Abstract

Potential conflict of interest: Laura M. Kulik is on the advisory board for Gilead, Bayer, Eisai, Salix, and Bristol‐Myers Squibb. Richard Finn consults for Pfizer, Bayer, Novartis, Merck, and Bristol‐Myers Squibb. Claude B. Sirlin consults for and has received grants from Virtualscopics. Lewis R. Roberts consults for Wako, Medscape, and Axis; advises Tavec and Bayer; is on the speakers' bureau for Onlive; and has received grants from Ariad, BTG, and Gilead. Andrew Zhu consults for Bristol‐Myers Squibb, Eisai, Merck, Novartis, Sanofi, and Bayer. The funding for the development of this Practice Guideline was provided by the American Association for the Study of Liver Diseases. Guiding Principles and Objectives GUIDING PRINCIPLES This document presents official recommendations of the American Association for the Study of Liver Diseases (AASLD) on the surveillance, diagnosis, and treatment of hepatocellular carcinoma (HCC) occurring in the setting of adults with cirrhosis. Unlike previous AASLD practice guidelines, the current guideline was developed in compliance with the Institute of Medicine standards for trustworthy practice guidelines and uses the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.1 Multiple systematic reviews of the literature were conducted to support the recommendations in this practice guideline. An enhanced understanding of the guideline can be obtained by reading the applicable portions of the systematic reviews. In addition, more detailed information may be found in the associated guidance document related to clinically important aspects of HCC that lacked sufficient evidence to warrant a systematic review. The guideline focuses on a broad spectrum of clinical practice, including surveillance of patients with cirrhosis for HCC, establishing the diagnosis of HCC, and various therapeutic options for the treatment of HCC. To address other issues on HCC such as epidemiology, staging, and additional aspects of diagnosis and treatment, the authors have created a new guidance document that will be published soon and is based upon the previous HCC AASLD guidelines by Bruix and Sherman.2 KEY QUESTIONS The guideline developers from the AASLD identified key questions that health care providers are faced with frequently in the evaluation and management of patients with HCC. These questions were: Should adults with cirrhosis undergo surveillance for HCC? If so, which surveillance test is best? Should adults with cirrhosis and suspected HCC undergo diagnostic evaluation with multiphasic computed tomography (CT) or multiphasic magnetic resonance imaging (MRI)? Should adults with cirrhosis and an indeterminate hepatic nodule undergo a biopsy, repeated imaging, or alternative imaging for the diagnostic evaluation? Should adults with Child‐Pugh class A cirrhosis and early‐stage HCC (T1 or T2) be treated with resection or local‐regional (LRT) therapy? Should adults with cirrhosis and HCC that has been resected or ablated successfully undergo adjuvant therapy? Should adults with cirrhosis awaiting liver transplantation and HCC (T1) be treated or undergo observation? Should adults with cirrhosis and HCC (Organ Procurement and Transplantation Network [OPTN] T2) awaiting liver transplantation undergo transplantation alone or transplantation with bridging therapy while waiting? Should adults with cirrhosis awaiting liver transplantation and HCC beyond Milan criteria (T3) undergo transplantation after being down‐staged to within Milan criteria? Should adults with cirrhosis and HCC (T2 or T3, no vascular involvement) who are not candidates for resection or transplantation be treated with transarterial chemoembolization, transarterial radioembolization, or external radiation? Should adults with Child‐Pugh class A/B cirrhosis and advanced HCC with macrovascular invasion and/or metastatic disease be treated with systemic or locoregional therapies or no therapy? TARGET AUDIENCE This guideline is intended primarily for health care providers who care for patients with cirrhosis. Additionally, the guideline may inform policy decisions regarding patients with HCC. Background BURDEN OF DISEASE According to the World Health Organization, HCC is the fifth most common tumor worldwide and the second most common cause of cancer‐related death (http://globocan.iarc.fr/old/FactSheets/cancers/liver-new.asp). Male‐to‐female predominance is greater than 2:1 with liver cancer, and approximately 83% of the estimated 782,000 new HCC cases in 2012 occurred in less developed regions of the world, with East and South Asia plus sub‐Saharan Africa being the regions of highest incidence, Southern Europe and North America being the regions of intermediate incidence, and Northern Europe and South Central Asia being the regions of lowest incidence.3 The incidence of HCC has been rising rapidly in the United States over the last 20 years.4 According to estimates from the Surveillance Epidemiology End Results (SEER) program of the National Cancer Institute, the United States will have witnessed an estimated 39,230 cases of HCC and 27,170 HCC deaths in 2016 (https://seer.cancer.gov). In addition, a recent study using the SEER registry projects that the incidence of HCC will continue to rise until 2030,5 with the highest increase in Hispanics, followed by African Americans and then Caucasians, with a decrease noted among Asian Americans. The increase in incidence of HCC in the United States is attributed primarily to the hepatitis C virus (HCV) epidemic, prompting Petrick et al.4 to suggest that preventive efforts should target the birth cohort with the highest prevalence of HCV infection (1945‐1965). Recent data have also shown that metabolic disorders—defined as nonalcoholic fatty liver disease (NAFLD) and the metabolic syndrome—contribute numerically more to the burden of HCC than any other risk factor including HCV infection,6 which is due primarily to the high prevalence of NAFLD in the population overall. HIGH‐RISK GROUP The presence of cirrhosis represents a key risk factor for the development of HCC. The prevalence of cirrhosis among patients with HCC has been estimated to be 85%‐95%,7 and the HCC incidence rate among patients with cirrhosis has been shown to be 2%‐4% per year.9 Therefore, patients with cirrhosis constitute a high‐risk group for efforts at prevention and early detection. The fact that patients with HCC have underlying liver disease impacts the management and therapeutic options substantially. The key questions posed above reflect common scenarios in this patient population and provide the framework for this practice guideline. We used the Child‐Pugh classification to define the underlying degree of liver dysfunction instead of the Model for End‐Stage Liver Disease (MELD) classification, mainly because it is more commonly used in this context. Methods of Guideline Development An experienced methodologist moderated and facilitated the process of selecting the aforementioned key questions. A group of AASLD content experts worked collaboratively with an independent research group specializing in conducting systematic reviews to synthesize the available evidence. The research group provided curated evidence summaries following the GRADE approach (Table 1).1 In this approach, the quality of evidence in each systematic review is rated as high, moderate, low, or very low based on the domains of precision, directness, consistency, and risk of bias. Following a comprehensive analysis of each systematic review, the guideline writing group based its recommendations on the quality of the evidence, balance of benefits and harms, patients' values and preferences, and other clinical considerations. Based on this assessment, the guideline writing group generated AASLD recommendations that are graded as either strong (apply to most patients with minimal variation) or conditional (apply to a majority of patients). The strength of recommendation is not only determined by the quality of evidence. Other factors—including the balance of benefits and harms, patients' values and preferences, and feasibility of the recommended action—all play a role in determining the strength of recommendations. Technical remarks are added to recommendations to help reconcile the level of the recommendation with the quality of the evidence and to facilitate implementation. Evidence profiles for the corresponding systematic review for each of the key questions are presented in the Appendix. For the key questions with sparse, indirect evidence, relevant studies are summarized after each recommendation. Table 1 - The GRADE Approach 1. Rating the quality of evidence Study design Initial rating of quality of evidence Rate down when: Rate up when: RCT High Risk of bias Large effect (e.g,. RR = 0.5) Moderate Inconsistency Very large effect (e.g., RR = 0.2) Imprecision Dose response gradient Observational Low Indirectness All plausible confounding would increase the association Very low Publication bias 2. Determinants of the strength of a recommendation Quality of evidence Balance of benefit and harms Patient values and preferences Resources and costs 3. Implication of the strength of a recommendation Strong Population: Most people in this situation would want the recommended course of action and only a small proportion would not. Health care workers: Most people should receive the recommended course of action. Policy makers: The recommendation can be adapted as policy in most situations. Conditional Population: The majority of people in this situation would want the recommended course of action, but many would not. Health care workers: Be prepared to help patients make a decision that is consistent with their values using decision aids and shared decision making. Policy makers: There is a need for substantial debate and involvement of stakeholders. For patients, a strong recommendation implies that most patients in this situation would want the recommended course of action and only a small proportion would not. For clinicians, this would imply that patients should receive the recommended course of action, with consistent benefits and few side effects. For policy makers, the recommendation could be adopted as a policy in most situations and potentially could be used as a quality measure. For strong recommendations, the recommendation is prefaced by "The AASLD recommends..."In contrast, a conditional recommendation (also sometimes termed a "weak" recommendation) for patients would imply that the majority of patients in this situation would want the recommended course of action, but many would not. For clinicians making a conditional recommendation, the balance of benefits, harms, and burdens is uncertain; and they should be prepared to help patients make a decision that is consistent with their own values using a shared decision‐making approach. For policy makers, this recommendation type could imply a need for substantial debate and involvement of all stakeholders and is likely insufficient to be used as a quality measure. For conditional recommendations, the recommendation is prefaced by "The AASLD suggests..." Table 2 - Clinical Questions Evaluated Question Population Intervention Comparison Outcome 1 Adults with cirrhosis Surveillance for HCC No surveillance Survival 2 Adults with cirrhosis and suspected HCC Diagnostic evaluation with multiphasic CT Diagnostic evaluation with multiphasic MRI Sensitivity and specificity 3 Adults with cirrhosis and an indeterminate hepatic nodule Biopsy Repeated or alternative imaging Sensitivity and specificity 4 Adults with Child‐Pugh class A cirrhosis and stage T1 or T2 HCC Resection Local‐regional therapy Survival, recurrence, morbidity 5 Adults with cirrhosis and HCC successfully resected or ablated Adjuvant therapy No adjuvant therapy Survival 6 Adults with cirrhosis awaiting liver transplantation and T1 HCC Local‐regional therapy Observation Survival, progression to T3/waitlist dropout 7 Adults with cirrhosis awaiting liver transplantation and T2 HCC Bridging therapy Observation Survival, progression to T3/waitlist dropout 8 Adults with cirrhosis awaiting liver transplantation and T3 HCC Down‐staging and transplant No transplant Posttransplant survival, recurrence 9 Adults with cirrhosis and HCC (T2 or T3, no vascular involvement) who are not candidates for resection or transplantation Transarterial chemoembolization Transarterial radioembolization or external radiation Survival 10 Adults with Child‐Pugh class A/B cirrhosis and advanced HCC with macrovascular invasion and/or metastatic disease Systemic therapy Local‐regional therapy or no therapy Survival 1. Should Adults With Cirrhosis Undergo Surveillance for HCC, and If So, Which Surveillance Test Is Best? Recommendations 1A. The AASLD recommends surveillance of adults with cirrhosis because it improves overall survival. Quality/Certainty of Evidence: Moderate Strength of Recommendation: Strong 1B. The AASLD suggests surveillance using ultrasound (US), with or without alpha‐fetoprotein (AFP), every 6 months. Quality/Certainty of Evidence: Low Strength of Recommendation: Conditional 1C. The AASLD suggests not performing surveillance of patients with Child‐Pugh class C cirrhosis unless they are on the transplant waiting list, given the low anticipated survival for these patients. Quality/Certainty of the Evidence: Low Strength of Recommendation: Conditional Technical Remarks It is not possible to determine which type of surveillance test—US alone or the combination of US plus AFP—leads to a greater improvement in survival. The optimal interval of surveillance ranges from 4 to 8 months. Modification in surveillance strategy based on etiology of liver diseases or risk stratification models cannot be recommended at this time. BACKGROUND The goal of surveillance and screening is to reduce mortality.10 HCC meets the criteria for the development of a surveillance program11 given that patients with cirrhosis are a high‐risk group7 and can be readily identified. The previous AASLD guidelines on HCC2 summarize the populations at the highest risk to have chronic viral hepatitis B and cirrhosis due to HCV. A randomized surveillance study performed in another high‐risk group, hepatitis B virus (HBV) carriers, showed a 37% reduction in mortality for those who underwent surveillance.12 However, there are no randomized trials in Western populations with cirrhosis secondary to chronic HCV or fatty liver disease, and thus there is some controversy surrounding whether surveillance truly leads to a reduction in mortality in this population of patients with cirrhosis. Another source of controversy is which surveillance tests should be used. Although it is well established that US should be part of surveillance, it is unknown whether the addition of biomarkers such as AFP allows for improved survival. The previous AASLD guidelines recommend US as the primary modality.2 Because of these uncertainties, the aim of this question was to determine whether current data are in support of HCC surveillance in adults with cirrhosis, and if so, what type of surveillance is best. Evidence and Rationale The evidence profile of surveillance for HCC is included in Supporting Table 1, which uses the data from a recent systematic review on surveillance.13 There were no randomized controlled trials (RCTs) of surveillance in patients with cirrhosis. There were 38 observational cohort studies that evaluated surveillance in patients with cirrhosis, making the overall quality of the evidence moderate (Supporting Table 1). The majority of the data was reported with 3‐year survival. The pooled 3‐year survival rate was 50.8% among the 4735 patients who underwent HCC surveillance, compared with only 27.9% among the 6115 patients without previous surveillance, with an odds ratio (OR) of 1.90 (95% confidence interval [CI], 1.67‐2.17; P < 0.001). There were six studies that controlled for lead‐time bias, and the improvement in survival persisted (3‐year survival rates of 39.7% for surveillance versus 29.1% without surveillance; P < 0.001). Of the 23 studies evaluated, 10 were considered high‐quality studies in which the 3‐year survival with surveillance was greater than no surveillance (45.6% versus 28.8%; P < 0.001.) In addition to improved survival, surveillance also led to an increase in the detection of early‐stage HCC, with an OR of 2.11 (95% CI, 1.88‐2.33) compared with no surveillance. In terms of anticipated absolute effects, surveillance led to 163 per 1000 more patients detected at early stages compared with no surveillance. In addition, surveillance led to more curative treatments compared with no surveillance (61.8% versus 38.2%; P < 0.001). Thus, improvement in survival seen with surveillance appears to be due to higher early‐stage detection and higher curative treatment rates. The surveillance tests used most commonly were US and AFP. Of the studies identified, only four used US alone, whereas the rest relied on US and AFP at 6‐month intervals. The use of US plus AFP improves detection of early‐stage HCC compared with no surveillance, with an OR of 2.16 (95% CI, 1.80‐2.60), whereas US alone had an OR of 2.04 (95% CI, 1.55‐2.68). Both US alone and US plus AFP led to similar rates of curative treatment (OR, 2.23 for US [95% CI, 1.83‐2.71] and 2.19 for US plus AFP [95% CI, 1.89‐2.53]). There were no studies that directly compared US alone versus US plus AFP to determine which was superior in terms of early‐stage detection or curative therapy. The studies were also evaluated to determine whether US alone or US plus AFP improved survival. US plus AFP had a pooled risk ratio of 1.86 (95% CI, 1.76‐1.97) for improving survival, whereas US alone had a slightly lower pooled risk ratio of 1.75 (95% CI, 1.56‐1.98) for improving survival. There was no statistical difference between the two strategies. However, there are serious issues when comparing these surveillance tests for their impact on survival, which include: (1) no description of the trigger to perform a diagnostic test, (2) some studies appear to evaluate AFP or US rather than the combination, (3) no mention of the performance characteristics of these tests, and (4) most importantly, the studies were not powered to determine an improvement in survival. FUTURE RESEARCH Given the current burden of HCC and the projected continued increase in incidence of this tumor, better studies including appropriate study design comparing US with US plus AFP as surveillance strategies are needed. Such studies should evaluate the characteristics of US, including its operator dependency and reliability as a surveillance test in specific patient populations. In addition, it would be important to determine whether other serum biomarkers in addition to AFP complement US, such as des‐gamma carboxy prothrombin, AFP L3, and other novel serum tests.14 2. Should Adults With Cirrhosis and Suspected HCC Undergo Diagnostic Evaluation With Multiphasic CT or Multiphasic MRI? Recommendation 2. The AASLD recommends diagnostic evaluation for HCC with either multiphasic CT or multiphasic MRI because of similar diagnostic performance characteristics. Quality/Certainty of Evidence: Low for CT versus MRI Strength of Recommendation: Strong Technical Remarks The selection of the optimal modality and contrast agent for a particular patient depends on multiple factors beyond diagnostic accuracy. These include modality availability, scan time, throughput, scheduling backlog, institutional technical capability, examination costs and charges, radiologist expertise, patient preference, and safety considerations. All studies were performed at academic centers. Because of the greater technical complexity of multiphasic MRI compared with multiphasic CT, generalizability to practices without liver MRI expertise is not yet established. BACKGROUND In patients with cirrhosis and suspected HCC, diagnostic imaging is used to noninvasively verify the presence of HCC (diagnosis) and determine its extent (radiological staging). The goals are to measure tumor burden, guide management, and help prioritize patients for possible liver transplantation. Unlike most other malignancies, the diagnosis of HCC can be established noninvasively, and treatment may be initiated based on imaging alone, without confirmatory biopsy. The rationale is that in patients with cirrhosis, the pretest probability of HCC is sufficiently high, and the pretest probability of lesions that may mimic HCC at imaging is sufficiently low such that a lesion meeting HCC imaging criteria can be assumed reliably and confidently to be HCC. Although there is strong consensus that the imaging diagnosis of HCC requires multiphasic imaging, there is not agreement about which diagnostic imaging test to use. Commonly used methods in clinical practice include multiphasic CT with extracellular agents, multiphasic MRI with extracellular agents (gadolinium‐based compounds that stay in the extracellular space and permit characterization of blood flow), and multiphasic MRI with gadoxetate disodium (a specific gadolinium‐based compound that accumulates in hepatocytes and permits characterization of hepatocellular "function" in addition to blood flow). EVIDENCE AND RATIONALE The evidence profile of diagnostic accuracy for HCC is included in Supporting Table 2, which uses the data from a de novo systematic review on imaging in HCC performed to address this question. There were no randomized comparative studies of CT versus MRI, no studies identified that compared multiphasic MRI with an extracellular agent versus multiphasic MRI with gadoxetate disodium, and no data on patient preference. There were 19 observational studies in patients with cirrhosis and suspected HCC that compared the per‐lesion diagnostic accuracy of CT and MRI, reporting true positive, false positive, false negative, and true negative values. An additional 14 studies reported only detection rate (sensitivity), but these are not further discussed, as sensitivity cannot be interpreted in the absence of data on specificity and/or positive predictive value. Quality of evidence was low and was downgraded because of the methodological limitations of the included studies, inconsistency across studies, and possible publication bias. The performance characteristics of these imaging modalities overall and for lesions of different sizes are reviewed below. With regard to overall accuracy, eight studies compared multiphasic MRI using an extracellular agent versus multiphasic CT. MRI with an extracellular agent provided higher pooled sensitivity than CT (0.76 [95% CI, 0.72‐0.81] versus 0.63 [95% CI, 0.57‐0.69]; P < 0.001) with similar specificity (0.78 [95% CI, 0.63‐0.88] versus 0.82 [95% CI, 0.71‐0.89]; P = 0.62). Eight studies compared multiphasic MRI with gadoxetate disodium versus multiphasic CT. MRI with gadoxetate disodium provided higher pooled sensitivity than CT (0.87 [95% CI, 0.79‐0.93] versus 0.73 [95% CI, 0.64‐0.81]; P < 0.02) with similar specificity (0.94 [95% CI, 0.90‐0.97] versus 0.96 [95% CI, 0.90‐0.98]; P = 0.47). When looking specifically at lesions larger than 2 cm, three studies compared multiphasic MRI with an extracellular agent versus multiphasic CT and showed a similar pooled sensitivity, with a higher pooled specificity of 0.87 versus 0.7 (P = 0.02). Examining accuracy in HCC between 1 and 2 cm, there were six studies that compared multiphasic MRI versus CT, and this also showed similar sensitivity and specificity. For HCC <1 cm, two studies compared multiphasic CT versus multiphasic MRI with an extracellular agent. The sensitivity of MRI for <1 cm was significantly higher compared with CT (0.69 versus 0.49; P = 0.049), whereas the specificity was, at a trend level, lower (0.46 versus 0.69; P = 0.08). Although multiphasic MRI may be marginally more sensitive than CT in a pooled analysis of comparative studies, the differences in pooled diagnostic performance are insufficient to recommend MRI over CT. Mitigating factors include the low quality of the evidence, concerns about generalizability to nonacademic settings, and recognition that multiple factors beyond diagnostic accuracy inform the selection of optimal imaging modalities in individual patients. Compared with multiphasic CT, multiphasic MRI has important advantages and disadvantages. Advantages include greater soft tissue contrast, more comprehensive assessment of nodule and background liver tissue properties, and absence of ionizing radiation. Disadvantages include greater technical complexity, longer scan times, lower throughput, increased susceptibility to artifact, less consistent image quality (largely because of patient factors such as breath holding, difficulty holding still, or high‐volume ascites), larger number of potential contraindications, higher charges, and—especially outside the United States—lower availability and longer scheduling backlogs. From a patient perspective, CT is faster, more spacious, and provokes less claustrophobia, but it exposes patients to radiation. Both modalities require IV access and contrast agents, the use of which may be problematic in patients with acute kidney injury or chronic renal failure.15 FUTURE RESEARCH Although not used widely in North America, multiphasic contrast‐enhanced US also can be used to diagnose HCC noninvasively, and further studies are needed.17 Prospective studies should include multiphasic CT, multiphasic MRI with an extracellular agent, and multiphasic MRI with gadoxetate disodium 8, and data on costs and patient preference should be collected. Of note, a multicenter trial of US transplantation patients with HCC underwent both MRI and CT at multiple fixed time points while awaiting transplantation has recently completed enrollment and may further elucidate which technique is optimal in this particular patient population (NCT01082224.) 3. Should Adults With Cirrhosis and an Indeterminate Hepatic Nodule Undergo a Biopsy, Repeated Imaging, or Alternative Imaging for the Diagnostic Evaluation? Recommendations 3A. The AASLD suggests several options in patients with cirrhosis and an indeterminate nodule, including follow‐up imaging, imaging with an alternative modality or alternative contrast agent, or biopsy, but cannot recommend one option over the other. Quality/Certainty of Evidence: Very Low Strength of Recommendation: Conditional 3B. The AASLD suggests against routine biopsy of every indeterminate nodule. Quality/Certainty of Evidence: Very Low Strength of Recommendation: Conditional Technical Remarks Biopsy may be required in selected cases, but its routine use is not suggested. Biopsy has the potential to establish a timely diagnosis in cases in which a diagnosis is required to affect therapeutic decision making; however, biopsy has a risk of bleeding, tumor seeding, and the possibility that a negative biopsy is due to the failure to obtain tissue representative of the nodule rather than a truly benign nodule. Stringent imaging criteria with high specificity for ≥10 mm HCC have been developed by the American College of Radiology through its Liver Imaging Reporting and Data System (LI‐RADS),25 the OPTN,26 and previous AASLD guidelines,2 and include arterial phase hyperenhancement in combination with washout appearance and/or capsule appearance. Lesions that do not meet these guidelines or are smaller than 1 cm are considered indeterminate. BACKGROUND In its previous HCC clinical practice guidelines,2 the AASLD recommended biopsy for all indeterminate lesions initially detected by surveillance ultrasound, with the presumed rationale being that biopsy can establish a definitive diagnosis, thereby permitting earlier intervention. Because of its many limitations, however, biopsy may not be an optimal strategy in all cases. Biopsy is expensive, may cause anxiety or pain, and has a risk of complications, including tumor track seeding and bleeding.27 Sampling error, especially for very small lesions, is an additional drawback. A negative biopsy may not exclude malignancy, and repeated biopsies may be necessary to establish a diagnosis. Follow‐up imaging may be especially relevant in patients awaiting liver transplantation with a single small, indeterminate nodule, given that biopsy confirmation of <20 mm HCC would not change management or contribute to liver transplantation priority. Because there is controversy regarding optimal workup for an indeterminate nodule, the aim of this question was to determine whether current data are able to elucidate an optimal strategy. EVIDENCE AND RATIONALE The evidence profile is included in Supporting Table 2, which uses the data from a de novo systematic review on imaging in HCC performed to address this question. Based on an extensive search strategy detailed in the systematic review, there were no comparative studies identified that directly address this question, although two single‐center, noncomparative studies were identified that examined the role of biopsy. Forner et al.17 in 2008 reported outcomes for ≤2 cm hepatic nodules detected during surveillance ultrasound in patients with cirrhosis. The authors performed percutaneous biopsy of ≤2 cm nodules in addition to MRI and contrast‐enhanced US. They found a sensitivity and specificity of MRI to be 61.7% and 96.6%, whereas contrast‐enhanced US was 51.7% and 93.1% compared with the standard, which was biopsy. When both tests were in concordance, the sensitivity was only 33%, with 100% specificity. Biopsy had a false negative rate of 30%, as patients with suspicious imaging findings or growth were rebiopsied up to three times. In 2011, Khalili et al. 28 reported that in patients with cirrhosis,