Risk factors and predictors of recurrent variceal bleeding in cirrhotic patients awaiting transplantation

Abstract

Objective: to identify the risk factors and predictors of recurrent variceal hemorrhage in cirrhotic patients awaiting liver transplantation (LT).Materials and methods. A comparative retrospective study was conducted in 51 patients with decompensated cirrhosis, who were on the waiting list for LT. Demographic, clinical and laboratory parameters, MELD-Na score, Child–Turcotte–Pugh score, hepatic encephalopathy grade, ascites grade, class of varicose veins, number of consecutive variceal ligations, as well as manometric study with calculation of intrahe- patic venous pressure gradient index in groups of patients with (n = 39) and without recurrent bleeding (n = 12) were analyzed. The proportions of patients in different groups were compared by the Kaplan–Meier method with determination of the logarithmic test (Log-Rank). The accumulated risks in the compared groups were estimated using the mathematical model of proportional hazards (Cox regression) in univariate and multivariate analysis.Results. Within 60 months from the beginning of follow-up and simultaneous prophylaxis by combination of non-selective beta-blockers and endoscopic variceal ligation (EVL), 39 out of 51 patients (75.6%) developed recurrent bleeding. Analysis revealed significant differences (risk factors for recurrent bleeding): creatinine le- vels, MELD-Na score, hepatic encephalopathy grade, mean hepatic venous pressure gradient (HVPG) and its level >14 mmHg. By the Kaplan–Meier method with the Log-Rank test, it was established that the proportion of patients without recurrent bleeding was significantly higher in the group of patients with HVPG ≤14 mmHg than in the group with HVPG >14 mmHg (p = 0.027).Conclusion. The main independent predictor of variceal rebleeding is HVPG >14 mm Hg, which increases the risk by 3.837 times if the gradient value is changed by 1 mm. The second independent predictor is higher hepatic encephalopathy grade: if the grade increases by one, the risk of recurrent hemorrhage increases 1.8 times.

Keywords

• liver transplantation
• ascites
• recurrent variceal bleeding
• endoscopic variceal ligation
• nonselective beta-blockers
• risk factors
• independent predictors