Prediction of Esophageal Variceal Bleeding in B-Viral Liver Cirrhosis Using the P2/MS Noninvasive Index Based on Complete Blood CountsKim B.K.a · Ahn S.H.a–c · Han K.-H.a–d · Park J.Y.a–c · Han M.S.a · Jo J.H.a · Kim J.K.a–c · Lee K.S.a–c · Chon C.Y.a–c · Kim D.Y.a–c
aDepartment of Internal Medicine and bYonsei Institute of Gastroenterology, Yonsei University College of Medicine, cLiver Cirrhosis Clinical Research Center, and dBrain Korea 21 Project for Medical Science, Seoul, Korea
Do you have an account?
- Rent for 48h to view
- Buy Cloud Access for unlimited viewing via different devices
- Synchronizing in the ReadCube Cloud
- Printing and saving restrictions apply
Rental: USD 8.50
Cloud: USD 20.00
Article / Publication Details
Background/Aim: Periodic endoscopy for esophageal varices (EVs) and prophylactic treatment of high-risk EVs, i.e. medium/large EVs, small EVs with the red-color sign or decompensation, are recommended in cirrhotic patients. We assessed the cumulative risks for future EV bleeding using the following simple P2/MS index: (platelet count)2/[monocyte fraction (%) × segmented neutrophil fraction (%)]. Methods: We enrolled 475 consecutive B-viral cirrhosis patients for 4 years, none of whom experienced EV bleeding. All underwent laboratory work-ups, endoscopy and ultrasonography. Those with EV bleeding took a nonselective β-blocker as prophylaxis. The major endpoint was the first occurrence of EV bleeding, analyzed using the Kaplan-Meier and Cox regression methods. Results: Among patients with EV bleeding (n = 131), 25 experienced their first EV bleeding during follow-up. To differentiate the risk for EV bleeding, we divided them into two subgroups according to their P2/MS value (subgroup 1: P2/MS ≥9 and subgroup 2: P2/MS <9). The risk was significantly higher in subgroup 2 (p = 0.029). From multivariate analysis, a lower P2/MS (p = 0.040) remained a significant predictor for EV bleeding along with large varix size (p = 0.015), red-color sign (p = 0.041) and Child-Pugh classification B/C (p = 0.001). In subgroup 1, the risk for EV bleeding was similar to that of patients with low-risk EVs (p = 0.164). Conclusions: The P2/MS is a reliable predictor for the risk of EV bleeding among patients with EV bleeding. According to risk stratification, different prophylactic treatments should be considered for the subgroup with a P2/MS <9.
© 2012 S. Karger AG, Basel
- Bosch J, Berzigotti A, Garcia-Pagan JC, Abraldes JG: The management of portal hypertension: rational basis, available treatments and future options. J Hepatol 2008;48(suppl 1):S68–S92.
- Merli M, Nicolini G, Angeloni S, Rinaldi V, De Santis A, Merkel C, Attili AF, Riggio O: Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol 2003;38:266–272.
- Mehta G, Abraldes JG, Bosch J: Developments and controversies in the management of oesophageal and gastric varices. Gut 2010;59:701–705.
- Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W: Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007;46:922–938.
- Lee JH, Yoon JH, Lee CH, Myung SJ, Keam B, Kim BH, Chung GE, Kim W, Kim YJ, Jang JJ, Lee HS: Complete blood count reflects the degree of oesophageal varices and liver fibrosis in virus-related chronic liver disease patients. J Viral Hepat 2009;16:444–452.
- Kim BK, Han KH, Park JY, Ahn SH, Kim JK, Paik YH, Lee KS, Chon CY, Kim do Y: Prospective validation of P2/MS noninvasive index using complete blood counts for detecting oesophageal varices in B-viral cirrhosis. Liver Int 2010;30:860–866.
- Garcia-Tsao G, Bosch J: Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med 2010;362:823–832.
- Merkel C, Zoli M, Siringo S, van Buuren H, Magalotti D, Angeli P, Sacerdoti D, Bolondi L, Gatta A: Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the north Italian Endoscopic Club (NIEC) index. Am J Gastroenterol 2000;95:2915–2920.
- Kleber G, Sauerbruch T, Ansari H, Paumgartner G: Prediction of variceal hemorrhage in cirrhosis: a prospective follow-up study. Gastroenterology 1991;100:1332–1337.
- Castera L, Le Bail B, Roudot-Thoraval F, Bernard PH, Foucher J, Merrouche W, Couzigou P, de Lédinghen V: Early detection in routine clinical practice of cirrhosis and oesophageal varices in chronic hepatitis C: comparison of transient elastography (fibroscan) with standard laboratory tests and non-invasive scores. J Hepatol 2009;50:59–68.
- Kazemi F, Kettaneh A, N’Kontchou G, Pinto E, Ganne-Carrie N, Trinchet JC, Beaugrand M: Liver stiffness measurement selects patients with cirrhosis at risk of bearing large oesophageal varices. J Hepatol 2006;45:230–235.
- Vizzutti F, Arena U, Romanelli RG, Rega L, Foschi M, Colagrande S, Petrarca A, Moscarella S, Belli G, Zignego AL, Marra F, Laffi G, Pinzani M: Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology 2007;45:1290–1297.
- European Association for the Study of the Liver: EASL clinical practice guidelines: Management of chronic hepatitis B. J Hepatol 2009;50:227–242.
- Liaw YF, Leung N, Kao JH, Piratvisuth T, Gane E, Han KH, Guan R, Lau GK, Locarnini S: Asian-Pacific consensus statement on the management of chronic hepatitis B: A 2008 update. Hepatol Int 2008;2:263–283.
- Lok AS, McMahon BJ: Chronic hepatitis B: update 2009. Hepatology 2009;50:661–662.
- Heagerty PJ, Lumley T, Pepe MS: Time-dependent ROC curves for censored survival data and a diagnostic marker. Biometrics 2000;56:337–344.
- Fluss R, Faraggi D, Reiser B: Estimation of the Youden index and its associated cutoff point. Biom J 2005;47:458–472.
- Berzigotti A, Gilabert R, Abraldes JG, Nicolau C, Bru C, Bosch J, García-Pagan JC: Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis. Am J Gastroenterol 2008;103:1159–1167.
- Cales P, de Ledinghen V, Halfon P, Bacq Y, Leroy V, Boursier J, Foucher J, Bourlière M, de Muret A, Sturm N, Hunault G, Oberti F: Evaluating the accuracy and increasing the reliable diagnosis rate of blood tests for liver fibrosis in chronic hepatitis C. Liver Int 2008;28:1352–1362.
- Myers RP: Noninvasive markers of liver fibrosis: playing the probabilities. Liver Int2008;28:1328–1331.
- Abraldes JG, Tarantino I, Turnes J, Garcia-Pagan JC, Rodes J, Bosch J: Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis. Hepatology 2003;37:902–908.
- Lo GH, Chen WC, Wang HM, Lee CC: Controlled trial of ligation plus nadolol versus nadolol alone for the prevention of first variceal bleeding. Hepatology 2010;52:230–237.
- Gentile I, Thabut D: Noninvasive prediction of oesophageal varices: as simple as blood count? Liver Int 2010;30:1091–1093.
- Gentile I, Viola C, Graf M, Liuzzi R, Quarto M, Cerini R, Piazza M, Borgia G: A simple noninvasive score predicts gastroesophageal varices in patients with chronic viral hepatitis. J Clin Gastroenterol 2008;43:81–87.
- Giannini EG: Review article: thrombocytopenia in chronic liver disease and pharmacologic treatment options. Aliment Pharmacol Ther 2006;23:1055–1065.
Poynard T, Trabut JB, Ratziu V, Thabut D: Prediction of oesophageal varices with platelet count/spleen diameter ratio or platelets alone. Gut 2004;53:913–914; author reply 914.
Cioni G, Tincani E, D’Alimonte P, Cristani A, Ventura P, Abbati G, Vignoli A, Romagnoli R, Ventura E: Relevance of reduced portal flow velocity, low platelet count and enlarged spleen diameter in the non-invasive diagnosis of compensated liver cirrhosis. Eur J Med 1993;2:408–410.
- Wognum AW, Westerman Y, Visser TP, Wagemaker G: Distribution of receptors for granulocyte-macrophage colony-stimulating factor on immature CD34+ bone marrow cells, differentiating monomyeloid progenitors, and mature blood cell subsets. Blood 1994;84:764–774.
- Kubota A, Okamura S, Omori F, Shimoda K, Otsuka T, Ishibashi H, Niho Y: High serum levels of granulocyte-macrophage colony-stimulating factor in patients with liver cirrhosis and granulocytopenia. Clin Lab Haematol 1995;17:61–63.
Article / Publication Details
Copyright / Drug Dosage / DisclaimerCopyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.