51
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Shchekochikhin DY, Kozlovskaya NL, Kopylov FY, Syrkin AL, Shilov EM. Hyponatremia: A clinical approach. TERAPEVT ARKH 2017; 89:134-140. [DOI: 10.17116/terarkh2017898134-140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Hyponatremia is the most common electrolyte metabolic abnormality in clinical practice. The unfavorable course of many diseases is associated with hyponatremia. Acute severe hyponatremia is life-threatening because cerebral edema may develop. Less obvious chronic hyponatremia increases the risk of balance problems, falls and fractures, especially in elderly patients. In any occasion, hyponatremia should not be now regarded only as a laboratory phenomenon in critically ill patients, but it necessitates a thorough clinical analysis of each individual case and appropriate therapy. The paper presents approaches to diagnosing and treating hyponatremia in various clinical situations.
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52
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Jiménez JV, Carrillo-Pérez DL, Rosado-Canto R, García-Juárez I, Torre A, Kershenobich D, Carrillo-Maravilla E. Electrolyte and Acid-Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach. Dig Dis Sci 2017; 62:1855-1871. [PMID: 28501971 DOI: 10.1007/s10620-017-4597-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 04/26/2017] [Indexed: 12/17/2022]
Abstract
Electrolyte and acid-base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid-base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid-base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid-base spectrum. Because most electrolyte and acid-base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.
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Affiliation(s)
- José Víctor Jiménez
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Diego Luis Carrillo-Pérez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Rodrigo Rosado-Canto
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - David Kershenobich
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Eduardo Carrillo-Maravilla
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico.
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53
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Tanabe N, Takami T, Fujisawa K, Matsumoto T, Yamamoto N, Sakaida I. Effectiveness of tolvaptan monotherapy and low-dose furosemide/tolvaptan combination therapy for hepatoprotection and diuresis in a rat cirrhotic model. J Clin Biochem Nutr 2017; 61:53-59. [PMID: 28751810 PMCID: PMC5525014 DOI: 10.3164/jcbn.16-122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/25/2017] [Indexed: 12/30/2022] Open
Abstract
Spironolactone and furosemide, which are used to treat ascites associated with decompensated cirrhosis, are ineffective in treating refractory ascites. Hence, combination therapy with tolvaptan, a vasopressin V2 receptor antagonist, has been approved in Japan. Tolvaptan monotherapy and combination therapy with furosemide inhibit fibrosis in cardiac remodeling; hence, we examined these therapies in a rat cirrhotic model, including their usefulness in inhibiting hepatic fibrosis. In the present study, we used a model of hepatic fibrosis induced by a choline-deficient l-amino-acid-defined diet + diethylnitrosamine. Rats were divided into a low-dose furosemide group (15 mg/kg/day), a high-dose furosemide group (100 mg/kg/day), a tolvaptan monotherapy group (10 mg/kg/day), a low-dose furosemide/tolvaptan combination therapy group, and a control group which received neither furosemide nor tolvaptan; we then assessed diuretic effects and hepatic fibrosis. The tolvaptan monotherapy group and the furosemide/tolvaptan combination therapy group demonstrated significantly higher urine volume than the control group and the low-dose furosemide group. In addition, tolvaptan monotherapy and low-dose furosemide/tolvaptan combination therapy were found to inhibit hepatic fibrosis and yield a hepatoprotective effect by an antioxidative mechanism. The results of the present study suggest that tolvaptan monotherapy and low-dose furosemide/tolvaptan combination therapy are highly effective for hepatoprotection and diuresis.
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Affiliation(s)
- Norikazu Tanabe
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi 755-8505, Japan
| | - Taro Takami
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi 755-8505, Japan
| | - Koichi Fujisawa
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi 755-8505, Japan.,Center of Research and Education for Regenerative Medicine, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi 755-8505, Japan
| | - Toshihiko Matsumoto
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi 755-8505, Japan.,Department of Oncology & Laboratory Medicine, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi 755-8505, Japan
| | - Naoki Yamamoto
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi 755-8505, Japan.,Yamaguchi University Health Administration Center, 1677-1 Yoshida, Yamaguchi, Yamaguchi 753-8511, Japan
| | - Isao Sakaida
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi 755-8505, Japan
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Enescu A, Petrescu F, Mitruţ P, Pădureanu V, Petrescu OI, Albu VC, Moraru AL, Enescu AŞ. Hyponatremia - unfavourable prognostic factor in hepatic cirrhosis. ACTA ACUST UNITED AC 2017; 54:207-210. [PMID: 28002032 DOI: 10.1515/rjim-2016-0036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Indexed: 11/15/2022]
Abstract
Hyponatremia is defined by a level of Na in serum below or equal to 136 mEq/L while in hepatic cirrhosis it is classically considered as relevant only at a level of Na below 130 mEq/L. Hyponatremia frequently occurs in patients with end-stage hepatic disease. The frequency and severity are variable but it has been estimated that it occurs with a frequency of 57% in hospitalized patients with cirrhosis and in those on waiting lists for hepatic transplants. Signs and symptoms of hyponatremia are related to dysfunctions of the central nervous system, due to migration of the water from intravascular space to the brain cells, resulting in the occurrence of cerebral edema. Therapeutic options in hyponatremia are limited and are based on restriction of water consumption, exclusion of diuretics and vaptans. Hepatic transplant remains the only definitive treatment for end-stage hepatic diseases in which hyponatremia has occurred.
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55
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Solà E, Sanchez-Cabús S, Rodriguez E, Elia C, Cela R, Moreira R, Pose E, Sánchez-Delgado J, Cañete N, Morales-Ruiz M, Campos F, Balust J, Guevara M, García-Valdecasas JC, Ginès P. Effects of alfapump™ system on kidney and circulatory function in patients with cirrhosis and refractory ascites. Liver Transpl 2017; 23:583-593. [PMID: 28318147 DOI: 10.1002/lt.24763] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 02/18/2017] [Indexed: 12/28/2022]
Abstract
The alfapump system has been proposed as a new treatment for the management of refractory ascites. The system removes ascites from the peritoneal cavity to urinary bladder, producing a continuous low-volume paracentesis. The aim of the study is to investigate the effects of treatment with the alfapump™ system on kidney and circulatory function in patients with cirrhosis and refractory ascites. This was a prospective study including 10 patients with cirrhosis and refractory ascites. Primary outcomes were changes in glomerular filtration rate (GFR), as assessed by isotopic techniques, and changes in circulatory function assessed by arterial pressure, cardiac output, and activity of vasoconstrictor systems. Secondary outcomes were the need for large-volume paracentesis and adverse events. Follow-up was 1 year. GFR decreased significantly from 67 mL/minute/1.73 m2 (41-90 mL/minute/1.73 m2 ) at baseline to 45 mL/minute/1.73 m2 (36-74 mL/minute/1.73 m2 ) at month 6 (P = 0.04). Mean arterial pressure and cardiac output did not change significantly; however, there was a marked increase in plasma renin activity and norepinephrine concentration (median percent increase with respect to baseline +191% and 59%, respectively). There were 68 episodes of complications of cirrhosis in 8 patients during follow-up, the most frequent being acute kidney injury. In conclusion, treatment with alfapump™ system was associated with marked activation of endogenous vasoconstrictor systems and impairment of kidney function. The chronological relationship observed between kidney impairment and vasoconstrictor systems activation after device insertion suggests a cause-effect relationship, raising the possibility that treatment with alfapump impairs effective arterial blood volume mimicking a postparacentesis circulatory dysfunction syndrome. In this context, the potential role of albumin in counteracting these effects should be investigated in future studies. Liver Transplantation 23 583-593 2017 AASLD.
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Affiliation(s)
- Elsa Solà
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Ezequiel Rodriguez
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Chiara Elia
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Raquel Cela
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Rebeca Moreira
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Jordi Sánchez-Delgado
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Hospital Parc Taulí, Sabadell, Spain
| | | | - Manuel Morales-Ruiz
- Biochemistry and Molecular Genetics Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Jaume Balust
- Anesthesiology Department, Hospital Clínic, Barcelona, Spain
| | - Mónica Guevara
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Pere Ginès
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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56
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Fortune B, Cardenas A. Ascites, refractory ascites and hyponatremia in cirrhosis. Gastroenterol Rep (Oxf) 2017; 5:104-112. [PMID: 28533908 PMCID: PMC5421465 DOI: 10.1093/gastro/gox010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/09/2017] [Indexed: 02/06/2023] Open
Abstract
Ascites is the most common complication related to cirrhosis and is associated with increased morbidity and mortality. Ascites is a consequence of the loss of compensatory mechanisms to maintain the overall effective arterial blood volume due to worsening splanchnic arterial vasodilation as a result of clinically significant portal hypertension. In order to maintain effective arterial blood volume, vasoconstrictor and antinatriuretic pathways are activated, which increase overall sodium and fluid retention. As a result of progressive splanchnic arterial vasodilation, intestinal capillary pressure increases and results in the formation of protein-poor fluid within the abdominal cavity due to increased capillary permeability from the hepatic sinusoidal hypertension. In some patients, the fluid can translocate across diaphragmatic fenestrations into the pleural space, leading to hepatic hydrothorax. In addition, infectious complications such as spontaneous bacterial peritonitis can occur. Eventually, as the liver disease progresses related to higher portal pressures, loss of a compensatory cardiac output and further splanchnic vasodilation, kidney function becomes compromised from worsening renal vasoconstriction as well as the development of impaired solute-free water excretion and severe sodium retention. These mechanisms then translate into significant clinical complications, such as refractory ascites, hepatorenal syndrome and hyponatremia, and all are linked to increased short-term mortality. Currently, liver transplantation is the only curative option for this spectrum of clinical manifestations but ongoing research has led to further insight on alternative approaches. This review will further explore the current understanding on the pathophysiology and management of ascites as well as expand on two advanced clinical consequences of advanced liver disease, refractory ascites and hyponatremia.
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Affiliation(s)
- Brett Fortune
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, NY, USA
| | - Andres Cardenas
- Institut de Malalties Digestives i Metabolique, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Abstract
Health-related quality of life (HRQOL) has become an important outcome for patients with liver cirrhosis as the number of transplantation candidates increases by the progression of treatment strategies. Falls and fall-related injuries are common in patients with liver cirrhosis and negatively affect HRQOL. Many factors increase the risk for falls such as minimal hepatic encephalopathy, psychoactive drugs, muscle strength, autonomic dysfunction, hyponatremia, and sleep problems. It is important to understand the underlying mechanisms for falls in cirrhotic patients to prevent severe injuries such as fractures, decrease healthcare costs, and improve HRQOL. Healthcare professionals, including physiotherapists and nurses, should be aware of the higher risk for falls in this population and therapeutic interventions must be designed for patients, especially those waiting on the transplant list.
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58
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Menon S, Thompson LS, Tan M, Chahal S, Black D, Hill KA, Gritton D, Hathaway C, Perry I. Development and cost–benefit analysis of a nurse-led paracentesis and infusion service. ACTA ACUST UNITED AC 2016. [DOI: 10.12968/gasn.2016.14.9.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shyam Menon
- Department of Gastroenterology, Royal Wolverhampton NHS Trust
| | | | - Maria Tan
- Department of Gastroenterology, Royal Wolverhampton NHS Trust
| | - Sundeep Chahal
- Department of Gastroenterology, Royal Wolverhampton NHS Trust
| | - Doreen Black
- Department of Gastroenterology, Royal Wolverhampton NHS Trust
| | - Keely Anne Hill
- Department of Gastroenterology, Royal Wolverhampton NHS Trust
| | - Dean Gritton
- Department of Gastroenterology, Royal Wolverhampton NHS Trust
| | | | - Ian Perry
- Department of Gastroenterology, Royal Wolverhampton NHS Trust
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Iwasa M, Sugimoto R, Mifuji-Moroka R, Hara N, Yoshikawa K, Tanaka H, Eguchi A, Yamamoto N, Sugimoto K, Kobayashi Y, Hasegawa H, Takei Y. Factors contributing to the development of overt encephalopathy in liver cirrhosis patients. Metab Brain Dis 2016; 31:1151-6. [PMID: 27353278 DOI: 10.1007/s11011-016-9862-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/19/2016] [Indexed: 12/17/2022]
Abstract
The aim of this study was to clarify the relationships among psychometric testing results, blood ammonia (NH3) levels, electrolyte abnormalities, and degree of inflammation, and their associations with the development of overt hepatic encephalopathy (HE) in liver cirrhosis (LC) patients. The relationships between covert HE and blood NH3, sodium (Na), and C-reactive protein (CRP) were examined in 40 LC patients. The effects of elevated NH3, hyponatremia, and elevated CRP on the development of overt HE were also investigated. The covert HE group had significantly lower serum Na levels and significantly higher serum CRP levels. During the median observation period of 11 months, 10 patients developed overt HE, and the results of multivariate analysis showed that covert HE and elevated blood NH3 were factors contributing to the development of overt HE. Electrolyte abnormalities and mild inflammation are involved in the pathogenesis of HE. Abnormal psychometric testing results and hyperammonemia are linked to subsequent development of overt HE.
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Affiliation(s)
- Motoh Iwasa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
| | - Ryosuke Sugimoto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Rumi Mifuji-Moroka
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Nagisa Hara
- Nutrition Unit, Mie University Hospital, Tsu, Japan
| | - Kyoko Yoshikawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Hideaki Tanaka
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Akiko Eguchi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Norihiko Yamamoto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Kazushi Sugimoto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Yoshinao Kobayashi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Hiroshi Hasegawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Yoshiyuki Takei
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Mie University, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
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Polis S, Zang L, Mainali B, Pons R, Pavendranathan G, Zekry A, Fernandez R. Factors associated with medication adherence in patients living with cirrhosis. J Clin Nurs 2016; 25:204-12. [PMID: 26769208 DOI: 10.1111/jocn.13083] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2015] [Indexed: 12/16/2022]
Abstract
AIMS AND OBJECTIVES Medication adherence in people with cirrhosis is largely unknown. This study aims to determine adherence patterns and factors associated with adherence in patients with cirrhosis. BACKGROUND Prescribed medications are a pivotal component in the clinical management of cirrhosis with potential to retard disease progression and reduce complication risks. Medication adherence is necessary to optimise health outcomes. Understanding why medications are missed may help to develop strategies and inform nursing practice. DESIGN Prospective cohort study. METHODS Participants (n = 29) diagnosed with cirrhosis attending a tertiary hospital consented to complete a self-reported survey. Demographic information, adherence to medications, patient knowledge and quality of life data were collected, collated, checked and analysed using SPSS version 21. RESULTS Less than half of the 28 patients who completed the adherence questionnaire (n = 13, 46%) reported that they had never missed medication. Being forgetful, being away from home and falling asleep contributed to nonadherence. Having less abdominal symptoms, less fatigue and increased emotional well-being were significantly associated with patients never missing medications. CONCLUSIONS To our knowledge this is the first published study to describe adherent behaviour and the reasons medications are missed in this population. The percentage of nonadherent participants is of concern considering the potential morbidity risk that is associated with missed medications and rebound symptoms of cirrhosis. Strategies to improve and sustain adherence levels are required including enhanced adherence counselling offered to patients who are deteriorating or experience periodic exacerbation of symptoms. RELEVANCE TO CLINICAL PRACTICE Study findings have the potential to change clinical practice especially the way nurses target motivational adherence counselling, key treatment messages, education and adherence monitoring. The results presented here provide a basis for developing adherence strategies and nursing management plans to improve adherence and health outcomes in people with cirrhosis.
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Affiliation(s)
- Suzanne Polis
- Centre for Research in Nursing and Health, Kogarah, New South Wales, Australia.,The Kirby Institute, UNSW Australia, Kensington, New South Wales, Australia
| | - Ling Zang
- Department of Gastroenterology, St George Hospital, Kogarah, New South Wales, Australia
| | - Bhawana Mainali
- Department of Gastroenterology, St George Hospital, Kogarah, New South Wales, Australia
| | - Rachel Pons
- Department of Nutrition and Dietetics, St George Hospital, Kogarah, New South Wales, Australia
| | | | - Amany Zekry
- Department of Gastroenterology, St George Hospital, Kogarah, New South Wales, Australia.,Clinical School of Medicine, St George Hospital, UNSW, Australia
| | - Ritin Fernandez
- Centre for Research in Nursing and Health, Kogarah, New South Wales, Australia.,School of Nursing and Midwifery, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
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61
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Yamada T, Ohki T, Hayata Y, Karasawa Y, Kawamura S, Ito D, Kojima K, Seki M, Toda N, Tagawa K. Potential Effectiveness of Tolvaptan to Improve Ascites Unresponsive to Standard Diuretics and Overall Survival in Patients with Decompensated Liver Cirrhosis. Clin Drug Investig 2016; 36:829-35. [DOI: 10.1007/s40261-016-0434-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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62
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Nakagawa A, Atsukawa M, Tsubota A, Kondo C, Okubo T, Arai T, Itokawa N, Narahara Y, Iwakiri K. Usefulness of portal vein pressure for predicting the effects of tolvaptan in cirrhotic patients. World J Gastroenterol 2016; 22:5104-5113. [PMID: 27275103 PMCID: PMC4886386 DOI: 10.3748/wjg.v22.i21.5104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 03/19/2016] [Accepted: 03/30/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To elucidate influencing factors of treatment response, then tolvaptan has been approved in Japan for liquid retention.
METHODS: We herein conducted this study to clarify the influencing factors in 40 patients with decompensated liver cirrhosis complicated by liquid retention. Tolvaptan was administered at a dosage of 7.5 mg once a day for patients with conventional diuretic-resistant hepatic edema for 7 d. At the initiation of tolvaptan, the estimated hepatic venous pressure gradient (HVPG) value which was estimated portal vein pressure was measured using hepatic venous catheterization. We analyzed the effects of tolvaptan and influencing factors associated with treatment response.
RESULTS: Subjects comprised patients with a median age of 65 (range, 40-82) years. According to the Child-Pugh classification, class A was 3 patients, class B was 19, and class C was 18. Changes from the baseline in body weight were -1.0 kg (P = 2.04 × 10-6) and -1.3 kg (P = 1.83 × 10-5), respectively. The median HVPG value was 240 (range, 105-580) mmH2O. HVPG was only significant influencing factor of the weight loss effect. When patients with body weight loss of 2 kg or greater from the baseline was defined as responders, receiver operating characteristic curve analysis showed that the optimal HVPG cutoff value was 190 mmH2O in predicting treatment response. The response rate was 87.5% (7/8) in patients with HVPG of 190 mmH2O or less, whereas it was only 12.5% (2/16) in those with HVPG of greater than 190 mmH2O (P = 7.46 × 10-4). We compared each characteristics factors between responders and non-responders. As a result, HVPG (P = 0.045) and serum hyaluronic acid (P = 0.017) were detected as useful factors.
CONCLUSION: The present study suggests that tolvaptan in the treatment of liquid retention could be more effective for patients with lower portal vein pressure.
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Urinary excretion of the water channel aquaporin 2 correlated with the pharmacological effect of tolvaptan in cirrhotic patients with ascites. J Gastroenterol 2016; 51:620-7. [PMID: 26610908 DOI: 10.1007/s00535-015-1143-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/28/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The water channel aquaporin 2 (AQP2) at the apical membrane of renal collecting duct cells mediates water reabsorption. The expression of AQP2 at the apical membrane is tightly regulated by vasopressin and was quantitated by measurement of the urinary form by a recently developed ELISA. Tolvaptan, an antagonist of vasopressin type 2 receptor, inhibits water reabsorption in cirrhosis. The aim of this study was to determine the correlation between the pharmacological effect of tolvaptan and the dynamics of urinary AQP2 levels. METHODS Tolvaptan was administered to 41 cirrhotic patients with ascites unresponsive to standard diuretic therapy. Urinary excretion of AQP2 and urinary osmolarity were measured at the baseline and at 4, 8, and 24 h after administration of tolvaptan. RESULTS At the baseline, urinary AQP2/creatinine ratios were significantly higher in cirrhotic patients with ascites than in healthy controls (P < 0.0001). After administration of tolvaptan, urinary AQP2/creatinine ratios decreased by 45.0 % at 4 h and 77.0 % at 8 h. Similarly, urinary osmolarity decreased by 42.0 % at 4 h and 41.5 % at 8 h. Urinary AQP2 levels and urinary osmolarity significantly correlated at the baseline and at all time points after tolvaptan administration. The degree of the decrease in urinary AQP2 levels and degree of the decrease in urinary osmolarity correlated significantly at 4 h (r = 0.452, P = 0.009) and 8 h (r = 0.384, P = 0.030) after tolvaptan administration. CONCLUSIONS These results indicate that the vasopressin-AQP2 system plays a major role in fluid retention in cirrhosis and that the pharmacological effect of tolvaptan to inhibit water reabsorption can be monitored by measurement of the dynamics of urinary AQP2 levels.
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Lizaola B, Bonder A, Tapper EB, Mendez-Bocanegra A, Cardenas A. The Changing Role of Sodium Management in Cirrhosis. ACTA ACUST UNITED AC 2016; 14:274-84. [DOI: 10.1007/s11938-016-0094-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Guo H, Wu LJ, Jin Z, Li XZ, Jin JJ. Vasopressin V2-receptor antagonist tolvaptan for treating cirrhotic patients with hyponatremia and hepatic edema: A systemic review. Shijie Huaren Xiaohua Zazhi 2016; 24:938-946. [DOI: 10.11569/wcjd.v24.i6.938] [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] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of vasopressin V2-receptor antagonist tolvaptan in treating cirrhotic patients with hyponatremia and hepatic edema.
METHODS: Randomized controlled trials (RCTs) about tolvaptan in treating cirrhotic patients with hyponatremia and hepatic edema were searched from the following databases: Embase, PubMed, Medline, Cochrane Library, Google Scholar, China National Knowledge Infrastructure (CNKI), VIP and Wanfang Database. The related research data were extracted, and RevMan5.3 was used for systemic review and meta-analysis.
RESULTS: Eight RCTs including 725 patients met the inclusion criteria. Meta-analysis showed that compared with placebo, tolvaptan could significantly increase serum sodium concentration [weighted mean difference (WMD) = 7.36 mmol/L, 95%CI: 4.15-10.57, P < 0.001] and 24-h urine volume (WMD = 1060.98 mL/24 h, 95%CI: 529.43-1592.52, P < 0.001), and reduce the body weight and abdominal circumference (body weight: WMD = -1.14 kg, 95%CI: -1.34--0.94, P < 0.001; abdominal circumference: WMD = -2.18 cm, 95%CI: -3.02--1.34, P < 0.001). The effects of tolvaptan on serum potassium, serum creatinine, heart rate, systolic pressure and diastolic pressure were not statistically different from those of the placebo (P > 0.05). The incidence of adverse reactions were not statistically different between the tolvaptan and placebo groups (RR = 1.43, 95%CI: 0.73-2.80, P = 0.300).
CONCLUSION: Tolvaptan could provide a new drug option for cirrhotic patients with hyponatremia and hepatic edema.
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Iwasa M, Takei Y. Pathophysiology and management of hepatic encephalopathy 2014 update: Ammonia toxicity and hyponatremia. Hepatol Res 2015; 45:1155-62. [PMID: 25604571 DOI: 10.1111/hepr.12495] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/15/2015] [Accepted: 01/17/2015] [Indexed: 02/08/2023]
Abstract
Hyperammonemia is a major factor involved in the pathogenesis of hepatic encephalopathy (HE). Ammonia elicits astrocyte swelling and causes brain edema. In addition, hyponatremia, a condition frequently observed in hepatic cirrhosis, also exacerbates brain edema, potentially becoming a factor that exacerbates HE. Therefore, as a treatment strategy for HE, alleviating ammonia toxicity is essential. In addition to restricting protein intake, synthetic disaccharides such as lactulose and lactitol, probiotics that improve gut flora, and rifaximin, an antibiotic with poor bioavailability, are also administrated. Additionally, branched-chain amino acids and carnitine have also been administrated. Moreover, we investigated the current trend in the concomitant use of drugs with different mechanisms of action. In Japan, the V2 receptor antagonist tolvaptan can be administrated to hepatic cirrhosis patients with fluid retention. This drug is also useful as a countermeasure for hyponatremia in hepatic cirrhosis, and elucidating its effects in HE patients may therefore become an agenda in the future. These observations indicate that ammonia toxicity, gut flora control and low sodium control are major focuses in HE improvement and long-term prognosis.
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Affiliation(s)
| | - Yoshiyuki Takei
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Abstract
PURPOSE Acid-base disturbances were investigated in patients with cirrhosis in relation to hemodynamic derangement to analyze the hyperventilatory effects and the metabolic compensation. METHODS A total of 66 patients with cirrhosis and 44 controls were investigated during a hemodynamic study. RESULTS Hyperventilatory hypocapnia was present in all patients with cirrhosis and progressed from Child class A to C (P<0.01). Arterial pH increased significantly from class A to C (P<0.001) and was correlated inversely to the mean arterial blood pressure (r=-0.30, P<0.02), systemic vascular resistance (r=-0.25, P<0.05), indocyanine green clearance (r=-0.37, P<0.005), and serum sodium (r=-0.38, P<0.002). Metabolic compensation was shown by a reduced standard base excess in all patients (P<0.001). Standard base excess contained elements related to changes in serum albumin, water dilution, and effects of unidentified ions (all P<0.001). A significant hepatic component in the acid-base disturbances could not be identified. CONCLUSION Hypocapnic alkalosis is related to disease severity and hyperdynamic systemic circulation in patients with cirrhosis. The metabolic compensation includes alterations in serum albumin and water retention that may result in a delicate acid-base balance in these patients.
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Younossi Z, Henry L. Overall health-related quality of life in patients with end-stage liver disease. Clin Liver Dis (Hoboken) 2015; 6:9-14. [PMID: 31040976 PMCID: PMC6490633 DOI: 10.1002/cld.480] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 03/25/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Zobair Younossi
- Center for Liver Diseases, Department of MedicineInova Fairfax HospitalFalls ChurchVA,Betty and Guy Beatty Center for Integrated ResearchInova Health SystemFalls ChurchVA
| | - Linda Henry
- Center for Liver Diseases, Department of MedicineInova Fairfax HospitalFalls ChurchVA,Betty and Guy Beatty Center for Integrated ResearchInova Health SystemFalls ChurchVA
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Deng WJ, Zhang HR, Li HY, Shi W. Factors associated with quality of life in patients with cirrhosis. Shijie Huaren Xiaohua Zazhi 2015; 23:2729-2735. [DOI: 10.11569/wcjd.v23.i17.2729] [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] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate and evaluate the factors related to the quality of life in patients with cirrhosis.
METHODS: The quality of life for 214 cirrhosis patients treated at our hospital was assessed using the Chinese version of Medical Outcomes Study Short Form-36 (SF-36) questionnaire. Relevant clinical data for patients were also collected to conduct univariate analysis and multivariate stepwise regression analysis.
RESULTS: Univariate analysis showed that factors affecting the quality of life in all dimensions in patients with cirrhosis were percentage of treatment costs accounting for family income, fatigue, anorexia, dizziness, family economic burden, anxiety and depression (P < 0.05). Multivariate linear regression analysis demonstrated that age, dizziness, loss of appetite, anxiety, depression, and family economic burden significantly affect the quality of life scores in patients with cirrhosis (P < 0.05).
CONCLUSION: The factors influencing the quality of life in patients with cirrhosis are complex and multifactorial.
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Yan L, Xie F, Lu J, Ni Q, Shi C, Tang C, Yang J. The treatment of vasopressin V2-receptor antagonists in cirrhosis patients with ascites: a meta-analysis of randomized controlled trials. BMC Gastroenterol 2015; 15:65. [PMID: 26054761 PMCID: PMC4460759 DOI: 10.1186/s12876-015-0297-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 05/29/2015] [Indexed: 12/15/2022] Open
Abstract
Background Ascites is the most common complication of cirrhosis. It may lead to the consequence of poor prognosis and the deterioration of quality of life. Asopressin V2 receptor antagonists is a kind of vaptans, and it has been proved to be effective in hyponatremia patients. We conducted a meta-analysis about treatment of vaptans in cirrhosis patients with ascites. Methods Following our selection criteria, we collected a total of 14 studies containing 16 randomized controlled trials (2620 patients) from a series of database about the treatment with vaptans for cirrhosis with ascites patients. The included studies compared the treatment effect of lixivaptan (VPA 985), or RMJ-351647, or satavaptan, or tolvaptan with placebo. Results The included vaptans (asopressin V2 receptor antagonists) showed significant effect of increasing the serum sodium concentration for cirrhosis patients (WMD = 2.11 mmol/L, p < 0.00001). Patients also could acquire significant improvement of ascites, as this kind of aquaretics can significantly reduce ascites patients’ weight (WMD = −1.53, p < 0.00001), abdominal girth (WMD = −2.04, p < 0.00001), and the ratio of worsening ascites (RR = 0.51, p = 0.001). Though the drug did not produce more total adverse events (RR = 1.04, p = 0.09) and the total serious events (RR = 1.04, p = 0.42), the emergence of excessive correction of serum sodium concentrations (>145 mmol/L) was more frequently noted in patients under the employment of vaptans (RR = 2.14, 95 % CI [1.45, 3.16], p = 0.0001). Whether with the administration of vaptans for short-term or long-term, no survival benefit was detected from the selected studies. Conclusions Asopressin V2 receptor antagonists could play an effective and safe role in symptomatic treatment for cirrhosis patients with ascites, especially for refractory ascites patients who presented insufficient response to conventional diuretics.
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Affiliation(s)
- Long Yan
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Feng Xie
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Jiongjiong Lu
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Qingqiang Ni
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Changying Shi
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Caixi Tang
- Hepatobiliary and pancreatic surgery center, Zhuzhou Central Hospital, Zhuzhou, 412007, China.
| | - Jiamei Yang
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
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John S, Thuluvath PJ. Hyponatremia in cirrhosis: Pathophysiology and management. World J Gastroenterol 2015; 21:3197-205. [PMID: 25805925 PMCID: PMC4363748 DOI: 10.3748/wjg.v21.i11.3197] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/02/2014] [Accepted: 01/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. The development of ascites in patients with cirrhosis is multi-factorial. Portal hypertension and the associated systemic vasodilation lead to activation of the sodium-retaining neurohumoral mechanisms which include the renin-angiotensin-aldosterone system, sympathetic nervous system and antidiuretic hormone (ADH). The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume resulting in the development of ascites. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and ascites leads to impairment of the kidneys to eliminate solute- free water. This leads to additional compensatory mechanisms including non-osmotic secretion of ADH, also known as arginine vasopressin, further worsening excess water retention and thereby hyponatremia. Hyponatremia is associated with increased morbidity and mortality in patients with cirrhosis, and is an important prognostic marker both before and after liver transplant. The management of hyponatremia in this setting is a challenge as conventional therapy for hyponatremia including fluid restriction and loop diuretics are frequently inefficacious. In this review, we discuss the pathophysiology and various treatment modalities, including selective vasopressin receptor antagonists, for the management of hyponatremia in patients with cirrhosis.
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72
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Younossi Z, Henry L. Systematic review: patient-reported outcomes in chronic hepatitis C--the impact of liver disease and new treatment regimens. Aliment Pharmacol Ther 2015; 41:497-520. [PMID: 25616122 DOI: 10.1111/apt.13090] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 11/07/2014] [Accepted: 01/03/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Treatment for chronic hepatitis C (CH-C) is rapidly changing and moving away from an interferon and ribavirin-based therapy to interferon-free ribavirin-free all oral regimens. These regimens are simpler and shorter to administer with very high efficacy rates and better side effect profiles. As advances in the treatment of CH-C occur, it is imperative to capture both clinical outcomes (efficacy and safety) as well as patient-reported outcomes (PROs). In fact, PROs assesses and quantifies the impact of these regimens on patient experience. PROs assess patients' health-related quality of life (HRQOL) especially in the realms of fatigue and neuropsychiatric issues such as depression which can affect treatment adherence and work productivity. AIM To review the literature related to PRO's in HCV patients and summarise the impact of CH-C and its treatment on PROs. METHODS Databases Ovid MEDLINE and PubMed were searched from 1990 to October 2014 using a combination of MEsh, thesaurus terms and relevant text words: hepatitis C, CH-C, treatment, quality of life, health-related quality of life, fatigue, work productivity, adherence, patient-reported outcomes, direct acting anti-viral agents and second generation direct acting anti-viral agents. Each manuscript was assessed for pertinence to the issue of PROs in CH-C as well as the quality of study design and publications. RESULTS From the literature, it is evident that CH-C patients have baseline PRO impairment. Furthermore, treatment with interferon with or without ribavirin and first generation DAAs causes additional PRO burden which can negatively impact treatment adherence and indirectly, treatment efficacy and work productivity. The new treatment regimens with interferon- and ribavirin-free regimens not only have very high efficacy, but also result in the improvement of PRO scores as early as 2 weeks into treatment as well as possibly better adherence to treatment regimens. CONCLUSIONS CH-C and its treatment have been associated with patient-reported outcome impairment. The new IF-free and RBV-free regimens are associated with high efficacy and substantial improvement of patient-reported outcomes in clinical trial setting. Although very encouraging, more data are needed to assess patient-reported outcomes, adherence and work productivity of CH-C patients in the real world setting of clinical practice.
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Affiliation(s)
- Z Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
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Cárdenas A, Riggio O. Correction of hyponatraemia in cirrhosis: treating more than a number! J Hepatol 2015; 62:13-4. [PMID: 25281862 DOI: 10.1016/j.jhep.2014.09.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 09/25/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Andrés Cárdenas
- GI Unit, Institut Clinic de Malalties Digestives i Metaboliques, Hospital Clinic, and University of Barcelona, Spain.
| | - Oliviero Riggio
- GI and Liver Unit, Department of Clinical Medicine, "Sapienza" University of Rome, Italy
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Younossi Z, Henry L. The impact of the new antiviral regimens on patient reported outcomes and health economics of patients with chronic hepatitis C. Dig Liver Dis 2014; 46 Suppl 5:S186-96. [PMID: 25458773 DOI: 10.1016/j.dld.2014.09.025] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 09/29/2014] [Indexed: 12/11/2022]
Abstract
Hepatitis C is an important cause of chronic liver disease worldwide with an estimated 170 million people infected. Hepatitis C virus (HCV)-infected patients are physically and mentally impacted by fatigue, depression and anxiety causing an impairment of health related quality of life (HRQOL), lower worker productivity and other patient reported outcomes (PROs). Although anti-HCV regimens containing first generation direct acting antiviral agents (DAAs) were associated with significant side effects, the second generation DAAs, sofosbuvir (SOF) and simeprevir (SMV), are associated with fewer side effects, better tolerability and high cure rates. Despite these advantages, key stakeholders are currently trying to find ways to best integrate these new therapeutic regimens into the management of patients with chronic hepatitis C for the benefit of all. The purpose of this article is to offer insight into the other key and equally important outcomes (PRO's, HRQOL and cost) which should be considered when assessing the applicability of these new regimens for the care of patients infected with HCV. Our review provides evidence that the new treatment regimens for HCV not only have high efficacy rates but are also associated with better patient reported outcomes and cost per case of HCV cured. Additionally, compared to other medical interventions, these new regimens are cost-effective from a societal perspective.
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Affiliation(s)
- Zobair Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA.
| | - Linda Henry
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
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Low-dose tolvaptan for the treatment of dilutional hyponatremia in cirrhosis: a case report and literature review. Case Reports Hepatol 2014; 2014:795261. [PMID: 25383228 PMCID: PMC4208386 DOI: 10.1155/2014/795261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 04/03/2014] [Accepted: 04/15/2014] [Indexed: 11/17/2022] Open
Abstract
Dilutional hyponatremia is common in decompensated cirrhosis and can be successfully treated by tolvaptan, a vasopressin V2-receptor antagonist. Data were lacking regarding the effects of tolvaptan on cirrhotic patients with a Child-Pugh score of >10 and a serum sodium concentration of <120 mmol/L. We report a case of forties man with a 20-year history of chronic hepatitis B presenting with yellow urine and skin. Laboratory tests demonstrated prolonged prothrombin time, markedly elevated total bilirubin, severe hyponatremia, and a Child-Pugh score of >10. The patient was diagnosed with dilutional hyponatremia and was treated with recommended dosage tolvaptan at first. The serum concentration of sodium recover but the patient felt obviously thirsty. As the dosage of tolvaptan was decreased accordingly from 15 mg to 5 mg, the patient still maintained the ideal concentration of serum sodium. This case emphasizes that cirrhotic patient with higher Child-Pugh scores and serum sodium concentration of <120 mmol/L can be treated with lower dose of tolvaptan.
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Orr JG, Homer T, Ternent L, Newton J, McNeil CJ, Hudson M, Jones DEJ. Health related quality of life in people with advanced chronic liver disease. J Hepatol 2014; 61:1158-65. [PMID: 25010259 DOI: 10.1016/j.jhep.2014.06.034] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 06/19/2014] [Accepted: 06/30/2014] [Indexed: 02/06/2023]
Abstract
Cirrhosis has a long natural history with considerable symptomatic impacts, particularly in advancing disease. Measuring health related quality of life (HRQOL) in liver disease provides detail about the nature and extent of its effects on individuals. Understanding the drivers of impaired HRQOL can help identify targets for improvement through new treatments or health systems service delivery. Evaluation of novel therapies which target symptomatic improvement, should be done with suitable outcome measures, including HRQOL assessment. In this article, we provide an overview of HRQOL in advanced liver disease for the clinician. A clear description of the important HRQOL tools is given alongside a discussion of the factors, which are known to contribute to impaired HRQOL in advanced liver disease.
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Affiliation(s)
- James G Orr
- Institute of Cellular Medicine, Newcastle University, UK
| | - Tara Homer
- Institute of Health and Society, Newcastle University, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, UK
| | - Julia Newton
- Institute of Cellular Medicine, Newcastle University, UK
| | - Calum J McNeil
- Institute of Cellular Medicine, Newcastle University, UK
| | - Mark Hudson
- Institute of Cellular Medicine, Newcastle University, UK
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Nakamura T, Torimura T, Iwamoto H, Kurogi J, Inoue H, Hori Y, Sumie S, Fukushima N, Sakata M, Koga H, Abe M, Ikezono Y, Hashimoto O, Ueno T, Oho K, Okamura T, Okuda S, Kawamoto A, Ii M, Asahara T, Sata M. CD34(+) cell therapy is safe and effective in slowing the decline of hepatic reserve function in patients with decompensated liver cirrhosis. J Gastroenterol Hepatol 2014; 29:1830-8. [PMID: 24731186 DOI: 10.1111/jgh.12622] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Preclinical studies in rodent models of chronic liver fibrosis have shown that transplantation of peripheral blood (PB) CD34(+) cells leads to hepatic regeneration and a reduction of liver fibrosis by suppressing hepatic stellate cell activity and increasing matrix metalloproteinase activity. The aim of this study was to examine the safety and clinical efficacy of intrahepatic transplantation of autologous granulocyte colony-stimulating factor (G-CSF)-mobilized PB-CD34(+) cells in patients with decompensated liver cirrhosis. METHODS PB-CD34(+) cells were isolated from G-CSF-mobilized apheresis products. Ten patients were treated with G-CSF-mobilized PB-CD34(+) cells (treatment group) and seven patients were treated with standard medical therapy. For mobilization, patients in the treatment group received subcutaneous injections of 10 μg G-CSF/kg/day for 5 days. The cells were then injected at three different doses (5 × 10(5) , 1 × 10(6) and 2 × 10(6) cells/kg) through the hepatic artery. Thereafter, all patients were followed up for 24 months. RESULTS G-CSF treatment and leukapheresis were well tolerated, and no serious adverse events were observed. Patients in the treatment group had a significant but transient splenomegaly. After 24 weeks, serum albumin was significantly increased in patients who had received middle or high doses of CD34(+) cells compared with baseline. Doppler ultrasound showed a significant increase in hepatic blood flow velocity and blood flow volume after CD34(+) cell therapy. The hepatic vein pressure gradient decreased in two patients who received high-dose CD34(+) cells at week 16. CONCLUSIONS CD34(+) cell therapy is feasible, safe and effective in slowing the decline of hepatic reserve function.
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Affiliation(s)
- Toru Nakamura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan; Liver Cancer Division, Research Center for Innovative Cancer Therapy, Kurume University, Kurume, Japan
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Jara M, Bednarsch J, Malinowski M, Lüttgert K, Orr J, Puhl G, Seehofer D, Neuhaus P, Stockmann M. Predictors of quality of life in patients evaluated for liver transplantation. Clin Transplant 2014; 28:1331-8. [PMID: 25053350 DOI: 10.1111/ctr.12426] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Health-related quality of life (HRQOL) is severely impaired in advanced liver disease. The purpose of this study was to evaluate the impact of actual liver function and disease-specific factors on HRQOL of patients evaluated for liver transplantation. PATIENTS AND METHODS Disease-specific QOL was analyzed in 142 patients evaluated for liver transplantation using the German version of the Chronic Liver Disease Questionnaire (CLDQ-D). We performed quantitative liver function tests and collected clinical and demographical data of patients after their referral to our transplant department. Values were correlated with CLDQ-D scores. RESULTS Neither model for end-stage liver disease (MELD) nor dynamic liver function test results were related to quality of life. Serum albumin concentration was a strong but not independent factor correlated with global CLDQ-D (r = 0.269, p < 0.001). Independent predictors of global CLDQ-D were ascites and butyrylcholinesterase serum concentration (B = -0.486, p < 0.001 and B = 0.196, p = 0.002, respectively). CONCLUSION Actual liver function is not related to decreased quality of life, whereas ascites and hypoproteinemia represent the major factors influencing physical and social aspects of daily life in potential liver transplant candidates.
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Affiliation(s)
- Maximilian Jara
- Department of General, Visceral and Transplantation Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Abu Zeinah GF, Al-Kindi SG, Hassan AA, Allam A. Hyponatraemia in cancer: association with type of cancer and mortality. Eur J Cancer Care (Engl) 2014; 24:224-31. [PMID: 24661476 DOI: 10.1111/ecc.12187] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2014] [Indexed: 11/28/2022]
Abstract
Hyponatraemia is common in patients with cancer. The objectives of this study are to investigate the severity distribution of hyponatraemia and its association with mortality. We retrospectively reviewed medical records for patients admitted to a national centre for cancer care and research in Qatar between 2008 and 2012. A model was built through multivariate analyses to investigate the role of hyponatraemia in mortality. Patients were grouped into those who had moderate-severe hyponatraemia (Na < 130) and those who only had normal-mild hyponatraemia (Na ≥ 130). A total of 2048 patients were included in this study. Prostate (57.1%), pancreatic (50%), liver (49%) and lung (40.2%) cancers showed the highest frequency of moderate-severe hyponatraemia, while breast cancer showed the lowest frequency at 23.5%. In the multivariate analyses, patients with moderate-severe hyponatraemia (Na < 130 mmol/L) were 4.28 times more likely to die than those with normal-mild hyponatraemia (Na ≥ 130) (P < 0.05). The present study shows that hyponatraemia is a common electrolyte disturbance among hospitalised patients with cancer diagnoses. The severity of hyponatraemia was a statistically significant independent factor associated with higher in-hospital mortality. This is in accordance with the reported literature and emphasises the importance of early diagnosis and correction of hyponatraemia.
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Affiliation(s)
- G F Abu Zeinah
- Department of Internal Medicine, New York Presbyterian Hospital, New York, NY
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80
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Abstract
Hyponatraemia is a common complication of advanced cirrhosis related to an impairment in the renal capacity for eliminating solute-free water, causing a retention of water that is disproportionate to the retention of sodium, thus leading to a reduction in serum sodium concentration and hypo-osmolality. The main pathogenic factor responsible for hyponatraemia is a non-osmotic hypersecretion of arginine vasopressin (AVP) or antidiuretic hormone from the neurohypophysis, related to circulatory dysfunction. Hyponatraemia in cirrhosis is associated with increased morbidity and mortality. Hyponatraemia is also associated with increased morbidity and impaired short-term survival after transplantation. The current standard of care based on restricting fluids to 1-1.5 L/day is rarely effective. Other approaches, such as albumin infusion and the use of vaptans-which act by specifically antagonizing the effects of AVP on the V2 receptors located in the kidney tubules-have been evaluated for their role in the management of hyponatraemia. The short-term treatment with vaptans is associated with a marked increase in renal solute-free water excretion and improvement of hyponatraemia; however their use in patients with end-stage liver disease is limited by hepatotoxic effects of some of these drugs. Long-term administration of vaptans seems to be effective in maintaining the improvement of serum sodium concentration, but the available information is still limited.
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Affiliation(s)
- Robert J Gianotti
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston MA and GI Unit, Institut Clinic de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona
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81
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Sakaida I, Kawazoe S, Kajimura K, Saito T, Okuse C, Takaguchi K, Okada M, Okita K. Tolvaptan for improvement of hepatic edema: A phase 3, multicenter, randomized, double-blind, placebo-controlled trial. Hepatol Res 2014; 44:73-82. [PMID: 23551935 DOI: 10.1111/hepr.12098] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 02/05/2013] [Accepted: 02/17/2013] [Indexed: 12/11/2022]
Abstract
AIM Hepatic edema is manifested by ascites, lower limb edema and intolerable symptoms. Some patients insufficiently respond to the conventional diuretic therapy. Therefore, a novel therapeutic option is required. We conducted a phase 3 study to confirm therapeutic effect of tolvaptan on hepatic edema associated with liver cirrhosis. METHODS In our multicenter, randomized, double-blind, placebo-controlled trial, liver cirrhosis patients who showed insufficient response to conventional diuretics were randomly assigned to 7-day administration of either tolvaptan at 7.5 mg/day or placebo as an add-on therapy to conventional diuretics. The primary outcome was change in bodyweight from baseline. RESULTS Of 164 eligible patients, 84 were assigned to tolvaptan and 80 to placebo. Change in bodyweight from baseline on the final dosing day was -0.44 kg (standard deviation [SD], 1.93) in the placebo group and -1.95 kg (SD, 1.77) in the tolvaptan group (P < 0.0001). Improvement rates for lower limb edema and ascites-related clinical symptoms were higher with tolvaptan than with placebo. Even in patients with low serum albumin (<2.5 g/dL), decrease in bodyweight was greater with tolvaptan than with placebo (P = 0.0163). In addition, tolvaptan significantly increased serum sodium concentration from baseline. CONCLUSION Add-on therapy with tolvaptan was effective for the treatment of hepatic edema and ascites-related clinical symptoms. Furthermore, tolvaptan is expected to improve low serum sodium concentration and to exert its effect regardless of serum albumin level. Add-on therapy with tolvaptan is therefore considered to be a novel therapeutic option for hepatic edema.
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Affiliation(s)
- Isao Sakaida
- Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi
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82
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Werkgartner G, Wagner D, Manhal S, Fahrleitner-Pammer A, Mischinger HJ, Wagner M, Grgic R, Roller RE, Kniepeiss D. Long-term quality of life of liver transplant recipients beyond 60 years of age. AGE (DORDRECHT, NETHERLANDS) 2013; 35:2485-2492. [PMID: 23529506 PMCID: PMC3825006 DOI: 10.1007/s11357-013-9527-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Accepted: 03/12/2013] [Indexed: 08/10/2023]
Abstract
Due to ameliorated surgery as well as better immunosuppression, the recipient age after liver transplantation has been extended over the past years. This study aimed to investigate the health related quality of life after liver transplantation in recipients beyond 60 years of age. The SF-36 was used to evaluate the recipients' health-related quality of life as standardized tool. It comprises 36 items that are attributed to 8 subscales attributed to 2 components: the physical component score and the mental component score. Differences in the health-related quality of life between the included aged recipients and age-matched general population as well as among female and male recipients. Aged recipients showed significantly lower scores in physical functioning (29 vs. 76, p = 0.001), role physical (42 vs. 73, p = 0.003), bodily pain (34 vs. 71, p = 0.003), general health (28 vs. 59, p = 0.001), vitality (25 vs. 61, p = 0.001), social functioning (36 vs. 87, p =0.001), role emotional (46 vs. 89, p = 0.001) as well as the physical component score (28 vs. 76, p = 0.001). Aged female recipients showed lower results as compared to males in social functioning, physical functioning, role physical, and social functioning (p = 0.03 respectively) but comparable results in the remaining. Quality of life seems to be an issue among aged recipients and should be assessed on a regular basis.
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Affiliation(s)
- G. Werkgartner
- />Division for General Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - D. Wagner
- />Division for Transplantation, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - S. Manhal
- />Office of the Vice Rector for Studies and Teaching, Medical University of Graz, Graz, Austria
| | - A. Fahrleitner-Pammer
- />Division for Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - H. J. Mischinger
- />Division for General Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - M. Wagner
- />Division for Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - R. Grgic
- />Division for Transplantation, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - R. E. Roller
- />Division for Geriatrics, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - D. Kniepeiss
- />Division for Transplantation, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
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83
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Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, Thompson CJ. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med 2013; 126:S1-42. [PMID: 24074529 DOI: 10.1016/j.amjmed.2013.07.006] [Citation(s) in RCA: 594] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hyponatremia is a serious, but often overlooked, electrolyte imbalance that has been independently associated with a wide range of deleterious changes involving many different body systems. Untreated acute hyponatremia can cause substantial morbidity and mortality as a result of osmotically induced cerebral edema, and excessively rapid correction of chronic hyponatremia can cause severe neurologic impairment and death as a result of osmotic demyelination. The diverse etiologies and comorbidities associated with hyponatremia pose substantial challenges in managing this disorder. In 2007, a panel of experts in hyponatremia convened to develop the Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations that defined strategies for clinicians caring for patients with hyponatremia. In the 6 years since the publication of that document, the field has seen several notable developments, including new evidence on morbidities and complications associated with hyponatremia, the importance of treating mild to moderate hyponatremia, and the efficacy and safety of vasopressin receptor antagonist therapy for hyponatremic patients. Therefore, additional guidance was deemed necessary and a panel of hyponatremia experts (which included all of the original panel members) was convened to update the previous recommendations for optimal current management of this disorder. The updated expert panel recommendations in this document represent recommended approaches for multiple etiologies of hyponatremia that are based on both consensus opinions of experts in hyponatremia and the most recent published data in this field.
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84
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Differential impact of hyponatremia and hepatic encephalopathy on health-related quality of life and brain metabolite abnormalities in cirrhosis. J Hepatol 2013; 59:467-73. [PMID: 23665182 PMCID: PMC3748234 DOI: 10.1016/j.jhep.2013.04.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 04/16/2013] [Accepted: 04/20/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hyponatremia (HN) and hepatic encephalopathy (HE) together can impair health-related quality of life (HRQOL) and cognition in cirrhosis. We aimed at studying the effect of hyponatremia on cognition, HRQOL, and brain MR spectroscopy (MRS) independent of HE. METHODS Four cirrhotic groups (no HE/HN, HE alone, HN alone (sodium <130 mEq/L), HE+HN) underwent cognitive testing, HRQOL using Sickness Impact Profile (SIP: higher score is worse; has psychosocial and physical sub-scores) and brain MRS (myoinositol (mI) and glutamate+glutamine (Glx)), which were compared across groups. A subset underwent HRQOL testing before/after diuretic withdrawal. RESULTS 82 cirrhotics (30 no HE/HN, 25 HE, 17 HE+HN, and 10 HN, MELD 12, 63% hepatitis C) were included. Cirrhotics with HN alone and without HE/HN had better cognition compared to HE groups (median abnormal tests no-HE/HN: 3, HN: 3.5, HE: 6.5, HE+HN: 7, p=0.008). Despite better cognition, HN only patients had worse HRQOL in total and psychosocial SIP while both HN groups (with/without HE) had a significantly worse physical SIP (p<0.0001, all comparisons). Brain MRS showed the lowest Glx in HN and the highest in HE groups (p<0.02). mI levels were comparably decreased in the three affected (HE, HE+HN, and HN) groups compared to no HE/HN and were associated with poor HRQOL. Six HE+HN cirrhotics underwent diuretic withdrawal which improved serum sodium and total/psychosocial SIP scores. CONCLUSIONS Hyponatremic cirrhotics without HE have poor HRQOL despite better cognition than those with concomitant HE. Glx levels were lowest in HN without HE but mI was similar across affected groups. HRQOL improved after diuretic withdrawal. Hyponatremia has a complex, non-linear relationship with brain Glx and mI, cognition and HRQOL.
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85
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Fortune BE, Garcia‐Tsao G. Hypervolemic hyponatremia: Clinical significance and management. Clin Liver Dis (Hoboken) 2013; 2:109-112. [PMID: 30992838 PMCID: PMC6448632 DOI: 10.1002/cld.179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Brett E. Fortune
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT
| | - Guadalupe Garcia‐Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT,Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, CT
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Abstract
Quality of life is a construct that reflects the positive and negative aspects of one's life, and is expanded upon by health-related quality of life (HRQL), which specifically address the impact of health on patients' well-being. Cirrhosis is the culmination of various pathways that leads into development of advanced hepatic fibrosis with its complications. This paper addresses the impact of cirrhosis on individuals HRQL. In addition, we will define what disease specific and general HRQL instruments aim to measure. We discuss the liver disease specific scales [Chronic Liver Disease Questionnaire (CLDQ), Liver Disease Quality of Life 1.0 (LDQOL)] and the most commonly used generic health profile [Short Form 36 Profile (SF-36)]. Furthermore, we examine recent literature which describes how to measure and what is known about quality of life of patients with cirrhosis. This information gives insight to health care providers concerning the impact of disease on patients if treatments are not only to improve health but also function and unexpected treatment outcomes.
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87
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Mellinger JL, Volk ML. Multidisciplinary management of patients with cirrhosis: a need for care coordination. Clin Gastroenterol Hepatol 2013; 11:217-23. [PMID: 23142204 PMCID: PMC3644483 DOI: 10.1016/j.cgh.2012.10.040] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 10/24/2012] [Indexed: 02/07/2023]
Abstract
Cirrhosis is a common chronic condition with high rates of morbidity and mortality. Optimal medical management involves a multidisciplinary approach, but coordination between medical specialties needs to be improved. This clinical perspective discusses care coordination interventions that have been successful in other disease states and how they could be applied to the management of cirrhosis.
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Affiliation(s)
- Jessica L Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan 48109-5362, USA
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88
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Abstract
Hyponatraemia--the most common serum electrolyte disorder--has also emerged as an important marker of the severity and prognosis of important diseases such as heart failure and cirrhosis. Acute hyponatraemia can cause severe encephalopathy, but the rapid correction of chronic hyponatraemia can also profoundly impair brain function and even cause death. With the expanding elderly population and the increased prevalence of hyponatraemia in this segment of society, prospective studies are needed to examine whether correcting hyponatraemia in the elderly will diminish cognitive impairment, improve balance and reduce the incidence of falls and fractures. Given that polypharmacy is also common in the elderly population, the various medications that may stimulate arginine vasopressin release and/or enhance the hormone's action to increase water absorption must also be taken into consideration. Whether hyponatraemia in a patient with cancer is merely a marker of poor prognosis or whether its presence may alter the patient's quality of life remains to be examined. In any case, hyponatraemia can no longer be considered as just a biochemical bystander in the ill patient. A systematic diagnostic approach is necessary to determine the specific aetiology of a patient's hyponatraemia. Therapy must then be dictated not only by recognized reversible causes such as advanced hypothyroidism, adrenal insufficiency, diuretics or other medicines, but also by whether the hyponatraemia occurred acutely or chronically. Information is emerging that the vast majority of cases of hyponatraemia are caused by the nonosmotic release of arginine vasopressin. Now that vasopressin V2-receptor blockers are available, a new era of clinical investigation is necessary to examine whether hyponatraemia is just a marker of severe disease or whether correction of hyponatraemia could improve a patient's quality of life. Such an approach must involve prospective randomized studies in different groups of patients with hyponatraemia, including those with advanced heart failure, those with cirrhosis, patients with cancer, and the elderly.
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