The influence of prehabilitation in patients with liver cirrhosis before liver transplantation: a randomized clinical trial.

BACKGROUND: The high prevalence of liver cirrhosis in Slovakia leads to a great need for transplant treatment. The outcome of liver transplantation is influenced by several factors. AIM: The main objective of this study is to test the effectiveness of prehabilitation compared to standard of care. DESIGN: Prospective, double-arm, randomized, open-registry study. SETTING: Patient in F. D. Roosevelt Teaching Hospital, Slovakia, Banská Bystrica. POPULATION: The participants consisted of patients with liver cirrhosis (55 men, 25 women). METHODS: The patients were randomized to the active prehabilitation group (N.=39) or the standard of care group (SOC) (N.=41). SOC represents the standard of care for patients prior to liver transplantation, consisting of a formal oral interview lasting 30 minutes. In addition to SOC, each patient with decompensated liver cirrhosis also underwent a prehabilitation intervention that included rehabilitation and nutrition support. Patients completed the exercises under the supervision of a physician during hospitalisation. RESULTS: After one month, the liver frailty index improved in the prehabilitation group (P=0.05). No improvement in MELD (Model of End Stage Liver Disease) was found in the group that underwent the prehabilitation program (P=0.28), and no improvement was found in the Child-Pugh score after one month (P=0.13). In the prehabilitation groups compared with the SOC group, differences were not found in the MELD score (P=0.11). Better clinical outcomes according to the Child-Pugh score was found for the prehabilitation group compared with the SOC group (P=0.02). According to LFI, there was no difference between the groups (P=0.26). Very low adherence was found after three months. Only three patients in the SOC group and six patients in the prehabilitation group came to the check-up. Due to low adherence after 3 months in patients with liver cirrhosis, it is not possible to make an adequate comparison between groups after three months. CONCLUSIONS: Despite the great effort to maintain adherence, it was not possible to draw a conclusion about the effectiveness of prehabilitation in patients before liver transplantation compared to standard of care because the main problem in Slovak patients with liver cirrhosis is low adherence. More studies are needed to identify the barriers that lead to low adherence in patients with liver cirrhosis. CLINICAL REHABILITATION IMPACT: A promising result was found due to improvement of the Liver Frailty Index and the Child-Pugh Score after one month in the prehabilitation group.

Concomitant diverticulosis among patients undergoing liver transplantation. Does it influence the length of hospitalization after the procedure?

Aim of the study: We tried to assess the influence of concomitant diverticulosis and other factors, e.g., Child-Pugh (C-P) and MELD scores, viral etiology, and presence of alcoholic disease, on short-term results of liver transplantation (LT) with an emphasis on duration of patient's hospitalization. Material and methods: This prospective study was performed on 206 cirrhotic patients who were selected for LT. In order to assess the presence of diverticculosis we performed colonoscopy. Results: The duration of hospitalization after LT did not differ significantly between patients with and without diverticulosis (27.5 [21.0-33.5] vs. 24.0 [18.0-32.0] days, p = 0.28). Patients with C-P class C were hospitalized longer in comparison to the class B patients. It is reflected in the positive correlation between C-P score and days of hospitalization (r = 0.22, p = 0.002). Patients with diverticulosis were significantly older (59.6 [51.1-63.3] vs. 52.9 [43.8-59.2] years, p = 0.03). Alcoholic liver disease (ALD) was associated with a greater risk of diverticulosis (OR = 3.89, 95% CI [1.13-15.87], p = 0.04). Conclusions: Presence of diverticulosis among subjects undergoing LT did not influence the duration of hospitalization after the procedure. Significantly longer hospitalization was observed in patients with the most advanced liver disease according to C-P score. To determine the exact impact of diverticulosis on short-term results of LT additional studies are required.

Applicability and prognostic value of frailty assessment tools among hospitalized patients with advanced chronic liver disease.

AIM: To assess and compare the feasibility and prognostic value of various frailty assessment tools among decompensated cirrhosis inpatients. METHODS: Our prospective observational registry included consecutive patients admitted for cirrhosis between June 2017 and July 2018. Exclusion criteria were intensive-care unit admission, hepatocellular carcinoma outside of the Milan criteria, and other malignancies. Frailty at baseline was assessed with the Liver Frailty Index (LFI), Clinical Frailty Scale (CFS), Fried Frailty Score (FFS), and Short Physical Performance Battery test (SPPB). The follow-up lasted for at least 180 days. RESULTS: The study enrolled 168 patients (35.1% women, median age 57.9 years). The most frequent primary etiology was alcohol-related liver disease (78.6%). The Median Model for End-Stage Liver Disease (MELD) was 16. The 80th percentile of frailty scores was LFI>5.4, CFS>4, FFS>3, and SPPB<5, and it identified patients with higher mortality. LFI and CFS had the highest numerical prognostic value for in-hospital, and 90- and 180-day mortality. In a bivariate analysis of the risk of death or liver transplantation, the combination of MELD and LFI had the highest concordance (0.771±0.04). In a multivariate model, MELD score (HR 1.17, 95% CI 1.12-1.22), overt encephalopathy (2.39, 1.27-4.48), infection at baseline (2.32, 1.23-4.34), and numerical LFI (1.41, 1.02-1.95) were independent predictors of overall mortality. CONCLUSION: Frailty assessment using the evaluated tools is feasible among hospitalized cirrhotic patients, identifying those with worse prognosis. CFS had the highest applicability and accuracy for the initial assessment and LFI for the initial and follow-up assessments.

Challenging management of severe chronic disorders in acute pandemic situation: Chronic liver disease under COVID-19 pandemic as the proof-of-principle model to orchestrate the measures in 3PM context.

Chronic liver disease management is a comprehensive approach requiring multi-professional expertise and well-orchestrated healthcare measures thoroughly organized by responsible medical units. Contextually, the corresponding multi-faceted chain of healthcare events is likely to be severely disturbed or even temporarily broken under the force majeure conditions such as global pandemics. Consequently, the chronic liver disease is highly representative for the management of any severe chronic disorder under lasting pandemics with unprecedented numbers of acutely diseased persons who, together with the chronically sick patient cohorts, have to be treated using the given capacity of healthcare systems with their limited resources. Current study aimed at exploring potentially negative impacts of the SARS CoV-2 outbreak on the quality of the advanced chronic liver disease (ACLD) management considering two well-classified parameters, namely, (1) the continuity of the patient registrations and (2) the level of mortality rates, comparing pre-COVID-19 statistics with these under the current pandemic in Slovak Republic. Altogether 1091 registrations to cirrhosis registry (with 60.8% versus 39.2% males to females ratio) were included with a median age of 57 years for patients under consideration. Already within the very first 3 months of the pandemic outbreak in Slovakia (lockdown declared from March 16, 2020, until May 20, 2020), the continuity of the patient registrations has been broken followed by significantly increased ACLD-related death rates. During this period of time, the total number of new registrations decreased by about 60% (15 registrations in 2020 versus 38 in 2018 and 38 in 2019). Corresponding mortality increased by about 52% (23 deaths in 2020 versus 10 in 2018 and 12 in 2019). Based on these results and in line with the framework of 3PM guidelines, the pandemic priority pathways (PPP) are strongly recommended for maintaining tertiary care uninterrupted. For the evidence-based implementation of PPP, creation of predictive algorithms and individualized care strategy tailored to the patient is essential. Resulting classification of measures is summarized as follows:The Green PPP Line is reserved for prioritized (urgent and comprehensive) treatment of patients at highest risk to die from ACLD (tertiary care) as compared to the risk from possible COVID-19 infection.The Orange PPP Line considers patients at middle risk of adverse outcomes from ACLD with re-addressing them to the secondary care. As further deterioration of ACLD is still probable, pro-active management is ascertained with tertiary center serving as the 24/7 telemedicine consultation hub for a secondary facility (on a physician-physician level).The Red PPP Line is related to the patients at low risk to die from ACLD, re-addressing them to the primary care. Since patients with stable chronic liver diseases without advanced fibrosis are at trivial inherent risk, they should be kept out of the healthcare setting as far as possible by the telemedical (patient-nurse or patient- physician) measurements. The assigned priority has to be monitored and re-evaluated individually-in intervals based on the baseline prognostic score such as MELD. The approach is conform with principles of predictive, preventive and personalized medicine (PPPM / 3PM) and demonstrates a potential of great clinical utility for an optimal management of any severe chronic disorder (cardiovascular, neurological and cancer) under lasting pandemics.

Acute-on-chronic liver failure: a single-centre experience.

AIM OF THE STUDY: We set out to determine the applicability of acute-on-chronic liver failure (ACLF) diagnostic criteria and characteristics of thus defined ACLF sub-cohorts in a real-life clinical context. MATERIAL AND METHODS: Retrospective charts' analysis of consecutive patients hospitalized with decompensated liver disease. Inclusion criteria: acute decompensation, informed consent. Exclusion criteria: malignancy. Diagnostic tools: 1st phase - CLIF-SOFA score calculated manually; 2nd phase - CLIF-C ACLF score calculated at www.efclif.com. RESULTS: Of 432 hospitalized patients aged 52 years, 41% were female, with MELD 20, 32% patients had acute decompensation (AD); main triggers were alcoholic hepatitis (38%), infections (26%), and variceal bleeding (23%). Of patients with AD, ACLF grades 0-3 was present in 64%, 19%, 13%, and 4%, respectively. In hospital mortality according to final AD/ACLF grade in ACLF 0-3 was 7.5%, 42%, 47%, and 80%, respectively (p < 0.0001). CONCLUSIONS: Diagnosing ACLF is nowadays easy; it helps to stratify patients at admission, and refine risk stratification at day 7. The main trigger of AD/ACLF in this region is alcohol. Currently, there are no ACLF-specific treatments; however, timely intensive supportive care can influence the prognosis. Even though still elusive and controversial, the ACLF concept can help systematize management of patients admitted with acute decompensation of advanced chronic liver disease.