title: Value of Adjusted Blood Requirement Index in determining failure to control bleed in patients with variceal bleeding.
abstract: BACKGROUND
  Variceal bleeding is a serious complication in patients with cirrhosis. Among the criteria that were proposed in Baveno conferences, the Adjusted Blood Requirement Index (ABRI) has not been validated prospectively in clinical practice. We therefore aim to evaluate the measurement of ABRI as a marker of failure to control bleeding and to evaluate the consistency of ABRI in relation to other criteria of failure to control variceal bleeding.
  
  
  METHODS
  All patients with variceal bleeding who presented to Aga Khan University Hospital from January 2010 to December 2012 who were administered transfusion of packed red blood cells were included after obtaining informed consent. All patients were managed as per the standard protocol with intravenous terlipressin along with band ligation and injection of cyanoacrylate in cases of esophageal and fundal varices, respectively. Hemoglobin and hematocrit were measured every 6 h for 48 h and then every 12 h until 5 days of index bleed in each patient. Packed cells were transfused if hemoglobin decreased below 8 g/dl. The number of blood units transfused, change in hemoglobin values, and ABRI were calculated after each unit of blood transfusion till 120 h. In patients in whom bleed could not be controlled, an ABRI value of 0.75 or more was compared with other Baveno IV-based parameters that define failure to control variceal bleeding.
  
  
  RESULTS
  During the study period, 137 eligible patients with variceal bleed were admitted. The mean age of the patients was 52±12 years. The majority of patients (50.4%) were in Child-Pugh class B, followed by 38% in Child-Pugh class C. According to the Baveno IV criteria, overall failure to control acute variceal bleeding occurred in 52 (37.9%) patients. Excluding ABRI, failure to control bleeding was found in 22/137 (16%) patients, whereas ABRI-based criteria showed that in 34/137 (24.8%) patients, bleeding could not be controlled. There were only four (2.9%) patients with variceal bleeding in whom ABRI and other additional Baveno IV-based criteria for failure to control bleeding were present. When ABRI was compared with other criteria for failure to control bleeding, it showed a sensitivity and specificity of 19 and 25%, respectively.
  
  
  CONCLUSIONS
  This study showed that ABRI is not a useful additional tool to define failure to control bleeding after variceal hemorrhage in cirrhotic patients.
authors.affiliation: aDepartment of Medicine, Section of Gastroenterology, Aga Khan University Hospital, Aga Khan University bDepartment of Medicine, National Institute of Liver and Gastrointestinal Diseases, Dow University Hospital, Karachi, Pakistan.
authors.forename: Shahab
authors.initials: S
authors.lastname: Abid
authors.forename: Abdullah B
authors.initials: AB
authors.lastname: Khalid
authors.forename: Safia
authors.initials: S
authors.lastname: Awan
authors.forename: Hasnain A
authors.initials: HA
authors.lastname: Shah
authors.forename: Saeed
authors.initials: S
authors.lastname: Hamid
authors.forename: Wasim
authors.initials: W
authors.lastname: Jafri
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017707:Erythrocyte Transfusion / Q000379:methods*; D004932:Esophageal and Gastric Varices / Q000097:blood / Q000150:complications / Q000628:therapy*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000097:blood / Q000209:etiology / Q000628:therapy*; D006400:Hematocrit; D006454:Hemoglobins / Q000378:metabolism; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D017211:Treatment Failure; D055815:Young Adult
chemical_list: D006454:Hemoglobins