Kim BS, Kim HG. Child-Pugh, MELD, MELD-Na, and ALBI scores: which liver function models best predicts prognosis for HCC patient with ascites? Scandinavian Journal of Gastroenterology. 2020 Aug; 55(8): 951-7. doi: 10.1080/00365521.2020.1788139.

Krige J, Spence RT, Jonas E, Hoogerboord M, Ellsmere J. A new recalibrated four-category Child-Pugh Score performs better than the original Child-Pugh and MELD scores in predicting in-hospital mortality in decompensated alcoholic cirrhotic patients with acute variceal bleeding: a real-world cohort analysis. World Journal of Surgery. 2020 Jan; 44: 241-6. doi: 10.1007/s00268-019-05211-8.

Giannelli V, Roux O, Laouénan C, Manchon P, Ausloos F, Bachelet D et al. Impact of cardiac function, refractory ascites and beta blockers on the outcome of patients with cirrhosis listed for liver transplantation. Journal of Hepatology. 2020 Mar; 72(3): 463-71. doi: 10.1016/j.jhep.2019.10.002.

Jepsen P, Watson H, Macdonald S, Vilstrup H, Jalan R. MELD remains the best predictor of mortality in outpatients with cirrhosis and severe ascites. Alimentary Pharmacology & Therapeutics. 2020 Aug; 52(3): 492-9. doi: 10.1111/apt.15882.

Will V, Rodrigues SG, Berzigotti A. Current treatment options of refractory ascites in liver cirrhosis-A systematic review and meta-analysis. Digestive and Liver Disease. 2022 Aug; 54(8): 1007-14. doi: 10.1016/j.dld.2021.12.007.

Chin A, Bastaich DR, Dahman B, Kaplan DE, Taddei TH, John BV. Refractory hepatic hydrothorax is associated with increased mortality with death occurring at lower MELD-Na compared to cirrhosis and refractory ascites. Hepatology. 2024 Apr; 79(4): 844-56. doi: 10.1097/HEP.0000000000000577.

Rudler M, Mallet M, Sultanik P, Bouzbib C, Thabut D. Optimal management of ascites. Liver International. 2020 Feb; 40: 128-35. doi: 10.1111/liv.14361.

Avital Yehudit O'Glasser, MD. Perioperative Management of the Patient with Liver Disease (MELD Score - Age above 12 years). Last cited: [23rd Jul 2024]. Available at: https://reference.medscape.com/calculator/359/meld-score-age-above-12-years.

Kim WR, Biggins SW, Kremers WK, Wiesner RH, Kamath PS, Benson JT et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. New England Journal of Medicine. 2008 Sep; 359(10): 1018-26. doi: 10.1056/NEJMoa0801209.

Kotak PS, Kumar J, Kumar S, Varma A, Acharya S. Navigating Cirrhosis: A Comprehensive Review of Liver Scoring Systems for Diagnosis and Prognosis. Cureus. 2024 Mar; 16(3). doi: 10.7759/cureus.57162.

Pan X, Zhou Z, Jin X, Shi D. Clinical characteristics and risk factors of severe hyponatremia in cirrhotic patients treated with terlipressin. Journal of Clinical Pharmacy and Therapeutics. 2020 Feb; 45(1): 191-8. doi: 10.1111/jcpt.13057.

Lin HR, Liao QX, Lin XX, Zhou Y, Lin JD, Xiao XJ. Development of a nomogram for predicting in-hospital mortality in patients with liver cirrhosis and sepsis. Scientific Reports. 2024; 14. doi: 10.1038/s41598-024-60305-1.

Bozkurt Babuş S, Köse A, Erdoğan S, Kiraz M, İyikesici F. Risk factors and mortality in elderly patients with severe hyponatremia admitted to the emergency department. Irish Journal of Medical Science (1971-). 2023 Apr; 192(2): 861-70. doi: 10.1007/s11845-022-02989-w.

Maassel NL, Fleming MM, Luo J, Zhang Y, Pei KY. Model for end-stage liver disease sodium as a predictor of surgical risk in cirrhotic patients with ascites. Journal of Surgical Research. 2020 Jun; 250: 45-52. doi: 10.1016/j.jss.2019.12.037.

Yuksek A, Acehan S, Satar S, Gulen M, Balcik M, Sevdimbas S et al. Predictors of 30-day mortality in patients diagnosed with hepatic encephalopathy on admission to the emergency department. European Journal of Gastroenterology & Hepatology. 2023 Dec; 35(12): 1402-9. doi: 10.1097/MEG.0000000000002646.

Pereira G, Baldin C, Piedade J, Reis V, Valdeolivas T, Victor L et al. Combination and sequential evaluation of acute-on-chronic liver failure (ACLF) and hyponatremia and prognosis in cirrhotic patients. Digestive and Liver Disease. 2020 Jan; 52(1): 91-7. doi: 10.1016/j.dld.2019.08.013.

Thuluvath PJ, Alukal JJ, Zhang T. Impact of hyponatremia on morbidity, mortality, and resource utilization in portal hypertensive ascites: a nationwide analysis. Journal of Clinical and Experimental Hepatology. 2022 May; 12(3): 871-5. doi: 10.1016/j.jceh.2021.10.145.

Kumar H, Singh SK, Kishore K. Study of Hyponatremia in Cirrhosis of Liver and Its Prognostic Value. European Journal of Cardiovascular Medicine. 2023 Apr; 13(2).

McDonald MF, Barrett SC, Malik TH, Anand A, Keeling SS, Christmann CR et al. Elevated serum sodium in recipients of liver transplantation has a substantial impact on outcomes. Transplant International. 2021 Oct; 34(10): 1971-83. doi: 10.1111/tri.13968.

Hernaez R, Liu Y, Kramer JR, Rana A, El-Serag HB, Kanwal F. Model for end-stage liver disease-sodium underestimates 90-day mortality risk in patients with acute-on-chronic liver failure. Journal of Hepatology. 2020 Dec; 73(6): 1425-33. doi: 10.1016/j.jhep.2020.06.005.

Basmaji J, Hornby L, Rochwerg B, Luke P, Ball IM. Impact of donor sodium levels on clinical outcomes in liver transplant recipients: a systematic review. European Journal of Gastroenterology & Hepatology. 2020 Dec; 32(12): 1489-96. doi: 10.1097/MEG.0000000000001776.

Zhang QK and Wang ML. Value of model for end-stage liver disease-serum sodium scores in predicting complication severity grades after liver transplantation for acute-on-chronic liver failure. InTransplantation Proceedings 2019 Apr; 51(3): 833-841. doi: 10.1016/j.transproceed.2019.01.027.

Choudhary NS, Sonavane A, Saraf N, Saigal S, Rastogi A, Bhangui P et al. Poor performance status predicts mortality after living donor liver transplantation. Journal of Clinical and Experimental Hepatology. 2020 Jan 1;10(1):37-42. doi: 10.1016/j.jceh.2019.06.006.

Kulkarni AV, Kumar P, Sharma M, Sowmya TR, Talukdar R, Rao PN et al. Pathophysiology and prevention of paracentesis-induced circulatory dysfunction: a concise review. Journal of Clinical and Translational Hepatology. 2020 Mar; 8(1): 42. doi: 10.14218/JCTH.2019.00048.