1451
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Alsebaey A, Elhelbawy M. Insulin resistance is not a risk factor for oesophageal varices development in hepatitis C. Trop Doct 2019; 49:281-285. [PMID: 31296148 DOI: 10.1177/0049475519863231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Chronic hepatitis C (HCV) patients commonly have insulin resistance which is a risk factor for disease progression. Oesophageal varices may bleed with high mortality. We aimed to assess the relationship between insulin resistance and oesophageal varices. HCV-related compensated liver cirrhosis patients (n = 146) underwent gastroscopy and homeostasis model assessment (HOMA)-IR, HOMA-β and HOMA-S calculations. Their average age was 54.98 years; most (84.9%) patients were men and non-diabetic (60.3%). Patients with oesophageal varices had higher median Model for End-Stage Liver Disease (MELD) scores and comparable Child-Pugh class. Patients with and without oesophageal varices had comparable (P > 0.05) HOMA scores and insulin resistance percentage of 82.9% versus 85.5%. We therefore conclude that insulin resistance is unrelated to the presence of oesophageal varices.
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Affiliation(s)
- Ayman Alsebaey
- Associate Professor, Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen El-Koom, Egypt
| | - Mostafa Elhelbawy
- Lecturer, Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen El-Koom, Egypt
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1452
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Hiramine Y, Uto H, Mawatari S, Kanmura S, Imamura Y, Hiwaki T, Saishoji A, Yada T, Inada Y, Sakamoto H, Higashi H, Kubozono O, Maenohara S, Ido A. Effect of tolvaptan on the prognosis of patients with hepatic ascites. Hepatol Res 2019; 49:765-777. [PMID: 30916842 DOI: 10.1111/hepr.13337] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 12/12/2022]
Abstract
AIM Despite accumulating evidence concerning the efficacy of tolvaptan in the treatment of body fluid retention or hyponatremia, the effect of tolvaptan on the prognosis of patients with hepatic ascites has not been fully investigated. METHODS A total of 628 patients with hepatic ascites who were treated with diuretics (furosemide, spironolactone, or tolvaptan) between 2007 and 2017 were enrolled and divided into two groups: those who received tolvaptan (original tolvaptan group, n = 278) and those who did not (original control group, n = 350). The cumulative survival rates between the groups were compared and the factors associated with survival in patients with hepatic ascites were identified using a Cox regression analysis. In addition, propensity score matching was applied in patients who started conventional diuretics for new-onset hepatic ascites after September 2013 (pre-matching tolvaptan group, n = 177; pre-matching control group, n = 63), and the cumulative survival rates were compared between the post-matching tolvaptan and control groups. RESULTS The survival rate was significantly higher in the tolvaptan group than the control group (P = 0.005), and tolvaptan therapy was identified as an independent factor associated with survival (hazard ratio 0.721 for death relative to control, P < 0.001). The propensity score-matched comparison also showed a significantly higher survival rate in the tolvaptan group (n = 51) than in the control group (n = 51) (P = 0.009). CONCLUSIONS This study suggests that tolvaptan might improve the prognosis of patients with hepatic ascites.
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Affiliation(s)
- Yasunari Hiramine
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Hirofumi Uto
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan.,Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Seiichi Mawatari
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Shuji Kanmura
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yasushi Imamura
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Takuya Hiwaki
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Akiko Saishoji
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan.,Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Takazumi Yada
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan
| | - Yukiko Inada
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan
| | - Hidemori Sakamoto
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan
| | - Hirofumi Higashi
- Department of Hygiene and Public Health, National Institute of Fitness and Sports in Kanoya, Kagoshima, Japan
| | - Osamu Kubozono
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Shigeho Maenohara
- Department of Surgery, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Akio Ido
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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1453
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Fiore M, Di Franco S, Alfieri A, Passavanti MB, Pace MC, Kelly ME, Damiani G, Leone S. Spontaneous bacterial peritonitis caused by Gram-negative bacteria: an update of epidemiology and antimicrobial treatments. Expert Rev Gastroenterol Hepatol 2019; 13:683-692. [PMID: 31107612 DOI: 10.1080/17474124.2019.1621167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Spontaneous bacterial peritonitis (SBP) is a main infectious complication in end-stage liver disease (ESLD) patients. The increasing trend of bacterial resistance in ESLD patients with SBP has been associated with low treatment efficacy of traditional therapy. Cephalosporin use has been restricted to community-acquired infections and in areas/health care settings with low rates of multidrug-resistant (MDR) bacteria. To date, several changes are necessary with regard to empiric therapy recommendations in areas/health care settings with high rates of MDR bacteria. Areas covered: An overview of the epidemiology and antimicrobial treatments of SBP caused by Gram-negative bacteria. Expert opinion: Broad-spectrum antibiotics have been recommended as empiric therapy for suspected SBP in areas/health care settings with high rates of MDR bacteria and secondary treatment, with newer antibiotics, for SBP caused by MDR-Gram-negative bacteria (i.e. new beta-lactam/beta-lactamase inhibitor combinations, cefiderocol, plazomicin, and eravacycline) either alone or in combination.
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Affiliation(s)
- Marco Fiore
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Sveva Di Franco
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Aniello Alfieri
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Maria Beatrice Passavanti
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Maria Caterina Pace
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Molly E Kelly
- b Case Western Reserve University School of Medicine , Cleveland , OH , USA
| | - Giovanni Damiani
- c Department of Pathophysiology and Transplantation , University of Milan , Italy
| | - Sebastiano Leone
- d Division of Infectious Diseases , "San Giuseppe Moscati" Hospital , Avellino , Italy
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1454
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Huelin P, Solà E, Elia C, Solé C, Risso A, Moreira R, Carol M, Fabrellas N, Bassegoda O, Juanola A, de Prada G, Albertos S, Piano S, Graupera I, Ariza X, Napoleone L, Pose E, Filella X, Morales-Ruiz M, Rios J, Fernández J, Jiménez W, Poch E, Torres F, Ginès P. Neutrophil Gelatinase-Associated Lipocalin for Assessment of Acute Kidney Injury in Cirrhosis: A Prospective Study. Hepatology 2019; 70:319-333. [PMID: 30810244 DOI: 10.1002/hep.30592] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/12/2019] [Indexed: 12/14/2022]
Abstract
Kidney biomarkers appear to be useful in differential diagnosis between acute tubular necrosis (ATN) and other types of acute kidney injury (AKI) in cirrhosis, particularly hepatorenal syndrome (HRS-AKI). Distinction is important because treatment is different. However, kidney biomarkers are still not used in clinical practice. The aim of the current study was to investigate the accuracy of several biomarkers in differential diagnosis of AKI and in predicting kidney outcome and patient survival. This was a prospective study of 320 consecutive cases of AKI in patients hospitalized for decompensated cirrhosis. Evaluation of AKI was made with a diagnostic algorithm that included identification and removal/treatment of precipitating factors and albumin administration (1 g/kg for 2 days) to patients with AKI stage 1B or greater. Urinary neutrophil gelatinase-associated lipocalin (NGAL), monomeric NGAL (mNGAL), interleukin-18, and standard biomarkers were measured at diagnosis and on days 3, 7, and 14. Of the 320 cases, 153 were hypovolemia-induced AKI (48%), 93 were HRS-AKI (29%), 39 were ATN (12%), and 35 were due to miscellaneous causes (11%). Among all biomarkers, urinary NGAL measured at day 3 had the greatest accuracy for differential diagnosis between ATN and other types of AKI (area under the receiver operating characteristic curve, 0.87; 95% confidence interval, 0.78-0.95). The cutoff with the best predictive accuracy for ATN diagnosis was 220 µg/g creatinine. Progression of AKI during hospitalization was associated with persistently high NGAL levels, and NGAL was an independent predictive factor of AKI progression. Likewise, NGAL was also an independent predictive factor of 28-day mortality together with Model for End-Stage Liver Disease score. Conclusion: These results support the use of NGAL in clinical practice within the context of a diagnostic algorithm for differential diagnosis of AKI and outcome prediction in cirrhosis.
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Affiliation(s)
- Patricia Huelin
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Elsa Solà
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Chiara Elia
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Cristina Solé
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Alessandro Risso
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Rebeca Moreira
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Marta Carol
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Núria Fabrellas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Octavi Bassegoda
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Adrià Juanola
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Gloria de Prada
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Sonia Albertos
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Salvatore Piano
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Isabel Graupera
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Xavier Ariza
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Laura Napoleone
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Xavier Filella
- Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Manuel Morales-Ruiz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - José Rios
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Barcelona, Catalonia, Spain.,Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Javier Fernández
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Wladimiro Jiménez
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Esteban Poch
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Servei de Nefrologia, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Ferran Torres
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Barcelona, Catalonia, Spain.,Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
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1455
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Can L-carnitine supplementation and exercise improve muscle complications in patients with liver cirrhosis who receive branched-chain amino acid supplementation? Eur J Gastroenterol Hepatol 2019; 31:878-884. [PMID: 31150367 DOI: 10.1097/meg.0000000000001368] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to elucidate the efficacy of the combination of L-carnitine and exercise, reported to prevent muscle wasting, for muscle complications (function, volume, and cramping) in patients with liver cirrhosis (LC) who received branched-chain amino acid supplementation. MATERIALS AND METHODS From December 2017 to April 2018, 18 patients with LC who had been given branched-chain amino acid granule supplementation (12.45 g/day) were enrolled (mean age 68.4±10.8 years; 10 males and eight females; Child-Pugh A : B=9 : 9). After evaluating the average number of daily steps, oral L-carnitine supplementation (1000 mg/day) and additional exercise (plus 2000 steps/day) were added for 6 months. Every 4 weeks, a pedometer, a hand dynamometer, ergometer, and bioelectrical impedance analysis were used to evaluate daily steps, muscle function and muscle volume, and muscle cramps were recorded using a numerical rating scale. RESULTS Average steps and serum levels of total and free carnitine were increased from before treatment to the final measurement (1883.5±1211.6 vs. 3165.1±1800.0/day, 62.6±16.5 vs. 110.9±28.6 μmol/l, and 47.7±15.2 vs. 83.2±21.5 μmol/l, respectively; P<0.01), whereas there were no significant changes in the ratios of handgrip strength, leg strength, and muscle volume after 6 months [1.00±0.13 (P=0.991), 1.07±0.13 (P=0.073), and 0.992±0.036 (P=0.390), respectively]. However, the frequency of complaints of muscle cramping was reduced as compared with the start of therapy (baseline, 3 months, and 6 months: 6.3±4.8, 3.1±3.3, and 2.1±2.0, respectively) (P=0.025, Holm's method), whereas numerical rating scale did not show any significant improvement. CONCLUSION L-Carnitine may have an important role for prevention of muscle wasting and reducing the frequency of muscle cramping.
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1456
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Solé C, Solà E, Huelin P, Carol M, Moreira R, Cereijo U, Mas J, Graupera I, Pose E, Napoleone L, dePrada G, Juanola A, Fabrellas N, Torres F, Morales‐Ruiz M, Farrés J, Jiménez W, Ginès P. Characterization of inflammatory response in hepatorenal syndrome: Relationship with kidney outcome and survival. Liver Int 2019; 39:1246-1255. [PMID: 30597709 PMCID: PMC6767546 DOI: 10.1111/liv.14037] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/21/2018] [Accepted: 12/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several lines of evidence indicate that decompensated cirrhosis is characterized by the presence of systemic inflammation. Hepatorenal syndrome (HRS-AKI) is a unique type of renal failure that occurs at late stages of cirrhosis. However, confirmation of the presence and significance of such inflammatory response in HRS-AKI is lacking. AIM AND METHODS To characterize the systemic inflammatory response, as estimated by measuring a large number of cytokines, in 161 patients hospitalized for an acute decompensation of cirrhosis: 44 patients without acute kidney injury (AKI), 63 patients with hypovolaemia-induced AKI and 58 patients with HRS-AKI. RESULTS HRS-AKI was characterized by an altered cytokine profile compared to the other two groups, particularly IL-6, IL-8, TNF-α, VCAM-1, fractalkine and MIP-1α. The inflammatory response was not related to presence of bacterial infection, concomitant acute-on-chronic liver failure or severity of renal dysfunction. Patients who responded to terlipressin and albumin had only a decrease in TNF-α and RANTES after treatment without changes in other cytokines. Interestingly, patients with persistent HRS-AKI had higher levels of IP-10 and VCAM-1 compared to those with resolution of HRS-AKI. VCAM-1 was also an independent predictor of 3-month mortality. A systems biology analysis approach showed that the inflammatory status of HRS-AKI was similar to that of chronic nonhepatic inflammatory conditions, such as lupus erythematosus or inflammatory bowel disease. CONCLUSION Hepatorenal syndrome is characterized by a marked systemic inflammatory state, reminiscent of that of nonhepatic inflammatory diseases, that correlates with patient outcomes.
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Affiliation(s)
- Cristina Solé
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | - Elsa Solà
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | - Patricia Huelin
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | - Marta Carol
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Faculty of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain
| | - Rebeca Moreira
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | | | | | - Isabel Graupera
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | - Elisa Pose
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | - Laura Napoleone
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | - Gloria dePrada
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | - Adrià Juanola
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
| | - Núria Fabrellas
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Faculty of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain
| | - Ferran Torres
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic Barcelona & Biostatistics Unit, Faculty of MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Manuel Morales‐Ruiz
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD),Biochemistry and Molecular Genetics DepartmentHospital Clínic de BarcelonaBarcelonaSpain
| | | | - Wladimiro Jiménez
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD),Biochemistry and Molecular Genetics DepartmentHospital Clínic de BarcelonaBarcelonaSpain
| | - Pere Ginès
- Liver UnitHospital Clínic de Barcelona, University of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD)
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1457
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Xu X, Guo X, De Stefano V, Silva-Junior G, Goyal H, Bai Z, Zhao Q, Qi X. Nonselective beta-blockers and development of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis. Hepatol Int 2019; 13:468-481. [PMID: 31175581 DOI: 10.1007/s12072-019-09951-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/11/2019] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT), which is associated with reduced portal vein velocity, is considered to be an indicator for worse outcomes in liver cirrhosis. Nonselective beta-blockers (NSBBs), which are widely used for primary and secondary prophylaxis of esophageal variceal bleeding in liver cirrhosis, can significantly decrease the portal vein velocity. We proposed a hypothesis that the use of NSBBs might facilitate the development of PVT in cirrhotic patients. The PubMed, EMBASE, and Cochrane Library databases were searched. Major meeting abstracts and randomized-controlled trials regarding the use of NSBBs in liver cirrhosis were also hand-searched. The number of patients who developed PVT in groups treated with or without NSBBs was pooled. Odds ratios (ORs) or risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Subgroup meta-analyses were performed according to the type of studies, region, and study quality. Meta-regression and sensitivity analyses were performed to explore the source of heterogeneity. Nine of the 6416 retrieved papers were finally included. Overall, meta-analysis demonstrated that NSBBs were significantly associated with the development of PVT (OR 4.62, 95% CI 2.50-8.53; p < 0.00001). The heterogeneity was statistically significant (I2 = 80%; p < 0.00001). Subgroup meta-analyses still demonstrated a significantly positive association of NSBBs with the development of PVT in cohort studies (RR 2.57, 95% CI 1.46-4.51; p = 0.001) and case-control studies (OR 8.17, 95% CI 2.46-27.06; p = 0.0006). Sensitivity analyses based on subgroups find the source of heterogeneity. Based on the systematic review and meta-analysis, we found that the use of NSBBs increased a 4.62-fold risk of PVT in cirrhotic patients.
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Affiliation(s)
- Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
| | - Valerio De Stefano
- Fondazione Policlinico A. Gemelli IRCCS, Istituto Di Ematologia, Università Cattolica, Rome, Italy
| | - Gilberto Silva-Junior
- Department of General Medicine and Hepatology, Quinta D'Or Hospital, Rio de Janeiro, Brazil
| | - Hemant Goyal
- Department of Internal Medicine, School of Medicine, Mercer University, Macon, GA, USA
| | - Zhaohui Bai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Qingchun Zhao
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China.
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1458
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Fernández J, Clària J, Amorós A, Aguilar F, Castro M, Casulleras M, Acevedo J, Duran-Güell M, Nuñez L, Costa M, Torres M, Horrillo R, Ruiz-Del-Árbol L, Villanueva C, Prado V, Arteaga M, Trebicka J, Angeli P, Merli M, Alessandria C, Aagaard NK, Soriano G, Durand F, Gerbes A, Gustot T, Welzel TM, Salerno F, Bañares R, Vargas V, Albillos A, Silva A, Morales-Ruiz M, Carlos García-Pagán J, Pavesi M, Jalan R, Bernardi M, Moreau R, Páez A, Arroyo V. Effects of Albumin Treatment on Systemic and Portal Hemodynamics and Systemic Inflammation in Patients With Decompensated Cirrhosis. Gastroenterology 2019; 157:149-162. [PMID: 30905652 DOI: 10.1053/j.gastro.2019.03.021] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/25/2019] [Accepted: 03/14/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND & AIMS We investigated the effect of albumin treatment (20% solution) on hypoalbuminemia, cardiocirculatory dysfunction, portal hypertension, and systemic inflammation in patients with decompensated cirrhosis with and without bacterial infections. METHODS We performed a prospective study to assess the effects of long-term (12 weeks) treatment with low doses (1 g/kg body weight every 2 weeks) and high doses (1.5 g/kg every week) of albumin on serum albumin, plasma renin, cardiocirculatory function, portal pressure, and plasma levels of cytokines, collecting data from 18 patients without bacterial infections (the Pilot-PRECIOSA study). We also assessed the effect of short-term (1 week) treatment with antibiotics alone vs the combination of albumin plus antibiotics (1.5 g/kg on day 1 and 1 g/kg on day 3) on plasma levels of cytokines in biobanked samples from 78 patients with bacterial infections included in a randomized controlled trial (INFECIR-2 study). RESULTS Circulatory dysfunction and systemic inflammation were extremely unstable in many patients included in the Pilot-PRECIOSA study; these patients had intense and reversible peaks in plasma levels of renin and interleukin 6. Long-term high-dose albumin, but not low-dose albumin, was associated with normalization of serum level of albumin, improved stability of the circulation and left ventricular function, and reduced plasma levels of cytokines (interleukin 6, granulocyte colony-stimulating factor, interleukin 1 receptor antagonist, and vascular endothelial growth factor) without significant changes in portal pressure. The immune-modulatory effects of albumin observed in the Pilot-PRECIOSA study were confirmed in the INFECIR-2 study. In this study, patients given albumin had significant reductions in plasma levels of cytokines. CONCLUSIONS In an analysis of data from 2 trials (Pilot-PRECIOSA study and INFECIR-2 study), we found that albumin treatment reduced systemic inflammation and cardiocirculatory dysfunction in patients with decompensated cirrhosis. These effects might be responsible for the beneficial effects of albumin therapy on outcomes of patients with decompensated cirrhosis. ClinicalTrials.gov, Numbers: NCT00968695 and NCT03451292.
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Affiliation(s)
- Javier Fernández
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain.
| | - Joan Clària
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Alex Amorós
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Ferrán Aguilar
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Miriam Castro
- Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | - Juan Acevedo
- South West Liver Unit, Derriford Hospital, Plymouth, United Kingdom
| | | | - Laura Nuñez
- Bioscience Research Group, Grifols, Barcelona, Spain
| | | | - Mireia Torres
- Bioscience Research Group, Grifols, Barcelona, Spain
| | | | - Luis Ruiz-Del-Árbol
- Department of Gastroenterology, Hospital Ramón y Cajal and CIBERehd, Madrid, Spain
| | - Cándido Villanueva
- Department of Gastroenterology, Hospital de Sant Pau and CIBERehd, Barcelona, Spain
| | | | | | - Jonel Trebicka
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Department of Internal Medicine, University Hospital of Bonn, Bonn, Germany
| | - Paolo Angeli
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Manuela Merli
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | - Niels Kristian Aagaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - German Soriano
- Department of Gastroenterology and Hepatology, Hospital of Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain
| | - François Durand
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Munich, Germany
| | - Thierry Gustot
- Liver Transplant Unit, Erasme Hospital (ULB), Brussels, Belgium
| | - Tania M Welzel
- Medical Department I, Goethe University, Frankfurt, Germany
| | - Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, Milano, Italy
| | - Rafael Bañares
- Department of Gastroenterology, Hospital Gregorio Marañon, and CIBERehd, Madrid, Spain
| | - Victor Vargas
- Department of Internal Medicine, Hospital Vall d'Hebron and CIBERehd, Barcelona, Spain
| | - Agustin Albillos
- Department of Gastroenterology, Hospital Ramón y Cajal and CIBERehd, Madrid, Spain
| | - Aníbal Silva
- Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | | | - Marco Pavesi
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, United Kingdom
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Richard Moreau
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; Inserm, Université Paris Diderot-Paris 7, Centre de Recherche sur l'Inflammation, Paris, France
| | - Antonio Páez
- Bioscience Research Group, Grifols, Barcelona, Spain
| | - Vicente Arroyo
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
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1459
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Lv Y, Zuo L, Zhu X, Zhao J, Xue H, Jiang Z, Zhuge Y, Zhang C, Sun J, Ding P, Ren W, Li Y, Zhang K, Zhang W, He C, Zhong J, Peng Q, Ma F, Luo J, Zhang M, Wang G, Sun M, Dong J, Bai W, Guo W, Wang Q, Yuan X, Wang Z, Yu T, Luo B, Li X, Yuan J, Han N, Zhu Y, Niu J, Li K, Yin Z, Nie Y, Fan D, Han G. Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut 2019; 68:1297-1310. [PMID: 30415233 DOI: 10.1136/gutjnl-2018-317057] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 09/20/2018] [Accepted: 09/29/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Early placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10-13) with cirrhosis and acute variceal bleeding (AVB). However, early TIPS criteria may overestimate the mortality risk in a significant proportion of patients, and the survival benefit conferred by early TIPS in such patients has been questioned. Alternative criteria have been proposed to refine the criteria used to identify candidates for early TIPS. Nevertheless, the true survival benefit provided (or not) by early TIPS compared with standard treatment in the different risk categories has not been investigated in specifically designed comparative studies. DESIGN We collected data on 1425 consecutive patients with cirrhosis and AVB who were admitted to 12 university hospitals in China between December 2010 and June 2016. Of these, 206 patients received early TIPS, and 1219 patients received standard treatment. The Fine and Gray competing risk regression model was used to compare the outcomes between the two groups that were stratified based on the currently available risk stratification systems after adjusting for liver disease severity and other potential confounders. RESULTS Overall, early TIPS was associated with an 80% relative risk reduction (RRR) in mortality at 6 weeks (adjusted HR=0.20; 95% CI: 0.10 to 044; p<0.001) and 51% RRR at 1 year (adjusted HR=0.49, 95% CI: 0.32 to 0.73; p<0.001) compared with standard treatment. In stratification analyses, the RRRs in mortality did not significantly differ among the risk categories. However, the absolute risk reductions (ARRs) of mortality were more pronounced in high-risk patients. The ARRs at 6 weeks were -2.1%, -10.2% and -32.4% in Model for End-stage Liver Disease (MELD) ≤11, 12-18 and ≥19 patients and were -1.5%, -9.1% and -23.2% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). The ARRs for mortality at 1 year were -1.7%, -5.4% and -32.7% in MELD ≤11, 12-18 and ≥19 patients, respectively, and -3.6%, -5.2% and -20.3% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). After adjusting for liver disease severity and other potential confounders, a survival benefit was observed in MELD ≥19 or Child-Pugh C patients but not in MELD ≤11 or Child-Pugh A patients. In MELD 12-18 patients, a survival benefit was observed within 6 weeks but not at 1 year. In Child-Pugh B patients, a survival benefit was observed in those with active bleeding but not those without active bleeding. However, the evaluation of active bleeding was associated with a high interobserver variability. Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding or rebleeding and new or worsening ascites, without increasing the risk of overt hepatic encephalopathy. CONCLUSIONS Early TIPS was associated with improved survival in patients with MELD ≥19 or Child-Pugh C cirrhosis but not in patients with MELD ≤11 or Child-Pugh A cirrhosis. For MELD 12-18 or Child-Pugh B patients, future studies addressing optimal selection criteria for early TIPS remain highly warranted.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Luo Zuo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, The Southern Medical University, Guangzhou, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zaibo Jiang
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Junhui Sun
- Hepatobiliaryand Pancreatic Intervention Center, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Li
- Department of Interventional Radiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kewei Zhang
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jiawei Zhong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qifeng Peng
- Department of Interventional Radiology, Nanfang Hospital, The Southern Medical University, Guangzhou, China
| | - Fuquan Ma
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Junyang Luo
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ming Zhang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Minhuang Sun
- Department of Interventional Radiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Junjiao Dong
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xulong Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tianlei Yu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jing Niu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yongzhan Nie
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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1460
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Zhou R, Fan X, Schnabl B. Role of the intestinal microbiome in liver fibrosis development and new treatment strategies. Transl Res 2019; 209:22-38. [PMID: 30853445 DOI: 10.1016/j.trsl.2019.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/26/2019] [Accepted: 02/14/2019] [Indexed: 02/06/2023]
Abstract
Liver cirrhosis is a major cause of morbidity and mortality worldwide. The most common chronic liver diseases in western countries are alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD). Although these diseases have different causes, liver fibrosis develops via shared mechanisms. The liver and intestinal microbiome are linked by the portal vein and have bidirectional interactions. Changes in the intestinal microbiome contribute to the pathogenesis and progression of liver diseases including ALD, NAFLD, viral hepatitis and cholestatic disorders, based on studies in patients and animal models. Intestinal microbial dysbiosis has been associated with liver cirrhosis and its complications. We review the mechanisms by which alterations in the microbiome contribute to liver fibrosis and discuss microbiome-based treatment approaches.
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Affiliation(s)
- Rongrong Zhou
- Department of Infectious Diseases, Xiangya Hospital, Central South University, and Key Laboratory of Viral Hepatitis, Changsha, Hunan, China; Department of Medicine, University of California San Diego, La Jolla, California
| | - Xuegong Fan
- Department of Infectious Diseases, Xiangya Hospital, Central South University, and Key Laboratory of Viral Hepatitis, Changsha, Hunan, China
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, California; Department of Medicine, VA San Diego Healthcare System, San Diego, California.
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1461
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Castillo L, Prachuapthunyachart S, Hall M, Shelby S, Quiros-Tejeira RE, Vo HD. Antibiotic use in cirrhotic children with acute upper gastrointestinal bleeding: A retrospective study using the pediatric health information system (PHIS) database. Medicine (Baltimore) 2019; 98:e16505. [PMID: 31335721 PMCID: PMC6709249 DOI: 10.1097/md.0000000000016505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Prior studies have demonstrated positive impacts of antibiotic use on reducing mortality, rebleeding events, and length of hospitalization in adult cirrhotic patients with acute upper gastrointestinal bleeding (UGIB). We aimed to investigate the use of antibiotics in cirrhotic children with acute UGIB and its impact on patient outcomes.This was a retrospective study using the Pediatric Health Information System database. Cirrhotic patients aged 0 to 18 years with acute UGIB, admitted between October 2005 and September 2015, were identified based on ICD-9 codes. Patients with no documented endoscopy during admission were excluded.Forty-four (23 females) cirrhotic children were eligible for data analysis. The median patient age was 6 years. Etiology of acute UGIB included esophageal varices (n = 37), non-variceal bleeding (n = 4), and both (n = 3). A significant proportion of cirrhotic children with acute UGIB (n = 30, 68%) were given intravenous antibiotics within 48 hours of admission. Among children who did not develop bacteremia, 68% received antibiotics vs. 32% who did not (P = .6). The rate of readmission within 30 days of discharge was 7% in patients with antibiotics vs. 21% in those without antibiotics (P = .3).This study suggested that antibiotic use within 48 hours of admission in cirrhotic children with acute UGIB might have a positive impact on the percentage of children free of bacteremia and the readmission rate. A prospective study should investigate whether prophylactic antibiotics should be targeted only to a subgroup of cirrhotic children with acute UGIB who are particularly at high risk for bacterial infection.
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Affiliation(s)
- Lina Castillo
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
| | - Sittichoke Prachuapthunyachart
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
| | - Mel Hall
- Performance Improvement, Children's Hospital and Medical Center, Omaha, NE, USA
| | - Shaija Shelby
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
| | - Ruben E Quiros-Tejeira
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
| | - Hanh D Vo
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
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1462
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Simonetti RG, Perricone G, Nikolova D, Bjelakovic G, Gluud C. Plasma expanders for people with cirrhosis and large ascites treated with abdominal paracentesis. Cochrane Database Syst Rev 2019; 6:CD004039. [PMID: 31251387 PMCID: PMC6598734 DOI: 10.1002/14651858.cd004039.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Plasma volume expanders are used in connection to paracentesis in people with cirrhosis to prevent reduction of effective plasma volume, which may trigger deleterious effect on haemodynamic balance, and increase morbidity and mortality. Albumin is considered the standard product against which no plasma expansion or other plasma expanders, e.g. other colloids (polygeline , dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol have been compared. However, the benefits and harms of these plasma expanders are not fully clear. OBJECTIVES To assess the benefits and harms of any plasma volume expanders such as albumin, other colloids (polygeline, dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol versus no plasma volume expander or versus another plasma volume expander for paracentesis in people with cirrhosis and large ascites. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CNKI, VIP, Wanfang, Science Citation Index Expanded, and Conference Proceedings Citation Index until January 2019. Furthermore, we searched FDA, EMA, WHO (last search January 2019), www.clinicaltrials.gov/, and www.controlled-trials.com/ for ongoing trials. SELECTION CRITERIA Randomised clinical trials, no matter their design or year of publication, publication status, and language, assessing the use of any type of plasma expander versus placebo, no intervention, or a different plasma expander in connection with paracentesis for ascites in people with cirrhosis. We considered quasi-randomised, retrieved with the searches for randomised clinical trials only, for reports on harms. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We calculated the risk ratio (RR) or mean difference (MD) using the fixed-effect model and the random-effects model meta-analyses, based on the intention-to-treat principle, whenever possible. If the fixed-effect and random-effects models showed different results, then we made our conclusions based on the analysis with the highest P value (the more conservative result). We assessed risks of bias of the individual trials using predefined bias risk domains. We assessed the certainty of the evidence at an outcome level, using GRADE, and constructed 'Summary of Findings' tables for seven of our review outcomes. MAIN RESULTS We identified 27 randomised clinical trials for inclusion in this review (24 published as full-text articles and 3 as abstracts). Five of the trials, with 271 participants, assessed plasma expanders (albumin in four trials and ascitic fluid in one trial) versus no plasma expander. The remaining 22 trials, with 1321 participants, assessed one type of plasma expander, i.e. dextran, hydroxyethyl starch, polygeline, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus another type of plasma expander, i.e. albumin in 20 of these trials and polygeline in one trial. Twenty-five trials provided data for quantitative meta-analysis. According to the Child-Pugh classification, most participants were at an intermediate to advanced stage of liver disease in the absence of hepatocellular carcinoma, recent gastrointestinal bleeding, infections, and hepatic encephalopathy. All trials were assessed as at overall high risk of bias. Ten trials seemed not to have been funded by industry; twelve trials were considered unclear about funding; and five trials were considered funded by industry or a for-profit institution.We found no evidence of a difference in effect between plasma expansion versus no plasma expansion on mortality (RR 0.52, 95% CI 0.06 to 4.83; 248 participants; 4 trials; very low certainty); renal impairment (RR 0.32, 95% CI 0.02 to 5.88; 181 participants; 4 trials; very low certainty); other liver-related complications (RR 1.61, 95% CI 0.79 to 3.27; 248 participants; 4 trials; very low certainty); and non-serious adverse events (RR 1.04, 95% CI 0.32 to 3.40; 158 participants; 3 trials; very low certainty). Two of the trials stated that no serious adverse events occurred while the remaining trials did not report on this outcome. No trial reported data on health-related quality of life.We found no evidence of a difference in effect between experimental plasma expanders versus albumin on mortality (RR 1.03, 95% CI 0.82 to 1.30; 1014 participants; 14 trials; very low certainty); serious adverse events (RR 0.89, 95% CI 0.10 to 8.30; 118 participants; 2 trials; very low certainty); renal impairment (RR 1.17, 95% CI 0.71 to 1.91; 1107 participants; 17 trials; very low certainty); other liver-related complications (RR 1.10, 95% CI 0.82 to 1.48; 1083 participants; 16 trials; very low certainty); and non-serious adverse events (RR 1.37, 95% CI 0.66 to 2.85; 977 participants; 14 trials; very low certainty). We found no data on heath-related quality of life and refractory ascites. AUTHORS' CONCLUSIONS Our systematic review and meta-analysis did not find any benefits or harms of plasma expanders versus no plasma expander or of one plasma expander such as polygeline, dextrans, hydroxyethyl starch, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus albumin on primary or secondary outcomes. The data originated from few, small, mostly short-term trials at high risks of systematic errors (bias) and high risks of random errors (play of chance). GRADE assessments concluded that the evidence was of very low certainty. Therefore, we can neither demonstrate or discard any benefit of plasma expansion versus no plasma expansion, and differences between one plasma expander versus another plasma expander.Larger trials at low risks of bias are needed to assess the role of plasma expanders in connection with paracentesis. Such trials should be conducted according to the SPIRIT guidelines and reported according to the CONSORT guidelines.
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Affiliation(s)
- Rosa G Simonetti
- Cochrane Hepato‐Biliary GroupBlegdamsvej 9, 7811CopenhagenDenmark2100
| | - Giovanni Perricone
- Azienda Socio‐Sanitaria Territoriale Grande Ospedale Metropolitano NiguardaS.C. Epatologia e GastroenterologiaPiazza Ospedale Maggiore, 3MilanItaly20162
- UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free HospitalLiver Failure GroupLondonUK
| | - Dimitrinka Nikolova
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Goran Bjelakovic
- Medical Faculty, University of NisDepartment of Internal MedicineZorana Djindjica 81NisSerbia18000
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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1463
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Abstract
Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even though in the last decades survival has been improved because of the widespread adoption of effective treatments and optimization of general medical care, mortality is still significantly high, and decompensated patients pose a complex challenge requiring a multidisciplinary approach that is crucial to improve survival. The aims of this commentary are to review the most recent advances in the management of esophageal variceal bleeding and to highlight useful information to aid hepatologists in clinical practice.
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Affiliation(s)
- Alberto Zanetto
- Digestive Disease Section, Yale University School of Medicine, 333 Cedar Street 1080 LMP New Haven, Connecticut, 06520-8019, USA.,VA-CT Healthcare System, 950 Campbell Ave, West Haven, Connecticut, 06516, USA
| | - Guadalupe Garcia-Tsao
- Digestive Disease Section, Yale University School of Medicine, 333 Cedar Street 1080 LMP New Haven, Connecticut, 06520-8019, USA.,VA-CT Healthcare System, 950 Campbell Ave, West Haven, Connecticut, 06516, USA
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1464
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Zhou K, Fountzilas C. Outcomes and Quality of Life of Systemic Therapy in Advanced Hepatocellular Carcinoma. Cancers (Basel) 2019; 11:E861. [PMID: 31234316 PMCID: PMC6627968 DOI: 10.3390/cancers11060861] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most commonly diagnosed cancers worldwide; most patients are diagnosed with advanced disease for which there is no known cure. Tremendous progress has been made over the past decade in the development of new agents for HCC, including small-molecule kinase inhibitors such as sorafenib, lenvatinib, cabozantinib, regorafenib, and monoclonal antibodies like ramucirumab, nivolumab, and pembrolizumab. Ideal use of these agents in clinics has improved the long-term outcome of patients with advanced HCC as well as introduced unique toxicities that can affect quality of life. These toxicities usually are thought to be partially related to cirrhosis, a major risk factor for the development of HCC and a pathophysiological barrier complicating the optimal delivery of antineoplastic therapy. Additionally, side effects of medications together with advanced HCC symptoms not only decrease quality of life, but also cause treatment interruptions and dose reductions that can potentially decrease efficacy. Physicians caring for patients with advanced HCC are called to optimally manage HCC along with cirrhosis in order to prolong life while at the same time preserve the quality of life. In this review, we aimed to summarize outcomes and quality of life with the use of modern systemic treatments in advanced HCC and provide a physician reference for treatment toxicity and cirrhosis management.
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Affiliation(s)
- Kehua Zhou
- Catholic Health System Internal Medicine Training Program, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14214, USA.
| | - Christos Fountzilas
- Division of Gastrointestinal Medicine, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA.
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1465
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Stratmann K, Fitting D, Zeuzem S, Bojunga J, Trebicka J, Friedrich-Rust M, Dultz G. Establishing an indwelling peritoneal catheter as a standard procedure for hospitalized patients with ascites: Retrospective data on feasibility, effectiveness and safety. United European Gastroenterol J 2019; 7:673-681. [PMID: 31210945 DOI: 10.1177/2050640619842442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 03/13/2019] [Indexed: 12/16/2022] Open
Abstract
Background The use of an indwelling peritoneal catheter system in hospitalized patients with ascites could facilitate patient management by the prevention of repetitive abdominal paracentesis. Despite these possible benefits, the use of indwelling catheters is not widely established. Objective This retrospective study aimed to evaluate the feasibility, effectiveness and safety of the use of an indwelling catheter for ascites drainage in the clinical routine. Methods This retrospective study included all indwelling peritoneal catheter placements in our department in hospitalized patients with cirrhosis between 2014 and 2017. Results A total of 324 indwelling catheter placements for ascites in 192 hospitalized patients with cirrhosis were included. The catheter (7F, 8 cm) was placed ultrasound-assisted bed-side on the hospital ward. The technical success rate of the catheter placement was 99.7% (323/324). In 17.5% (64/324) the catheter was placed to optimize ascitic drainage prior to an abdominal intervention (e.g. transjugular intrahepatic portosystemic shunt). The median time of catheter retention was 48 hours (8-168 hours) and the median cumulative amount of drained ascites 8000 ml (550-28,000). The most common adverse event was acute kidney injury (49/324, 15.1%); the risk was particularly higher in patients with a Model for End-Stage Liver Disease (MELD) score ≥ 16 (p = 0.028; odds ratio 2.039). Ascitic fistula after catheter removal was observed in 9.6% (31/324). Catheter-related infections occurred in 4.3% (14/324), and bleeding was documented in three cases (0.8%) with one major bleeding (0.3%). Conclusion The placement of an indwelling catheter for repetitive ascitic drainage in hospitalized patients with cirrhosis can be established in the clinical routine, facilitating patient management. High-MELD patients especially have to be monitored for acute kidney injury.
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Affiliation(s)
- Katharina Stratmann
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Daniel Fitting
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Jörg Bojunga
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Jonel Trebicka
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Georg Dultz
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
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1466
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Schweighardt AE, Juba KM. A Systematic Review of the Evidence Behind Use of Reduced Doses of Acetaminophen in Chronic Liver Disease. J Pain Palliat Care Pharmacother 2019; 32:226-239. [DOI: 10.1080/15360288.2019.1611692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Anne E. Schweighardt
- Anne E. Schweighardt, PharmD, and Katherine M. Juba, PharmD, are with the Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York, USA
| | - Katherine M. Juba
- Anne E. Schweighardt, PharmD, and Katherine M. Juba, PharmD, are with the Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York, USA
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1467
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Chaudhary S, Stanley AJ. Optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101618. [PMID: 31785731 DOI: 10.1016/j.bpg.2019.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 05/23/2019] [Indexed: 01/31/2023]
Abstract
Endoscopy is the gold standard for evaluating and treating acute upper gastrointestinal bleeding (UGIB). The optimal timing of endoscopy is a very important consideration in the overall management of UGIB, but there is on going uncertainty regarding timing of the procedure, particularly in those with more severe bleeding. This is reflected by inconsistencies between current guidelines. Although evidence suggests endoscopy should be undertaken within 24 h for all admitted patients with UGIB, a small group of patients with severe bleeding or high-risk features may require more urgent endoscopy. The exact timing of the procedure in this high-risk group remains unclear, with recent data suggesting that performing endoscopy too early may be associated with worse outcome. In this article we examine the evidence for optimal timing of endoscopy in patients presenting with UGIB and suggest a clinical approach to this important aspect of patient management.
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1468
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Lombardi A, Mondelli MU, Bruno R. RE: Effects of Long-Term Norfloxacin Therapy in Patients With Advanced Cirrhosis. Gastroenterology 2019; 156:2352-2353. [PMID: 30880018 DOI: 10.1053/j.gastro.2019.01.273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/18/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Andrea Lombardi
- Department of Internal Medicine and Therapeutics, University of Pavia and Infectious Diseases Unit, Department of Medical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo and Division of Infectious Diseases II and Immunology, Department of Medical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mario U Mondelli
- Department of Internal Medicine and Therapeutics, University of Pavia and Division of Infectious Diseases II and Immunology, Department of Medical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raffaele Bruno
- Infectious Diseases Unit, IRCCS "San Matteo" and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Pavia, Italy
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1469
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Wong RJ, Robinson A, Ginzberg D, Gomes C, Liu B, Bhuket T. Assessing the safety of beta-blocker therapy in cirrhosis patients with ascites: A meta-analysis. Liver Int 2019; 39:1080-1088. [PMID: 30614656 DOI: 10.1111/liv.14040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/26/2018] [Accepted: 01/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Beta-blocker therapy is effective at reducing risks of variceal bleeding. However, beta-blockers may detrimentally exacerbate the underlying haemodynamic changes in cirrhosis. A systematic review and meta-analysis was performed to evaluate impact of beta-blockers on all-cause mortality among cirrhosis patients with ascites. METHODS A literature search identified studies that evaluated beta-blocker vs no beta-blocker therapy in cirrhosis patients with ascites. The primary outcome was all-cause mortality with subcohort analysis of patients with refractory or severe ascites. Quality of observational studies was assessed with Newcastle-Ottawa Scale and overall certainty of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS Eight observational studies, representing 3627 cirrhosis patients with ascites (1630 treated with beta-blockers and 1997 not treated), were included. Pooled all-cause mortality was 38.6% in beta-blocker group vs 42.2% in no beta-blocker group (RR 0.93, 95% CI 0.77-1.13, χ2 = 54.03, I2 = 87%). Subcohort analysis of cirrhosis patients with refractory or severe ascites demonstrated 33.3% mortality in beta-blocker group vs 32.1% in no beta-blocker group (RR 0.99, 95% CI 0.70-1.40, χ2 = 32.99, and I2 = 82%). Three studies were good quality and five studies were fair quality. GRADE rating was 'very low' certainty of evidence, given concern for bias and inconsistency stemming from significant heterogeneity. CONCLUSION No significant increase in all-cause mortality was observed in cirrhosis patients with ascites treated with beta-blockers. However, given the low certainty of the evidence, high quality prospective studies are needed.
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Affiliation(s)
- Robert J Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Ann Robinson
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Dina Ginzberg
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Chantal Gomes
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Benny Liu
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
| | - Taft Bhuket
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA
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1470
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Wickremeratne T, Turner S, O'Beirne J. Systematic review with meta-analysis: ultra-thin gastroscopy compared to conventional gastroscopy for the diagnosis of oesophageal varices in people with cirrhosis. Aliment Pharmacol Ther 2019; 49:1464-1473. [PMID: 31059160 DOI: 10.1111/apt.15282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/06/2018] [Accepted: 04/08/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Haemorrhage from ruptured oesophageal varices is a common cause of death in people with cirrhosis. Guidelines recommend screening for varices at time of cirrhosis diagnosis and throughout the course of the disease. Conventional gastroscopy is the criterion standard for variceal screening; however, is invasive, costly, and carries risks related to use of sedation. Ultra-thin gastroscopy (using endoscopes with a shaft diameter ≤6 mm) has been proposed as an alternative method of variceal screening that mitigates these risks. AIM To determine the diagnostic accuracy of ultra-thin gastroscopy compared to conventional gastroscopy for the diagnosis of varices in people with cirrhosis. METHODS MEDLINE, EMBASE and Cochrane library databases were searched for studies that evaluated the accuracy of ultra-thin gastroscopy compared to conventional gastroscopy in the diagnosis of oesophageal varices. RESULTS Ten studies, 7 in known cirrhosis, with 752 participants were included in this systematic review. The overall prevalence of oesophageal varices was 42%. On bivariate modelling, pooled estimates of sensitivity and specificity were 98% (95% CI 93%-99%) and 96% (95% CI 91%-99%) respectively. The positive and negative likelihood ratios were 28 (95% CI 10.7-73.2) and 0.02 (95% CI 0.01-0.72) respectively. Kappa coefficient for inter-observer agreement for any varices ranged from 0.45 to 0.90. No serious adverse events related to ultra-thin gastroscopy were reported. CONCLUSIONS Ultra-thin gastroscopy is accurate in the diagnosis of oesophageal varices, safe and well tolerated. It is a valid alternative to conventional gastroscopy for the screening and surveillance of varices in people with cirrhosis.
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Affiliation(s)
- Tehara Wickremeratne
- Gastroenterology and Hepatology, Sunshine Coast University Hospital, Birtinya, Qld, Australia
| | - Stephanie Turner
- Gastroenterology and Hepatology, Sunshine Coast University Hospital, Birtinya, Qld, Australia
| | - James O'Beirne
- Gastroenterology and Hepatology, Sunshine Coast University Hospital, Birtinya, Qld, Australia.,Hepatology, University of the Sunshine Coast, Sippy downs, Qld, Australia
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1471
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Lv Y, Yang Z, Liu L, Li K, He C, Wang Z, Bai W, Guo W, Yu T, Yuan X, Zhang H, Xie H, Yao L, Wang J, Li T, Wang Q, Chen H, Wang E, Xia D, Luo B, Li X, Yuan J, Han N, Zhu Y, Niu J, Cai H, Xia J, Yin Z, Wu K, Fan D, Han G. Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial. Lancet Gastroenterol Hepatol 2019; 4:587-598. [PMID: 31153882 DOI: 10.1016/s2468-1253(19)30090-1] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/12/2019] [Accepted: 03/12/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The survival benefit of early placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with cirrhosis and acute variceal bleeding is controversial. We aimed to assess whether early TIPS improves survival in patients with advanced cirrhosis and acute variceal bleeding. METHODS We did an investigator-initiated, open-label, randomised controlled trial at an academic hospital in China. Consecutive patients with advanced cirrhosis (Child-Pugh class B or C) and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy were randomly assigned (2:1) to receive either early TIPS (done within 72 h after initial endoscopy [early TIPS group]) or standard treatment (vasoactive drugs continued to day 5, followed by propranolol plus endoscopic band ligation for the prevention of rebleeding, with TIPS as rescue therapy when needed [control group]). Randomisation was done by web-based randomisation system using a Pocock and Simon's minimisation method with Child-Pugh class (B vs C) and presence or absence of active bleeding as adjustment factors. The primary outcome was transplantation-free survival, analysed in the intention-to-treat population, excluding individuals subsequently found to be ineligible for enrolment. This study is registered with ClinicalTrials.gov, number NCT01370161, and is completed. FINDINGS From June 26, 2011, to Sept 30, 2017, 373 patients were screened and 132 patients were randomly assigned to the early TIPS group (n=86) or to the control group (n=46). After exclusion of three individuals subsequently found to be ineligible for enrolment (two patients in the early TIPS group with non-cirrhotic portal hypertension or hepatocellular carcinoma, and one patient in the control group due to non-cirrhotic portal hypertension), 84 patients in the early TIPS group and 45 patients in the control group were included in the intention-to-treat population. 15 (18%) patients in the early TIPS group and 15 (33%) in the control group died; two (2%) patients in the early TIPS group and one (2%) in the control group underwent liver transplantation. Transplantation-free survival was higher in the early TIPS group than in the control group (hazard ratio 0·50, 95% CI 0·25-0·98; p=0·04). Transplantation-free survival at 6 weeks was 99% (95% CI 97-100) in the early TIPS group compared with 84% (75-96; absolute risk difference 15% [95% CI 5-48]; p=0·02) and at 1 year was 86% (79-94) in the early TIPS group versus 73% (62-88) in the control group (absolute risk difference 13% [95% CI 2-28]; p=0·046). There were no significant differences between the two groups in the incidence of hepatic hydrothorax (two [2%] of 84 patients in the early TIPS group vs one [2%] of 45 in the control group; p=0·96), spontaneous bacterial peritonitis (one [1%] vs three [7%]; p=0·12), hepatic encephalopathy (29 [35%] vs 16 [36%]; p=1·00), hepatorenal syndrome (four [5%] vs six [13%]; p=0·10), and hepatocellular carcinoma (four [5%] vs one [2%]; p=0·68). There was no significant difference in the number of patients who experienced other serious adverse events (ten [12%] vs 11 [24%]; p=0·07) or non-serious adverse events (21 [25%] vs 19 [42%]; p=0·05) between groups. INTERPRETATION Early TIPS with covered stents improved transplantation-free survival in selected patients with advanced cirrhosis and acute variceal bleeding and should therefore be preferred to the current standard of care. FUNDING National Natural Science Foundation of China, National Key Technology R&D Program, Optimized Overall Project of Shaanxi Province, Boost Program of Xijing Hospital.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhiping Yang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Lei Liu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tianlei Yu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xulong Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hongbo Zhang
- Department of Digestive Endoscopy, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Huahong Xie
- Department of Digestive Endoscopy, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Liping Yao
- Department of Digestive Endoscopy, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianhong Wang
- Department of Ultrasound, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tao Li
- Department of Ultrasound, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Chen
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Enxin Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jing Niu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hongwei Cai
- Department of Medical Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi'an, China; Department of Technology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jielai Xia
- Department of Medical Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
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1472
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Dong Y, Li Y, Zhang Y, Zhang T, Zhu L, Dong Y, Wang T. Cefoperazone/sulbactam therapeutic drug monitoring in patients with liver cirrhosis: Potential factors affecting the pharmacokinetic/pharmacodynamic target attainment. Basic Clin Pharmacol Toxicol 2019; 125:353-359. [PMID: 31056857 DOI: 10.1111/bcpt.13245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/24/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Yuzhu Dong
- Department of Pharmacy The First Affiliated Hospital of Xi'an Jiaotong University Xi'an China
| | - Ying Li
- Department of Pharmacy The First Affiliated Hospital of Xi'an Jiaotong University Xi'an China
- Department of Pharmacy Xi'an NO.3 Hospital Xi'an China
| | - Ying Zhang
- Department of Pharmacy The First Affiliated Hospital of Xi'an Jiaotong University Xi'an China
| | - Tao Zhang
- Department of Pharmacy The First Affiliated Hospital of Xi'an Jiaotong University Xi'an China
| | - Li Zhu
- Infections Department The First Affiliated Hospital of Xi'an Jiaotong University Xi'an China
| | - Yaling Dong
- Department of Pharmacy The First Affiliated Hospital of Xi'an Jiaotong University Xi'an China
| | - Taotao Wang
- Department of Pharmacy The First Affiliated Hospital of Xi'an Jiaotong University Xi'an China
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1473
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Ding X, Yu Y, Chen M, Wang C, Kang Y, Lou J. Causative agents and outcome of spontaneous bacterial peritonitis in cirrhotic patients: community-acquired versus nosocomial infections. BMC Infect Dis 2019; 19:463. [PMID: 31122192 PMCID: PMC6533661 DOI: 10.1186/s12879-019-4102-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 05/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is a serious complication and common cause of death in patients with liver cirrhosis. This study was conducted to compare the microbiological characteristics, drug resistance, and treatment outcomes for nosocomial SBP and community-acquired SBP. Methods A retrospective study was performed on 334 patients with culture-positive SBP at Beijing Youan Hospital, China, between January 2012 and December 2016. The medical records for these patients were reviewed, and their clinical and laboratory data were analyzed. Results A total of 155 (46.4%) patients with nosocomial SBP and 179 (53.6%) with community-acquired SBP were included in this study. From the patients’ ascitic fluids, 334 pathogenic strains, including 178 Gram-negative bacterial strains, 138 Gram-positive bacterial strains and 18 other microbial strains were isolated. E. coli was the major pathogen (24.3%), followed by Klebsiella pneumoniae (12.0%) and Enterococcus faecium (10.5%). The proportion of Enterococcus was significantly higher in the patients with nosocomial SBP (6.1% vs. 27.7%, P < 0.001) than in the patients with community-acquired SBP. The main pathogens isolated from the nosocomial infections were significantly more resistant to the first-line recommended drug. Compared with community-acquired SBP, nosocomial SBP had a poorer outcome (36.8% vs. 24.6%; P = 0.016). The independent predictors for 30-day mortality included nosocomial infection, Child-Pugh classification, hepatocellular carcinoma, renal failure and hepatic encephalopathy. Conclusion Gram-negative bacteria were the major pathogens involved in SBP in the cirrhotic patients. The strains isolated from the patients with nosocomial SBP displayed higher drug resistance than those isolated from patients with community-acquired SBP. Compared with community-acquired SBP, nosocomial SBP had a poorer outcome. When choosing drug treatments, the acquisition site of infection and the local epidemiological situation should be taken into account.
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Affiliation(s)
- Xiurong Ding
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Yanhua Yu
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Ming Chen
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Chen Wang
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Yanfang Kang
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Jinli Lou
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
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1474
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Yuan L, Zeng BM, Liu LL, Ren Y, Yang YQ, Chu J, Li Y, Yang FW, He YH, Lin SD. Risk factors for progression to acute-on-chronic liver failure during severe acute exacerbation of chronic hepatitis B virus infection. World J Gastroenterol 2019; 25:2327-2337. [PMID: 31148904 PMCID: PMC6529889 DOI: 10.3748/wjg.v25.i19.2327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/29/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute exacerbation in patients with chronic hepatitis B virus (HBV) infection results in different severities of liver injury. The risk factors related to progression to hepatic decompensation (HD) and acute-on-chronic liver failure (ACLF) in patients with severe acute exacerbation (SAE) of chronic HBV infection remain unknown.
AIM To identify risk factors related to progression to HD and ACLF in compensated patients with SAE of chronic HBV infection.
METHODS The baseline characteristics of 164 patients with SAE of chronic HBV infection were retrospectively reviewed. Independent risk factors associated with progression to HD and ACLF were identified. The predictive values of our previously established prediction model in patients with acute exacerbation (AE model) and the model for end-stage liver disease (MELD) score in predicting the development of ACLF were evaluated.
RESULTS Among 164 patients with SAE, 83 (50.6%) had compensated liver cirrhosis (LC), 43 had progression to HD without ACLF, and 29 had progression to ACLF within 28 d after admission. Independent risk factors associated with progression to HD were LC and low alanine aminotransferase. Independent risk factors for progression to ACLF were LC, high MELD score, high aspartate aminotransferase (AST) levels, and low prothrombin activity (PTA). The area under the receiver operating characteristic of the AE model [0.844, 95% confidence interval (CI): 0.779-0.896] was significantly higher than that of MELD score (0.690, 95%CI: 0.613-0.760, P < 0.05) in predicting the development of ACLF.
CONCLUSION In patients with SAE of chronic HBV infection, LC is an independent risk factor for progression to both HD and ACLF. High MELD score, high AST, and low PTA are associated with progression to ACLF. The AE model is a better predictor of ACLF development in patients with SAE than MELD score.
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Affiliation(s)
- Ling Yuan
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Bai-Mei Zeng
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Lu-Lu Liu
- Department of Gastroenterology, Jiangsu Province Hospital, Pukou Branch, Nanjing 210000, Jiangsu Province, China
| | - Yi Ren
- Department of Respiratory Medicine, the Fifth People’s Hospital of Chongqing, Chongqing 400062, China
| | - Yan-Qing Yang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Jun Chu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Ying Li
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Fang-Wan Yang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Yi-Huai He
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Shi-De Lin
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
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1475
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Chapman B, Gow P, Sinclair M, Hanrahan T, Angus P, McClure T, Mills C, Terbah R, Testro A. Continuous terlipressin infusion is associated with improved diet intake and muscle strength in patients awaiting liver transplant. JHEP Rep 2019; 1:107-113. [PMID: 32039358 PMCID: PMC7001556 DOI: 10.1016/j.jhepr.2019.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/30/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Portal hypertension contributes to the pathogenesis of malnutrition and sarcopenia in cirrhosis via multiple mechanisms. Terlipressin is a vasopressin analogue that we administer via continuous outpatient infusion, as a bridge to transplantation in patients with hepatorenal syndrome or refractory ascites. We describe, for the first time, the impact of outpatient terlipressin on nutritional and muscle parameters. Methods Nutrition (subjective global assessment), handgrip strength, dietary intake (energy, protein), frequency of paracentesis and severity of liver disease (model for end-stage liver disease score) were prospectively recorded at terlipressin commencement and follow-up (transplantation, cessation or census date). Results Nineteen patients were included (89% male, median age 59.6 years, median model for end-stage liver disease score 24), of whom 12 had hepatorenal syndrome and 7 had refractory ascites. All patients were malnourished at baseline, 63% (n = 12) had sarcopenic-range grip strength, and mean paracentesis frequency was 2.86 ± 1.62/month. Median duration of terlipressin was 51 days (interquartile range 29–222). Fourteen patients (74%) were transplanted, 2 delisted (10%) and 3 (16%) continued terlipressin. Energy and protein intake improved significantly following terlipressin, from 17.94 ± 5.43 kcal/kg to 27.70 ± 7.48 kcal/kg, and 0.74 ± 0.28 g/kg to 1.16 ± 0.31 g/kg, respectively (both p < 0.001). Handgrip strength increased from 25.36 ± 8.13 kg to 28.49 ± 7.63 kg (p = 0.001). Linear regression analysis demonstrated hand grip strength increased 0.075% for every 1-day of terlipressin (p = 0.005). The frequency of large-volume paracentesis reduced by 46%, to 1.57 ± 1.51/month (p = 0.001). Conclusion Continuous terlipressin infusion reduces the complications of portal hypertension and is associated with an improvement in nutritional and muscle parameters in patients on the liver transplant waiting list, in whom such characteristics usually demonstrate progressive decline. This validates both the aetiological role of portal hypertension in malnutrition and represents a promising new anabolic therapy. Lay summary Malnutrition and poor muscle strength are common in liver disease and often get worse while patients await liver transplant. Terlipressin is a medication used to treat portal hypertension in patients with hepatorenal syndrome. It is usually given for a few days or weeks in patients confined to hospital. Our centre provides outpatient terlipressin for weeks to months as a bridge to liver transplant. In patients treated with terlipressin at our hospital, we observed a substantial increase in their dietary intake and muscle strength, which may improve their quality of life and outcomes after liver transplant. Malnutrition and poor muscle strength are highly prevalent in cirrhotics with hepatorenal syndrome. Terlipressin infusion increased energy and protein intake in patients with hepatorenal syndrome. Handgrip strength continued to increase with every day of terlipressin therapy Medium to long-term terlipressin infusion was safe and efficacious as a bridge to liver transplant.
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Affiliation(s)
- Brooke Chapman
- Department of Nutrition and Dietetics, Austin Health, Heidelberg, Victoria, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Timothy Hanrahan
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Peter Angus
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Tess McClure
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Chris Mills
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Ryma Terbah
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
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1476
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High Prevalence of Multidrug Resistant Bacteria in Cirrhotic Patients with Spontaneous Bacterial Peritonitis: Is It Time to Change the Standard Antimicrobial Approach? Can J Gastroenterol Hepatol 2019; 2019:6963910. [PMID: 31214551 PMCID: PMC6535816 DOI: 10.1155/2019/6963910] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/20/2019] [Accepted: 04/03/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) has a deleterious clinical impact in end-stage liver disease, and multidrug resistance has increased, raising concern about effectiveness of traditional antibiotic regimens. PATIENTS AND METHODS Single-center retrospective study of ascitic fluid infections in cirrhotic patients. RESULTS We analyzed medical records related to 2129 culture-positive ascitic fluid and found 183 samples from cirrhotic patients. There were 113 monobacterial SBP cases from 97 cirrhotic patients; 57% of patients were male; hepatitis C and alcohol were the main etiologies for cirrhosis. Multidrug resistant bacteria were isolated in 46.9% of SBP samples, and third-generation cephalosporin and quinolone resistant reached 38.9% and 25.7% of SBP cases. CONCLUSION SBP due to multidrug resistant bacteria is a growing problem, and one should consider reported resistance profiles for the decision-making process of empirical first-line treatment prescription.
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1477
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Mandorfer M, Hernández-Gea V, Reiberger T, García-Pagán JC. Hepatic Venous Pressure Gradient Response in Non-Selective Beta-Blocker Treatment—Is It Worth Measuring? ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s11901-019-00469-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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1478
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Solà E, Solé C, Ginès P. New Strategies for the Management of Decompensated Cirrosis: Long-Term Albumin Administration for Everyone? Hepatology 2019; 69:2289-2291. [PMID: 30468512 DOI: 10.1002/hep.30357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Elsa Solà
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - Cristina Solé
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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1479
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Abstract
Cirrhosis with portal hypertension and related complications are associated with a high mortality. Excess of circulating vasodilators and cardiodepressive substances lead to a hyperdynamic circulation with changed myocardial structure and function. The entity cirrhotic cardiomyopathy seems to be involved in different aspects of hepatic decompensation, which focuses on new targets of treatment. Areas covered: This review deals with contemporary aspects of cirrhotic cardiomyopathy, and the literature search was undertaken by PubMed with 'cirrhotic' and 'cardiomyopathies' as MeSH Terms. Cirrhotic cardiomyopathy is defined as the presence of systolic and diastolic dysfunction and electrophysiological abnormalities. The diagnosis is based on contemporary Doppler/Echocardiography measurements or quantitative magnetic resonance imaging. Cirrhotic cardiomyopathy is independent of the etiology of the liver disease but related to severity and survival. Expert commentary: The outcome of invasive procedures and liver transplantation is influenced by the presence of cardiac dysfunction. Therefore, a cautious cardiac evaluation should be included in the patient evaluation prior to liver transplantation. Liver transplantation ameliorates most of the abnormalities seen in cirrhotic cardiomyopathy, but no specific treatment can yet be recommended.
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Affiliation(s)
- Søren Møller
- a Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
| | - Karen V Danielsen
- a Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark.,b Gastroenterology Unit, Medical Division, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
| | - Signe Wiese
- a Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark.,b Gastroenterology Unit, Medical Division, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
| | - Jens D Hove
- c Department of Cardiology, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
| | - Flemming Bendtsen
- b Gastroenterology Unit, Medical Division, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
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1480
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Artru F, Samuel D. Approaches for patients with very high MELD scores. JHEP Rep 2019; 1:53-65. [PMID: 32039352 PMCID: PMC7001538 DOI: 10.1016/j.jhepr.2019.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 02/08/2023] Open
Abstract
In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.
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Affiliation(s)
- Florent Artru
- Liver Unit, CHRU Lille, France, University of Lille, LIRIC team, Inserm unit 995
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, F-94800, France; Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, Villejuif, F-94800, France; Inserm, Unité 1193, Université Paris-Saclay, Villejuif, F-94800, France; Hepatinov, Villejuif, F-94800, France
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1481
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Angeli P, Bernardi M. Reply to: "Prophylaxis of spontaneous bacterial peritonitis: is there still room for quinolones?". J Hepatol 2019; 70:1028-1030. [PMID: 30723006 DOI: 10.1016/j.jhep.2019.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Dept. of Medicine (DIMED), University of Padova, Italy.
| | - Mauro Bernardi
- Dept. of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Italy
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1482
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Powell EE, Skoien R, Rahman T, Clark PJ, O'Beirne J, Hartel G, Stuart KA, McPhail SM, Gupta R, Boyd P, Valery PC. Increasing Hospitalization Rates for Cirrhosis: Overrepresentation of Disadvantaged Australians. EClinicalMedicine 2019; 11:44-53. [PMID: 31317132 PMCID: PMC6610783 DOI: 10.1016/j.eclinm.2019.05.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Limited information is available about hospitalization rates for cirrhosis in Australia. METHODS Using information on all hospital episodes of care for patients admitted to Queensland hospitals during 2008-2016, we report age-standardized hospitalization rates/10,000 person-years, in-hospital case-fatality rate among these admissions (n = 30,327), and examine the factors associated with hospital deaths using logistic regression analyses. FINDINGS Hospitalization rates increased from 8.50/10,000 (95% confidence interval (CI) 8.18-8.82) to 11.21/10,000 (95%CI 10.87-11.54) between 2008 and 2016, and peaked in men aged 55-59 years (34.03/10,000) and in Indigenous Australians (32.79/10,000). The number of admissions increased by 61.7% from 2701 admissions in 2008 to 4367 in 2016. During the same period, the percentage increase varied by socioeconomic disadvantage (3.2%/year in the most affluent vs. 9.4%/year in the most disadvantaged quintile; p < 0.001). Alcohol misuse was a contributing factor for cirrhosis in 55.1% of admissions, and socioeconomic disadvantage in 26.8%. The overall in-hospital case-fatality rate was 9.7% for males and 9.3% for females, and decreased in males (p < 0.001). Predictors of in-hospital mortality included hepatorenal syndrome (adjusted odds ratio (AOR) = 7.24, 95%CI 5.99-8.75), HCC (AOR = 2.53, 95%CI 2.20-2.91), hepatic encephalopathy (AOR = 1.94, 95%CI 1.61-2.34), acute peritonitis (AOR = 1.93, 95%CI 1.61-2.33), jaundice (AOR = 1.82, 95%CI 1.20-2.75), age ≥ 70 years (AOR = 1.63, 95%CI 1.38-1.92), a higher comorbidity index (p = 0.021), and residence outside of a "major city" (p < 0.001). INTERPRETATION The increasing healthcare use by Australians with cirrhosis has resource and economic implications. Our data highlight the disproportionate impact of cirrhosis on Indigenous Australians and people from the most socioeconomically disadvantaged areas. FUNDING Brisbane Diamantina Health Partners.
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Key Words
- Adjusted odds ratios, AOR
- Charlson Comorbidity Index, CCI
- Chronic liver disease
- Chronic liver diseases, CLDs
- Confidence interval, CI
- Epidemiology
- Hepatic encephalopathy, HE
- Hepatitis B virus, HBV
- Hepatitis C virus, HCV
- Hepatocellular carcinoma, HCC
- In-hospital mortality
- International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian, ICD-10-AM
- Interquartile range, IQR
- Least Absolute Shrinkage and Selection Operators, LASSO
- Length of stay, LOS
- Non-alcoholic fatty liver disease, NAFLD
- Odds ratios, OR
- Radio-frequency ablation, RFA
- Temporal
- Trans-arterial chemoembolization, TACE
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Affiliation(s)
- Elizabeth E. Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Richard Skoien
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Tony Rahman
- Gastroenterology & Hepatology Department, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Paul J. Clark
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Department of Gastroenterology and Hepatology, Mater Hospitals, Brisbane, QLD, Australia
| | - James O'Beirne
- Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Gunter Hartel
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Katherine A. Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Steven M. McPhail
- Centre for Functioning and Health Research, Queensland Health and the School of Public Health and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Peter Boyd
- Cairns Base Hospital, Cairns, QLD, Australia
| | - Patricia C. Valery
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
- Corresponding author.
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1483
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Nguyen-Tat M, Jäger J, Rey JW, Nagel M, Labenz C, Wörns MA, Galle PR, Marquardt JU. Terlipressin and albumin combination treatment in patients with hepatorenal syndrome type 2. United European Gastroenterol J 2019; 7:529-537. [PMID: 31065370 PMCID: PMC6488797 DOI: 10.1177/2050640619825719] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/04/2018] [Indexed: 12/12/2022] Open
Abstract
Background Hepatorenal syndrome (HRS) is associated with a poor prognosis. In HRS type 1, loss of renal function is rapidly progressive, while HRS type 2 is characterised by chronic ascites and more moderately elevated renal parameters. While treatment with terlipressin/albumin is well established in type 1, its effectiveness in chronic HRS is less clear. Objective The aim of this study was to evaluate the effectiveness of terlipressin/albumin treatment in patients with HRS type 2. Methods All patients with a first episode of HRS between April 2013 and February 2016 were included in this observational study. Relevant clinical and laboratory parameters were recorded and patients were followed. Results A total of 106 patients with HRS were included. With terlipressin therapy reversal of HRS types 1 and 2 was achieved in 48% and 46% of patients (p = 0.84) with relapse rates of 8% vs 50% (p = 0.001). Overall survival (OS) and survival free of liver transplantation (LTx) were similar in HRS types 1 and 2 (p = 0.69; p = 0.64). In multivariate analysis response to treatment was independently associated with better OS in HRS type 2, in addition to established risk factors such as lower Model for End-Stage Liver Disease score, absence of hepatic encephalopathy and eligibility for LTx. Conclusion A terlipressin treatment course seems to be justified in selected patients with HRS type 2, especially in countries and settings with long transplant waiting lists. In addition treatment response might also help to identify HRS type 2 patients with a more favourable outcome.
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Affiliation(s)
- Marc Nguyen-Tat
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
- Department of Medicine II, Klinikum
Osnabrück, Osnabrück, Germany
| | - Julia Jäger
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | | | - Michael Nagel
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | - Christian Labenz
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | - Marcus-Alexander Wörns
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | - Peter Robert Galle
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | - Jens Uwe Marquardt
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
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1484
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Porther R, Ross G, Nagasayi S. Breathlessness in liver disease: A case of hepatopulmonary syndrome . Clin Med (Lond) 2019; 19:250-251. [PMID: 31092521 PMCID: PMC6542230 DOI: 10.7861/clinmedicine.19-3-250] [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] [Indexed: 11/27/2022]
Abstract
Hepatopulmonary syndrome (HPS) is often not considered as a cause of breathlessness in patients with liver cirrhosis. It consists of a triad of liver disease, intrapulmonary shunting and hypoxaemia. Here we discuss HPS in a patient presenting with acute on chronic breathlessness and typical features of orthodeoxia and platypnoea. Evidence of intrapulmonary shunting on imaging was essential to making the diagnosis, which carries a poor prognosis and was an urgent indication for liver transplantation.
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Affiliation(s)
| | - Gavin Ross
- Withybush General Hospital, Haverfordwest, UK
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1485
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Prophylaxis of spontaneous bacterial peritonitis: Is there still room for quinolones? J Hepatol 2019; 70:1027-1028. [PMID: 30718094 DOI: 10.1016/j.jhep.2018.12.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/21/2018] [Indexed: 12/15/2022]
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1486
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Bräsen JH, Mederacke YS, Schmitz J, Diahovets K, Khalifa A, Hartleben B, Person F, Wiech T, Steenbergen E, Großhennig A, Manns MP, Schmitt R, Mederacke I. Cholemic Nephropathy Causes Acute Kidney Injury and Is Accompanied by Loss of Aquaporin 2 in Collecting Ducts. Hepatology 2019; 69:2107-2119. [PMID: 30633816 DOI: 10.1002/hep.30499] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/22/2018] [Indexed: 02/07/2023]
Abstract
Impairment of renal function often occurs in patients with liver disease. Hepatorenal syndrome is a significant cause of acute kidney injury (AKI) in patients with cirrhosis (HRS-AKI, type 1). Causes of non-HRS-AKI include cholemic nephropathy (CN), a disease that is characterized by intratubular bile casts and tubular injury. As data on patients with CN are obtained primarily from case reports or autopsy studies, we aimed to investigate the frequency and clinical course of CN. We identified 149 patients who underwent kidney biopsy between 2000 and 2016 at the Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School. Of these, 79 had a history of liver disease and deterioration of renal function. When applying recent European Association for the Study of the Liver criteria, 45 of 79 patients (57%) presented with AKI, whereas 34 patients (43%) had chronic kidney disease (CKD). Renal biopsy revealed the diagnosis of CN in 8 of 45 patients with AKI (17.8%), whereas none of the patients with CKD was diagnosed with CN. Univariate analysis identified serum bilirubin, alkaline phosphatase, and urinary bilirubin and urobilinogen as predictive factors for the diagnosis of CN. Histological analysis of AKI patients with normal bilirubin, elevated bilirubin, and the diagnosis of CN revealed loss of aquaporin 2 (AQP2) expression in collecting ducts in patients with elevated bilirubin and CN. Biopsy-related complications requiring medical intervention occurred in 4 of 79 patients (5.1%). Conclusion: CN is a common finding in patients with liver disease, AKI, and highly elevated bilirubin. Loss of AQP2 in AKI patients with elevated bilirubin and CN might be the result of toxic effects of cholestasis and in part be responsible for the impairment of renal function.
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Affiliation(s)
- Jan Hinrich Bräsen
- Institute of Pathology, Nephropathology Unit, Hannover Medical School, Hannover, Germany
| | - Young-Seon Mederacke
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jessica Schmitz
- Institute of Pathology, Nephropathology Unit, Hannover Medical School, Hannover, Germany
| | - Kateryna Diahovets
- Institute of Pathology, Nephropathology Unit, Hannover Medical School, Hannover, Germany
| | - Abedalrazag Khalifa
- Institute of Pathology, Nephropathology Unit, Hannover Medical School, Hannover, Germany
| | - Björn Hartleben
- Institute of Pathology, Nephropathology Unit, Hannover Medical School, Hannover, Germany
| | - Fermín Person
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Thorsten Wiech
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Eric Steenbergen
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anika Großhennig
- Institute for Biostatistics, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Roland Schmitt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Ingmar Mederacke
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
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1487
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Kamimura K, Sakamaki A, Kamimura H, Setsu T, Yokoo T, Takamura M, Terai S. Considerations of elderly factors to manage the complication of liver cirrhosis in elderly patients. World J Gastroenterol 2019; 25:1817-1827. [PMID: 31057296 PMCID: PMC6478616 DOI: 10.3748/wjg.v25.i15.1817] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 02/06/2023] Open
Abstract
The aging of the organ function causes sensitivity to the disease progression and need careful consideration for the medical treatment. With the increase of aging population, the opportunity to provide medical treatment for people in very old age is rapidly increasing therefore, the understanding of the various physiological changes of cellular function, size and function of organs are essential for the decision of therapeutic options. Among the various chronic conditions seen in elderly people, we have focused on liver cirrhosis, since despite specific therapeutic options for many of liver diseases including direct acting antivirals for hepatitis C virus, nucleoside analogs for hepatitis B, and corticosteroids for autoimmune hepatitis, there is currently no standard therapy to treat liver cirrhosis, which is the final stage of these liver diseases. Therefore, management of the various symptoms of liver cirrhosis is essential, and aging-related parameters must be considered in the decision making for therapeutic strategies and dosage of the available medicine. In this mini-review, we have summarized the therapeutic options to manage various symptoms of liver cirrhosis, carefully considering the physiological changes of various organs associated with aging.
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Affiliation(s)
- Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Akira Sakamaki
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Hiroteru Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Toru Setsu
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Takeshi Yokoo
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Masaaki Takamura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
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1488
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Abstract
Purpose of review Patients with cirrhosis are at high risk of developing serious infections. Bacterial infections remain the most common cause of morbidity and mortality in these patients. This review is focused on the prevalence of infections in those with cirrhosis, including multidrug-resistant (MDR) pathogens, pathogenesis of infection-related acute-on-chronic liver failure (ACLF), current treatment recommendations, and prophylactic strategies in patients with cirrhosis. Recent findings Recent epidemiological studies have noted an emerging prevalence of MDR bacterial infections and associated with poor prognosis, and a high rate of treatment failure and mortality. Therefore, new recommendations on empirical antibiotic use based on epidemiological data have been developed in order to improve outcomes. Summary Spontaneous bacterial peritonitis (SBP) and urinary tract infection (UTI) are the most frequent infections followed by pneumonia, cellulitis, and bacteremia, while pneumonia carries the highest risk of mortality. The incidence of MDR bacterial infections has been increasing, especially in healthcare-associated settings. Second infections that develop during hospitalization, multiple organ failures, and high MELD score are associated with poor survival. Preventive measures, early diagnosis, and adequate treatment of infections are essential key concepts in minimizing morbidity and mortality in patients with cirrhosis.
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1489
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Paine CH, Biggins SW, Pichler RH. Albumin in Cirrhosis: More Than a Colloid. ACTA ACUST UNITED AC 2019; 17:231-243. [DOI: 10.1007/s11938-019-00227-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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1490
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Simbrunner B, Röthenbacher A, Haslacher H, Bauer D, Chromy D, Bucsics T, Schwabl P, Paternostro R, Scheiner B, Trauner M, Mandorfer M, Schwarzinger I, Reiberger T. Ascitic fluid polymorphic nuclear cell count impacts on outcome of cirrhotic patients with ascites. United European Gastroenterol J 2019; 7:651-661. [PMID: 31210943 DOI: 10.1177/2050640619843000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/25/2019] [Indexed: 12/13/2022] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is defined as an ascitic polymorphonuclear cell count (A-PMN) > 250 cells/µl. Objective We aimed to investigate the prognostic value of ascitic fluid cell counts in patients without SBP. Patients and methods A total of 178 patients were included and stratified by ascitic cell counts at index paracentesis: A-LEUK-low (<250/µl), A-LEUK-intermediate (250-500/µl) and A-LEUK-SBP (>500/µl) for leukocytes; A-PMN-low (<125/µl), A-PMN-intermediate (125-250/µl) and A-PMN-SBP (>250/µl) for PMN cells. Results One-year mortality was comparable between group A-LEUK-SBP (53.9%) and patients with subclinical cell counts (34.5% for A-LEUK-low, 43.5% for A-LEUK-intermediate, log-rank p = 0.547). However, we observed an increase in one-year mortality already in group A-PMN-intermediate with 75% and A-PMN-SBP with 80.9% (vs 40.5% for A-PMN-low, log-rank p = 0.016).Importantly, increases of A-PMN cell counts between two paracenteses were associated with increased mortality: per 100 cells/µl increase of absolute A-PMN cell count: hazard ratio (HR): 1.03 (95% confidence interval (CI): 1.01-1.06), p = 0.005; per 5% increase of relative PMN cell count: HR: 1.15 (95% CI: 1.06-1.26), p = 0.001. Conclusion Patients with PMN cell counts of 125-250/µl are at high risk for mortality, which was very similar to SBP patients with PMN cell counts >250/µl. This highlights the need for preventive strategies. The prognostic value of changes in relative ascitic PMN cell counts should be evaluated in future studies.
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Affiliation(s)
- Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Annika Röthenbacher
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - David Chromy
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Ilse Schwarzinger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
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1491
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Keaveny AP. Obesity and acute-on-chronic liver failure. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:153. [PMID: 31157274 PMCID: PMC6511562 DOI: 10.21037/atm.2019.01.82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 12/23/2023]
Affiliation(s)
- Andrew P Keaveny
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
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1492
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Piano S, Singh V, Caraceni P, Maiwall R, Alessandria C, Fernandez J, Soares EC, Kim DJ, Kim SE, Marino M, Vorobioff J, Barea RDCR, Merli M, Elkrief L, Vargas V, Krag A, Singh SP, Lesmana LA, Toledo C, Marciano S, Verhelst X, Wong F, Intagliata N, Rabinowich L, Colombato L, Kim SG, Gerbes A, Durand F, Roblero JP, Bhamidimarri KR, Boyer TD, Maevskaya M, Fassio E, Kim HS, Hwang JS, Gines P, Gadano A, Sarin SK, Angeli P, Brodersen C, Bruns T, de Man RA, Fialla AD, Gambino C, Gautam V, Girala M, Juanola A, Kim JH, Kim TH, Kumar P, Lattanzi B, Lee TH, Rinaldi Lesmana CA, Moreau R, Nath P, Navarro G, Park JW, Pinero G, Pyrsopoulos NT, Restellini S, Romero G, Sacco M, Sevá-Pereira T, Simón-Talero M, Song DS, Suk KT, Van Vlierberghe H, Yim SY, Yoon EL, Zaccherini G. Epidemiology and Effects of Bacterial Infections in Patients With Cirrhosis Worldwide. Gastroenterology 2019; 156:1368-1380.e10. [PMID: 30552895 DOI: 10.1053/j.gastro.2018.12.005] [Citation(s) in RCA: 273] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 11/30/2018] [Accepted: 12/07/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis. METHODS We collected data from 1302 hospitalized patients with cirrhosis and bacterial or fungal infections at 46 centers (15 in Asia, 15 in Europe, 11 in South America, and 5 in North America) from October 2015 through September 2016. We obtained demographic, clinical, microbiology, and treatment data at time of diagnosis of infection and during hospitalization. Patients were followed until death, liver transplantation, or discharge. RESULTS The global prevalence of multidrug-resistant (MDR) bacteria was 34% (95% confidence interval 31%-37%). The prevalence of MDR bacteria differed significantly among geographic areas, with the greatest prevalence in Asia. Independent risk factors for infection with MDR bacteria were infection in Asia (particularly in India), use of antibiotics in the 3 months before hospitalization, prior health care exposure, and site of infection. Infections caused by MDR bacteria were associated with a lower rate of resolution of infection, a higher incidence of shock and new organ failures, and higher in-hospital mortality than those caused by non-MDR bacteria. Administration of adequate empirical antibiotic treatment was independently associated with improved in-hospital and 28-day survival. CONCLUSIONS In a worldwide study of hospitalized patients, we found a high prevalence of infection with MDR bacteria in patients with cirrhosis. Differences in the prevalence of MDR bacterial infections in different global regions indicate the need for different empirical antibiotic strategies in different continents and countries. While we await new antibiotics, effort should be made to decrease the spread of MDR bacteria in patients with cirrhosis.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Catalonia, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Catalonia, Spain
| | - Elza Cotrim Soares
- Gastroenterology Division, Medicine Department, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Sung Eun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang City, Republic of Korea
| | - Monica Marino
- Liver Unit, Hospital Dr. Carlos B. Udaondo, Buenos Aires, Argentina
| | | | | | - Manuela Merli
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Laure Elkrief
- Service de Transplantation, Service d'Hépato-gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Victor Vargas
- Liver Unit, Department of Internal Medicine, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | | | | | - Claudio Toledo
- Gastroenterology Unit, Hospital Valdivia, Universidad Austral de Chile, Valdivia, Chile
| | - Sebastian Marciano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Nicolas Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Liane Rabinowich
- Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center and Tel-Aviv University, Tel-Aviv, Israel
| | - Luis Colombato
- Gastroenterology Department, Buenos Aires British Hospital, Argentine Catholic University, Buenos Aires, Argentina
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Francois Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University Paris Diderot, Paris, France
| | - Juan Pablo Roblero
- Departamento de Medicina, Universidad de Chile Campus Centro, Hospital Clínico San Borja Arriarán, Santiago, Chile
| | | | - Thomas D Boyer
- Department of Medicine, University of Arizona, Tucson, Arizona
| | | | - Eduardo Fassio
- Liver Unit, Hospital Nacional Prof. Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | - Hyoung Su Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jae Seok Hwang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Pere Gines
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Catalonia, Spain
| | - Adrian Gadano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy.
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1493
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Jansen C, Trebicka J. Editorial: diastolic dysfunction seems not to be decisive for survival after transjugular intrahepatic portosystemic stent-shunt. Aliment Pharmacol Ther 2019; 49:1101-1102. [PMID: 30920049 DOI: 10.1111/apt.15221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Christian Jansen
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, University Clinic Frankfurt, Frankfurt, Germany.,European Foundation for Study of Chronic Liver Failure, Barcelona, Spain.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Institute of Bioengineering Catalunya, Barcelona, Spain
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1494
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Shribman S, Warner TT, Dooley JS. Clinical presentations of Wilson disease. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S60. [PMID: 31179297 DOI: 10.21037/atm.2019.04.27] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The main presenting features of Wilson disease, many of which mimic common hepatic and neurologic disorders, are discussed. There is a need for specialists in these and related fields to be aware of hints from within and, more importantly, outside their area of expertise that should alert them to consider the diagnosis. Delayed diagnosis and treatment are potentially damaging for the patient. The importance of recognising and promptly investigating Wilson disease at the initial presentation should be understood by all those who assess patients with hepatic or neurologic disorders and/or train others in their specialty.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | - Thomas T Warner
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | - James S Dooley
- UCL Institute for Liver and Digestive Health, Division of Medicine, Royal Free Campus, London, UK
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1495
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Völker D, Grünhage F, Wagenpfeil S, Lammert F, Stokes CS. Serum 25-hydroxyvitamin D levels and mortality risk in patients with liver cirrhosis: a protocol for a systematic review and meta-analysis of observational studies. Syst Rev 2019; 8:73. [PMID: 30904016 PMCID: PMC6431049 DOI: 10.1186/s13643-019-0988-6] [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: 08/01/2017] [Accepted: 03/13/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Liver cirrhosis represents a substantial global burden in terms of morbidity and mortality. Observational studies have reported an increased risk of death with low circulating 25-hydroxyvitamin D concentrations in such patients. Because the occurrence of inadequate vitamin D status is very common in patients with liver cirrhosis, the aim of this study is to conduct a meta-analysis of observational studies in such patients to assess whether vitamin D deficiency increases their risk of mortality. METHODS We will search electronic databases (MEDLINE, Embase, Web of Science, CENTRAL and Google Scholar from time of inception until now), conference proceedings and conduct manual searches to identify studies eligible for inclusion. There will be no restrictions based on publication status or language, and the meta-analysis will be reported in accordance with the MOOSE guidelines. We will employ random-effects meta-analysis to assess the relationship between vitamin D deficiency and risk of mortality. Quality of studies will be judged using the Newcastle-Ottawa scale, and between-trial heterogeneity will be evaluated by means of subgroup and sensitivity analyses. DISCUSSION The study will assess the effects of serum 25-hydroxyvitamin D concentrations on mortality in patients with liver cirrhosis. The results will be published in a high-quality peer-reviewed journal. SYSTEMATIC REVIEW REGISTRATION Prospero CRD42016052007 .
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Affiliation(s)
- Désirée Völker
- Department of Medicine II, Saarland University Medical Center, Saarland University, Kirrberger Str. 100, 66421 Homburg, Germany
| | - Frank Grünhage
- Department of Medicine II, Saarland University Medical Center, Saarland University, Kirrberger Str. 100, 66421 Homburg, Germany
- Department of Internal Medicine, Grevenbroich St. Elisabeth Hospital, Grevenbroich, Germany
| | - Stefan Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Campus Homburg, Homburg, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Kirrberger Str. 100, 66421 Homburg, Germany
| | - Caroline S. Stokes
- Department of Medicine II, Saarland University Medical Center, Saarland University, Kirrberger Str. 100, 66421 Homburg, Germany
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1496
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Trebicka J, Amoros A, Pitarch C, Titos E, Alcaraz-Quiles J, Schierwagen R, Deulofeu C, Fernandez-Gomez J, Piano S, Caraceni P, Oettl K, Sola E, Laleman W, McNaughtan J, Mookerjee RP, Coenraad MJ, Welzel T, Steib C, Garcia R, Gustot T, Rodriguez Gandia MA, Bañares R, Albillos A, Zeuzem S, Vargas V, Saliba F, Nevens F, Alessandria C, de Gottardi A, Zoller H, Ginès P, Sauerbruch T, Gerbes A, Stauber RE, Bernardi M, Angeli P, Pavesi M, Moreau R, Clària J, Jalan R, Arroyo V. Addressing Profiles of Systemic Inflammation Across the Different Clinical Phenotypes of Acutely Decompensated Cirrhosis. Front Immunol 2019; 10:476. [PMID: 30941129 PMCID: PMC6434999 DOI: 10.3389/fimmu.2019.00476] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/21/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Patients with acutely decompensated cirrhosis (AD) may or may not develop acute-on-chronic liver failure (ACLF). ACLF is characterized by high-grade systemic inflammation, organ failures (OF) and high short-term mortality. Although patients with AD cirrhosis exhibit distinct clinical phenotypes at baseline, they have low short-term mortality, unless ACLF develops during follow-up. Because little is known about the association of profile of systemic inflammation with clinical phenotypes of patients with AD cirrhosis, we aimed to investigate a battery of markers of systemic inflammation in these patients. Methods: Upon hospital admission baseline plasma levels of 15 markers (cytokines, chemokines, and oxidized albumin) were measured in 40 healthy controls, 39 compensated cirrhosis, 342 AD cirrhosis, and 161 ACLF. According to EASL-CLIF criteria, AD cirrhosis was divided into three distinct clinical phenotypes (AD-1: Creatinine<1.5, no HE, no OF; AD-2: creatinine 1.5-2, and or HE grade I/II, no OF; AD-3: Creatinine<1.5, no HE, non-renal OF). Results: Most markers were slightly abnormal in compensated cirrhosis, but markedly increased in AD. Patients with ACLF exhibited the largest number of abnormal markers, indicating "full-blown" systemic inflammation (all markers). AD-patients exhibited distinct systemic inflammation profiles across three different clinical phenotypes. In each phenotype, activation of systemic inflammation was only partial (30% of the markers). Mortality related to each clinical AD-phenotype was significantly lower than mortality associated with ACLF (p < 0.0001 by gray test). Among AD-patients baseline systemic inflammation (especially IL-8, IL-6, IL-1ra, HNA2 independently associated) was more intense in those who had poor 28-day outcomes (ACLF, death) than those who did not experience these outcomes. Conclusions: Although AD-patients exhibit distinct profiles of systemic inflammation depending on their clinical phenotypes, all these patients have only partial activation of systemic inflammation. However, those with the most extended baseline systemic inflammation had the highest the risk of ACLF development and death.
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Affiliation(s)
- Jonel Trebicka
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Department of Internal Medicine I, University of Bonn, Bonn, Germany.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Mechanical Biology, Institute for Bioengineering of Catalonia, Barcelona, Spain.,J.W. Goethe University Hospital, Frankfurt, Germany
| | - Alex Amoros
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Carla Pitarch
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Esther Titos
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - José Alcaraz-Quiles
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Robert Schierwagen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,J.W. Goethe University Hospital, Frankfurt, Germany
| | - Carmen Deulofeu
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | | | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Karl Oettl
- Department of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Elsa Sola
- Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Wim Laleman
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | | | | | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Tania Welzel
- J.W. Goethe University Hospital, Frankfurt, Germany
| | - Christian Steib
- Department of Medicine II, Liver Center Munich, University Hospital LMU Munich, Munich, Germany
| | - Rita Garcia
- Department of Digestive Diseases and CIBERehd, Facultad de Medicina, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Thierry Gustot
- Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Rafael Bañares
- Department of Digestive Diseases and CIBERehd, Facultad de Medicina, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | | | | | | | - Faouzi Saliba
- Hôpital Paul Brousse, Université Paris-Sud, Villejuif, France
| | - Frederic Nevens
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | | | - Heinz Zoller
- Department of Hepatology and Gastroenterology, University Clinic Innsbruck, Innsbruck, Austria
| | - Pere Ginès
- Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Tilman Sauerbruch
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, Liver Center Munich, University Hospital LMU Munich, Munich, Germany
| | - Rudolf E Stauber
- Department of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Marco Pavesi
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), UMRS1149, Paris, France.,Université Paris Diderot-Paris 7, Département Hospitalo-Universitaire (DHU) UNITY, Paris, France.,Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Paris, France.,Laboratoire d'Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
| | - Joan Clària
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
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1497
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Dong V, Karvellas CJ. Acute-on-chronic liver failure: Objective admission and support criteria in the intensive care unit. JHEP Rep 2019; 1:44-52. [PMID: 32039351 PMCID: PMC7001553 DOI: 10.1016/j.jhepr.2019.02.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/16/2019] [Accepted: 01/30/2019] [Indexed: 12/12/2022] Open
Abstract
Cirrhosis is a leading cause of morbidity and mortality throughout the world. Significant complications include variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, and infection. When these complications are severe, admission to the intensive care unit (ICU) is often required for organ support and management. Intensive care therapy can also serve as a bridge to liver transplantation. Along with decompensation of cirrhosis, the concept of acute-on-chronic liver failure (ACLF) has emerged. This involves an acute precipitating event, such as the development of infection in a patient with cirrhosis, which leads to acute deterioration of hepatic function and extrahepatic organ failure. Extrahepatic complications often include renal, cardiovascular, and respiratory failures. Patients with significant extrahepatic and hepatic failures need ICU admission for organ support. Again, in patients who are deemed suitable liver transplant candidates, intensive care management may allow bridging to liver transplantation. However, patients with a Chronic Liver Failure Consortium ACLF score greater than 70 at 48 to 72 hours post-ICU admission do not seem to benefit from ongoing intensive support and a palliative approach may be more appropriate.
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Affiliation(s)
- Victor Dong
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Constantine J Karvellas
- Division of Gastroenterology, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
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1498
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Piano S, Tonon M, Angeli P. Predicting Outcomes of Liver Transplantation in Patients With Nonalcoholic Steatohepatitis: Pretransplant Renal Function Is Key. Liver Transpl 2019; 25:362-364. [PMID: 30657244 DOI: 10.1002/lt.25413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
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1499
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Armstrong MJ, Gohar F, Dhaliwal A, Nightingale P, Baker G, Greaves D, Mangat K, Zia Z, Karkhanis S, Olliff S, Mehrzad H, Steeds RP, Tripathi D. Diastolic dysfunction on echocardiography does not predict survival after transjugular intrahepatic portosystemic stent-shunt in patients with cirrhosis. Aliment Pharmacol Ther 2019; 49:797-806. [PMID: 30773660 DOI: 10.1111/apt.15164] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/06/2018] [Accepted: 01/06/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiac dysfunction is frequently observed in patients with cirrhosis. There remains a paucity of data from routine clinical practice regarding the role of echocardiography in the pre-assessment of transjugular intrahepatic portosystemic stent-shunt. AIM Our study aimed to investigate if echocardiography parameters predict outcomes after transjugular intrahepatic portosystemic stent-shunt insertion in cirrhosis. METHODS Patients who underwent echocardiography and transjugular intrahepatic portosystemic stent-shunt insertion at the liver unit (Birmingham, UK) between 1999 and 2016 were included. All echocardiography measures (including left ventricle ejection fraction; early maximal ventricular filling/late filling velocity ratio, diastolic dysfunction as per British Society of Echocardiography guidelines) were independently reviewed by a cardiologist. Predictors of 30-day and overall transplant free-survival were assessed. RESULTS One Hundred and Seventeen patients with cirrhosis (median age 56 years; 54% alcohol; Child-Pugh B/C 71/14.5%; Model For End-Stage Liver Disease 12) underwent transjugular intrahepatic portosystemic stent-shunt for ascites (n = 78) and variceal haemorrhage (n = 39). Thirty-day and overall transplant-free survival was 90% (n = 105) and 31% (n = 36), respectively, over a median 663 (IQR 385-2368) days follow-up. Model for End-Stage Liver Disease (P < 0.001) and Child-Pugh Score (P = 0.002) significantly predicted 30-day and overall transplant-free survival. Model for End-Stage Liver Disease ≥15 implied three-fold risk of death. Six per cent (n = 7) of patients pre-transjugular intrahepatic portosystemic stent-shunt had a history of ischaemic heart disease and 34% (n = 40) had 1 or more cardiovascular disease risk factors. Fifty per cent (n = 59) had an abnormal echocardiogram and 33% (n = 39) had grade 1-3 diastolic dysfunction. On univariate analysis none of the echocardiography measures pre-intervention were related to 30-day or overall transplant-free survival post-transjugular intrahepatic portosystemic stent-shunt. CONCLUSIONS Ventricular, in particular diastolic dysfunction in patients with cirrhosis does not predict survival after transjugular intrahepatic portosystemic stent-shunt insertion. Model for End-Stage Liver Disease and Child-Pugh scores remain the best predictors of survival. Further prospective study is required to clarify the role of routine echocardiography prior to transjugular intrahepatic portosystemic stent-shunt insertion.
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Affiliation(s)
- Matthew J Armstrong
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK.,NIHR Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK
| | - Farhan Gohar
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK
| | - Amritpal Dhaliwal
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK.,NIHR Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK
| | - Peter Nightingale
- Medical Statistics, Institute of Translational Medicine, Queen Elizabeth University Hospital, Birmingham, UK
| | - Graham Baker
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK
| | - Daniel Greaves
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK
| | - Kam Mangat
- Department of Diagnostic Imaging, National University Hospital (NUH), Singapore, Singapore
| | - Zergum Zia
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Salil Karkhanis
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Simon Olliff
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Homoyon Mehrzad
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Rick P Steeds
- Department of Cardiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Dhiraj Tripathi
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK.,NIHR Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK
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1500
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Kockerling D, Nathwani R, Forlano R, Manousou P, Mullish BH, Dhar A. Current and future pharmacological therapies for managing cirrhosis and its complications. World J Gastroenterol 2019; 25:888-908. [PMID: 30833797 PMCID: PMC6397723 DOI: 10.3748/wjg.v25.i8.888] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/17/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
Due to the restrictions of liver transplantation, complication-guided pharmacological therapy has become the mainstay of long-term management of cirrhosis. This article aims to provide a complete overview of pharmacotherapy options that may be commenced in the outpatient setting which are available for managing cirrhosis and its complications, together with discussion of current controversies and potential future directions. PubMed/Medline/Cochrane Library were electronically searched up to December 2018 to identify studies evaluating safety, efficacy and therapeutic mechanisms of pharmacological agents in cirrhotic adults and animal models of cirrhosis. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in cirrhotic patients with moderate/large varices, but appear ineffective for primary prevention of variceal development and may compromise renal function and haemodynamic stability in advanced decompensation. Recent observational studies suggest protective, haemodynamically-independent effects of beta-blockers relating to reduced bacterial translocation. The gut-selective antibiotic rifaximin is effective for secondary prophylaxis of hepatic encephalopathy; recent small trials also indicate its potential superiority to norfloxacin for secondary prevention of spontaneous bacterial peritonitis. Diuretics remain the mainstay of uncomplicated ascites treatment, and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites. Vaptans have not demonstrated clinical effectiveness in treating refractory ascites and may cause detrimental complications. Despite initial hepatotoxicity concerns, safety of statin administration has been demonstrated in compensated cirrhosis. Furthermore, statins are suggested to have protective effects upon fibrosis progression, decompensation and mortality. Evidence as to whether proton pump inhibitors cause gut-liver-brain axis dysfunction is conflicting. Emerging evidence indicates that anticoagulation therapy reduces incidence and increases recanalisation rates of non-malignant portal vein thrombosis, and may impede hepatic fibrogenesis and decompensation. Pharmacotherapy for cirrhosis should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education.
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Affiliation(s)
- David Kockerling
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Rooshi Nathwani
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Roberta Forlano
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Pinelopi Manousou
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Benjamin H Mullish
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Ameet Dhar
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
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