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Reddy KR, Weinberg EM, Gonzalez SA, Izzy MJ, Simonetto DA, Frederick RT, Rubin RA, Fricker Z, Ikahihifo-Bender J, Harte M, Garcia S, Campbell K, Olofson A, Razavi RF, James JM, Patel H, Kim-Lee G, Witkiewicz S, Tobin W, Jamil K. Safety and efficacy of continuous terlipressin infusion in HRS-AKI in a transplant population. Liver Transpl 2024; 30:1026-1038. [PMID: 38771635 PMCID: PMC11398294 DOI: 10.1097/lvt.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 05/06/2024] [Indexed: 05/23/2024]
Abstract
Hepatorenal syndrome-acute kidney injury (HRS-AKI) is associated with significant morbidity and mortality. While liver transplantation is the definitive treatment, continuous terlipressin infusion for HRS-AKI may provide benefit and, as such, was assessed in a population composed of candidates for liver transplant (LT). Fifty hospitalized LT-eligible patients with HRS-AKI received a single bolus followed by continuous terlipressin infusion. Acute-on-chronic liver failure grade 3, serum creatinine (SCr)>5.0 mg/dL, or Model for End-Stage Liver Disease (MELD) ≥35 were exclusions. Fifty hospitalized patients who received midodrine and octreotide or norepinephrine for HRS-AKI served as a historical comparator cohort. Complete response (CR) was defined as a ≥30% decrease in SCr with end-of-treatment (EOT) SCr≤1.5, partial response as a ≥30% decrease in SCr with EOT SCr>1.5, and nonresponse as a <30% decrease in SCr. CR rate was significantly higher in the terlipressin cohort compared to the historical cohort (64% vs. 16%, p <0.001). Survival, while numerically higher in those who received terlipressin, was statistically similar (D30: 94% vs. 82%, p =0.12; D90: 78% vs. 68%, p =0.37). Renal replacement therapy (RRT) was more common among terlipressin NR than CR and PR (70% vs. 3% vs. 13%, p < 0.001). EOT MELD and SCr were significantly lower within terlipressin cohort (MELD: 19 vs. 25, SCr: 1.4 vs. 2.1 mg/dL, p <0.001). Sixteen of 40 terlipressin-treated patients received LT-alone (terlipressin CR in 10/16). One patient on terlipressin had a hypoxic respiratory failure that responded to diuretics; one possibly had drug-related rash. With continuous terlipressin infusion, a CR rate of 64% was observed with a favorable safety profile. Terlipressin use was associated with lower EOT MELD and SCr than the historical midodrine and octreotide/norepinephrine cohort; LT-alone was accomplished in a high proportion of complete terlipressin responders.
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Affiliation(s)
- K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ethan M Weinberg
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stevan A Gonzalez
- Division of Hepatology, Department of Medicine, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas, USA
| | - Manhal J Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - R Todd Frederick
- Division of Hepatology, Department of Advanced Organ Therapies and Transplantation, California Pacific Medical Center, San Francisco, California, USA
| | - Raymond A Rubin
- Department of Transplantation, Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jade Ikahihifo-Bender
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Maggie Harte
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sandra Garcia
- Division of Hepatology, Department of Medicine, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas, USA
| | - Kathryn Campbell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy Olofson
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Ryan F Razavi
- Division of Hepatology, Department of Advanced Organ Therapies and Transplantation, California Pacific Medical Center, San Francisco, California, USA
| | - Janelle M James
- Department of Transplantation, Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Het Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace Kim-Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - William Tobin
- International HealthCare, LLC, Norwalk, Connecticut, USA
| | - Khurram Jamil
- Formerly at Department of Research & Development, Mallinckrodt Pharmaceuticals, Scientific Affairs, Bridgewater, New Jersey, USA
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Kaur P, Verma N, Garg P, Ralmilay S, Wadhawan A, Nadda R, Prajapati J, Sharma G, Rathi S, De A, Premkumar M, Taneja S, Singal AK, Duseja A. Myokines are associated with progression, course and mortality in alcohol-associated liver disease. Aliment Pharmacol Ther 2024; 60:1005-1020. [PMID: 39135311 DOI: 10.1111/apt.18202] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/24/2024] [Accepted: 07/29/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND AND AIMS Myokines are the muscle-derived hormones orchestrating muscle and systemic health. Their role in the progression of alcohol-associated liver disease (ALD) remains elusive. METHODS Three-hundred-one patients across the spectrum of ALD including fatty liver (FL, N = 13), compensated cirrhosis (CC, N = 17), non-acute decompensation (NAD, N = 95), acute decompensation (AD, N = 51) and acute-on-chronic liver failure (ACLF, N = 125) were recruited between 2021 and 2023. Plasma myostatin, decorin levels, nutritional status, handgrip strength (HGS), systemic inflammation, infection, ammonia, disease course and 30-day mortality were recorded. RESULTS Patients aged 48 years (IQR: 38-52) and 97.7% of males were enrolled. Myostatin was elevated while decorin was reduced in cirrhosis compared to without cirrhosis, and further in DC compared to CC (p < 0.001). A step-wise increase in myostatin and reduction in decorin was observed transitioning from NAD to AD to ACLF (p < 0.001). Myostatin was further increased and decorin was reduced along with the grades and organ failures in AD and ACLF (p < 0.001, each). Baseline decorin (AUC: 0.797) and its combination with MELD (AUC: 0.814) predicted disease resolution in AD and ACLF. Although, both myostatin (aOR: 18.96) and decorin (aOR: 0.02) could predict mortality, decorin was independent (aOR: 0.04) and additive to MELD (AUC of MELD+logDecorin + logTLC + HE-grade:0.815); p < 0.05 each. Myostatin increased and decorin reduced with inflammation, hyperammonaemia, malnutrition and HGS in AD and ACLF (p < 0.05, each). CONCLUSION Myokines are linked with malnutrition, fibrosis, systemic inflammation, organ failures, disease course and mortality in ALD. Decorin enhances the risk estimation of mortality of MELD in AD and ACLF. Therapeutic modulation of myokines is a potentially disease-modifying target in ALD.
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Affiliation(s)
- Parminder Kaur
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratibha Garg
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Samonee Ralmilay
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aishani Wadhawan
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Nadda
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jiya Prajapati
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Sharma
- Department of Translational and Regenerative Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani K Singal
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Yang JX, Peng YM, Zeng HT, Lin XM, Xu ZL. Drainage of ascites in cirrhosis. World J Hepatol 2024; 16:1245-1257. [DOI: 10.4254/wjh.v16.i9.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 07/20/2024] [Accepted: 07/29/2024] [Indexed: 09/23/2024] Open
Abstract
For cirrhotic refractory ascites, diuretics combined with albumin and vasoactive drugs are the first-line choice for ascites management. However, their therapeutic effects are limited, and most refractory ascites do not respond to medication treatment, necessitating consideration of drainage or surgical interventions. Consequently, numerous drainage methods for cirrhotic ascites have emerged, including large-volume paracentesis, transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, automated low-flow ascites pump, cell-free and concentrated ascites reinfusion therapy, and peritoneal catheter drainage. This review introduces the advantages and disadvantages of these methods in different aspects, as well as indications and contraindications for this disease.
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Affiliation(s)
- Jia-Xing Yang
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Yue-Ming Peng
- Department of Nursing, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Hao-Tian Zeng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Xi-Min Lin
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
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Pomej K, Masel EK, Kreye G. Palliative care in terminally ill advanced chronic liver disease patients. Wien Klin Wochenschr 2024:10.1007/s00508-024-02436-z. [PMID: 39254776 DOI: 10.1007/s00508-024-02436-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 08/16/2024] [Indexed: 09/11/2024]
Abstract
While mortality rates from advanced chronic liver disease (ACLD) are rapidly increasing, patients with an advanced disease stage have a comparable or even higher symptom burden than those with other life-limiting diseases. Although evidence is limited there is increasing recognition of the need to improve care for patients with ACLD; however, there are many limiting factors to providing good palliative care for these patients, including unpredictable disease progression, the misconception of palliative care and end of life care as being equivalent, a lack of confidence in prescribing medication and a lack of time and resources. Health professionals working with these patients need to develop the skills to ensure effective palliative care, while referral to specialized palliative care centers should be reserved for patients with complex needs. Basic palliative care, along with active disease management, is best delivered by the treating hepatologists. This includes discussions about disease progression and advance care planning, alongside the active management of disease complications. Liver disease is closely associated with significant social, psychological, and financial burdens for patients and their caregivers. Strategies to engage the discussion in multidisciplinary teams early in disease progression help to ensure addressing these issues proactively. This review summarizes the evidence on palliative care for patients with ACLD, provides examples of current best practice and offers suggestions on how disease-modifying and palliative care can coexist, to ensure that patients do not miss opportunities for quality of life improving interventions.
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Affiliation(s)
- Katharina Pomej
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Eva Katharina Masel
- Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gudrun Kreye
- Division of Palliative Medicine, Clinical Department of Medicine 2, Krems University Hospital, Karl Landsteiner Private University for Health Sciences, Mitterweg 10, 3500, Krems an der Donau, Austria.
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Kelly C, Buscarini E, Manfredi G, Gregory S, Heneghan MA. Hepatic manifestations of hereditary haemorrhagic telangiectasia. Liver Int 2024; 44:2220-2234. [PMID: 38847503 DOI: 10.1111/liv.16008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/01/2024] [Accepted: 05/25/2024] [Indexed: 08/30/2024]
Abstract
Hereditary haemorrhagic telangiectasia is a genetic condition of abnormal blood vessel formation resulting from an imbalance of pro- and anti-angiogenic products of the transforming growth factor β/bone morphogenetic protein signalling pathway which contributes to vascular remodelling and maintenance. Hepatic vascular malformations are common although less frequently symptomatic, but may result in high-output cardiac failure, portal hypertension and biliary ischaemia. Whilst the understanding of the genetic and cell signalling pathways that are the hallmark of hereditary haemorrhagic telangiectasia have been clarified, there remain challenges in therapy for these patients. Only patients with symptomatic hepatic vascular malformations require treatment, with most (63%) responding to first-line medical therapy. For non-responders, bevacizumab is effective in reducing cardiac output in those with heart failure secondary to hepatic vascular malformations as well as other manifestations of the disease. Although liver transplantation is the only curative option, optimal timing is critical. Novel anti-angiogenetic drugs and those that target aberrant cell signalling pathway are being explored.
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Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, Kings College Hospital, London, UK
| | | | - Guido Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
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6
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Lv Y, Wang Q, Luo B, Bai W, Li M, Li K, Wang Z, Xia D, Guo W, Li X, Yuan J, Zhang N, Wang X, Xie H, Pan Y, Nie Y, Yin Z, Fan D, Han G. Identifying the optimal measurement timing and hemodynamic targets of portal pressure gradient after TIPS in patients with cirrhosis and variceal bleeding: a prospective cohort study. J Hepatol 2024:S0168-8278(24)02485-1. [PMID: 39181214 DOI: 10.1016/j.jhep.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 07/28/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND & AIMS The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after TIPS remains inconclusive. This study aimed to identify the ideal moment of hemodynamic measurements and the optimal target of PPG in patients undergoing covered TIPS for variceal bleeding. METHODS Between May 2018 and December 2021, 466 consecutive patients with recurrent variceal bleeding treated with covered TIPS were prospectively included. Post-TIPS PPG were measured immediately (immediate PPG), 24-72 hours (early PPG), and again 1 month (late PPG) after TIPS placement. The agreement among PPGs measured at different time points was assessed by intra-class correlation coefficient (ICC) and Bland-Altman method. The unadjusted and confounder-adjusted effects of PPGs on the clinical outcomes (portal hypertension complications [PHC], overt hepatic encephalopathy [OHE], further decompensation, and death) were assessed using Fine and Gray competing risk regression models. RESULTS The agreement between early PPG and late PPG (ICC: 0.34) was better than that between immediate PPG and late PPG (ICC: 0.23, p<0.001). Early PPG revealed an excellent predictive value for PHC risk (early PPG ≥ vs <12 mmHg: adjusted HR [95%CI]: 2.17 [1.33-3.55], p=0.002) as well as OHE (0.40 [0.17-0.91], p=0.030) while immediate PPG did not. Late PPG showed a predictive value for PHC risk but not OHE. By targeting the lowest risk of further decompensation, we identified an optimal hemodynamic target with early PPG ranging 11 to 14 mmHg that was associated with a decreased risk of OHE while effectively preventing PHC. CONCLUSIONS PPG measured 24 to 72 hours after TIPS correlates with long term PPG and clinical outcomes, and hemodynamic target with a PPG 11-14 mmHg reduced encephalopathy but not compromised clinical efficacy. IMPACT AND IMPLICATIONS The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) remains inconclusive. Here we show that post-TIPS PPG measured at least 24 hours but not immediately after the procedure correlated with long-term PPG and clinical events, therefore should be used for decision making in order to improve clinical outcomes. Targeting post-TIPS PPG at 11-14 mmHg or 20%-50% relative reduction from pre-TIPS baseline that measured 24-72 hours after procedure reduced encephalopathy but not compromised clinical efficacy, therefore could be used to guide TIPS creation and revision in patients with cirrhosis and variceal bleeding undergoing covered TIPS. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov, ID: NCT03590288.
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Affiliation(s)
- Yong Lv
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Menghao Li
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Kai Li
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Dongdong Xia
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Na Zhang
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Xing Wang
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Huahong Xie
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yongzhan Nie
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Daiming Fan
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China.
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Li S, Zhang Y, Lin Y, Zheng L, Fang K, Wu J. Development and validation of prediction models for nosocomial infection and prognosis in hospitalized patients with cirrhosis. Antimicrob Resist Infect Control 2024; 13:85. [PMID: 39113159 PMCID: PMC11304655 DOI: 10.1186/s13756-024-01444-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/27/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Nosocomial infections (NIs) frequently occur and adversely impact prognosis for hospitalized patients with cirrhosis. This study aims to develop and validate two machine learning models for NIs and in-hospital mortality risk prediction. METHODS The Prediction of Nosocomial Infection and Prognosis in Cirrhotic patients (PIPC) study included hospitalized patients with cirrhosis at the Qingchun Campus of the First Affiliated Hospital of Zhejiang University. We then assessed several machine learning algorithms to construct predictive models for NIs and prognosis. We validated the best-performing models with bootstrapping techniques and an external validation dataset. The accuracy of the predictions was evaluated through sensitivity, specificity, predictive values, and likelihood ratios, while predictive robustness was examined through subgroup analyses and comparisons between models. RESULTS We enrolled 1,297 patients into derivation cohort and 496 patients into external validation cohort. Among the six algorithms assessed, the Random Forest algorithm performed best. For NIs, the PIPC-NI model achieved an area under the curve (AUC) of 0.784 (95% confidence interval [CI] 0.741-0.826), a sensitivity of 0.712, and a specificity of 0.702. For in-hospital mortality, the PIPC- mortality model achieved an AUC of 0.793 (95% CI 0.749-0.836), a sensitivity of 0.769, and a specificity of 0.701. Moreover, our PIPC models demonstrated superior predictive performance compared to the existing MELD, MELD-Na, and Child-Pugh scores. CONCLUSIONS The PIPC models showed good predictive power and may facilitate healthcare providers in easily assessing the risk of NIs and prognosis among hospitalized patients with cirrhosis.
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Affiliation(s)
- Shuwen Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Yu Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Yushi Lin
- Department of Infectious Diseases, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Luyan Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Kailu Fang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Jie Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China.
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Garcia-Guix M, Ardevol A, Sapena V, Alvarado-Tápias E, Huertas A, Brujats A, Fajardo J, Cuyas B, Poca M, Guarner C, Torras X, Escorsell À, Villanueva C. Influence of further decompensation on survival across clinical stages of decompensated cirrhosis: The role of portal hypertension and HVPG changes. Liver Int 2024; 44:1971-1989. [PMID: 38634685 DOI: 10.1111/liv.15937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND AIMS Decompensated-cirrhosis encompasses several stages with different prognosis, such as bleeding, ascites and bleeding-plus-ascites. Development of further-decompensation worsens survival, while non-selective β-blockers (NSBBs) can modify the risk. However, how this applies to each stage is uncertain. We aimed to investigate, in each stage of decompensated-cirrhosis, the influence of further-decompensation on mortality and whether changes in portal-pressure (HVPG) under NSBBs influence these outcomes. METHODS Patients with variceal bleeding were consecutively included differentiating those with bleeding-alone from those who also had ascites. Patients with ascites and high-risk varices referred for primary-prophylaxis were also investigated. A baseline haemodynamic study was performed and was repeated after 1-3-months under NSBBs. Outcomes were investigated by competing-risk. RESULTS Totally 103 patients had bleeding-alone, 186 bleeding-plus-ascites and 187 ascites-alone. Mean follow-up was 32-months (IQR, 12-60). Patients with bleeding-plus-ascites had higher HVPG and were more hyperdynamic than patients with ascites-alone and these than those with bleeding-alone. At each stage, the mortality risk was more than twice in patients developing further-decompensation vs. those without (p < .001). In each stage, HVPG-decrease under NSBBs showed better discrimination to predict further-decompensation than the baseline MELD, Child-Pugh or HVPG, by time-dependent ROC-curves (c-statistic >70%). At each stage, patients without HVPG-decreases, either ≥10% or ≥20% from the baseline, had higher risk of further-decompensation (sHR from 2.43 to 6.73, p < .01) and worse survival. CONCLUSIONS In each stage of decompensated cirrhosis, mortality risk significantly and very markedly increase with further-decompensation. HVPG-non-response to NSBBs may adequately stratify the risk of further decompensation and death, in each stage. This suggests potential benefit with pre-emptive therapies in HVPG-non-responders at each-stage.
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Affiliation(s)
- Marta Garcia-Guix
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alba Ardevol
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Sapena
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
- Medical Statistics Core Faculty, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Edilmar Alvarado-Tápias
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Anna Huertas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Brujats
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier Fajardo
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Berta Cuyas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - María Poca
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Carlos Guarner
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Xavier Torras
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Àngels Escorsell
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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9
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Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, Todi SK, Mohan A, Hegde A, Jagiasi BG, Krishna B, Rodrigues C, Govil D, Pal D, Divatia JV, Sengar M, Gupta M, Desai M, Rungta N, Prayag PS, Bhattacharya PK, Samavedam S, Dixit SB, Sharma S, Bandopadhyay S, Kola VR, Deswal V, Mehta Y, Singh YP, Myatra SN. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024; 28:S104-S216. [PMID: 39234229 PMCID: PMC11369928 DOI: 10.5005/jp-journals-10071-24677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 09/06/2024] Open
Abstract
How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.
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Affiliation(s)
- Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Subhash K Todi
- Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Ashit Hegde
- Department of Medicine & Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, India
| | - Camila Rodrigues
- Department of Microbiology, P D Hinduja National Hospital, Mumbai, India
| | - Deepak Govil
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Divya Pal
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mukesh Desai
- Department of Immunology, Pediatric Hematology and Oncology Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Narendra Rungta
- Department of Critical Care & Anaesthesiology, Rajasthan Hospital, Jaipur, India
| | - Parikshit S Prayag
- Department of Transplant Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Srinivas Samavedam
- Department of Critical Care, Ramdev Rao Hospital, Hyderabad, Telangana, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Sudivya Sharma
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Susruta Bandopadhyay
- Department of Critical Care, AMRI Hospitals Salt Lake, Kolkata, West Bengal, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Vikas Deswal
- Consultant, Infectious Diseases, Medanta - The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Yogendra P Singh
- Department of Critical Care, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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10
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Liu C, Zhang L, Zhang S, Li X, Wong YJ, Liang X, Wang Y, Wu X, Gou W, Lv J, Hu S, Fu J, Huang J, Ge G, Huang M, Wang F, Zhang Q, Ren T, Meng Z, Ding D, Zhuoga B, Zhuoga C, Fan J, Dang D, Miao L, Song Z, Xiao X, Wu H, Jiang K, Liu T, Gao Y, Ma L, Fang T, Wang Y, Zhang Q, Zhu D, Ji D, Cao Z, Zeng QL, Li J, Chen P, Wei Y, Tong Z, Hong Z, Liang X, Li Y, Nan Y, Qi X. Carvedilol to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension stratified by liver stiffness: study protocol for a randomied, double-blind, placebo-controlled, multicentre trial in China. BMJ Open 2024; 14:e081623. [PMID: 38991669 PMCID: PMC11243284 DOI: 10.1136/bmjopen-2023-081623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION Patients with clinically significant portal hypertension (CSPH) are recommended to be treated with non-selective beta-blockers (ie, carvedilol) to prevent the first hepatic decompensation event by the renewing Baveno VII consensus. CSPH is defined by hepatic venous pressure gradient (HVPG)≥10 mm Hg; however, the HVPG measurement is not widely adopted due to its invasiveness. Liver stiffness (LS)≥25 kPa can be used as a surrogate of HVPG≥10 mm Hg to rule in CSPH with 90% of the positive predicting value in majority aetiologies of patients. A compelling argument is existing for using LS≥25 kPa to diagnose CSPH and then to initiate carvedilol in patients with compensated cirrhosis, and about 5%-6% of patients under this diagnosis criteria may not be benefited from carvedilol and are at risk of lower heart rate and mean arterial pressure. Randomised controlled trial on the use of carvedilol to prevent liver decompensation in CSPH diagnosed by LS remains to elucidate. Therefore, we aimed to investigate if compensated cirrhosis patients with LS≥25 kPa may benefit from carvedilol therapy. METHODS AND ANALYSIS This study is a randomised, double-blind, placebo-controlled, multicentre trial. We will randomly assign 446 adult compensated cirrhosis patients with LS≥25 kPa and without any previous decompensated event and without high-risk gastro-oesophageal varices. Patients are randomly divided into two groups, with 223 subjects in group A and 223 subjects in group B. Group A is a carvedilol intervention group, while group B is a placebo group. All patients in both groups will receive aetiology therapies and are followed up at an interval of 6 months. The 3-year incidences of decompensated events of cirrhosis-related and liver-related death are the primary outcome. The secondary outcomes include development of each complication of portal hypertension individually (ascites, variceal bleeding or overt hepatic encephalopathy), development of spontaneous bacterial peritonitis and other bacterial infections, development of new varices, growth of small varices to large varices, delta changes in LS and spleen stiffness, change in hepatic dysfunction assessed by Child-Pugh and model for end-stage liver disease score, change in platelet count, development of hepatocellular carcinoma, development of portal vein thrombosis and adverse events with a 3-year follow-up. A predefined interim analysis will be performed to ensure that the calculation is reasonable. ETHICS AND DISSEMINATION The study protocol has been approved by the ethics committees of the Sixth People's Hospital of Shenyang (2023-05-003-01) and independent ethics committee for clinical research of Zhongda Hospital, affiliated to Southeast University (2023ZDSYLL433-P01). The results from this trial will be submitted for publication in peer-reviewed journals and will be presented at international conferences. TRIAL REGISTRATION NUMBER ChiCTR2300073864.
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Affiliation(s)
- Chuan Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University), Nanjing, Jiangsu, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, State Key Laboratory of Digital Medical Engineering, Nanjing, Jiangsu, China
| | - Liting Zhang
- The Portal Hypertension Research Institute, Department of Hepatology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Shuairan Zhang
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xiaoguo Li
- The Portal Hypertension Research Institute, Department of Hepatology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yu-Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Xuan Liang
- Shenyang Sixth People's Hospital, Shenyang, Liaoning, China
| | - Yan Wang
- Shenyang Sixth People's Hospital, Shenyang, Liaoning, China
| | - Xiaofeng Wu
- Shenyang Sixth People's Hospital, Shenyang, Liaoning, China
| | - Wei Gou
- Qingdao Sixth People's Hospital, Qingdao, Shandong, China
| | - Jiaojian Lv
- Lishui People's Hospital, Lishui, Zhejiang, China
| | - Shengjuan Hu
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia, China
| | - Junliang Fu
- Department of Infectious Disease Medicine, The Fifth center of PLA General Hospital, Beijing, China
| | - Ju Huang
- Zhenjiang Third People's Hospital, Zhenjiang, Jiangsu, China
| | - Guohong Ge
- Zhenjiang Third People's Hospital, Zhenjiang, Jiangsu, China
| | - Mingxing Huang
- Zhuhai Third People's Hospital, Zhuhai, Guangdong, China
| | - Fang Wang
- Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Qingge Zhang
- Department of Infectious Diseases, Xingtai People's Hospital, Xingtai, Hebei, China
| | - Tao Ren
- Sichuan University Huaxi Hospital Tibet Chengban Branch, Chengdu, Sichuan, China
| | - Zhongji Meng
- Department of Infectious Diseases, Institute of Biomedical Research, Regulatory Mechanism and Targeted Therapy for Liver Cancer Shiyan Key Laboratory, Hubei Provincial Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
- Hubei Key Laboratory of Embryonic Stem Cell Research, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Deping Ding
- Department of Infectious Diseases, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Basang Zhuoga
- Third People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, China
| | - Cidan Zhuoga
- Third People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, China
| | - Jian Fan
- Handan Infectious Disease Hospital, Handan, Hebei, China
| | - Dianjie Dang
- Handan Infectious Disease Hospital, Handan, Hebei, China
| | - Liang Miao
- Qinhuangdao Third Hospital, Qinhuangdao, Hebei, China
| | - Zhaomin Song
- Qinhuangdao Third Hospital, Qinhuangdao, Hebei, China
| | - Xingguo Xiao
- Department of Gastroenterology, Zhengzhou Central Hospital, Zhengzhou, Henan, China
| | - Huili Wu
- Department of Gastroenterology, Zhengzhou Central Hospital, Zhengzhou, Henan, China
| | - Kai Jiang
- Fourth Department, Digestive Disease Center, Suining Central Hospital, Suining, Sichuan, China
| | - Tianyu Liu
- Fourth Department, Digestive Disease Center, Suining Central Hospital, Suining, Sichuan, China
| | - Youfang Gao
- Department of Infectious Disease, The People's Hospital of Bozhou, Bozhou, Anhui, China
| | - Lan Ma
- Department of Infectious Disease, The People's Hospital of Bozhou, Bozhou, Anhui, China
| | - Tao Fang
- Jinhua People's Hospital, Jinhua, Zhejiang, China
| | - Yuehua Wang
- Jinhua People's Hospital, Jinhua, Zhejiang, China
| | - Qianhua Zhang
- Department of Hepatology, Zhongshan Second People's Hospital, Zhongshan, Guangdong, China
| | - Da Zhu
- Department of Hepatology, Zhongshan Second People's Hospital, Zhongshan, Guangdong, China
| | - Dong Ji
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhujun Cao
- Department of Infectious Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing-Lei Zeng
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jie Li
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ping Chen
- Shulan Hangzhou Hospital, Hangzhou, Zhejiang, China
| | - Yufang Wei
- The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, China
| | - Zhaowei Tong
- Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang, China
| | - Zhongsi Hong
- Department of Infectious Diseases, Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Xiao Liang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yiling Li
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yuemin Nan
- Department of Traditional and Western Medical Hepatology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaolong Qi
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University), Nanjing, Jiangsu, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, State Key Laboratory of Digital Medical Engineering, Nanjing, Jiangsu, China
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11
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Przybyszewski EM, Wilechansky RM, Diaz PM, Allegretti AS, VanWagner LB, Cullaro G, Levitsky J, Ginès P, Piano S, Asrani SK, Patidar KR. Controversies in terlipressin and transplantation in the United States: How do we MELD the two? Liver Transpl 2024; 30:753-759. [PMID: 38537069 PMCID: PMC11175996 DOI: 10.1097/lvt.0000000000000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/15/2024] [Indexed: 04/05/2024]
Abstract
Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a severe complication of cirrhosis that carries a poor prognosis. The recent Food and Drug Administration approval of terlipressin has substantial implications for managing HRS-AKI and liver allocation in the United States. Terlipressin has been available in Europe for over a decade, and several countries have adapted policy changes such as Model for End-Stage Liver Disease (MELD) score "lock" for HRS-AKI. In this article, we outline the European experience with terlipressin use and explore the question of whether terlipressin treatment for HRS-AKI should qualify for the MELD score "lock" in the United States in those who respond to therapy. Arguments for the MELD lock include protecting waitlist priority for terlipressin responders or partial responders who may miss offers due to MELD reduction in the terlipressin treatment window. Arguments against MELD lock include the fact that terlipressin may produce a durable response and improve overall survival and that equitable access to terlipressin is not guaranteed due to cost and availability. We subsequently discuss the proposed next steps for studying terlipressin implementation in the United States. A successful approach will require the involvement of all major stakeholders and the mobilization of our transplant community to spearhead research in this area.
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Affiliation(s)
- Eric M. Przybyszewski
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert M. Wilechansky
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paige McLean Diaz
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lisa B. VanWagner
- Division of Digestive and Liver Diseases, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Giuseppe Cullaro
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pere Ginès
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
- Fundació Clínic per la Recerca Biomèdica-Institut d’Investigació Biomèdica August Pi-Sunyer (IDIBAPS)
- Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD)
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Italy
| | | | - Kavish R. Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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12
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Lee Y, Kim T, Kim DE, Jo EM, Kim DW, Kim HJ, Seong EY, Song SH, Rhee H. Differences in the incidence, characteristics, and outcomes of patients with acute kidney injury in the medical and surgical intensive care units. Kidney Res Clin Pract 2024; 43:518-527. [PMID: 38934030 PMCID: PMC11237328 DOI: 10.23876/j.krcp.23.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/27/2024] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Though acute kidney injury (AKI) is a prevalent complication in critically ill patients, knowledge on the epidemiological differences and clinical characteristics of patients with AKI admitted to medical and surgical intensive care units (ICUs) remains limited. METHODS Electronic medical records of patients in ICUs in Pusan National University Hospital and Pusan National University Hospital Yangsan, from January 2011 to December 2020, were retrospectively analyzed. Different characteristics of AKI between patients were analyzed. The contribution of AKI to the in-hospital mortality rate was assessed using a Cox proportional hazards model. RESULTS A total of 7,150 patients were included in this study. AKI was more frequent in medical (48.7%) than in surgical patients (19.7%), with the severity of AKI higher in medical patients. In surgical patients, hospital-acquired AKI was more frequent (51.0% vs. 49.0%), whereas community-acquired AKI was more common in medical patients (58.5% vs. 41.5%). 16.9% and 5.9% of medical and surgical patients died in the hospital, respectively. AKI affected patient groups to different degrees. In surgical patients, AKI patients had 4.778 folds higher risk of mortality (95% confidence interval [CI], 3.577-6.382; p < 0.001) than non-AKI patients; whereas in medical AKI patients, it was 1.239 (95% CI, 1.051-1.461; p = 0.01). CONCLUSION While the prevalence of AKI itself is higher in medical patients, the impact of AKI on mortality was stronger in surgical patients compared to medical patients. This suggests that more attention is needed for perioperative patients to prevent and manage AKI.
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Affiliation(s)
- Yeji Lee
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Taeil Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Eon Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Mi Jo
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Da Woon Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Hyo Jin Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Eun Young Seong
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Sang Heon Song
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Harin Rhee
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
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13
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Du L, Wei N, Maiwall R, Song Y. Differential diagnosis of ascites: etiologies, ascitic fluid analysis, diagnostic algorithm. Clin Chem Lab Med 2024; 62:1266-1276. [PMID: 38112289 DOI: 10.1515/cclm-2023-1112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023]
Abstract
Ascites is the pathological accumulation of fluid within the peritoneal cavity. It often occurs as results of liver cirrhosis, malignant neoplasia, tuberculous infection, cardiac insufficiency, renal diseases, etc. Determining the etiology is an essential step in the management of patients with new-onset ascites. Abdominal paracentesis with appropriate ascitic fluid analysis is probably the most cost-effective method of determining the cause of ascites. We performed a literature search of PubMed and identified articles published in the field of ascites, to evaluate diagnostic values of various parameters in defining the etiologies of ascites and then provides diagnostic algorithm for patients with new-onset ascites. In patients with ascites, the constituent ratio of underlying etiology varies between developed and developing countries. It is a challenge to define the etiologies of ascites in developing countries. Routine ascitic fluid analysis should include the serum ascites albumin gradient (SAAG), total protein concentration, cell count and differential. Optional ascitic fluid analysis includes cholesterol, fluid culture, cytology, tumor markers, lactate dehydrogenase, adenosine deaminase (ADA), triglyceride, amylase, glucose, brain natriuretic peptide (BNP), etc. Our review evaluated diagnostic values of the above parameters in defining the etiologies of ascites. Diagnostic algorithm established in this review would provide a practical and convenient diagnostic strategy for clinicians in diagnosing patients with new-onset ascites.
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Affiliation(s)
- Li Du
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Ning Wei
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Yuhu Song
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
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Beran A, Mohamed MFH, Vargas A, Aboursheid T, Aziz M, Hernaez R, Patidar KR, Nephew LD, Desai AP, Orman E, Chalasani N, Ghabril MS. Early Diagnostic Paracentesis Improves Outcomes of Hospitalized Patients With Cirrhosis and Ascites: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2024:00000434-990000000-01206. [PMID: 38916217 DOI: 10.14309/ajg.0000000000002906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION Diagnostic paracentesis is recommended for patients with cirrhosis admitted to the hospital, but adherence is suboptimal with unclear impact on clinical outcomes. The aim of this meta-analysis was to assess the outcomes of early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. METHODS We searched multiple databases for studies comparing early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. The pooled odds ratio (OR) and mean difference with confidence intervals (CIs) for proportional and continuous variables were calculated using the random-effects model. Early diagnostic paracentesis was defined as receiving diagnostic paracentesis within 12-24 hours of admission. The primary outcome was in-hospital mortality. Secondary outcomes were length of hospital stay, acute kidney injury, and 30-day readmission. RESULTS Seven studies (n = 78,744) (n = 45,533 early vs n = 33,211 delayed diagnostic paracentesis) were included. Early diagnostic paracentesis was associated with lower in-hospital mortality (OR 0.61, 95% CI 0.46-0.82, P = 0.001), length of hospital stay (mean difference -4.85 days; 95% CI -6.45 to -3.20; P < 0.001), and acute kidney injury (OR 0.62, 95% CI 0.42-0.92, P = 0.02) compared with delayed diagnostic paracentesis, with similar 30-day readmission (OR 1.11, 95% CI 0.52-2.39, P = 0.79). Subgroup analysis revealed consistent results for in-hospital mortality whether early diagnostic paracentesis performed within 12 hours (OR 0.51, 95% CI 0.32-0.79, P = 0.003, I2 = 0%) or within 24 hours of admission (OR 0.67, 95% CI 0.45-0.98, P = 0.04, I2 = 82%). Notably, the mortality OR was numerically lower when diagnostic paracentesis was performed within 12 hours, and the results were precise and homogenous ( I2 = 0%). DISCUSSION Findings from this meta-analysis suggest that early diagnostic paracentesis is associated with better patient outcomes. Early diagnostic paracentesis within 12 hours of admission may be associated with the greatest mortality benefit. Data from large-scale randomized trials are needed to validate our findings, especially if there is a greater mortality benefit for early diagnostic paracentesis within 12 hours.
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Affiliation(s)
- Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Mouhand F H Mohamed
- Department of Internal Medicine, Warren Alpert Medical School Brown University, Providence, Rhode Island, USA
| | - Alejandra Vargas
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Tarek Aboursheid
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, Illinois, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, Bon Secours Mercy Health, Toledo, Ohio, USA
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kavish R Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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15
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Sivapalan P, Ellekjaer KL, Perner A, Møller MH, Granholm A, Grønningsæter L, Ostermann M, Sweeney RM, Cronhjort M, Hästbacka J, Pfortmueller C, De Waele J, Nalos M, Jovaisa T, Reintam Blaser A, Cecconi M, Ergan B, Al-Fares A, Young PJ, Szczeklik W, Keus E, Alshamsi F, Khanna AK, Sigurdsson MI, Fujii T, Arabi YM, Meyhoff TS. Preferences for albumin use in adult intensive care unit patients with shock: An international survey. Acta Anaesthesiol Scand 2024; 68:1234-1243. [PMID: 39302760 DOI: 10.1111/aas.14479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/24/2024] [Accepted: 06/07/2024] [Indexed: 09/22/2024]
Abstract
INTRODUCTION Use of albumin is suggested for some patients with shock, but preferences for its use may vary among intensive care unit (ICU) physicians. METHODS We conducted an international online survey of ICU physicians with 20 questions about their use of albumin and their opinion towards a randomised trial among adults with shock comparing the use versus no use of albumin. RESULTS A total of 1248 respondents participated, with a mean response rate of 37%, ranging from 18% to 75% across 21 countries. Respondents mainly worked in mixed ICUs and 92% were specialists in intensive care medicine. The reported use of albumin in general shock varied as 18% reported 'almost never', 22% 'rarely', 34% 'occasionally', 22% 'frequently' and 4% 'almost always' using albumin. In septic shock, 19% reported 'almost never', 22% 'rarely', 29% 'occasionally', 22% 'frequently' and 7% 'almost always' using albumin. Physicians' preferences were more consistent for haemorrhagic- and cardiogenic shock, with more than 45% reporting 'almost never' using albumin. While the reported use of albumin for other purposes than resuscitation was infrequent (40%-85% reported 'almost never' for five other indications), the most frequent other indications were low serum albumin levels and improvement of the efficacy of diuretics. Most respondents (93%) would randomise adult ICU patients with shock to a trial of albumin versus no albumin. CONCLUSIONS In this international survey, the reported preferences for the use of albumin in adult ICU patients with shock varied considerably among surveyed ICU physicians. The support for a future randomised trial was high.
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Affiliation(s)
- Praleene Sivapalan
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Karen Louise Ellekjaer
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Lasse Grønningsæter
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital London, London, UK
| | - Rob Mac Sweeney
- Department of Intensive care, Royal Victoria Hospital, Belfast, UK
| | - Maria Cronhjort
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Solna, Sweden
| | - Johanna Hästbacka
- Department of Intensive Care, Tampere University Hospital, Wellbeing Services County of Pirkanmaa and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Carmen Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Marek Nalos
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J. E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Tomas Jovaisa
- Clinic of Anaesthesiology and Intensive Care, Vilnius University Faculty of Medicine, Vilnius, Lithuania
| | - Annika Reintam Blaser
- University of Tartu, Tartu, Estonia
- Department of Intensive Care, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Maurizio Cecconi
- Biomedical Sciences Department, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anaesthesia and Intensive Care, IRCCS-Humanitas Research Hospital, Rozzano, Italy
| | - Begum Ergan
- Department of Pulmonary and Critical Care, Dokuz Eylül University, Izmir, Turkey
| | - Abdulrahman Al-Fares
- Department of Anaesthesia, Critical Care Medicine and Pain Medicine, Kuwait Extracorporeal Life Support Program, Al-Amiri Hospital. Ministry of Health, Kuwait City, Kuwait
| | - Paul J Young
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Wojciech Szczeklik
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
- Military Hospital, Krakow, Poland
| | - Eric Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Ashish K Khanna
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Martin Ingi Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Anaesthesiology and Critical Care Medicine, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Tomoko Fujii
- Department of Intensive Care, Jikei University Hospital, Tokyo, Japan
| | - Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Tine Sylvest Meyhoff
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Lillebaelt Hospital, Kolding, Denmark
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16
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Kim WR, Raghunathan K, Martin GS, Davis EA, Sindhwani NS, Telang S, Lodaya K. Timely Albumin Infusion May Improve Resource Utilization in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. BIOMED RESEARCH INTERNATIONAL 2024; 2024:6673823. [PMID: 38899040 PMCID: PMC11186688 DOI: 10.1155/2024/6673823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/02/2024] [Accepted: 05/09/2024] [Indexed: 06/21/2024]
Abstract
Spontaneous bacterial peritonitis is a life-threatening complication of cirrhosis that can increase healthcare utilization. The impact of albumin administration timing on hospital resource utilization and its optimal timing is unclear, despite its efficacy in improving survival for cirrhosis patients with spontaneous bacterial peritonitis. A retrospective study was conducted to evaluate the influence of the timing of albumin administration on the length of stay and total hospital cost for patients with cirrhosis and spontaneous bacterial peritonitis who require fluid resuscitation. The study utilized de-identified data from Cerner Health Facts® data. Adult inpatients with a diagnosis of cirrhosis and SBP receiving ≥1 antibiotic and fluid resuscitation between January 1, 2009, and April 30, 2018, were included and stratified by albumin administration timing: ≤24 hours from hospital admission ("timely albumin") or >24 hours of admission or no albumin ("non-timely albumin"). We used a Kaplan-Meier curve with log-rank test to evaluate the association between timing of albumin administration and time to hospital discharge and a generalized linear model to examine the association between albumin timing and total hospital costs. We identified 1,308 hospitalizations, of which 301 contained valid cost data. The timely albumin group had a median time to discharge of 6.95 days compared to 7.78 days in the non-timely group (p = 0.02). Cost model showed that receiving timely albumin incurred 16% lower costs (p = 0.027) than patients in the non-timely albumin group. Timely albumin administration with an antibiotic regimen may shorten the length of stay and lower costs, thereby reducing hospital resource utilization in patients with cirrhosis and spontaneous bacterial peritonitis requiring fluid resuscitation.
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Affiliation(s)
- W. Ray Kim
- Division of Gastroenterology and HepatologyStanford University, Stanford, CA, USA
| | | | - Greg S. Martin
- Department of MedicineEmory University, Atlanta, GA, USA
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17
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Maiwall R, Singh SP, Angeli P, Moreau R, Krag A, Singh V, Singal AK, Tan SS, Puri P, Mahtab M, Lau G, Ning Q, Sharma MK, Rao PN, Kapoor D, Gupta S, Duseja A, Wadhawan M, Jothimani D, Saigal S, Taneja S, Shukla A, Puri P, Govil D, Pandey G, Madan K, Eapen CE, Benjamin J, Chowdhury A, Singh S, Salao V, Yang JM, Hamid S, Shalimar, Jasuja S, Kulkarni AV, Niriella MA, Tevethia HV, Arora V, Mathur RP, Roy A, Jindal A, Saraf N, Verma N, De A, Choudhary NS, Mehtani R, Chand P, Rudra O, Sarin SK. APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure. Hepatol Int 2024; 18:833-869. [PMID: 38578541 DOI: 10.1007/s12072-024-10650-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/20/2024] [Indexed: 04/06/2024]
Abstract
Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8-34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - Satender Pal Singh
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - Paolo Angeli
- Department of Internal Medicine and Hepatology, University of Padova, Padua, Italy
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure (EF CLIF), European Association for the Study of the Liver (EASL)-CLIF Consortium, and Grifols Chair, Barcelona, Spain
- Centre de Recherche sur l'Inflammation (CRI), Institut National de la Santé et de la Recherche Médicale (INSERM), Université Paris-Cité, Paris, France
- Service d'Hépatologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Beaujon, Clichy, France
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Virender Singh
- Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India
| | - Ashwani K Singal
- Department of Medicine, University of Louisville School of Medicine, Trager Transplant Center and Jewish Hospital, Louisville, USA
| | - S S Tan
- Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia
| | - Puneet Puri
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Mamun Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - George Lau
- Humanity and Health Medical Group, Humanity and Health Clinical Trial Center, Hong Kong SAR, China
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China
| | - Qin Ning
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- State Key Laboratory for Zoonotic Diseases, Wuhan, China
- Department of Pediatrics, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - P N Rao
- Department of Hepatology and Nutrition, Asian Institute of Gastroenterology, Hyderabad, India
| | - Dharmesh Kapoor
- Department of Hepatology, Gleneagles Global Hospitals, Hyderabad, Telangana, India
| | - Subhash Gupta
- Department of Surgery, Center for Liver and Biliary Sciences, Max Healthcare, Saket, New Delhi, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Manav Wadhawan
- Institute of Digestive & Liver Diseases, BLK Superspeciality Hospital Delhi, New Delhi, India
| | - Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharat Institute of Higher Education and Research, Chennai, India
| | - Sanjiv Saigal
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, India
| | - Deepak Govil
- Department of Critical Care and Anaesthesia, Medanta-The Medicity, Gurugram, Haryana, India
| | - Gaurav Pandey
- Gastroenterology and Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kaushal Madan
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - C E Eapen
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jaya Benjamin
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Chowdhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - Shweta Singh
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vaishali Salao
- Department of Critical Care, Fortis Hospital, Mulund, Mumbai, India
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Saeed Hamid
- Department of Hepatology, Aga Khan University, Karachi, Pakistan
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjiv Jasuja
- Department of Nephrology, Indraprastha Apollo Hospitals, New Delhi, India
| | | | - Madund A Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - Harsh Vardhan Tevethia
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - R P Mathur
- Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Akash Roy
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Hospitals, Kolkata, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Delhi (NCR), India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Narendra S Choudhary
- Department of Hepatology and Liver Transplantation, Medanta-The Medicity Hospital, Gurugram, Haryana, India
| | - Rohit Mehtani
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Phool Chand
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - Omkar Rudra
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India.
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18
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Wang X, Ding M, Wang W, Zheng X, Philips CA, Méndez-Sánchez N, Jin H, Qi X. Association Between Bowel Wall Thickening and Long-Term Outcomes in Decompensated Liver Cirrhosis. Adv Ther 2024; 41:2217-2232. [PMID: 37801231 DOI: 10.1007/s12325-023-02690-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/15/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Bowel wall thickening is commonly observed in liver cirrhosis, but few studies have explored its impact on the long-term outcomes of patients with cirrhosis. METHODS Overall, 118 patients with decompensated cirrhosis were retrospectively enrolled, in whom maximum wall thickness of small bowel, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum could be measured in computed tomography (CT) images. X-tile software was employed to determine the best cut-off values of each segment of bowel wall thickness for predicting the risk of further decompensation and death. Cumulative rates of further decompensation and death were calculated by Nelson-Aalen cumulative risk curve analyses. Predictors of further decompensation and death were evaluated by competing risk analyses. Sub-distribution hazard ratios (sHRs) were calculated. RESULTS Cumulative rates of further decompensation were significantly higher in patients with wall thickness of ascending colon ≥ 11.7 mm (P = 0.014), transverse colon ≥ 3.2 mm (P = 0.043), descending colon ≥ 9.8 mm (P = 0.035), and rectum ≥ 7.2 mm (P = 0.045), but not those with wall thickness of small bowel ≥ 8.5 mm (P = 0.312) or sigmoid colon ≥ 7.1 mm (P = 0.237). Wall thickness of ascending colon ≥ 11.7 mm (sHR = 1.70, P = 0.030), transverse colon ≥ 3.2 mm (sHR = 2.15, P = 0.038), and rectum ≥ 7.2 mm (sHR = 2.38, P = 0.045) were independent predictors of further decompensation, but not wall thickness of small bowel ≥ 8.5 mm (sHR = 1.19, P = 0.490), descending colon ≥ 9.8 mm (sHR = 1.53, P = 0.093) or sigmoid colon ≥ 7.1 mm (sHR = 0.63, P = 0.076). Small bowel, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum wall thickness were not significantly associated with death. CONCLUSIONS Colorectal wall thickening, but not small bowel wall, may be considered for the prediction of further decompensation in cirrhosis.
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Affiliation(s)
- Xueying Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
- Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Min Ding
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Weiwei Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
- Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Xiaojie Zheng
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology, Rajagiri Hospital, The Liver Institute, Center of Excellence in GI Sciences, Aluva, India
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic & Foundation, Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Hongxu Jin
- Emergency Medicine Department, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China.
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China.
- Postgraduate College, Jinzhou Medical University, Jinzhou, China.
- Postgraduate College, China Medical University, Shenyang, China.
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Rigo-Bonnin R, Amador A, Núñez-Gárate M, Mas-Bosch V, Padullés A, Cobo-Sacristán S, Castellote J. Determination of ertapenem in plasma and ascitic fluid by UHPLC-MS/MS in cirrhotic patients with spontaneous bacterial peritonitis. ADVANCES IN LABORATORY MEDICINE 2024; 5:173-180. [PMID: 38939197 PMCID: PMC11206183 DOI: 10.1515/almed-2023-0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/12/2023] [Indexed: 06/29/2024]
Abstract
Objectives Spontaneous bacterial peritonitis is a frequent severe complication in cirrhotic patients with ascites. Carbapenem antibiotics are currently the treatment of choice for patients with hospital-acquired or healthcare-related infections. However, there is limited evidence available on the efficacy of ertapenem in cirrhotic patients with spontaneous bacterial peritonitis. As a result, the pharmacokynetics and pharmacodynamics of this antibiotic are still unknown. The objective of this study was to develop and validate measurement procedures based on liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) to determine ertapenem concentrations in plasma and ascitic fluid. Methods Samples were pretreated by acetronile protein-precipitation. Chromatographic separation is performed on a C18 reversed-phase Acquity®-UPLC®-BEHTM column (2.1 × 100 mm id, 1.7 µm) using a non-linear gradient of water/acetonitrile containing 0.1 % of formic acid at a flow rate of 0.4 mL/min. Ertapenem and its internal standard (ertapenem-D4) are detected by tandem mass spectrometry using positive electrospray ionization and multiple reaction monitoring, and using 476.2 → 346.0/432.2 as mass transition for ertapenem and 480.2 → 350.0 for its internal standard. Results No significant interferences or carry-over contamination were observed. Imprecisions, absolute relative bias, matrix effects and normalized recoveries were ≤14.5 %, ≤9.3 % (92.8-104.5) % and (98.8-105.8) %, respectively. Chromatographic measurement procedures were linear from (0.50-100) mg/L. Conclusions The measurement procedures based on UHPLC-MS/MS developed and validated in this study could be useful in pharmacokynetic and pharmacodynamic studies in subjects with liver cirrhosis who develop spontaneous bacterial peritonitis treated with ertapenem.
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Affiliation(s)
- Raúl Rigo-Bonnin
- Clinical Laboratory, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Alberto Amador
- Service of Pharmacy, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - María Núñez-Gárate
- Clinical Laboratory, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Virgínia Mas-Bosch
- Clinical Laboratory, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Ariadna Padullés
- Unit of Hepatology and Liver Transplant, Service of Gastroenterology, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Sara Cobo-Sacristán
- Unit of Hepatology and Liver Transplant, Service of Gastroenterology, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - José Castellote
- Service of Pharmacy, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
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Rigo-Bonnin R, Amador A, Núñez-Gárate M, Mas-Bosch V, Padullés A, Cobo-Sacristán S, Castellote J. Medición de la concentración de ertapenem en el plasma y líquido ascítico mediante UHPLC-MS/MS. Aplicación en pacientes cirróticos con peritonitis bacteriana espontánea. ADVANCES IN LABORATORY MEDICINE 2024; 5:181-188. [PMID: 38939206 PMCID: PMC11206186 DOI: 10.1515/almed-2023-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/12/2023] [Indexed: 06/29/2024]
Abstract
Objetivos La peritonitis bacteriana espontánea es una complicación frecuente y grave de los pacientes cirróticos con ascitis. Actualmente, los antibióticos carbapenémicos son el tratamiento de elección en pacientes con peritonitis nosocomiales o relacionadas con el sistema sanitario. Pese a ello, los estudios de eficacia del ertapenem en pacientes cirróticos con peritonitis bacteriana espontánea son limitados y la farmacocinética y farmacodinamia de este antibiótico continúa siendo desconocida. Así, el objetivo de este estudio es desarrollar y validar procedimientos de medida basados en la cromatografía líquida de alta y rápida eficacia acoplada a la espectrometría de masas en tándem (UHPLC-MS/MS) para medir las concentraciones de ertapenem en el plasma y en el líquido ascítico. Métodos El pretratamiento de las muestras se realiza utilizando una precipitación de proteínas con acetonitrilo. La separación cromatográfica se lleva a cabo en una columna C18 de fase inversa Acquity®-UPLC®-BEHTM (2,1 × 100 mm id, 1,7 µm) utilizando un gradiente no lineal de agua/acetonitrilo que contiene un 0,1 % de ácido fórmico y an un flujo de 0,4 mL/min. El ertapenem y su patrón interno (ertapenem-D4) son detectados mediante espectrometría de masas en tándem en las modalidades de ionización mediante electroespray positiva y de monitorización múltiple de reacción utilizando, como transiciones de masa, 476,2→346,0/432,2 para el ertapenem y 480,2→350,0 para su patrón interno. Resultados No se observan interferencias ni contaminación por arrastre significativas. Las imprecisiones, los sesgos relativos absolutos, así como los efectos matriz y recuperaciones normalizadas son ≤14,5 %, ≤9,3 %, (92,8−104,5) % y (98,8−105,8) %, respectivamente. Los procedimientos de medida cromatográficos son lineales entre (0,50−100) mg/L. Conclusiones Los procedimientos de medida basados en la UHPLC-MS/MS desarrollados y validados podrían ser de utilidad para realizar estudios farmacocinéticos y farmacodinámicos en sujetos con cirrosis hepática que presentan peritonitis bacteriana espontánea tratados con ertapenem.
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Affiliation(s)
- Raúl Rigo-Bonnin
- Laboratorio Clínico, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
| | - Alberto Amador
- Servicio de Farmacia, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
| | - María Núñez-Gárate
- Laboratorio Clínico, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
| | - Virgínia Mas-Bosch
- Laboratorio Clínico, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
| | - Ariadna Padullés
- Unidad de Hepatología y Trasplante Hepático, Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
| | - Sara Cobo-Sacristán
- Unidad de Hepatología y Trasplante Hepático, Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
| | - José Castellote
- Servicio de Farmacia, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
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Fujiwara K, Kondo T, Fujimoto K, Yumita S, Ogawa K, Ishino T, Nakagawa M, Iwanaga T, Tsuchiya S, Koroki K, Kanzaki H, Inoue M, Kobayashi K, Kiyono S, Nakamura M, Kanogawa N, Ogasawara S, Nakamoto S, Chiba T, Koizumi J, Kato J, Kato N. Clinical risk factors for portal hypertension-related complications in systemic therapy for hepatocellular carcinoma. J Gastroenterol 2024; 59:515-525. [PMID: 38583112 PMCID: PMC11128395 DOI: 10.1007/s00535-024-02097-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 03/07/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND During systemic therapy, the management of portal hypertension (PH)-related complications is vital. This study aimed to clarify factors associated with the incidence and exacerbation of PH-related complications, including the usefulness of contrast-enhanced computed tomography (CECT) in the management of PH-related complications during systemic therapy. METHODS A total of 669 patients who received systemic therapy as first-line treatment (443 patients for sorafenib, 131 for lenvatinib, and 90 for atezolizumab/bevacizumab [ATZ/BEV]) were enrolled in this retrospective study. Additionally, the lower esophageal intramural vessel diameters (EIV) on CECT and endoscopic findings in 358 patients were compared. RESULTS The cutoff values of the EIV diameter on CECT were 3.1 mm for small, 5.1 mm for medium, and 7.6 mm for large varices, demonstrating high concordance with the endoscopic findings. esophageal varices (EV) bleeding predictors include EIV ≥ 3.1 mm and portal vein tumor thrombosis (PVTT). In patients without EV before systemic therapy, factors associated with EV exacerbation after 3 months were EIV ≥ 1.9 mm and ATZ/BEV use. Predictors of hepatic encephalopathy (HE) include the ammonia level or portosystemic shunt diameter ≥ 6.8 mm. The incidence of HE within 2 weeks was significantly higher (18%) in patients with an ammonia level ≥ 73 μmol/L and a portosystemic shunt ≥ 6.8 mm. The exacerbating factors for ascites after 3 months were PVTT and low albumin levels. CONCLUSIONS Careful management is warranted for patients with risk factors for exacerbation of PH-related complications; moreover, the effective use of CECT is clinically important.
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Affiliation(s)
- Kisako Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takayuki Kondo
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan.
- Ultrasound Center, Chiba University Hospital, Chiba, Japan.
| | - Kentaro Fujimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Sae Yumita
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Keita Ogawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takamasa Ishino
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Miyuki Nakagawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Terunao Iwanaga
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Satoshi Tsuchiya
- Department of Radiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keisuke Koroki
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Hiroaki Kanzaki
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masanori Inoue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kazufumi Kobayashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masato Nakamura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Naoya Kanogawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Shingo Nakamoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Tetsuhiro Chiba
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Jun Koizumi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Ultrasound Center, Chiba University Hospital, Chiba, Japan
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Kosuta I, Premkumar M, Reddy KR. Review article: Evaluation and care of the critically ill patient with cirrhosis. Aliment Pharmacol Ther 2024; 59:1489-1509. [PMID: 38693712 DOI: 10.1111/apt.18016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. AIM Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. METHODS We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. RESULTS Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. CONCLUSIONS Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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23
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Helil AS, Haile SA, Birhanu Y, Desalegn H, Desalegn DM, Geremew RA, Gebreyohannes Z, Mohammed A, Wondimagegnehu DD, Ayana G, Tizazu AM, Desta K. Bacterial profile, drug resistance pattern, clinical and laboratory predictors of ascites infection in cirrhosis patients. BMC Infect Dis 2024; 24:528. [PMID: 38797850 PMCID: PMC11128108 DOI: 10.1186/s12879-024-09418-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/20/2024] [Indexed: 05/29/2024] Open
Abstract
Ascites is a pathological collection of free fluid in the peritoneal cavity, which is a common complication in patients with cirrhosis, an advanced liver disease. Bacterial infection increases the mortality rate of hospitalized patients with cirrhosis, irrespective of the severity of the liver disease. Around 60% of patients with compensated cirrhosis developed ascites within 10 years during the course of their disease. The in-hospital mortality rate due to spontaneous bacterial peritonitis (SBP) could exceed 90%, but with early diagnosis and prompt antibiotic therapy, this rate has been shown to decrease to 20%. Here, we enrolled adult (age ≥ 18) patients with liver disease with evidence of cirrhosis who developed ascites and assessed the presence of spontaneous ascites fluid infection (SAFI) in these patients. Of the total 218 patients, 22.9% (50/218) develop ascites infection. The liver organ function tests like alanine aminotransferase, aspartate aminotransferase, total bilirubin, and direct bilirubin were found to be significantly (P < 0.05) higher in patients with ascites fluid infection compared to patients with non-ascites fluid infection. Of the gram-negative bacteria, K. pneumonia and E. coli were isolated and found to be 100% resistant to amoxicillin and clavulanate. From the gram-positive bacterial isolates, S. aureus was only resistant to penicillin, whereas Str. viridans was resistant to ceftriaxone, cefotaxime, cefepime, and penicillin. On the other hand, clinical features such as a history of jaundice, low arterial blood pressure, and ultrasound results such as a shrunken liver and enlarged spleen were also independent predictors of spontaneous bacterial peritonitis. In conclusion, given the high probability of death following SAFI, early detection, and treatment, as well as knowledge of the microbial agent, resistance profile, and predictive markers in various contexts, are essential for the timely diagnosis and management of SAFI in these patients.
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Affiliation(s)
- Abubeker Shemsu Helil
- Department of Medical Laboratory Science, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Shambel Araya Haile
- Department of Medical Laboratory Science, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Molecular and Translational Science, Monash University, Melbourne, Australia
| | - Yohannis Birhanu
- Department of Gastroenterology and Hepatology, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
| | - Hailemichael Desalegn
- Department of Gastroenterology and Hepatology, School of Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Daniel Melese Desalegn
- Department of Medical Laboratory Science, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rozina Ambachew Geremew
- Department of Microbiology, Immunology and Parasitology, School of Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Zenebe Gebreyohannes
- Department of Microbiology, Immunology and Parasitology, School of Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Awad Mohammed
- Regional laboratory capacity building, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | - Gonfa Ayana
- Regional laboratory capacity building, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Anteneh Mehari Tizazu
- Department of Microbiology, Immunology and Parasitology, School of Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Kassu Desta
- Department of Medical Laboratory Science, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
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24
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Elkbuli A, Bundschu N, Nasef H, Chin B, McClure DL, Rhodes-Lyons HX. National Analysis of Clinical Outcomes Associated With Cirrhotic Blunt Trauma Patients Undergoing Emergency Laparotomy Versus Non-operative Management: A Propensity Case-Matched Analysis. Am Surg 2024:31348241256078. [PMID: 38770924 DOI: 10.1177/00031348241256078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
INTRODUCTION This study aims to evaluate clinical outcomes among severely injured trauma patients presenting with isolated blunt abdominal solid organ injuries with a pre-diagnosis of liver cirrhosis (LC) undergoing emergency laparotomy vs nonoperative management (NOM). METHODS This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) dataset from 2017 to 2021. Adults (≥18 years) with a pre-existing diagnosis of LC who presented with severe blunt (ISS ≥ 16) isolated solid organ abdominal injuries and underwent laparotomy or NOM were included. Outcomes of interest included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and in-hospital complications such as acute renal failure and deep vein thrombosis. RESULTS 929 patients were included in this analysis, with 355 undergoing laparotomy and 574 managed nonoperatively. Laparotomy patients suffered greater in-hospital mortality (n = 186, 52.3% vs n = 115, 20.0%; P < .01), required significantly more blood within 4 hours (8.9 units vs 4.3 units, P < .01), and had a significantly longer ICU-LOS (10.2 days vs 6.7 days, P < .01). In the 1:1 propensity score matched analysis of 556 matched patients, in-hospital mortality was greater for laparotomy patients (52.3% vs 20.0%, P < .01). CONCLUSION Laparotomy was associated with significantly higher in-hospital mortality in propensity-matched trauma patients, longer ICU-LOS, and more blood products given at 4 hours compared to NOM. These findings illustrate that NOM may be a safe approach in managing severely injured trauma patients with isolated blunt abdominal solid organ injuries and a pre-diagnosis of LC.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Nikita Bundschu
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Hazem Nasef
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Brian Chin
- University of Hawaii, John A Burns School of Medicine, Honolulu, HI, USA
| | - David L McClure
- Department of Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Heather X Rhodes-Lyons
- Department of Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
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25
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Shi P, Liu J, Liang A, Zhu W, Fu J, Wu X, Peng Y, Yuan S, Wu X. Application of metagenomic next-generation sequencing in optimizing the diagnosis of ascitic infection in patients with liver cirrhosis. BMC Infect Dis 2024; 24:503. [PMID: 38769522 PMCID: PMC11107059 DOI: 10.1186/s12879-024-09396-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 05/09/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Metagenomic next-generation sequencing (mNGS) is an emerging technique for the clinical diagnosis of infectious disease that has rarely been used for the diagnosis of ascites infection in patients with cirrhosis. This study compared mNGS detection with conventional culture methods for the on etiological diagnosis of cirrhotic ascites and evaluated the clinical effect of mNGS. METHODS A total of 109 patients with ascites due to cirrhosis were included in the study. We compared mNGS with conventional culture detection by analyzing the diagnostic results, pathogen species and clinical effects. The influence of mNGS on the diagnosis and management of ascites infection in patients with cirrhosis was also evaluated. RESULTS Ascites cases were classified into three types: spontaneous bacterial peritonitis (SBP) (16/109, 14.7%), bacterascites (21/109, 19.3%) and sterile ascites (72/109, 66.1%). In addition, 109 patients were assigned to the ascites mNGS-positive group (80/109, 73.4%) or ascites mNGS-negative group (29/109, 26.6%). The percentage of positive mNGS results was significantly greater than that of traditional methods (73.4% vs. 28.4%, P < 0.001). mNGS detected 43 strains of bacteria, 9 strains of fungi and 8 strains of viruses. Fourteen bacterial strains and 3 fungal strains were detected via culture methods. Mycobacteria, viruses, and pneumocystis were detected only by the mNGS method. The mNGS assay produced a greater polymicrobial infection rate than the culture method (55% vs. 16%). Considering the polymorphonuclear neutrophil (PMN) counts, the overall percentage of pathogens detected by the two methods was comparable, with 87.5% (14/16) in the PMN ≥ 250/mm3 group and 72.0% (67/93) in the PMN < 250/mm3 group (P > 0.05). Based on the ascites PMN counts combined with the mNGS assay, 72 patients (66.1%) were diagnosed with ascitic fluid infection (AFI) (including SBP and bacterascites), whereas based on the ascites PMN counts combined with the culture assay, 37 patients (33.9%) were diagnosed with AFI (P < 0.05). In 60 (55.0%) patients, the mNGS assay produced positive clinical effects; 40 (85.7%) patients had their treatment regimen adjusted, and 48 patients were improved. The coincidence rate of the mNGS results and clinical findings was 75.0% (60/80). CONCLUSIONS Compared with conventional culture methods, mNGS can improve the detection rate of ascites pathogens, including bacteria, viruses, and fungi, and has significant advantages in the diagnosis of rare pathogens and pathogens that are difficult to culture; moreover, mNGS may be an effective method for improving the diagnosis of ascites infection in patients with cirrhosis, guiding early antibiotic therapy, and for reducing complications related to abdominal infection. In addition, explaining mNGS results will be challenging, especially for guiding the treatment of infectious diseases.
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Affiliation(s)
- Pei Shi
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China
| | - Juan Liu
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China
| | - An Liang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China
| | - Wentao Zhu
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China
| | - Jiwei Fu
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China
| | - Xincheng Wu
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China
| | - Yuchen Peng
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China
| | - Songsong Yuan
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China.
| | - Xiaoping Wu
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi Province, China.
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Schleicher EM, Gairing SJ, Castven D, Hock CS, Dobbermann H, Heinrich S, Meineck M, Kaps L, Galle PR, Weinmann-Menke J, Nguyen-Tat M, Marquardt JU, Labenz C. Lower uromodulin serum levels are associated with poorer prognosis in patients with cirrhosis and hepatorenal syndrome type 2. Am J Physiol Gastrointest Liver Physiol 2024; 326:G583-G590. [PMID: 38502914 DOI: 10.1152/ajpgi.00304.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/22/2024] [Accepted: 03/19/2024] [Indexed: 03/21/2024]
Abstract
Hepatorenal syndrome (HRS) is associated with a dismal prognosis in patients with cirrhosis, and therapeutic options are limited. Biomarkers to identify patients with poor response to therapy are urgently needed. This study aimed to evaluate the predictive value of serum levels of uromodulin (sUMOD) in patients with cirrhosis and HRS treated with terlipressin and albumin (T/A). In total, 156 patients [81 patients with HRS treated with T/A, 42 patients with cirrhosis without kidney injury, and 33 patients with cirrhosis with prerenal acute kidney injury (AKI)] were included. sUMOD levels were analyzed by ELISA. Patients with HRS were prospectively followed for the composite endpoint of hemodialysis-/liver transplantation-free survival (HD/LTx-free survival). Of the 81 patients with HRS, 40 had HRS type 1 and 41 type 2. In the cohort of patients with HRS treated with T/A, median sUMOD level was 100 ng/mL (IQR 64; 144). sUMOD differed significantly between patients with HRS compared with patients without AKI (P = 0.001) but not between patients with HRS and prerenal AKI (P = 0.9). In multivariable analyses, sUMOD levels in the lowest quartile were independently associated with a lower rate of complete response to T/A (OR 0.042, P = 0.008) and a higher risk for reaching the composite endpoint of HD/LTX-free survival (HR 2.706, P = 0.013) in patients with HRS type 2 treated with T/A. In contrast, sUMOD was not significantly associated with these outcomes in patients with HRS type 1. sUMOD may be a valuable biomarker for identifying patients with HRS type 2 treated with T/A to predict response and prognosis.NEW & NOTEWORTHY Biomarkers identifying patients with hepatorenal syndrome (HRS) and poor response to therapy are urgently needed. In this study, lower serum uromodulin (sUMOD) levels were associated with poorer response to therapy with terlipressin and albumin and consequently with poorer prognosis in patients with HRS type 2. In patients with HRS type 1, there was no association between sUMOD and poorer prognosis.
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Affiliation(s)
- Eva Maria Schleicher
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Darko Castven
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Charlotte Sophie Hock
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Henrike Dobbermann
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Sophia Heinrich
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Myriam Meineck
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Leonard Kaps
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter Robert Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Julia Weinmann-Menke
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Marc Nguyen-Tat
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jens U Marquardt
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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Roozbeh J, Ezzatzadegan Jahromi S, Rezazadeh MH, Hamidianjahromi A, Malekmakan L. Management of hepatorenal syndrome and associated outcomes: a systematic reviews. BMJ Open Gastroenterol 2024; 11:e001319. [PMID: 38631807 PMCID: PMC11033346 DOI: 10.1136/bmjgast-2023-001319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/11/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Hepatorenal syndrome (HRS), a multiorgan condition of acute kidney injury, is seen in advanced liver disease. This study aims to evaluate the current treatment for HRS. METHODS The authors searched PubMed, Scopus and Google Scholar literature. After quality assessment, 31 studies were included in this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology and the population, intervention, comparison and outcome scheme were used. We included human-controlled trials that evaluate the current treatment for HRS. Two authors independently screened articles for inclusion, extracted data and assessed the quality of included studies. RESULTS This study investigated the studies conducted on the effects of different treatments on follow-up of HRS patients. We gathered 440 articles, so 31 articles remained in our study. Of which 24 articles were conducted on terlipressin versus placebo or other treatments (midodrine/octreotide, norepinephrine, etc) that showed the higher rate of HRS reversal was detected for terlipressin in 17 studies (10 of them were significant), 2 studies achieved an insignificant lower rate of the model for end-stage liver disease score for terlipressin, 15 studies showed a decreased mortality rate in the terlipressin group (4 of them were significant). CONCLUSION This review showed that terlipressin has a significantly higher reversal rate of HRS than the other treatments. Even the results showed that terlipressin is more efficient than midodrine/octreotide and norepinephrine as a previous medication, in reverse HRS, increasing patient survival.
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Affiliation(s)
- Jamshid Roozbeh
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
| | - Shahrokh Ezzatzadegan Jahromi
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
| | - Mohamad Hossein Rezazadeh
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
| | - Anahid Hamidianjahromi
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
| | - Leila Malekmakan
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
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Tonon M, D'Ambrosio R, Calvino V, Tosetti G, Barone A, Incicco S, Gambino C, Gagliardi R, Borghi M, Zeni N, Piano S, Lampertico P, Angeli P. A new clinical and prognostic characterization of the patterns of decompensation of cirrhosis. J Hepatol 2024; 80:603-609. [PMID: 38110003 DOI: 10.1016/j.jhep.2023.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND & AIMS The prognostic impact of acute decompensation (AD), i.e. the development of complications that require hospitalization, has recently been assessed. However, complications of cirrhosis do not necessarily require hospitalization and can develop progressively, as in the recently defined non-acute decompensation (NAD). Nevertheless, there is no data regarding the incidence and prognostic impact of NAD. The aim of the study was to evaluate the incidence and the prognostic impact of NAD and AD in outpatients with cirrhosis. METHODS A total of 617 outpatients with cirrhosis from two Italian tertiary centers (Padua and Milan) were enrolled from January 2003 to June 2021 and followed prospectively until the end of the study, death or liver transplantation. The complications registered during follow-up were considered as AD if they required hospitalization, or NAD if managed at the outpatient clinic. RESULTS During follow-up, 154 patients (25.0% of total patients) developed complications, 69 patients (44.8%) developed NAD and 85 (55.2%) developed AD, while 29 patients with NAD (42.0%) developed a further episode of AD during follow-up. Sixty-month survival was significantly higher in patients with no decompensation than in patients with NAD or AD. On multivariable analysis, AD (hazard ratio [HR] 21.07, p <0.001), NAD (HR 7.13, p <0.001), the etiological cure of cirrhosis (HR 0.38, p <0.001) and model for end-stage liver disease score (HR 1.12, p = 0.003) were found to be independent predictors of mortality. CONCLUSIONS The first decompensation is non-acute in almost 50% of outpatients, though such events are still associated with decreased survival compared to no decompensation. Patients who develop NAD must be treated with extreme care and monitored closely to prevent the development of AD. IMPACT AND IMPLICATIONS This multicenter study is the first to investigate the role of non-acute decompensation (NAD) in patients with cirrhosis. In fact, while the unfavorable impact of acute decompensation is well known, there is currently a dearth of evidence on NAD, despite it being a common occurrence in clinical practice. Our data show that almost half of decompensations in patients with cirrhosis can be considered NAD and that such events are associated with a higher risk of mortality than no decompensation. This study has important clinical implications because it highlights the need to carefully consider patients who develop NAD, in order to prevent further decompensation and reduce mortality.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Roberta D'Ambrosio
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Giulia Tosetti
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Barone
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Simone Incicco
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Carmine Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Roberta Gagliardi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Marta Borghi
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Zeni
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; CRC "A. M. and A. Migliavacca" Centre for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy.
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Badal J, Badal B, Nawras M, Lee-Smith W, Stanley S, Hassan M, Ahmed Z. Diagnostic Paracentesis Within 1 Day Is Associated With Reduced Mortality and Length of Hospital Stay in Patients with Cirrhosis and Ascites. Dig Dis Sci 2024; 69:1454-1466. [PMID: 38217676 DOI: 10.1007/s10620-023-08249-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/09/2023] [Indexed: 01/15/2024]
Abstract
Spontaneous bacterial peritonitis (SBP) is the most common infection in patients with cirrhosis and is associated with high mortality. Although recent literature reports mortality benefits to early diagnostic paracentesis, current guidelines do not offer specific recommendations for how quickly diagnostic paracentesis should be performed in patients with cirrhosis and ascites who are admitted to the hospital. Therefore, we conducted a systematic review and meta-analysis to evaluate outcomes among patients admitted to the hospital with cirrhosis and ascites receiving paracentesis within ≤ 12, ≤ 1 day, and > 1 day. Eight studies with 116,174 patients were included in the final meta-analysis. The pooled risk of in-hospital mortality was significantly lower in patients who underwent early (≤ 12 h or ≤ 1 day) compared to delayed (> 12 h or > 1 day) paracentesis (RR: 0.69, p < 0.00001), and in patients who underwent paracentesis compared to no paracentesis (RR: 0.74, p < 0.00001). On subgroup analysis, in-hospital mortality was significantly lower in both paracentesis within ≤ 12 h (RR: 0.61, p = 0.02) vs. > 12 h, and within ≤ 1 day (RR: 0.70, p < 0.00001) vs. > 1 day. While there was a trend towards decreased mortality in those undergoing paracentesis within ≤ 12 h compared to ≤ 1 day, the difference did not reach statistical significance. The length of hospital stay was significantly shorter by 5.38 days in patients who underwent early (≤ 12 h) compared to delayed (> 12 h) paracentesis (95% CI 4.24-6.52, p < 0.00001). Early paracentesis is associated with reduced mortality and length of hospital stay. We encourage providers to perform diagnostic paracentesis in a timely manner, at least within 1 day of hospital admission, for all patients with cirrhosis and ascites.
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Affiliation(s)
- Joyce Badal
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA.
- UNC Faculty Physicians Center, 100 Eastowne Drive, Chapel Hill, NC, 27514, USA.
| | - Bryan Badal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, VA, USA
| | - Mohamad Nawras
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | | | - Sara Stanley
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Mona Hassan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Zohaib Ahmed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
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Koyama S, Nogami A, Yoneda M, Cheng S, Koike Y, Takeuchi Y, Iwaki M, Kobayashi T, Saito S, Utsunomiya D, Nakajima A. Chronological Course and Clinical Features after Denver Peritoneovenous Shunt Placement in Decompensated Liver Cirrhosis. Tomography 2024; 10:471-479. [PMID: 38668394 PMCID: PMC11055000 DOI: 10.3390/tomography10040036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/07/2024] [Accepted: 03/19/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Refractory ascites affects the prognosis and quality of life in patients with liver cirrhosis. Peritoneovenous shunt (PVS) is a treatment procedure of palliative interventional radiology for refractory ascites. Although it is reportedly associated with serious complications (e.g., heart failure, thrombotic disease), the clinical course of PVS has not been thoroughly evaluated. OBJECTIVES To evaluate the relationship between chronological course and complications after PVS for refractory ascites in liver cirrhosis patients. MATERIALS AND METHODS This was a retrospective study of 14 patients with refractory ascites associated with decompensated cirrhosis who underwent PVS placement between June 2011 and June 2023. The clinical characteristics, changes in cardiothoracic ratio (CTR), and laboratory data (i.e., brain natriuretic peptide (BNP), D-dimer, platelet) were evaluated. Follow-up CT images in eight patients were also evaluated for ascites and complications. RESULTS No serious complication associated with the procedure occurred in any case. Transient increases in BNP and D-dimer levels, decreased platelet counts, and the worsening of CTR were observed in the 2 days after PVS; however, they were improved in 7 days in all cases except one. In the follow-up CT, the amount of ascites decreased in all patients, but one patient with a continuous increase in D-dimer 2 and 7 days after PVS had thrombotic disease (renal and splenic infarction). The mean PVS patency was 345.4 days, and the median survival after PVS placement was 474.4 days. CONCLUSIONS PVS placement for refractory ascites is a technically feasible palliative therapy. The combined evaluation of chronological changes in BNP, D-dimer, platelet count and CTR, and follow-up CT images may be useful for the early prediction of the efficacy and complications of PVS.
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Affiliation(s)
- Shingo Koyama
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (S.K.); (S.C.); (Y.T.)
| | - Asako Nogami
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (A.N.); (M.Y.); (M.I.); (T.K.); (S.S.); (A.N.)
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (A.N.); (M.Y.); (M.I.); (T.K.); (S.S.); (A.N.)
| | - Shihyao Cheng
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (S.K.); (S.C.); (Y.T.)
| | - Yuya Koike
- Department of Interventional Radiology, Saiseikai Yokohama Nanbu Hospital, Yokohama 234-0054, Japan;
| | - Yuka Takeuchi
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (S.K.); (S.C.); (Y.T.)
| | - Michihiro Iwaki
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (A.N.); (M.Y.); (M.I.); (T.K.); (S.S.); (A.N.)
| | - Takashi Kobayashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (A.N.); (M.Y.); (M.I.); (T.K.); (S.S.); (A.N.)
| | - Satoru Saito
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (A.N.); (M.Y.); (M.I.); (T.K.); (S.S.); (A.N.)
- Department of Gastroenterology, Sanno Hospital, Tokyo 107-0052, Japan
| | - Daisuke Utsunomiya
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (S.K.); (S.C.); (Y.T.)
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan; (A.N.); (M.Y.); (M.I.); (T.K.); (S.S.); (A.N.)
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Mendez-Guerrero O, Carranza-Carrasco A, Chi-Cervera LA, Torre A, Navarro-Alvarez N. Optimizing nutrition in hepatic cirrhosis: A comprehensive assessment and care approach. World J Gastroenterol 2024; 30:1313-1328. [PMID: 38596498 PMCID: PMC11000076 DOI: 10.3748/wjg.v30.i10.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/23/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Cirrhosis is considered a growing cause of morbidity and mortality, which represents a significant public health problem. Currently, there is no effective treatment to reverse cirrhosis. Treatment primarily centers on addressing the underlying liver condition, monitoring, and managing portal hypertension-related complications, and evaluating the potential for liver transplantation in cases of decompensated cirrhosis, marked by rapid progression and the emergence of complications like variceal bleeding, hepatic encephalopathy, ascites, malnutrition, and more. Malnutrition, a prevalent complication across all disease stages, is often underdiagnosed in cirrhosis due to the complexities of nutritional assessment in patients with fluid retention and/or obesity, despite its crucial impact on prognosis. Increasing emphasis has been placed on the collaboration of nutritionists within hepatology and Liver transplant teams to deliver comprehensive care, a practice that has shown to improve outcomes. This review covers appropriate screening and assessment methods for evaluating the nutritional status of this population, diagnostic approaches for malnutrition, and context-specific nutrition treatments. It also discusses evidence-based recommendations for supplementation and physical exercise, both essential elements of the standard care provided to cirrhotic patients.
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Affiliation(s)
- Osvely Mendez-Guerrero
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Anaisa Carranza-Carrasco
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Luis Alberto Chi-Cervera
- Clínica de Especialidades Gastrointestinales y Hepáticas, Hospital Star Medica, Merida 97133, Yucatan, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Nalu Navarro-Alvarez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Molecular Biology, Universidad Panamericana School of Medicine, Campus México, Mexico City 03920, Mexico
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO 80045, United States
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Abdel-Samiee M, Awad SM, Mohamed AA, Abdelsameea E, Taha HAL. Prognosis of spontaneous bacterial peritonitis in patients with hepatocellular carcinoma. Am J Med Sci 2024; 367:171-180. [PMID: 38042406 DOI: 10.1016/j.amjms.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/27/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the fourth leading cause of death from cancer worldwide. Spontaneous bacterial peritonitis (SBP) is associated with poor prognosis. This study aimed to evaluate risk factors, differences in clinical characteristics and prognosis of SBP in patients with HCC in comparison with non-HCC patients. METHODS This study was conducted on patients with cirrhosis who were admitted to hospital with SBP. The patients were divided into two groups: SBP group with HCC (n = 150) and SBP group without HCC (n = 250). RESULTS Men and women accounted for 72% and 28% (n = 108 and 42, respectively) of the population in SBP group with HCC with mean age 55.8 ± 13.1 years. They accounted for 68.4% and 31.6% (n = 171 and 79, respectively) in the SBP group without HCC with mean age 56.8 ± 10.5 years. In-hospital mortality was 25.3% in the SBP group with HCC and 18.8% in SBP group without HCC. Gastrointestinal bleeding was the most common cause of death in both groups. No significant difference was observed in patient outcomes between the two studied groups. The deceased patients had significantly higher levels of leukocytes and neutrophils in ascitic fluid as well as a higher frequency of positive culture results than in patients who survived (p < 0.001). However, there was no significant difference in protein level in ascitic fluid or causative organism between patients who survived and those who died (p = 0.63 and 0.19, respectively). CONCLUSIONS Prognosis of SBP in patients with HCC seemed similar to that in patients without HCC.
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Affiliation(s)
- Mohamed Abdel-Samiee
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Samah Mohammad Awad
- Clinical Microbiology and Immunology and Molecular Microbiology in Liver and GIT Department, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | | | - Eman Abdelsameea
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt.
| | - Hussam Abdel-Latif Taha
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
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Raja K, Panackel C. Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice. J Clin Exp Hepatol 2024; 14:101306. [PMID: 38274509 PMCID: PMC10806298 DOI: 10.1016/j.jceh.2023.101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.
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Affiliation(s)
- Kaiser Raja
- Department of Gastroenterology and Hepatology, King's College Hospital London, Dubai, United Arab Emirates
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Yau AA, Buchkremer F. Hyponatremia in the Context of Liver Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:139-146. [PMID: 38649218 DOI: 10.1053/j.akdh.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/22/2023] [Accepted: 12/15/2023] [Indexed: 04/25/2024]
Abstract
Hyponatremia is common in patients with liver disease and is associated with increased mortality, morbidity, and a reduced quality of life. In liver transplantation, the inclusion of hyponatremia in organ allocation scores has reduced waitlist mortality. Portal hypertension and the resulting lowering of the effective arterial blood volume are important pathogenetic factors, but in most patients with liver disease, hyponatremia is multifactorial. Treatment requires a multifaceted approach that tries to reduce electrolyte-free water intake, restore urinary dilution, and increase nonelectrolyte solute excretion. Albumin therapy for hyponatremia is a peculiarity of advanced liver disease. Its use appears to be increasing, while the vaptans are currently only given in selected cases. Osmotic demyelination is a special concern in patients with liver disease. Serial checks of serum sodium concentrations and urine volume monitoring are mandatory.
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Affiliation(s)
- Amy A Yau
- Division of Nephrology, The Ohio State University, Columbus, OH
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Lv YF, Zhu B, Meng MM, Wu YF, Dong CB, Zhang Y, Liu BW, You SL, Lv S, Yang YP, Liu FQ. Development of a new Cox model for predicting long-term survival in hepatitis cirrhosis patients underwent transjugular intrahepatic portosystemic shunts. World J Gastrointest Surg 2024; 16:491-502. [PMID: 38463355 PMCID: PMC10921221 DOI: 10.4240/wjgs.v16.i2.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/23/2023] [Accepted: 01/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) placement is a procedure that can effectively treat complications of portal hypertension, such as variceal bleeding and refractory ascites. However, there have been no specific studies on predicting long-term survival after TIPS placement. AIM To establish a model to predict long-term survival in patients with hepatitis cirrhosis after TIPS. METHODS A retrospective analysis was conducted on a cohort of 224 patients who underwent TIPS implantation. Through univariate and multivariate Cox regression analyses, various factors were examined for their ability to predict survival at 6 years after TIPS. Consequently, a composite score was formulated, encompassing the indication, shunt reasonability, portal venous pressure gradient (PPG) after TIPS, percentage decrease in portal venous pressure (PVP), indocyanine green retention rate at 15 min (ICGR15) and total bilirubin (Tbil) level. Furthermore, the performance of the newly developed Cox (NDC) model was evaluated in an internal validation cohort and compared with that of a series of existing models. RESULTS The indication (variceal bleeding or ascites), shunt reasonability (reasonable or unreasonable), ICGR15, postoperative PPG, percentage of PVP decrease and Tbil were found to be independent factors affecting long-term survival after TIPS placement. The NDC model incorporated these parameters and successfully identified patients at high risk, exhibiting a notably elevated mortality rate following the TIPS procedure, as observed in both the training and validation cohorts. Additionally, in terms of predicting the long-term survival rate, the performance of the NDC model was significantly better than that of the other four models [Child-Pugh, model for end-stage liver disease (MELD), MELD-sodium and the Freiburg index of post-TIPS survival]. CONCLUSION The NDC model can accurately predict long-term survival after the TIPS procedure in patients with hepatitis cirrhosis, help identify high-risk patients and guide follow-up management after TIPS implantation.
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Affiliation(s)
- Yi-Fan Lv
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bing Zhu
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Ming-Ming Meng
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yi-Fan Wu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Cheng-Bin Dong
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Zhang
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bo-Wen Liu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Shao-Li You
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Sa Lv
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Yong-Ping Yang
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Fu-Quan Liu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Hari A, Štabuc B. Possible use of 2D shear wave liver elastography in new-onset ascites evaluation. BMC Gastroenterol 2024; 24:68. [PMID: 38331713 PMCID: PMC10851554 DOI: 10.1186/s12876-024-03159-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 02/05/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND No data on the use of 2D shear wave elastography exists regarding the evaluation of the new-onset ascites causality. AIMS To determine whether 2D shear wave elastography can help in the non-invasive assessment of the new-onset ascites cause. To assess the applicability of liver stiffness measured by 2D shear wave elastography using Esaote MyLab Nine apparatus in patients with ascites. METHODS In 52 consecutive patients with new-onset ascites (January 2020 to October 2021), liver stiffness using 2D shear wave elastography was prospectively measured. The reliable measurements were used for further analysis. Relevant clinical and laboratory data was collected. RESULTS The calculated liver stiffness measurement cut-off value of 14.4 kPa held 94% accuracy, 100% sensitivity, and 83% specificity when determining ascites with serum ascites albumin gradient ≥11 g/L. Reliable 2D shear wave elastography success rate was 84%. CONCLUSIONS 2D shear wave elastography may potentially be used to differentiate transudative from exudative ascites, especially in patients with portal hypertension and peritoneal carcinomatosis.
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Affiliation(s)
- Andrej Hari
- Department of gastroenterology and hepatology, University Medical Centre Ljubljana, Ljubljana, Slovenia.
| | - Borut Štabuc
- Department of gastroenterology and hepatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Ashritha A, Lal BB, Khanna R, Sood V, Sood AK, Alam S. Midodrine reduces new-onset acute kidney injury and hyponatremia in children with cirrhosis and ascites awaiting liver transplantation: Results from an open-label RCT. J Pediatr Gastroenterol Nutr 2024; 78:350-359. [PMID: 38374552 DOI: 10.1002/jpn3.12077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 02/21/2024]
Abstract
OBJECTIVES Midodrine, an oral α-1-adrenergic receptor agonist, counters arterial hypovolemia and reduces complications in adult patients with cirrhosis. This randomized controlled trial (RCT) aimed to assess the efficacy and safety of midodrine in preventing complications and improving survival in children with cirrhosis and ascites who are awaiting liver transplantation (LT). METHODS This open-label RCT conducted from January 2022 to May 2023 included children under 18 years with cirrhosis and ascites. Patients were randomized to receive either midodrine plus standard medical therapies (SMTs) or SMT alone. The primary outcome measure was the incidence of cirrhosis-related complications within 6 months. RESULTS Thirty-five subjects were enrolled and randomized. Patients in the midodrine arm had a lower incidence of new-onset acute kidney injury (AKI) compared with the SMT arm (11.1% vs. 41.2%). Patients in the midodrine arm showed a decline in serum creatinine and improvement in glomerular filtration rate, whereas no changes were observed in the SMT arm. There was a lower incidence of new-onset hyponatremia in the midodrine arm (20% vs. 56%). Midodrine led to reduction in plasma rennin activity (PRA) and improvement in systemic hemodynamics. There was no difference in the rate of resolution of ascites, recurrence of ascites, requirement of therapeutic paracentesis, cumulative albumin infusion requirement, episodes of spontaneous bacterial peritonitis, and hepatic encephalopathy between the two arms. CONCLUSION Midodrine, when added to SMT, was effective in reducing the incidence of new-onset AKI and hyponatremia in pediatric cirrhotics awaiting LT. It also improved systemic hemodynamics and showed a trend towards reducing PRA.
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Affiliation(s)
- A Ashritha
- Department of Pediatric Hepatology and Cardiology Section, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Bikrant B Lal
- Department of Pediatric Hepatology and Cardiology Section, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology and Cardiology Section, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikrant Sood
- Department of Pediatric Hepatology and Cardiology Section, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Arun K Sood
- Department of Pediatric Hepatology and Cardiology Section, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology and Cardiology Section, Institute of Liver and Biliary Sciences, New Delhi, India
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Rodrigues SG, van der Merwe S, Krag A, Wiest R. Gut-liver axis: Pathophysiological concepts and medical perspective in chronic liver diseases. Semin Immunol 2024; 71:101859. [PMID: 38219459 DOI: 10.1016/j.smim.2023.101859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/11/2023] [Accepted: 12/04/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Susana G Rodrigues
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Schalk van der Merwe
- Department of Gastroenterology and Hepatology, University hospital Gasthuisberg, University of Leuven, Belgium
| | - Aleksander Krag
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark, University of Southern Denmark, Odense, Denmark
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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Elkbuli A, Breeding T, Martinez B, Patel H, Chin B, Wright DD, Patterson R, Roberts J, Rhodes H. Evaluating Mortality Outcomes, Transfusion Characteristics, and Risk Factors Associated With Cirrhotic Trauma Patients Undergoing Emergency Laparotomy Versus Non-Operative Management: A National Analysis. Am Surg 2024:31348241230087. [PMID: 38272456 DOI: 10.1177/00031348241230087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Patients with liver cirrhosis (LC) demonstrate significantly elevated mortality rates following a traumatic event. This study aims to examine and compare the clinical outcomes in adult trauma patients with pre-existing LC undergoing laparotomy or non-operative management (NOM). Additionally, the study aims to investigate various patient outcomes, including mortality rate based on transfusion needs and timing. METHODS This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) 2017-21 to compare laparotomy vs NOM in adults (≥18 years) with pre-existing LC who presented to trauma facilities with isolated blunt solid organ abdominal injuries (Injury Severity Score ≥16, Abbreviated Injury Scale solid organ abdomen ≥3). RESULTS Among 929 patients, 38.2% underwent laparotomy, while 61.7% received NOM. The in-hospital mortality rate was lower for patients who received NOM (52.3% vs 20.0%, P < .01). The risk of in-hospital mortality was significantly associated with laparotomy (OR 5.22, 95% CI: 2.06-13.18, P < .01) and sepsis (OR 99.50, 95% CI: 6.99-1415.28, P < .01). On average an increase in blood units in 4 hours was observed among those who experienced an in-hospital mortality (OR 5.65, 95% CI: 3.05-8.24, P < .01) and those who underwent laparotomy (OR 3.85, 95% CI: 1.36-6.34, P < .01). CONCLUSION Trauma patients with moderate to severe isolated organ injury and Liver cirrhosis had significantly higher mortality rates, acute renal failure, whole blood units received, as well as longer ICU-LOS when undergoing laparotomy compared to non-operative management.
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Affiliation(s)
- Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Tessa Breeding
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Brian Martinez
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Heli Patel
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Brian Chin
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - D-Dre Wright
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Ryan Patterson
- Department of Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Jennifer Roberts
- Department of Trauma, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Heather Rhodes
- Center for Clinical Epidemiology and Public Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
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Rudyk DV, Tutchenko MI, Chub SL, Besedinsky MS. Portal hypertension and emergency care. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:1485-1489. [PMID: 39241149 DOI: 10.36740/wlek202407125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/08/2024]
Abstract
OBJECTIVE Aim: To evaluate the peculiarities of the course of complications and the provision of care for portal hypertension associated with the development of diureticresistant ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, and variceal bleeding. PATIENTS AND METHODS Materials and Methods: This research is based on a review of the literature in PubMed, CrossRef, Google Scholar sources on complicated portal hypertension. Such complications of portal hypertension as spontaneous bacterial peritonitis, ascites, hepatorenal sуndrome, variceal bleeding caused by sinistral portal hypertension are considered. The effectiveness of interventional treatment methods and laparoscopic surgical interventions has been demonstrated. CONCLUSION Conclusions: Diagnosis and treatment of patients with complicated portal hypertension requires a multidisciplinary approach, which is due to the diverse pathophysiological process of portal hypertension. The possibilities of providing emergency care to this category of patients depend on the level of medical training of the staff, the possibilities of medical and technical support in the provision of interventional care, the ineffectiveness of which necessitates surgical treatment using minimally invasive technologies.
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Affiliation(s)
- Diana V Rudyk
- BOGOMOLETS NATIONAL MEDICAL UNIVERSITY, KYIV, UKRAINE
| | | | - Sergiy L Chub
- BOGOMOLETS NATIONAL MEDICAL UNIVERSITY, KYIV, UKRAINE
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41
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Huang L, Han H. Diuretic use in patients with cirrhosis and complications of portal hypertension: Should we rethink the use of furosemide as first line? Clin Liver Dis (Hoboken) 2024; 23:e0090. [PMID: 38841197 PMCID: PMC11152790 DOI: 10.1097/cld.0000000000000090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/19/2023] [Indexed: 06/07/2024] Open
Affiliation(s)
- Linda Huang
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Hyosun Han
- Department of Medicine, Division of Gastrointestinal & Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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42
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Petiunin O, Shevchenko R, Brek O, Kolomenskyi O. Clinical classification of liver cirrhosis - a way to plan individual definitive treatment. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:160-165. [PMID: 38431821 DOI: 10.36740/wlek202401120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Aim: To develop clinical classification of liver cirrhosis, which can aid individualization and planning definitive treatment for this group of patients. PATIENTS AND METHODS Materials and Methods: Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "liver", "cirrhosis" and "classification"; or "liver", "cirrhosis" and "complications"; or "liver", "cirrhosis" and "treatment"; or "portal" ", "hypertension" and "complications". Articles were independently evaluated by each author, the etiological, morphological and current clinical classifications of LC were analyzed, their advantages and disadvantages identified, and after discussion classification of LC was developed by consensus. CONCLUSION Conclusions: The developed clinical classification of liver cirrhosis will facilitate the planning of therapeutic tactics for each patient, allow to personalize the treatment of patients with this pathology.
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Affiliation(s)
| | | | - Ostap Brek
- KHARKIV NATIONAL MEDICAL UNIVERSITY, KHARKIV, UKRAINE
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Hayward KL, Weersink RA, Bernardes CM, McIvor C, Rahman T, Skoien R, Clark PJ, Stuart KA, Hartel G, Valery PC, Powell EE. Changing Prevalence of Medication Use in People with Cirrhosis: A Retrospective Cohort Study Using Pharmaceutical Benefits Scheme Data. Drugs Real World Outcomes 2023; 10:605-618. [PMID: 37828144 PMCID: PMC10730495 DOI: 10.1007/s40801-023-00390-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Safe and appropriate use of medicines is essential to improve health outcomes in cirrhosis. However, little is known about the number and type of medicines dispensed to people with cirrhosis in Australia, as this predominantly occurs in the community. We aimed to characterise the prescriptions dispensed to people with cirrhosis and explore changes in the use of medication groups over time. METHODS Pharmaceutical Benefits Scheme data between 1 January 2016 and 30 June 2020 was extracted for consenting CirCare participants (multi-site, prospective, observational study). Prescriptions dispensed from cirrhosis diagnosis until liver transplant or death were included. Safety classifications for dispensed medicines were defined using published evidence-based recommendations. The pattern of medication use was analysed in 6-monthly time intervals. Generalised estimating equations models were used to estimate the change in consumption of medicines over time. RESULTS Five hundred twenty-two patients (mean age 60 years, 70% male, 34% decompensated at recruitment) were dispensed 89,615 prescriptions during the follow-up period, representing a median of 136 [interquartile range (IQR) 62-237] prescriptions and a median of 16 (IQR 11-23) unique medicines per patient (total n = 9306 medicines). The most commonly used medicines were proton pump inhibitors (PPIs) (dispensed at least once to 73% of patients), opioids (68%) and antibiotics (89%). Polypharmacy was prevalent, with 59-69% of observed participants in each time period dispensed five or more unique medicines. Prescription medication use increased over time (p < 0.001) independently of age, comorbidity burden and liver disease aetiology. The likelihood of taking PPIs, opioids, antidepressants and inhaled medicines also increased with each successive time period. Use of angiotensin therapies, metformin and statins differed over time between patients with compensated versus decompensated cirrhosis. General practitioners prescribed 69% of dispensed medicines, including a higher proportion of 'unsafe' and 'safety unknown' medicines compared with consultants/specialists (p < 0.001). CONCLUSIONS Polypharmacy is common in people with cirrhosis and some medication groups may be overused. Pharmacovigilance is required and future medication safety efforts should target high-risk prescribing practices and promote medication rationalisation in the community.
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Affiliation(s)
- Kelly L Hayward
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
| | - Rianne A Weersink
- Department of Clinical Pharmacy, Deventer Hospital, Deventer, The Netherlands
| | | | - Carolyn McIvor
- Department of Gastroenterology and Hepatology, Logan Hospital, Meadowbrook, QLD, Australia
| | - Tony Rahman
- Gastroenterology and Hepatology Department, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Richard Skoien
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Paul J Clark
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- Department of Gastroenterology and Hepatology, Mater Hospital, South Brisbane, QLD, Australia
| | - Katherine A Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Gunter Hartel
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.
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Osman KT, Nguyen JT, Patel AS, Qamar AA. The clinician's dilemma with spontaneous bacterial empyema. Clin Liver Dis (Hoboken) 2023; 22:188-192. [PMID: 38026122 PMCID: PMC10653581 DOI: 10.1097/cld.0000000000000076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/03/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Karim T. Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Julie T. Nguyen
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Division of Pulmonary Diseases & Critical Care Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Avignat S. Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Amir A. Qamar
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Division of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Zhang X, Li XX, Song JW, Zhang XC, Zhen C, Bi JF, Lu FY, Chen SM, Dan Huo D, Zhao P, Zhang DW, Tu B, Bao CM, Wang FS, Huang L. Clinical features, microbial spectrum, and antibiotic susceptibility patterns of spontaneous bacterial peritonitis in cirrhotic patients. Dig Liver Dis 2023; 55:1554-1561. [PMID: 37778896 DOI: 10.1016/j.dld.2023.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND AIMS The microbial spectrum and antimicrobial resistance patterns change over time and vary across regions in patients with spontaneous bacterial peritonitis (SBP). There is an urgent need to clarify the factors associated with in-hospital mortality in these patients. METHODS In this study, 377 patients with SBP and 794 patients with bacterascites were analyzed for the microbial spectrum, antimicrobial resistance profiles, and laboratory findings. RESULTS The most common pathogens were Escherichia coli (96, 25.5%), Staphylococcus epidermidis (55, 14.6%), and Enterococcus faecium (42, 11.1%). Multidrug-resistant (MDR) bacteria comprised 49.7% of gram-positive bacteria (GPB) and 48.8% of gram-negative bacteria (GNB). The most sensitive antibiotics were amikacin (91.5%), meropenem (89.8%) and piperacillin/tazobactam (87.6%). Extensively drug-resistant (XDR) (OR=51.457, p < 0.001), neutrophil count (OR=1.088, p < 0.001), and the model for end-stage liver disease (MELD) score (OR=1.124, p < 0.001) were independent predictive factors of in-hospital mortality in patients with SBP. CONCLUSION MDR represented nearly half of the bacteria isolated from patients with SBP, of which the high prevalence of extended-spectrum β-lactamase-producing and Carbapenem-resistant bacteria is concerning. The presence of XDR, higher MELD score, and neutrophil count were independent predictive factors associated with higher in-hospital mortality in patients with SBP, indicating that intensive care should be provided to these patients.
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Affiliation(s)
- Xin Zhang
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Xiao-Xi Li
- Department of clinical laboratory, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Jin-Wen Song
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | | | - Cheng Zhen
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Jing-Feng Bi
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Fu-Yu Lu
- Department of Information, Medical Supplies Center, Chinese PLA General Hospital, 100853, Beijing, China
| | - Su-Ming Chen
- Department of clinical laboratory, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Dan Dan Huo
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Peng Zhao
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Da-Wei Zhang
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Bo Tu
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China
| | - Chun-Mei Bao
- Department of clinical laboratory, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China.
| | - Fu-Sheng Wang
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China.
| | - Lei Huang
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, 100039, Beijing, China.
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Kumar R, Marrapu S. Dietary salt in liver cirrhosis: With a pinch of salt! World J Hepatol 2023; 15:1084-1090. [PMID: 37970619 PMCID: PMC10642432 DOI: 10.4254/wjh.v15.i10.1084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/21/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023] Open
Abstract
Patients with liver cirrhosis are advised to limit their sodium consumption to control excessive fluid accumulation. Salt is the most common form in which sodium is consumed daily. Consequently, various recommendations urge patients to limit salt intake. However, there is a lack of consistency regarding salt restriction across the guidelines. Moreover, there is conflicting evidence regarding the efficacy of salt restriction in the treatment of ascites. Numerous studies have shown that there is no difference in ascites control between patients with restriction of salt intake and those without restriction. Moreover, patients with cirrhosis may have several negative effects from consuming too little salt, although there are no recommendations on the lower limit of salt intake. Sodium is necessary to maintain the extracellular fluid volume; hence, excessive salt restriction can result in volume contraction, which could negatively impact kidney function in a cirrhotic patient. Salt restriction in cirrhotic patients can also compromise nutrient intake, which can have a negative impact on the overall outcome. There is insufficient evidence to recommend restricted salt intake for all patients with cirrhosis, including those with severe hyponatremia. The existing guidelines on salt restriction do not consider the salt sensitivity of patients; their nutritional state, volume status and sodium storage sites; and the risk of hypochloremia. This opinion article aims to critically analyze the existing literature with regard to salt recommendations for patients with liver cirrhosis and identify potential knowledge gaps that call for further research.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India.
| | - Sudheer Marrapu
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
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Iida H, Maehira H, Mori H, Nitta N, Maekawa T, Takebayashi K, Kaida S, Miyake T, Tani M. Effect of early administration of tolvaptan on pleural effusion post-hepatectomy. Langenbecks Arch Surg 2023; 408:406. [PMID: 37845430 DOI: 10.1007/s00423-023-03136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 10/04/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE This study evaluated the efficacy of tolvaptan administration at the early stage after hepatectomy to control pleural effusion and improve the postoperative course. METHODS Patients were administered tolvaptan (7.5 mg) and spironolactone (25 mg) from postoperative day 1 to postoperative day 5 (tolvaptan group, n = 68) for 13 months. Early administration of tolvaptan was not provided in the control group (n = 68); however, diuretics were appropriately administered according to the patient's condition. The amount of pleural effusion on computed tomography on postoperative day 5 was compared between the two groups. RESULTS The amount of pleural effusion and increase in body weight on postoperative day 5 showed significant differences in both groups (p < 0.001 and p = 0.019, respectively). However, the rate of pleural aspiration and the duration of postoperative hospitalization were comparable between the groups. The amount of intraoperative blood loss and lack of early administration of tolvaptan were identified as independent risk factors contributing to pleural effusion on multivariate analysis. CONCLUSION Early administration of tolvaptan to patients after hepatectomy was found to be capable of controlling postoperative pleural effusion and increase in body weight, but it did not reduce the rate of pleural aspiration or the hospitalization period.
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Affiliation(s)
- Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan.
| | - Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Nobuhito Nitta
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Takeru Maekawa
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Katsushi Takebayashi
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
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Tu H, Liu R, Zhang A, Yang S, Liu C. Risk factors for the mortality of hepatitis B virus-associated acute-on-chronic liver failure: a systematic review and meta-analysis. BMC Gastroenterol 2023; 23:342. [PMID: 37789279 PMCID: PMC10548554 DOI: 10.1186/s12876-023-02980-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/27/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Hepatitis B virus-associated acute-on-chronic liver failure (HBV-ACLF) has been confirmed as a prevalent form of end-stage liver disease in people subjected to chronic HBV infection. However, there has been rare in-depth research on the risk factors for the mortality of HBV-ACLF. This study aimed at determining the risk factors for the mortality of HBV-ACLF. METHODS The relevant research was selected from four electronic databases that have been published as of August 2023. The existing research was reviewed in accordance with the inclusion and exclusion criteria. The level of quality of previous research was evaluated using the Newcastle-Ottawa scale. Moreover, a pooled estimate of the odds ratios (ORs) with their associated 95% confidence intervals (CIs) was provided through a meta-analysis. The data were combined, and the risk variables that at least two studies had considered were analyzed. The publication bias was examined through Egger's test and Begg's test. RESULTS Twenty two studies that conformed to the inclusion criteria were selected from 560 trials. Eight risk variables in terms of HBV-ACLF mortality were determined, which covered INR (OR = 1.923, 95% CI = 1.664-2.221, P < 0.001), Monocytes (OR = 1.201, 95% CI = 1.113-1.296, P < 0.001), Cirrhosis (OR = 1.432, 95% CI = 1.210-1.696, P < 0.001), HE (OR = 2.553, 95% CI = 1.968-3.312, P < 0.001), HE grade (OR = 2.059, 95% CI = 1.561-2.717, P < 0.001), SBP (OR = 1.383, 95% CI = 1.080-1.769, P = 0.010), Hyponatremia (OR = 1.941, 95% CI = 1.614-2.334, P < 0.001), as well as HRS (OR = 2.610, 95% CI = 1.669-4.080, P < 0.001). CONCLUSION The most significant risk factors for HBV-ACLF mortality comprise HRS, HE, and HE grade, followed by INR and hyponatremia. The Monocytes, cirrhosis, and SBP have been confirmed as the additional key risk factors for HBV-ACLF mortality.
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Affiliation(s)
- Hanyun Tu
- School of Medicine, Jinan University, Guangzhou, 510632, China.
| | - Rong Liu
- Sichuan Institute of Product Quality Supervision and Inspection, Chengdu, 610100, China
| | - Anni Zhang
- School of Medicine, Jinan University, Guangzhou, 510632, China
| | - Sufei Yang
- Department of Cardiology, Daping Hospital, Army Medical University), Third Military Medical University, Chongqing, 400042, China
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, Anqing, 246004, China
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Iqbal A, Gangwani MK, Beran A, Dahiya DS, Sohail AH, Lee-Smith W, Aziz M, Hassan M. Nosocomial vs healthcare associated vs community acquired spontaneous bacterial peritonitis: Network meta-analysis. Am J Med Sci 2023; 366:305-313. [PMID: 37394136 DOI: 10.1016/j.amjms.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/24/2023] [Accepted: 06/26/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is a common complication in decompensated liver cirrhosis with ascitic fluid polymorphonuclear cell count > 250/mm3. Community acquired SBP (CA-SBP) occurs within the first 48 hours after hospital admission. Nosocomial SBP (N-SBP) occurs 48-72 hours after hospitalization. Healthcare associated SBP (HA-SBP) occurs in patients hospitalized in the preceding 90 days to months. We aim to evaluate mortality and resistance patterns to third generation cephalosporin among the three types. METHODS Multiple databases were systematically searched from inception through August 1st, 2022. Both pairwise (direct) and network (direct + indirect) meta-analysis was performed using a random effects model and DerSimonian Laird approach. Relative Risk (RR) with 95% confidence intervals (CI) were calculated. Network meta-analysis was conducted using frequentist approach. RESULTS A total of 14 studies with a total of 2302 SBP episodes were evaluated. On direct meta-analysis, mortality rate was higher in N-SBP compared to HA-SBP (RR 1.84, CI 1.43- 2.37) and CA-SBP (RR 1.69, CI 1.4-1.98), but not significantly different between HA-SBP and CA-SBP (RR=1.40, CI=0.71-2.76). Resistance to third generation cephalosporins was significantly higher in N-SBP compared to HA-SBP (RR=2.02, CI 1.26-3.22) and CA-SBP (RR=3.96, CI=2.50-3.60) as well as in HA-SBP compared to CA-SBP (RR=2.25, CI=1.33-3.81). CONCLUSIONS Our network meta-analysis shows increased mortality and antibiotic resistance with nosocomial SBP. We recommend clearly identifying such patients to manage accordingly as well as developing guidelines geared towards nosocomial infections to be able to optimally steer resistance patterns and reduce mortality.
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Affiliation(s)
- Amna Iqbal
- Department of Medicine, University of Toledo Medical Center, Toledo, Ohio, USA
| | | | - Azizullah Beran
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana, USA
| | | | - Amir Humza Sohail
- Department of General Surgery, New York University Langone Health, Long Island, NY,USA
| | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, Ohio, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Mona Hassan
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, Ohio, USA
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