Background: Advanced stages of liver cirrhosis lead to a dramatically increased mortality. For valid identification of\nthese patients suitable biomarkers are essential. The most important biomarkers for liver function are bilirubin and\nprothrombin time expressed as International Normalized Ratio (INR). However, the influence of several anticoagulants\non the prothrombin time limits its diagnostic value.\nAim of this study was the evaluation of cholesterol esterification (CE) fraction (esterified cholesterol vs. total cholesterol)\nas an alternative biomarker for liver synthesis and mortality prediction. Under physiological conditions the CE fraction\nin blood is closely regulated by lecithin-cholesterol acyltransferase (LCAT) which is produced in the liver.\nMethods: One hundred forty-two patients with liver disease clinically considered for orthotopic liver transplant for\ndifferent indications were enrolled in the study. One patient was excluded because of the intake of a direct oral factor\nXa inhibitor which has a strong impact on prothrombin time.\nResults: Results of CE fraction were in good agreement with INR (R2 = 0.73; p < 0.001). In patients who died or\nsurvived within three months mean CE fraction was 56% vs. 74% (p < 0.001) and mean INR was 2.0 vs. 1.3 (p < 0.001),\nrespectively. The predictive value of CE fraction for three-month mortality risk was higher compared to INR (p = 0.04).\nResults for one-year mortality were comparable.\nConclusions: The cholesterol esterification fraction is a valid biomarker for liver synthesis and allows reliable prediction\nof mortality. In contrast to INR, it is independent of anticoagulation and other analytical limitations of coagulation tests.
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