251
|
Stirnimann J, Stirnimann G. Nutritional Challenges in Patients with Advanced Liver Cirrhosis. J Clin Med 2019; 8:jcm8111926. [PMID: 31717529 PMCID: PMC6912781 DOI: 10.3390/jcm8111926] [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] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/05/2019] [Accepted: 11/05/2019] [Indexed: 12/13/2022] Open
Abstract
Patients with advanced liver cirrhosis are at risk of malnutrition and nutrition-associated complications. Significant ascites, a frequent finding in these patients, has an especially negative impact on oral nutrition. A negative caloric and protein balance can further deteriorate the already impaired synthetic function of the cirrhotic liver. An important factor in this situation is the diminished capacity of glycogen production and storage in the cirrhotic liver and, consequently, a reduced tolerability for fasting episodes. These episodes are frequently observed in hospitalized patients, e.g., while waiting for investigations, interventions or surgery. A comprehensive work-up of patients with advanced liver cirrhosis should include not only a thorough assessment regarding nutritional deficits, but also a muscularity analysis to identify patients with sarcopenia. The overall nutritional treatment goal is to cover caloric deficits and assure a sufficiently high protein intake. Furthermore, vitamin and micronutrient deficiencies should be identified and corrective measures implemented where required. Ideally, optimal nutrition management can not only prevent the progression of malnutrition and sarcopenia in patients with advanced liver cirrhosis, but positively influence the evolution of the liver disease.
Collapse
Affiliation(s)
- Jessica Stirnimann
- Division of Diabetology, Endocrinology, Nutritional Medicine and Metabolism, University Hospital Inselspital and University of Bern, 3010 Bern, Switzerland;
| | - Guido Stirnimann
- University Clinic for Visceral Surgery and Medicine, University Hospital Inselspital and University of Bern, 3010 Bern, Switzerland
- Correspondence: or ; Tel.: +41-31-632-2111
| |
Collapse
|
252
|
Martin Mateos R, Albillos A. Sepsis in Patients With Cirrhosis Awaiting Liver Transplantation: New Trends and Management. Liver Transpl 2019; 25:1700-1709. [PMID: 31408581 DOI: 10.1002/lt.25621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023]
Abstract
Bacterial infections are more frequent and severe in patients with advanced liver disease and, therefore, in liver transplant candidates. The increased risk of infection in these patients parallels the severity of the immune dysfunction associated with cirrhosis, which is related to systemic inflammation and progressive immunodeficiency. Other factors contribute to this risk, such as genetic polymorphisms, proton pump inhibitor overuse, the numerous invasive procedures and hospitalizations these patients go through, or the immunosuppressive effects of malnutrition or alcohol abuse. Bacterial infections have a great impact on disease progression and significantly increase mortality rates before and after liver transplantation. Mechanisms leading to organ failure in sepsis are associated not only with the hemodynamic derangement but also with an excessive inflammatory response triggered by infection. Furthermore, prophylactic and empirical antibiotic treatment strategies in patients with cirrhosis are being modified according to the growing prevalence of multidrug-resistant bacteria in the past decade. Also, new criteria have been introduced for the diagnosis of sepsis and septic shock. These new definitions have been validated in patients with cirrhosis and show a better accuracy to predict in-hospital mortality than previous criteria based on systemic inflammatory response syndrome. Accurate prophylaxis and early identification and treatment of bacterial infections are key to reducing the burden of sepsis in patients with cirrhosis awaiting liver transplantation.
Collapse
Affiliation(s)
- Rosa Martin Mateos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
253
|
Abstract
Ascites occurs in up to 70% of patients during the natural history of cirrhosis. Management of uncomplicated ascites includes sodium restriction and diuretic therapy, whereas that for refractory ascites (RA) is regular large-volume paracentesis with transjugular intrahepatic portosystemic shunt being offered in appropriate patients. Renal impairment occurs in up to 50% of patients with RA with type 1 hepatorenal syndrome (HRS) being most severe. Liver transplant remains the definitive treatment of eligible candidates with HRS, whereas combined liver and kidney transplant should be considered in patients requiring dialysis for more than 4 to 6 weeks or those with underlying chronic kidney disease.
Collapse
|
254
|
Bai Z, Bernardi M, Yoshida EM, Li H, Guo X, Méndez-Sánchez N, Li Y, Wang R, Deng J, Qi X. Albumin infusion may decrease the incidence and severity of overt hepatic encephalopathy in liver cirrhosis. Aging (Albany NY) 2019; 11:8502-8525. [PMID: 31596729 PMCID: PMC6814610 DOI: 10.18632/aging.102335] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The role of human albumin infusion for the prevention and treatment of overt hepatic encephalopathy (HE) in liver cirrhosis remains unclear. RESULTS Among the 708 patients without pre-existing overt HE, albumin infusion significantly decreased the incidence of overt HE (4.20% versus 12.70%, P<0.001) and in-hospital mortality (1.70% versus 5.40%, P=0.008). Among the 182 patients with overt HE at admission or during hospitalization, albumin infusion significantly improved overt HE (84.60% versus 68.10%, P=0.009) and decreased in-hospital mortality (7.70% versus 19.80%, P=0.018). Meta-analysis of 6 studies found that albumin infusion might decrease the risk of overt HE (OR=1.63, P=0.07), but the difference was not statistically significant. Meta-analysis of 3 studies found that albumin infusion significantly improved overt HE (OR=2.40, P=0.04). CONCLUSIONS Based on the results of our retrospective study and meta-analysis, albumin infusion might prevent from the occurrence of overt HE and improve the severity of overt HE in cirrhosis. Our retrospective study also suggested that albumin infusion improved the outcomes of cirrhotic patients regardless of overt HE. METHODS Cirrhotic patients consecutively admitted between January 2010 and June 2014 were considered in a retrospective study. A 1:1 propensity score matching analysis was performed. Additionally, publications regarding albumin infusion for the management of overt HE were systematically searched. Meta-analyses were performed by random-effect model. Odds ratio (OR) was calculated.
Collapse
Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, P.R. China
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Eric M. Yoshida
- Division of Gastroenterology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation and Faculty of Medicine, National Autonomous University of Mexico, Mexico
| | - Yingying Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Jiao Deng
- Department of Pharmacology, General Hospital of Northern Theater Command, (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| |
Collapse
|
255
|
Schneider F, Dureau AF, Hellé S, Betscha C, Senger B, Cremel G, Boulmedais F, Strub JM, Corti A, Meyer N, Guillot M, Schaaf P, Metz-Boutigue MH. A Pilot Study on Continuous Infusion of 4% Albumin in Critically Ill Patients: Impact on Nosocomial Infection via a Reduction Mechanism for Oxidized Substrates. Crit Care Explor 2019; 1:e0044. [PMID: 32166286 PMCID: PMC7063941 DOI: 10.1097/cce.0000000000000044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Care-related infections affect up to 11% of ICU patients. Running therapeutic albumin is sometimes associated to less infection: whether a specific method of its infusion is of any interest to modulate innate defense is unknown. Our objectives were: 1) to test whether the method for albumin infusion is important to prevent care-related infections and 2) to analyze in vitro the antioxidative role of albumin on host defense proteins during shock (using vasostatin-I as an example). Design In a prospective, randomized, open-label trial, shock patients were allocated to receive either continuously 4% albumin or intermittently 20% albumin, as long as they were infused with norepinephrine. A translational study including in vivo and in vitro analyses of albumin-vasostatin-I interactions is reported. Setting A tertiary ICU caring for 1,000 patients per year. Patients Fifty shock patients with serum albumin less than 20 g/L. Interventions In vivo colonization and nosocomial infections were recorded and time-dependent changes in serum albumin, chromogranin A, and vasostatin-I concentrations as well. In vitro, we studied biochemical albumin-vasostatin-I relationship using biochemical methods. Measurements and Main Results Over 18 days, we recorded a decrease in colonization (four vs 12 episodes; p = 0.035) and nosocomial infection frequency (two vs 13 episodes; p = 0.002) in patients infused continuously 4% albumin versus controls. In vitro, albumin interacts with the disulfide loop vasostatin-I (residues 17-40) and continuous 4% albumin infusion restores its oxidative status required for antimicrobial activity. Conclusions Continuous 4% albumin is effective in reducing care-related infections in shock patients by increasing the availability of antimicrobial vasostatin-I. This might guide future care of shock patients.
Collapse
Affiliation(s)
- Francis Schneider
- Inserm UMR 1121, Biomatériaux et Bioingénierie, département 11, Strasbourg, France.,Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle, Université de Strasbourg, Strasbourg, France
| | - Anne-Florence Dureau
- Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle, Université de Strasbourg, Strasbourg, France
| | - Sophie Hellé
- Inserm UMR 1121, Biomatériaux et Bioingénierie, département 11, Strasbourg, France.,Université de Strasbourg, Faculté de Médecine, Hôpital Civil, Fédération de Médecine Translationnelle, Strasbourg, France
| | - Cosette Betscha
- Inserm UMR 1121, Biomatériaux et Bioingénierie, département 11, Strasbourg, France.,Université de Strasbourg, Faculté de Chirurgie Dentaire, Hôpital Civil, Fédération de Médecine Translationnelle, Strasbourg, France
| | - Bernard Senger
- Inserm UMR 1121, Biomatériaux et Bioingénierie, département 11, Strasbourg, France.,Université de Strasbourg, Faculté de Chirurgie Dentaire, Hôpital Civil, Fédération de Médecine Translationnelle, Strasbourg, France
| | - Gérard Cremel
- Inserm UMR 1109 MN3T, Immuno-Rhumatologie-Moléculaire, Université de Strasbourg, Faculté de Médecine, Pôle API, Fédération de Médecine Translationnelle, Strasbourg, France
| | | | - Jean-Marc Strub
- CNRS-UMR7178, Laboratoire de Spectrométrie de Masse Bio-Organique, Département des Sciences Analytiques, Institut Pluridisciplinaire Hubert Curien, Strasbourg, France
| | - Angelo Corti
- Division of Experimental Oncology, San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Milan, Italy
| | - Nicolas Meyer
- Laboratoire de Bio-statistiques et Informatique Médicale, Faculté de Médecine de Strasbourg Université de Strasbourg, Strasbourg, France
| | - Max Guillot
- Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle, Université de Strasbourg, Strasbourg, France
| | - Pierre Schaaf
- Inserm UMR 1121, Biomatériaux et Bioingénierie, département 11, Strasbourg, France.,Université de Strasbourg, Faculté de Chirurgie Dentaire, Hôpital Civil, Fédération de Médecine Translationnelle, Strasbourg, France.,CNRS-UPR22, Institut Charles Sadron, Strasbourg, France
| | - Marie-Hélène Metz-Boutigue
- Inserm UMR 1121, Biomatériaux et Bioingénierie, département 11, Strasbourg, France.,Université de Strasbourg, Faculté de Chirurgie Dentaire, Hôpital Civil, Fédération de Médecine Translationnelle, Strasbourg, France
| |
Collapse
|
256
|
Abstract
PURPOSE OF REVIEW Intravenous fluid administration is a fundamental therapy in critical care, yet key questions remain unanswered regarding optimal fluid composition and dose. This review evaluates recent evidence regarding the effects of fluid resuscitation on pathophysiology, organ function, and clinical outcomes for critically ill patients. RECENT FINDINGS Recent findings suggest that intravenous fluid composition affects risk of kidney injury and death for critically ill adults. Generally, the risk of kidney injury and death appears to be greater with semisynthetic colloids compared with crystalloids, and with 0.9% sodium chloride compared with balanced crystalloids. Whether a liberal, restrictive, or hemodynamic responsiveness-guided approach to fluid dosing improves outcomes during sepsis or major surgery remains uncertain. SUMMARY As evidence on fluid resuscitation evolves, a reasonable approach would be to use primarily balanced crystalloids, consider 2-3 l for initial fluid resuscitation of hypovolemic or distributive shock, and use measures of anticipated hemodynamic response to guide further fluid administration.
Collapse
|
257
|
Tufoni M, Zaccherini G, Caraceni P. Prolonged albumin administration in patients with decompensated cirrhosis: the amount makes the difference. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S201. [PMID: 31656780 PMCID: PMC6789376 DOI: 10.21037/atm.2019.07.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 07/03/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Manuel Tufoni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| |
Collapse
|
258
|
Kabbani AR, Tergast TL, Manns MP, Maasoumy B. [Treatment strategies for acute-on-chronic liver failure]. Med Klin Intensivmed Notfmed 2019; 116:3-16. [PMID: 31463674 PMCID: PMC7095250 DOI: 10.1007/s00063-019-00613-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 12/15/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is a newly defined syndrome in patients with liver cirrhosis characterized by acute hepatic decompensation (jaundice, ascites, hepatic encephalopathy, bacterial infection and gastrointestinal bleeding), single or multiple organ failure and a high mortality (>15% within 28 days). The affected organ systems include not only the liver but also the circulation, lungs, kidneys, brain and/or coagulation. Pathophysiologically decisive is an uncontrolled inflammation that is induced by specific triggers and on the basis of previously (possibly not diagnosed) compensated as well as already decompensated liver cirrhosis leads to a severe systemic clinical syndrome, ACLF. The course during the first 72 h is decisive for the prognosis. In addition to treatment of the respective organ or system failure, the underlying triggers should be quickly identified and if necessary specifically treated. Often, however, these cannot (no longer) be determined with any certainty, in particular recent alcohol consumption as well as bacterial and viral infections play an important role. A specific treatment for the ACLF is (currently) not established. Some experimental approaches are currently being tested, including administration of granulocyte colony-stimulating factor (GCSF). Additionally, suitable patients should be presented to a liver transplantation center in a timely manner.
Collapse
Affiliation(s)
| | | | | | - B Maasoumy
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| |
Collapse
|
259
|
De Silvestro G, Marson P, Breda A, De Angelis V. Plasma-derived industry and plasma-derived medicinal products in the Italian National Blood Transfusion Service. Transfus Apher Sci 2019; 58:545-549. [PMID: 31431349 DOI: 10.1016/j.transci.2019.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The priority objectives of the Italian Transfusion System are self-sufficiency for blood components and for plasma-derived products. Currently the collection activity guarantees self-sufficiency of blood components, including plasma for clinical use, but not for plasma-derived drugs, ie albumin and immunoglobulins in particular. The National Plasma Program of 2016-2020, issued a Ministerial Decree on December, 2, 2016, aims to achieve this goal, both by increasing the collection of plasma and therefore its transfer to plasma derivation companies, and by increasing the appropriateness of the requests. Currently, the companies Grifols SpA, Kedrion SpA, CSL Behring, and Baxter-Baxalta Srl are present on the Italian market, individually or in business associations, with which the various Italian regions have established an agreement based on the national legislation.
Collapse
Affiliation(s)
| | - Piero Marson
- Department of Transfusion Medicine, Padua University Hospital, Padova, Italy
| | - Antonio Breda
- CoordinamentoRegionale Attività Trasfusionali (CRAT), Venetian Region, Italy
| | | |
Collapse
|
260
|
Facciorusso A, Antonino M, Orsitto E, Sacco R. Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art. Expert Rev Gastroenterol Hepatol 2019; 13:751-759. [PMID: 31304804 DOI: 10.1080/17474124.2019.1644167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Spontaneous bacterial peritonitis represents a frequent and severe complication in cirrhotic patients with ascites. In daily practice, the diagnosis of spontaneous bacterial peritonitis might be challenging in the absence of the typical signs and symptoms of infection such as fever or leukocytosis. Areas covered: Aim of this review is to revise the current state of the art on primary and secondary spontaneous bacterial peritonitis. Literature search in Medline/Pubmed was performed. Expert opinion: Historically, gram-negative bacteria were the most frequent etiologic agents of spontaneous bacterial peritonitis, with Escherichia coli and Klebsiella spp. being the most frequently isolated bacteria. However, major changes in this regard occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria. In particular, the increasing prevalence of quinolone-resistant bacteria challenged the prominent role of norfloxacin in spontaneous bacterial peritonitis prevention. Given the high mortality rate and the risk of developing the hepatorenal syndrome, prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis).
Collapse
Affiliation(s)
- Antonio Facciorusso
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Matteo Antonino
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Eugenio Orsitto
- b Department of Radiology, Azienda Ospedaliero-Universitaria Pisana , Pisa , Italy
| | - Rodolfo Sacco
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| |
Collapse
|
261
|
Angeli P. The first Chinese guidelines on the Management of Ascites and its Related Complications in Cirrhosis: a great goal for a great country. Hepatol Int 2019; 13:395-398. [PMID: 31313026 DOI: 10.1007/s12072-019-09961-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Affiliation(s)
- P Angeli
- Internal Medicine and Hepatology Unit (UIMH), Dept of Medicine (DIMED), Padova University-Teaching Hospital, Padua, Italy.
| |
Collapse
|
262
|
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.
Collapse
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
| |
Collapse
|
263
|
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.
Collapse
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
| | | |
Collapse
|
264
|
Wong F, Reddy KR, O’Leary JG, Tandon P, Biggins SW, Garcia-Tsao G, Maliakkal BJ, Lai JC, Fallon MB, Vargas HE, Subramanian R, Thuluvath PJ, Kamath PS, Thacker L, Bajaj JS. Impact of Chronic Kidney Disease on Outcomes in Cirrhosis. Liver Transpl 2019; 25:870-880. [PMID: 30908855 PMCID: PMC11075743 DOI: 10.1002/lt.25454] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 03/01/2019] [Indexed: 02/07/2023]
Abstract
We hypothesize that the prevalence of chronic kidney disease (CKD) among patients with cirrhosis has increased due to the increased prevalence of CKD-associated comorbidities, such as diabetes. We aimed to assess the characteristics of hospitalized patients with cirrhosis with CKD and its impact on renal and patient outcomes. The North American Consortium for the Study of End-Stage Liver Disease (NACSELD) prospectively enrolled nonelectively admitted patients with cirrhosis and collected data on demographics, laboratory results, in-hospital clinical course, and postdischarge 3-month outcomes. CKD positive (CKD+) patients, defined as having an estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease-4 variable formula) of ≤60 mL/minute for >3 months, were compared with chronic kidney disease negative (CKD-) patients for development of organ failures, hospital course, and survival. There were 1099 CKD+ patients (46.8% of 2346 enrolled patients) who had significantly higher serum creatinine (2.21 ± 1.33 versus 0.83 ± 0.21 mg/dL in the CKD- group) on admission, higher prevalence of nonalcoholic steatohepatitis cirrhosis etiology, diabetes, refractory ascites, and hospital admissions in the previous 6 months compared with the CKD- group (all P < 0.001). Propensity matching (n = 922 in each group) by Child-Pugh scores (9.78 ± 2.05 versus 9.74 ± 2.04, P = 0.70) showed that CKD+ patients had significantly higher rates of superimposed acute kidney injury (AKI; 68% versus 21%; P < 0.001) and eventual need for dialysis (11% versus 2%; P < 0.001) than CKD- patients. CKD+ patients also had more cases of acute-on-chronic liver failure as defined by the NACSELD group, which was associated with reduced 30- and 90-day overall survival (P < 0.001 for both). A 10 mL/minute drop in eGFR was associated with a 13.1% increase in the risk of 30-day mortality. In conclusion, patients with CKD should be treated as a high-risk group among hospitalized patients with cirrhosis due to their poor survival, and they should be monitored carefully for the development of superimposed AKI.
Collapse
Affiliation(s)
- Florence Wong
- Toronto General Hospital, University of Toronto, Toronto,
Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - Leroy Thacker
- Department of Statistics, Commonwealth University of
Virginia, Richmond, VA
| | - Jasmohan S. Bajaj
- Commonwealth University of Virginia and McGuire VA
Medical Center, Richmond, VA
| |
Collapse
|
265
|
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
| |
Collapse
|
266
|
|
267
|
Francoz C, Durand F, Kahn JA, Genyk YS, Nadim MK. Hepatorenal Syndrome. Clin J Am Soc Nephrol 2019; 14:774-781. [PMID: 30996046 PMCID: PMC6500947 DOI: 10.2215/cjn.12451018] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hepatorenal syndrome is a severe complication of end-stage cirrhosis characterized by increased splanchnic blood flow, hyperdynamic state, a state of decreased central volume, activation of vasoconstrictor systems, and extreme kidney vasoconstriction leading to decreased GFR. The contribution of systemic inflammation, a key feature of cirrhosis, in the development of hepatorenal syndrome has been highlighted in recent years. The mechanisms by which systemic inflammation precipitates kidney circulatory changes during hepatorenal syndrome need to be clarified. Early diagnosis is central in the management and recent changes in the definition of hepatorenal syndrome help identify patients at an earlier stage. Vasoconstrictive agents (terlipressin in particular) and albumin are the first-line treatment option. Several controlled studies proved that terlipressin is effective at reversing hepatorenal syndrome and may improve short-term survival. Not all patients are responders, and even in responders, early mortality rates are very high in the absence of liver transplantation. Liver transplantation is the only curative treatment of hepatorenal syndrome. In the long term, patients transplanted with hepatorenal syndrome tend to have lower GFR compared with patients without hepatorenal syndrome. Differentiating hepatorenal syndrome from acute tubular necrosis (ATN) is often a challenging yet important step because vasoconstrictors are not justified for the treatment of ATN. Hepatorenal syndrome and ATN may be considered as a continuum rather than distinct entities. Emerging biomarkers may help differentiate these two conditions and provide prognostic information on kidney recovery after liver transplantation, and potentially affect the decision for simultaneous liver-kidney transplantation.
Collapse
Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France.,INSERM U1149, University Paris Diderot, Paris, France; and
| | - François Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France.,INSERM U1149, University Paris Diderot, Paris, France; and
| | - Jeffrey A Kahn
- Division of Gastrointestinal and Liver Disease, Department of Medicine
| | - Yuri S Genyk
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, and
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| |
Collapse
|
268
|
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]
|
269
|
Neong SF, Adebayo D, Wong F. An update on the pathogenesis and clinical management of cirrhosis with refractory ascites. Expert Rev Gastroenterol Hepatol 2019; 13:293-305. [PMID: 30791777 DOI: 10.1080/17474124.2018.1555469] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ascites commonly complicates cirrhosis, becoming refractory to treatment with diuretics and sodium restriction in approximately 10% of patients. Pathogenesis of refractory ascites (RA) is multifactorial, the common final pathway being renal hypoperfusion and avid sodium retention. Refractory ascites has a negative prognostic implication in the natural history of cirrhosis. Management of RA include sodium restriction and regular large volume paracentesis (LVP) with albumin infusions, preventing paracentesis-induced circulatory dysfunction. In appropriate setting, transjugular intrahepatic porto-systemic shunt (TIPS) can be considered. Ascites clearance with TIPS can lead to nutritional improvement, avoiding sarcopenia. Liver transplantation (LT) remains the definitive treatment for eligible candidates. Areas covered: Our review summarizes current updates on pathogenesis and clinical management of RA including potential future therapeutic options such as the automated slow-flow ascites pump, chronic outpatient albumin infusion and cell-free and concentrated ascites reinfusion therapy. Expert commentary: Standard of care in patients with RA include LVP with albumin replacement and prompt referral for LT where indicated. Other novel therapeutic options on the horizon include automated low-flow ascites pump and cell-free, concentrated albumin reinfusion therapy.
Collapse
Affiliation(s)
- Shuet Fong Neong
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
| | - Danielle Adebayo
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
| | - Florence Wong
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
| |
Collapse
|
270
|
Solà E, Solé C, Ginès P. Reply to: "Midodrine and albumin in decompensated cirrhosis: Down but not out…". J Hepatol 2019; 70:812. [PMID: 30711218 DOI: 10.1016/j.jhep.2018.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 12/04/2022]
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 (IDIBAPS), 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 (IDIBAPS), 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 (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain.
| |
Collapse
|
271
|
Singh V, Singh A, Agarwal R. Midodrine and albumin in decompensated cirrhosis: Down but not out…. J Hepatol 2019; 70:811. [PMID: 30685125 DOI: 10.1016/j.jhep.2018.11.008] [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: 10/26/2018] [Revised: 11/07/2018] [Accepted: 11/14/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Akash Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
272
|
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: 111] [Impact Index Per Article: 22.2] [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.
Collapse
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
| |
Collapse
|
273
|
Dam G, Vilstrup H, Andersen PK, Bossen L, Watson H, Jepsen P. Effect of proton pump inhibitors on the risk and prognosis of infections in patients with cirrhosis and ascites. Liver Int 2019; 39:514-521. [PMID: 30472808 DOI: 10.1111/liv.14012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/30/2018] [Accepted: 11/17/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Many patients with cirrhosis use proton pump inhibitors. We aimed to determine their effects on the risk and prognosis of infections in patients with cirrhosis and ascites. METHODS We used data from three 1-year trials of satavaptan treatment of ascites (N = 1198) to compare incidence and 90-day mortality of first-time infections between users and nonusers of proton pump inhibitors. With standard and marginal structural Cox models, we adjusted for differences in gender, age, cirrhosis aetiology, Model for End-stage Liver Disease score, serum albumin, lactulose use, severity of ascites, and history of spontaneous bacterial peritonitis or variceal bleeding. RESULTS During the follow-up, 446 patients had an infection. At inclusion, 524 patients (44%) used proton pump inhibitors, and 645 (54%) used them at some point during the follow-up. Proton pump inhibitor use increased the rate of infections overall (adjusted hazard ratio = 1.43, 95% CI 1.18-1.74), and it also increased the rate of all specific types of infections except upper respiratory tract infections of presumably viral origin. The estimated cumulative risk of infections was 36.4% for proton pump inhibitor users vs 25.1% for nonusers at 6 months (relative risk = 1.45, 95% CI 1.22-1.73), and 45.2% vs 37.7% at 1 year (relative risk = 1.20, 95% 0.97-1.40). Use of proton pump inhibitors did not affect mortality during the 90 days following infection (adjusted hazard ratio = 0.83, 95% CI 0.53-1.31). CONCLUSIONS Approximately half of patients with cirrhosis and ascites use proton pump inhibitors. This use increases their risk of bacterial infections, but does not affect their prognosis after an infection occurs.
Collapse
Affiliation(s)
- Gitte Dam
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lars Bossen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
274
|
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.
Collapse
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
| |
Collapse
|
275
|
Irvine KM, Ratnasekera I, Powell EE, Hume DA. Causes and Consequences of Innate Immune Dysfunction in Cirrhosis. Front Immunol 2019; 10:293. [PMID: 30873165 PMCID: PMC6401613 DOI: 10.3389/fimmu.2019.00293] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/05/2019] [Indexed: 12/15/2022] Open
Abstract
Liver cirrhosis is an increasing health burden and public health concern. Regardless of etiology, patients with cirrhosis are at risk of a range of life-threatening complications, including the development of infections, which are associated with high morbidity and mortality and frequent hospital admissions. The term Cirrhosis-Associated Immune Dysfunction (CAID) refers to a dynamic spectrum of immunological perturbations that develop in patients with cirrhosis, which are intimately linked to the underlying liver disease, and negatively correlated with prognosis. At the two extremes of the CAID spectrum are systemic inflammation, which can exacerbate clinical manifestations of cirrhosis such as hemodynamic derangement and kidney injury; and immunodeficiency, which contributes to the high rate of infection in patients with decompensated cirrhosis. Innate immune cells, in particular monocytes/macrophages and neutrophils, are pivotal effector and target cells in CAID. This review focuses on the pathophysiological mechanisms leading to impaired innate immune function in cirrhosis. Knowledge of the phenotypic manifestation and pathophysiological mechanisms of cirrhosis associated immunosuppression may lead to immune targeted therapies to reduce susceptibility to infection in patients with cirrhosis, and better biomarkers for risk stratification, and assessment of efficacy of novel immunotherapies.
Collapse
Affiliation(s)
- Katharine Margaret Irvine
- Mater Research Institute, Translational Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Isanka Ratnasekera
- Mater Research Institute, Translational Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - David Arthur Hume
- Mater Research Institute, Translational Research Institute, The University of Queensland, Brisbane, QLD, Australia
| |
Collapse
|
276
|
O'Brien A. Con: The Unclear Benefit of Albumin. Liver Transpl 2019; 25:135-139. [PMID: 30447173 DOI: 10.1002/lt.25384] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/07/2018] [Indexed: 12/12/2022]
Abstract
Many studies have shown that 20% human albumin solution infusions improve circulatory function in patients with advanced liver disease, and this treatment is widely recommended and used by all hepatologists. However, it is more expensive than other crystalloids or colloids, and several countries suffer shortages of supply. This article examines whether other fluids might be considered for these patients.
Collapse
Affiliation(s)
- Alastair O'Brien
- Institute of Liver Disease and Digestive Health, University College London, London, United Kingdom
| |
Collapse
|
277
|
Bai Z, Guo X, Tacke F, Li Y, Li H, Qi X. Association of serum albumin level with incidence and mortality of overt hepatic encephalopathy in cirrhosis during hospitalization. Therap Adv Gastroenterol 2019; 12:1756284819881302. [PMID: 31636711 PMCID: PMC6783662 DOI: 10.1177/1756284819881302] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/18/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a serious complication of cirrhosis. Decreased serum albumin (ALB) level may facilitate the development of HE and accelerate the death of cirrhotic patients with HE. Recent evidence also suggests that human albumin infusion may reduce the incidence of HE and improve the outcomes of cirrhotic patients. This study aimed to explore the association of serum ALB level with the development of overt HE and HE-associated mortality during hospitalization. METHODS Cirrhotic patients admitted to our hospital between January 2010 and February 2019 were screened. Independent predictors for HE were identified by logistic regression analyses. Odds ratio (OR) with 95% confidence interval (95% CI) was calculated. Area under curve (AUC) was calculated by receiver operator characteristic curve analyses. RESULTS Of the 2376 included patients with cirrhosis but without HE at admission, 113 (4.8%) developed overt HE during hospitalizations. ALB level (OR = 0.878, 95% CI = 0.834-0.924) was an independent risk factor for development of overt HE. AUC of ALB level for predicting the development of overt HE was 0.770 (95% CI = 0.752-0.787, p < 0.0001), and the best cut-off value was ⩽31.6 g/l. Of the 183 included patients with cirrhosis and overt HE at admission, 20 (10.9%) died during hospitalizations. ALB level (OR = 0.864, 95% CI = 0.771-0.967) was an independent risk factor for death from overt HE. The AUC of ALB level for predicting death from overt HE was 0.737 (95% CI = 0.667-0.799, p = 0.0001), and the best cut-off value was ⩽22.8 g/l. CONCLUSIONS Decreased serum ALB level may be associated with higher risk of overt HE and HE-associated mortality during hospitalizations in cirrhosis.
Collapse
Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital
of Northern Theater Command (General Hospital of Shenyang Military Area),
Shenyang, PR China
- Postgraduate College, Shenyang Pharmaceutical
University, Shenyang, PR China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital
of Northern Theater Command (General Hospital of Shenyang Military Area),
Shenyang, PR China
| | - Frank Tacke
- Department of Gastroenterology and Hepatology,
Charité University Medical Center, Berlin, Germany
| | - Yingying Li
- Department of Gastroenterology, General Hospital
of Northern Theater Command (General Hospital of Shenyang Military Area),
Shenyang, PR China
- Postgraduate College, Jinzhou Medical
University, Jinzhou, PR China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital
of Northern Theater Command (formerly called General Hospital of Shenyang
Military Area), Shenyang, PR China
| | | |
Collapse
|
278
|
Choi S(C, Casias M, Tompkins D, Gonzalez J, Ray SD. Blood, blood components, plasma, and plasma products. SIDE EFFECTS OF DRUGS ANNUAL 2019; 41. [PMCID: PMC7148809 DOI: 10.1016/bs.seda.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This review of 2018 publications identifies side effects of blood, blood components, and plasma products. In addition, albumin, blood transfusion (erythrocytes, granulocytes, and platelets), blood substitutes (hemoglobin-based oxygen carriers), plasma products (alpha1-antitrypsin, C1 esterase inhibitor concentrate, cryoprecipitate, and fresh frozen plasma), plasma substitutes (etherified starches, and gelatin), globulins (intravenous immunoglobulin, subcutaneous immunoglobulin, and anti-D immunoglobulin), coagulation proteins (factor I, factor II, factor VIIa, factor VIII, factor IX, prothrombin complex concentrate, antithrombin III, and von Willebrand factor/factor VIII concentrates), erythropoietin and derivatives, thrombopoietin and receptor agonists, transmission of infectious agents through blood donation, and stem cells are reviewed. This chapter informs the reader about newly recognized and published data in the blood product domain.
Collapse
Affiliation(s)
- Seohyun (Claudia) Choi
- Department of Pharmacy Practice and Administration, Rutgers, The State University of New Jersey, Piscataway, NJ, United States,Medical Intensive Care Unit, Saint Barnabas Medical Center, Livingston, NJ, United States,Corresponding author:
| | - Michael Casias
- Department of Pharmacy Practice and Administration, Rutgers, The State University of New Jersey, Piscataway, NJ, United States,Hunterdon Medical Center, Flemington, NJ, United States
| | - Danielle Tompkins
- Department of Pharmacy Practice and Administration, Rutgers, The State University of New Jersey, Piscataway, NJ, United States,Hackensack University Medical Center, Hackensack, NJ, United States
| | - Jimmy Gonzalez
- Department of Pharmacy Practice and Administration, Rutgers, The State University of New Jersey, Piscataway, NJ, United States,Jersey Shore University Medical Center, Neptune City, NJ, United States
| | - Sidhartha D. Ray
- Department of Pharmaceutical & Biomedical Sciences, Touro College of Pharmacy, New York, NY, United States
| |
Collapse
|
279
|
Di Pascoli M, Fasolato S, Piano S, Bolognesi M, Angeli P. Long-term administration of human albumin improves survival in patients with cirrhosis and refractory ascites. Liver Int 2019; 39:98-105. [PMID: 30230204 DOI: 10.1111/liv.13968] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/02/2018] [Accepted: 09/12/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND & AIMS In patients with cirrhosis, the clinical benefit of the treatment with human albumin for ascites is debated, and no data are available regarding refractory ascites. In this study, in patients with cirrhosis and refractory ascites, we assessed the effect of long-term albumin administration on emergent hospitalization and mortality. METHODS Seventy patients with cirrhosis and refractory ascites, followed at the Unit of Internal Medicine and Hepatology, University and General Hospital of Padova, Italy, were included into the study. Forty-five patients were non-randomly assigned to receive long-term administration of human albumin at the doses of 20 g twice per week (n = 45), in addition to standard medical of care (SOC), and compared to those followed according to SOC. Patients were followed up to the end of the study, liver transplantation or death. RESULTS The cumulative incidence of 24-month mortality was significantly lower in patients treated with albumin than in the group of patients treated with SOC (41.6% vs 65.5%; P = 0.032). The period free of emergent hospitalization was significantly longer in patients treated with long-term administration of albumin (P = 0.008). Analysing separately the causes of inpatient admission, patients treated with albumin showed a reduction in the incidence of overt hepatic encephalopathy, ascites, spontaneous bacterial peritonitis (SBP) and non-SBP infections. In addition, a non-significant trend towards a reduced probability of hepatorenal syndrome was observed. CONCLUSION In patients with cirrhosis and refractory ascites, long-term treatment with albumin improves survival and reduces the probability of emergent hospitalizations.
Collapse
Affiliation(s)
- Marco Di Pascoli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Silvano Fasolato
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Massimo Bolognesi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine-DIMED, University of Padova, Padova, Italy
| |
Collapse
|
280
|
Xu X, Duan Z, Ding H, Li W, Jia J, Wei L, Linghu E, Zhuang H. Chinese guidelines on the management of ascites and its related complications in cirrhosis. Hepatol Int 2019; 13:1-21. [PMID: 30656520 DOI: 10.1007/s12072-018-09923-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/20/2018] [Indexed: 12/12/2022]
Abstract
The Chinese Society of Hepatology developed the current guidelines for the Management of Ascites and Its Related Complications in Cirrhosis based on the published evidences and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of cirrhotic ascites emphasizing a step-wise approach with the first-, second-, and third-line therapy. For refractory ascites, vasoconstrictors and albumin are recommended for splanchnic vasodilation and selective vasopressin (V2) receptor antagonists for moderate-to-severe hyponatremia. For spontaneous bacterial peritonitis, empirical anti-infection treatment was recommended based on the local microbiological examination of community- or hospital-acquired infections. For hepatorenal syndrome, the administration of vasopressor terlipressin and albumin is recommended.
Collapse
Affiliation(s)
- Xiaoyuan Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing, 100034, China.
| | - Zhongping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing, 100069, China
| | - Huiguo Ding
- Center for Hepatology and Gastroenterology, Beijing You-An Hospital, Capital Medical University, Beijing, China
| | - Wengang Li
- Liver Tumor Diagnosis, Treatment and Research Center, 302 Military Hospital of China, Beijing, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lai Wei
- Institute of Hepatology, Peking University People's Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, China
| | - Hui Zhuang
- Department of Pathogen Biology, Peking University Health Science Center, Beijing, China
| |
Collapse
|
281
|
Tramarin A, Tedesco D, Naldi M, Baldassarre M, Bertucci C, Bartolini M. New insights into the altered binding capacity of pharmaceutical-grade human serum albumin: site-specific binding studies by induced circular dichroism spectroscopy. J Pharm Biomed Anal 2019; 162:171-178. [DOI: 10.1016/j.jpba.2018.09.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/03/2018] [Accepted: 09/11/2018] [Indexed: 12/16/2022]
|
282
|
Bañares R, Bernardi M. Long-term albumin administration in patients with decompensated cirrhosis. It is time for a reappraisal. Liver Int 2019; 39:45-48. [PMID: 30576080 DOI: 10.1111/liv.13996] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/24/2018] [Indexed: 02/13/2023]
Affiliation(s)
- Rafael Bañares
- Departamento de Medicina, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.,CIBEREHD, Madrid, Spain
| | - Mauro Bernardi
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| |
Collapse
|
283
|
Bernardi M, Zaccherini G, Caraceni P. Pro: The Role of Albumin in Pre-Liver Transplant Management. Liver Transpl 2019; 25:128-134. [PMID: 30346096 DOI: 10.1002/lt.25356] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 10/10/2018] [Indexed: 02/07/2023]
Abstract
The wait-list mortality of patients with decompensated cirrhosis awaiting liver transplantation remains elevated due to the occurrence of complications. Etiologic treatments improve patient survival and lower the incidence of complications when applied in compensated cirrhosis, but a decompensated disease does not improve or even progress despite a response to therapy in a substantial number of patients. Thus, disease-modifying treatments that reduce the incidence of complications and improve survival are most needed. Such treatments should be able to counteract one or possibly more pathophysiological mechanisms and thus lead to the proinflammatory and pro-oxidant milieu that characterizes decompensated cirrhosis. In this respect, albumin represents a potentially ideal agent. In fact, besides its ability to expand plasma volume, albumin possesses nononcotic properties, exerting potent antioxidant and immune-modulating effects. Recent studies have assessed the effect of longterm albumin administration in decompensated cirrhosis. Although the results of these studies may appear conflicting, their analyses suggest that albumin, if given in a sufficient amount and for a sufficient duration, can significantly reduce the incidence of life-threatening complications of cirrhosis and patient mortality. For these reasons, we favor albumin administration to patients with decompensated cirrhosis wait-listed for liver transplantation.
Collapse
Affiliation(s)
- Mauro Bernardi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| |
Collapse
|
284
|
O'Brien A, Kamath PS, Trotter J. MACHT - Outpatient albumin infusions do not prevent complications of cirrhosis in patients on the liver transplant waiting list. J Hepatol 2018; 69:1217-1218. [PMID: 30314843 DOI: 10.1016/j.jhep.2018.09.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/21/2018] [Accepted: 09/26/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Alastair O'Brien
- Institute of Liver and Digestive Health, University College London, UK. a.o'
| | | | - James Trotter
- Baylor Scott & White Liver Consultants of Texas - Dallas, Liver Health - Austin, USA
| |
Collapse
|
285
|
Bernardi M, Caraceni P. Novel perspectives in the management of decompensated cirrhosis. Nat Rev Gastroenterol Hepatol 2018; 15:753-764. [PMID: 30026556 DOI: 10.1038/s41575-018-0045-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The current approaches to the management of patients with decompensated cirrhosis are based on targeted strategies aimed at preventing or treating specific complications of the disease. The improved knowledge of the pathophysiological background of advanced cirrhosis, represented by a sustained systemic inflammation strictly linked to a circulatory dysfunction, provides a novel paradigm for the management of these patients, with the ambitious target of modifying the course of the disease by preventing the onset of complications and multiorgan failure; these interventions will eventually improve patients' quality of life, prolong survival and reduce health-care costs. Besides aetiological treatments, these goals could be achieved by persistently antagonizing key pathophysiological events, such as portal hypertension, abnormal bacterial translocation from the gut, liver damage, systemic inflammation, circulatory dysfunction and altered immunological responses. Interestingly, in addition to strategies based on new therapeutic agents, these targets can be tackled by employing drugs that are already used in patients with cirrhosis for different indications or in other clinical settings, including non-absorbable oral antibiotics, non-selective β-blockers, human albumin and statins. The scope of the present Review includes reporting updated information on the treatments that promise to influence the course of advanced cirrhosis and thus act as disease-modifying agents.
Collapse
Affiliation(s)
- Mauro Bernardi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| |
Collapse
|
286
|
Affiliation(s)
- Ian A Rowe
- Leeds Institute for Data Analytics, University of Leeds, Leeds LS97TF, UK.
| | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
287
|
Caraceni P, Roncadori A, Bernardi M. Questions in the design of ANSWER - Authors' reply. Lancet 2018; 392:1623-1624. [PMID: 30496075 DOI: 10.1016/s0140-6736(18)32159-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/29/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Paolo Caraceni
- Department of Medical and Surgical Sciences, and Center for Applied Biomedical Research, University of Bologna, 40138 Bologna, Italy
| | | | - Mauro Bernardi
- Department of Medical and Surgical Sciences, and Center for Applied Biomedical Research, University of Bologna, 40138 Bologna, Italy.
| |
Collapse
|
288
|
Paine CH, Pichler RH. Treatment of Hyponatremia in End-Stage Liver Disease: New Tools in the Shed. Am J Gastroenterol 2018; 113:1728-1729. [PMID: 30323267 DOI: 10.1038/s41395-018-0269-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Cary H Paine
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Raimund H Pichler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
289
|
Bernardi M, Zaccherini G. Approach and management of dysnatremias in cirrhosis. Hepatol Int 2018; 12:487-499. [PMID: 30203382 DOI: 10.1007/s12072-018-9894-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022]
Abstract
Hypervolemic (dilutional) hyponatremia is the most common dysnatremia in cirrhosis, with a prevalence close to 50% in patients with ascites, while hypovolemic hyponatremia occurs in a minority of cases. Hyponatremia carries a poor prognosis, being associated with increased mortality and reduced survival after liver transplantation. Hypernatremia is rarer and is also associated with an adverse prognosis. Increased non-osmotic secretion of arginine vasopressin and altered renal tubular sodium handling due to impaired free water generation are the mechanisms leading to hypervolemic hyponatremia, while diuretic-induced fluid loss is the main cause of hypovolemic hyponatremia. Hypernatremia usually follows hypotonic fluid losses due to osmotic diuresis (glycosuria) or lactulose-induced diarrhea. The main clinical manifestations of dysnatremias are due to their effects on the central nervous system: astroglial cell hyperhydration follows hyponatremia-an abnormality that exacerbates ammonia neurotoxicity-while the opposite abnormality occurs with hypernatremia. Asymptomatic or mildly symptomatic hypervolemic hyponatremia is mainly managed by correcting of precipitating factors and non-osmotic fluid restriction. Severe, life-threatening hyponatremia requires hypertonic saline infusion, avoiding rapid and complete correction of serum sodium concentration to prevent neurological sequelae such as osmotic demyelination. V2 receptor blockade by vaptans may be considered in patients with sustained hyponatremia waitlisted for liver transplantation. Diuretic withdrawal and plasma volume expansion are required in hypovolemic hypernatremia. Prompt recognition, removal of the precipitating factor(s) and non-osmotic fluid administration represent the mainstays of hypernatremia management. Rapid correction of long-standing hypernatremia can lead to cerebral edema and has to be avoided.
Collapse
Affiliation(s)
- Mauro Bernardi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Policlinico S. Orsola-Malpighi, Via Albertoni, 15, 40138, Bologna, Italy.
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Policlinico S. Orsola-Malpighi, Via Albertoni, 15, 40138, Bologna, Italy
| |
Collapse
|
290
|
EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1499] [Impact Index Per Article: 249.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
|
291
|
Moving albumin into the small volume resuscitation era. Intensive Care Med 2018; 44:1967-1969. [PMID: 30043273 DOI: 10.1007/s00134-018-5313-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/12/2018] [Indexed: 01/05/2023]
|
292
|
Affiliation(s)
- Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06510, USA.
| |
Collapse
|