Serum cystatin C level: An excellent predictor of mortality in
patients with cirrhotic ascites
Yeon Seok Seo,*
Soo Young Park,
Moon Young Kim,
Sang Gyune Kim,
Jun Yong Park,
Hyung Joon Yim,*
Byoung Kuk Jang,** Seung Ha Park,
Ji Hoon Kim,* Ki Tae Suk,
Jin Dong Kim,
Tae Yeob Kim,
Eun Young Cho,*** Jun Sung Lee,
Soung Won Jung,
Jae Young Jang,
Won Young Tak,
Soon Koo Baik,
Jae Seok Hwang,** Young Seok Kim,
Joo Hyun Sohn
and Soon Ho Um*
Departments of *Internal Medicine,
Biostatistics, Korea University College of Medicine, and
Department of Internal Medicine, Yonsei University College
Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Department of Internal Medicine, Kyungpook National
University School of Medicine, **Department of Internal Medicine, Keimyung University College of Medicine, Daegu,
Department of Internal Medicine,
Yonsei University Wonju College of Medicine, Wonju,
Department of Internal Medicine, Soonchunhyang University College of Medicine, Asan,
Department of Internal Medicine, Inje University College of Medicine, Pusan,
Department of Internal Medicine, Hallym University College of Medicine,
Department of Internal Medicine, Cheju Halla General Hospital, Jeju, and ***Department of Internal Medicine, Wonkwang University College
of Medicine, Iksan, Korea
creatinine, cystatin C, hepatorenal syndrome,
liver cirrhosis, renal dysfunction.
Accepted for publication 2 September 2017.
Dr Soon Ho Um, Division of Gastroenterology
and Hepatology, Department of Internal
Medicine, Korea University College of
Medicine, 126-1, 5-Ga, Anam-Dong, Seongbuk-
Gu, Seoul 136-705, Korea.
Email: email@example.com; firstname.lastname@example.org
Declaration of conflict of interest: Authors
have nothing to declare.
Both authors contributed equally to this work
as joint ﬁrst authors.
Background and Aim: Although serum cystatin C level is considered a more accurate
marker of renal function in patients with liver cirrhosis, its prognostic efﬁcacy remains
uncertain. This study aimed to evaluate the prognostic efﬁcacy of serum cystatin C level
in patients with cirrhotic ascites.
Methods: Patients with cirrhotic ascites from 15 hospitals were prospectively enrolled
between September 2009 and March 2013. Cox regression analyses were performed to
identify independent predictive factors of mortality and development of type 1 hepatorenal
Results: In total, 350 patients were enrolled in this study. The mean age was
55.4 ± 10.8 years, and 267 patients (76.3%) were men. The leading cause of liver cirrhosis
was alcoholic liver disease (64.3%), followed by chronic viral hepatitis (29.7%). Serum
creatinine and cystatin C levels were 0.9 ± 0.4 mg/dL and 1.1 ± 0.5 mg/L, respectively.
Multivariate analyses revealed that international normalized ratio and serum bilirubin,
sodium, and cystatin C levels were independent predictors of mortality and international
normalized ratio and serum sodium and cystatin C levels were independent predictors of
the development of HRS-1. Serum creatinine level was not signiﬁcantly associated with
mortality and development of HRS-1 on multivariate analysis.
Conclusion: Serum cystatin C level was an independent predictor of mortality and
development of HRS-1 in patients with cirrhotic ascites, while serum creatinine level
was not. Predictive models based on serum cystatin C level instead of serum creatinine
level would be more helpful in the assessment of the condition and prognosis of patients
with cirrhotic ascites.
In patients with advanced liver cirrhosis and severe portal hyper-
tension, due to the renal arterial vasoconstriction and decrease in
renal blood ﬂow by activation of vasoconstrictor systems,
acute kidney injury (AKI) is frequently developed with the
incidence of 20% of hospitalized patients with decompensated
Development of AKI in these patients is
frequently progressive and independently associated with mortal-
Considering the prevalence and prognostic signiﬁcance of
AKI in cirrhotic patients, accurate assessment of renal function
is very important.
Serum creatinine (Cr) level is the simplest and the most widely
used marker of renal function. Most of the guidelines deﬁne AKI
based on the serum Cr level.
Serum Cr level is included as
one of the parameters of the model for end-stage liver disease
(MELD) score, developed for predicting the prognosis of patients
with liver cirrhosis,
and its efﬁcacy has been veriﬁed in various
However, serum Cr level could be inﬂuenced by
extrarenal factors, such as age, sex, and ethnicity.
creatine is synthesized in the liver before being stored in muscles
where it is phosphorylated to Cr. Therefore, protein–calorie
malnutrition and muscle wasting, frequently observed in patients
decrease Cr production, thereby decreasing
Journal of Gastroenterology and Hepatology 33 (2018) 910–917
© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd