Thyroid hormone profile is related to prognosis in acute decompensation of cirrhosis

Abstract

Objective: To investigate the prognostic significance of thyroid hormone profile in patients hospitalized for decompensated cirrhosis.

Subjects and methods: Prospective cohort study that included 119 subjects. All subjects were evaluated at admission and followed for 90 days. TSH, fT3, fT4 were measured within 24 hours of hospitalization.

Results: Higher fT4 and lower fT3 levels were observed among Child-Pugh C patients as compared to Child-Pugh A and B, and in those with acute-on-chronic liver failure (ACLF). Lower fT3/fT4 ratio was observed in those with ascites, infections, ACLF, and in Child-Pugh C. Ninety-day mortality was 26.9% and it was independently associated with higher Model for End-stage Liver Disease (MELD) and TSH, and lower fT3/fT4 ratio in multivariate analysis. A new prognostic model including MELD, TSH and fT3/fT4 ratio was devised. The areas under the receiver operating characteristic curves for MELD, fT3/fT4 ratio, TSH (μIU/mL), and the new model for predicting 90-day mortality were 0.847 ± 0.041, 0.841 ± 0.039, 0.658 ± 0.062, and 0.899 ± 0.031, respectively. The 90-day survival was 31.6% in patients with values of the predictive model ≥ -0.77 and 93.5% for values < -0.77 (P < 0.001).

Conclusions: Thyroid hormone profile was strongly associated with worse outcomes in patients with cirrhosis and might represent promising prognostic tools that can be incorporated in clinical practice.

Keywords: Liver cirrhosis; acute decompensation; thyroid hormones.

Figure 1. Thyroid hormones profile according to Child-Pugh classification. Significantly higher TSH levels were observed in Child-Pugh C patients as compared to Child-Pugh B (P = 0.033), but not for comparison between Child-Pugh A and C (P = 0.099; Figure 1A). Lower fT3 was observed in Child-Pugh C as compared to Child-Pugh A (P < 0.001) and Child-Pugh B (P < 0.001); also for Child-Pugh B than Child-Pugh A (P = 0.001; Figure 1B). Higher fT4 levels were observed in Child-Pugh C patients as compared to Child-Pugh A (P = 0.008) and Child-Pugh B (P < 0.001), but not for comparison between Child-Pugh A and B (Figure 1C). Significantly lower fT3/fT4 values were observed in Child-Pugh C patients as compared to Child-Pugh A (P < 0.001) and Child-Pugh B (P < 0.001). Child-Pugh B patients also present with lower fT3/fT4 ratio than Child-Pugh A (P = 0.003; Figure 1D).

Figure 2. Thyroid hormones profile according to the presence of ACLF at admission. No differences were observed for TSH levels according to ACLF (P = 0.196) (Figure 1D). Lower fT3 (Figure 2B; P < 0.001) and higher fT4 levels (Figure 2C; P = 0.001), as well as lower fT3/fT4 ratio (Figure 2D; P < 0.001) were observed among patients with ACLF.

Figure 3. Cumulative 90-day transplant-free survival of hospitalized patients with cirrhosis according to MELD score and fT3/fT4. Kaplan-Meier survival probability was 89.5% in patients with fT3/fT4 ≥ 1.38 and 42.9% for subjects with fT3/fT4 < 1.38 (P < 0.001) (Figure 3A). The 90-day survival was 45.5% in patients with MELD ≥ 17 and 89.3% for subjects with MELD < 17 (Figure 3B). Figure 3C exhibits the Kaplan-Meier curves according to the best cutoff of the prognostic model devised from regression analysis. The 90-day Kaplan-Meier survival probability was 31.6% in patients with values of the predictive model ≥ -0.77 and 93.5% for patients with values < -0.77 (P < 0.001, long-rank test).