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McGrath MS, Wentworth BJ. The Renin-Angiotensin System in Liver Disease. Int J Mol Sci 2024; 25:5807. [PMID: 38891995 PMCID: PMC11172481 DOI: 10.3390/ijms25115807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
The renin-angiotensin system (RAS) is a complex homeostatic entity with multiorgan systemic and local effects. Traditionally, RAS works in conjunction with the kidney to control effective arterial circulation, systemic vascular resistance, and electrolyte balance. However, chronic hepatic injury and resulting splanchnic dilation may disrupt this delicate balance. The role of RAS in liver disease, however, is even more extensive, modulating hepatic fibrosis and portal hypertension. Recognition of an alternative RAS pathway in the past few decades has changed our understanding of RAS in liver disease, and the concept of opposing vs. "rebalanced" forces is an ongoing focus of research. Whether RAS inhibition is beneficial in patients with chronic liver disease appears to be context-dependent, but further study is needed to optimize clinical management and reduce organ-specific morbidity and mortality. This review presents the current understanding of RAS in liver disease, acknowledges areas of uncertainty, and describes potential areas of future investigation.
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Affiliation(s)
- Mary S. McGrath
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA;
| | - Brian J. Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
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2
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Singh V, De A, Mehtani R, Angeli P, Maiwall R, Satapathy S, Singal AK, Saraya A, Sharma BC, Eapen CE, Rao PN, Shukla A, Shalimar, Choudhary NS, Alcantara-Payawal D, Arora V, Aithal G, Kulkarni A, Roy A, Shrestha A, Mamun Al Mahtab, Niriella MA, Siam TS, Zhang CQ, Huei LG, Yu ML, Roberts SK, Peng CY, Chen T, George J, Wong V, Yilmaz Y, Treeprasertsuk S, Kurniawan J, Kim SU, Younossi ZM, Sarin SK. Asia-Pacific association for study of liver guidelines on management of ascites in liver disease. Hepatol Int 2023; 17:792-826. [PMID: 37237088 DOI: 10.1007/s12072-023-10536-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/08/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Virendra Singh
- Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India.
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, India
| | - Paolo Angeli
- Department of Internal Medicine and Hepatology, University of Padova, Padua, Italy
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sanjaya Satapathy
- Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY, USA
| | - Ashwini K Singal
- University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - B C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, Delhi, India
| | - C E Eapen
- Department of Hepatology, Christian Medical College, Vellore, India
| | - P N Rao
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Akash Shukla
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guru Aithal
- Biomedical Research Unit, NIHR Nottingham Digestive Diseases, Nottingham, UK
| | - Anand Kulkarni
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, India
| | - Ananta Shrestha
- Department of Hepatology, The Liver Clinic, Liver Foundation, Kathmandu, Nepal
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Madunil A Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Tan Soek Siam
- Department of Hepatology, Hospital Selayang, Selangor Darul Ehsan, Malaysia
| | - Chun-Qing Zhang
- Department of Gastroenterology, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Lee Guan Huei
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ming-Lung Yu
- School of Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | | | - Cheng-Yuan Peng
- Centre for Digestive Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Tao Chen
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jacob George
- University of Sydney School of Medicine, Sydney, Australia
| | - Vincent Wong
- Mok Hing Yiu Professor of Medicine, Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Yusuf Yilmaz
- Liver Research Unit, Institute of Gastroenterology, Marmara University, Istanbul, Turkey
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | | | - Juferdy Kurniawan
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital Jakarta, Jakarta, Indonesia
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | | | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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3
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Baska F, Bozó É, Patócs T. Vasopressin receptor antagonists: a patent summary (2018-2022). Expert Opin Ther Pat 2023; 33:385-395. [PMID: 37226495 DOI: 10.1080/13543776.2023.2218546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Arginine-vasopressin hormone (AVP) is a key regulator in many essential physiological processes. The effect of AVP is mediated through three receptors within the body, these are the G protein-coupled vasopressin receptors, namely V1a, V1b (also called V3), and V2. Numerous studies investigated the role of these receptors in certain pathological conditions; therefore, stimulation or inhibition of these receptors may be a treatment option in these diseases. AREAS COVERED In this manuscript, the authors summarize recent patent activity (2018-2022) associated with vasopressin receptor antagonists (selective V1a or V2, and dual-acting V1a/V2), focusing mostly on chemical structures, their modifications, and potential clinical applications. Patent search was carried out using SciFinder, Espacenet, Patentscope, Cortellis Competitive Intelligence, and Derwent Innovation databases. EXPERT OPINION In recent years, vasopressin receptor antagonists have been in the spotlight of drug discovery, especially V1a selective molecules. Publishing balovaptan as a possible treatment for autism spectrum disorder (ASD), greatly increased the interest in CNS-acting vasopressin antagonists. In addition, peripherally active selective V2 and dual-acting V1a/V2 antagonists have also been developed. Although clinical trials were unsuccessful in many cases, there is still potential in the research of vasopressin receptor antagonists as shown by several currently ongoing clinical trials.
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Affiliation(s)
- Ferenc Baska
- Chemistry Division, Gedeon Richter Plc, Budapest 10, Hungary
| | - Éva Bozó
- Chemistry Division, Gedeon Richter Plc, Budapest 10, Hungary
| | - Tamás Patócs
- IP Department, Gedeon Richter Plc, Budapest, Hungary
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Straminelli L, Vicentini F, Di Sabato A, Montone CM, Cavaliere C, Rissanen K, Leonelli F, Vetica F. Stereoselective Synthesis of Spiro-Decalin Oxindole Derivatives via Sequential Organocatalytic Michael–Domino Michael/Aldol Reaction. J Org Chem 2022; 87:10454-10461. [PMID: 35875873 PMCID: PMC9365295 DOI: 10.1021/acs.joc.2c01046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
![]()
A highly stereoselective procedure for the synthesis
of spiro-polycyclic
oxindoles bearing five contiguous stereogenic centers including two
tetrasubstituted carbons has been developed. Under sequential organocatalysis
performed by a pyrrolidine-based organocatalyst and DBU, a highly
atom-economical Michael–domino Michael/aldol reaction sequence
was optimized, yielding variously functionalized spiro-decalin oxindoles
with excellent stereoselectivity (>99:1 dr, up to 92% ee).
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Affiliation(s)
- Leonardo Straminelli
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Francesco Vicentini
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Antonio Di Sabato
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Carmela Maria Montone
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Chiara Cavaliere
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Kari Rissanen
- Department of Chemistry, University of Jyväskylä, 40014 Jyväskylä, Finland
| | - Francesca Leonelli
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Fabrizio Vetica
- Department of Chemistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
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Abstract
Hyponatremia is the most common electrolyte disorder encountered in clinical practice, and it is a common complication of cirrhosis reflecting an increase in nonosmotic secretion of arginine vasopressin as a result of of the circulatory dysfunction that is characteristic of advanced liver disease. Hyponatremia in cirrhosis has been associated with poor clinical outcomes including increased risk of morbidity and mortality, poor quality of life, and heightened health care utilization. Despite this, the treatment of hyponatremia in cirrhosis remains challenging as conventional therapies such as fluid restriction are frequently ineffective. In this review, we discuss the epidemiology, clinical outcomes, pathogenesis, etiology, evaluation, and management of hyponatremia in cirrhosis.
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Affiliation(s)
- Helbert Rondon-Berrios
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Juan Carlos Q. Velez
- Ochsner Clinical School/The University of Queensland, Brisbane, Queensland, Australia AND Department of Nephrology, Ochsner Health, New Orleans, Louisiana, USA
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6
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Dočekal V, Vopálenská A, Měrka P, Konečná K, Jand'ourek O, Pour M, Císařová I, Veselý J. Enantioselective Construction of Spirooxindole-Fused Cyclopentanes. J Org Chem 2021; 86:12623-12643. [PMID: 34283607 DOI: 10.1021/acs.joc.1c01116] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The present study reports an asymmetric organocatalytic cascade reaction of oxindole derivates with α,β-unsaturated aldehydes efficiently catalyzed by simple chiral secondary amine. Spirooxindole-fused cyclopentanes were produced in excellent isolated yields (up to 98%) with excellent enantiopurities (up to 99% ee) and moderate to high diastereoselectivities. The synthetic utility of the protocol was exemplified on a set of additional transformations of the corresponding spiro compounds. In addition, a study showing the promising biological activity of selected enantioenriched products was accomplished.
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Affiliation(s)
- Vojtěch Dočekal
- Department of Organic Chemistry, Faculty of Science, Charles University, Hlavova 2030/8, 128 43 Prague 2, Czech Republic
| | - Andrea Vopálenská
- Department of Organic Chemistry, Faculty of Science, Charles University, Hlavova 2030/8, 128 43 Prague 2, Czech Republic
| | - Pavel Měrka
- Department of Organic Chemistry, Faculty of Science, Charles University, Hlavova 2030/8, 128 43 Prague 2, Czech Republic
| | - Klára Konečná
- Department of Biological and Medical Sciences, Faculty of Pharmacy in Hradec Králové, Charles University, Heyrovského 1203, 500 05 Hradec Králové, Czech Republic
| | - Ondřej Jand'ourek
- Department of Biological and Medical Sciences, Faculty of Pharmacy in Hradec Králové, Charles University, Heyrovského 1203, 500 05 Hradec Králové, Czech Republic
| | - Milan Pour
- Department of Organic and Bioorganic Chemistry, Faculty of Pharmacy in Hradec Králové, Charles University, Heyrovského 1203, 500 05 Hradec Králové, Czech Republic
| | - Ivana Císařová
- Department of Inorganic Chemistry, Faculty of Science, Charles University, Hlavova 2030/8, 128 43 Prague 2, Czech Republic
| | - Jan Veselý
- Department of Organic Chemistry, Faculty of Science, Charles University, Hlavova 2030/8, 128 43 Prague 2, Czech Republic
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7
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Zhou Y, Yang W, Liu G, Gao W. Risks of vaptans in hypernatremia and serum sodium overcorrection: A systematic review and meta-analysis of randomised controlled trials. Int J Clin Pract 2021; 75:e13939. [PMID: 33336480 DOI: 10.1111/ijcp.13939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 12/14/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Serum sodium overcorrection and hypernatremia are significant health risks. We conducted a systematic review and meta-analysis to evaluate the risks of vaptans in hypernatremia and serum sodium overcorrection. METHODS We searched PubMed, Embase, and CENTRAL for randomised controlled trials. We included studies comparing vaptans and placebo with data on hypernatremia and serum sodium overcorrection. The study quality was assessed using the Cochrane Collaboration's risk-of-bias assessment tool. Fixed-effect model meta-analysis was used to pool the data. Different analyses were performed to ensure the accuracy of the results. RESULTS Twenty-eight studies were included in the meta-analysis of hypernatremia incidence. Treatment with vaptans resulted in a higher risk of hypernatremia than placebo (3.8% vs 1.0%, odds ratio [OR] 2.69; 95% confidence interval [CI] 1.97-3.68). The subgroup with baseline hyponatremia had a lower risk of hypernatremia incidence; however, the use of loop diuretics increased the risk. Fourteen studies were included in the analysis of the incidence of serum sodium overcorrection. A higher risk of serum sodium overcorrection was found in using vaptans vs placebo (4.4% vs 1.4%; OR 2.26; 95% CI 1.32-3.86). CONCLUSION Vaptans showed higher risks in the incidence of hypernatremia and serum sodium overcorrection than placebo. In addition, combination with loop diuretics increased the risk of hypernatremia. The risk of serum sodium overcorrection should be concerned in patients with hyponatremia and normal serum sodium equally. Using a low dose of vaptans can reduce both risks.
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Affiliation(s)
- Ya Zhou
- Department of Health Care and Endocrinology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Wenru Yang
- Department of Health Care, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Guotao Liu
- Department of Health Care, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Weiyi Gao
- Department of Health Care, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Shandong, China
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Pinchot JW, Kalva SP, Majdalany BS, Kim CY, Ahmed O, Asrani SK, Cash BD, Eldrup-Jorgensen J, Kendi AT, Scheidt MJ, Sella DM, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Radiologic Management of Portal Hypertension. J Am Coll Radiol 2021; 18:S153-S173. [PMID: 33958110 DOI: 10.1016/j.jacr.2021.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 12/17/2022]
Abstract
Cirrhosis is a heterogeneous disease that cannot be studied as a single entity and is classified in two main prognostic stages: compensated and decompensated cirrhosis. Portal hypertension, characterized by a pathological increase of the portal pressure and by the formation of portal-systemic collaterals that bypass the liver, is the initial and main consequence of cirrhosis and is responsible for the majority of its complications. A myriad of treatment options exists for appropriately managing the most common complications of portal hypertension, including acute variceal bleeding and refractory ascites. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts, Chief, Division of Interventional Radiology, Massachusetts General Hospital
| | | | - Charles Y Kim
- Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina, Chief, Division of Interventional Radiology, Duke University Medical Center
| | | | - Sumeet K Asrani
- Baylor University Medical Center, Dallas, Texas, American Association for the Study of Liver Diseases
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas, American Gastroenterological Association
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts, Society for Vascular Surgery
| | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapy at Mayo Clinic Rochester
| | | | | | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, Chair, FMLH credentials committee, Division chief of IR at Medical College of Wisconsin
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Sparapani S, Millet-Boureima C, Oliver J, Mu K, Hadavi P, Kalostian T, Ali N, Avelar CM, Bardies M, Barrow B, Benedikt M, Biancardi G, Bindra R, Bui L, Chihab Z, Cossitt A, Costa J, Daigneault T, Dault J, Davidson I, Dias J, Dufour E, El-Khoury S, Farhangdoost N, Forget A, Fox A, Gebrael M, Gentile MC, Geraci O, Gnanapragasam A, Gomah E, Haber E, Hamel C, Iyanker T, Kalantzis C, Kamali S, Kassardjian E, Kontos HK, Le TBU, LoScerbo D, Low YF, Mac Rae D, Maurer F, Mazhar S, Nguyen A, Nguyen-Duong K, Osborne-Laroche C, Park HW, Parolin E, Paul-Cole K, Peer LS, Philippon M, Plaisir CA, Porras Marroquin J, Prasad S, Ramsarun R, Razzaq S, Rhainds S, Robin D, Scartozzi R, Singh D, Fard SS, Soroko M, Soroori Motlagh N, Stern K, Toro L, Toure MW, Tran-Huynh S, Trépanier-Chicoine S, Waddingham C, Weekes AJ, Wisniewski A, Gamberi C. The Biology of Vasopressin. Biomedicines 2021; 9:89. [PMID: 33477721 PMCID: PMC7832310 DOI: 10.3390/biomedicines9010089] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 12/29/2020] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
Vasopressins are evolutionarily conserved peptide hormones. Mammalian vasopressin functions systemically as an antidiuretic and regulator of blood and cardiac flow essential for adapting to terrestrial environments. Moreover, vasopressin acts centrally as a neurohormone involved in social and parental behavior and stress response. Vasopressin synthesis in several cell types, storage in intracellular vesicles, and release in response to physiological stimuli are highly regulated and mediated by three distinct G protein coupled receptors. Other receptors may bind or cross-bind vasopressin. Vasopressin is regulated spatially and temporally through transcriptional and post-transcriptional mechanisms, sex, tissue, and cell-specific receptor expression. Anomalies of vasopressin signaling have been observed in polycystic kidney disease, chronic heart failure, and neuropsychiatric conditions. Growing knowledge of the central biological roles of vasopressin has enabled pharmacological advances to treat these conditions by targeting defective systemic or central pathways utilizing specific agonists and antagonists.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Chiara Gamberi
- Biology Department, Concordia University, Montreal, QC H4B 1R6, Canada; (S.S.); (C.M.-B.); (J.O.); (K.M.); (P.H.); (T.K.); (N.A.); (C.M.A.); (M.B.); (B.B.); (M.B.); (G.B.); (R.B.); (L.B.); (Z.C.); (A.C.); (J.C.); (T.D.); (J.D.); (I.D.); (J.D.); (E.D.); (S.E.-K.); (N.F.); (A.F.); (A.F.); (M.G.); (M.C.G.); (O.G.); (A.G.); (E.G.); (E.H.); (C.H.); (T.I.); (C.K.); (S.K.); (E.K.); (H.K.K.); (T.B.U.L.); (D.L.); (Y.F.L.); (D.M.R.); (F.M.); (S.M.); (A.N.); (K.N.-D.); (C.O.-L.); (H.W.P.); (E.P.); (K.P.-C.); (L.S.P.); (M.P.); (C.-A.P.); (J.P.M.); (S.P.); (R.R.); (S.R.); (S.R.); (D.R.); (R.S.); (D.S.); (S.S.F.); (M.S.); (N.S.M.); (K.S.); (L.T.); (M.W.T.); (S.T.-H.); (S.T.-C.); (C.W.); (A.J.W.); (A.W.)
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10
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Endpoints and design of clinical trials in patients with decompensated cirrhosis: Position paper of the LiverHope Consortium. J Hepatol 2021; 74:200-219. [PMID: 32896580 DOI: 10.1016/j.jhep.2020.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/09/2020] [Accepted: 08/02/2020] [Indexed: 12/15/2022]
Abstract
Management of decompensated cirrhosis is currently geared towards the treatment of complications once they occur. To date there is no established disease-modifying therapy aimed at halting progression of the disease and preventing the development of complications in patients with decompensated cirrhosis. The design of clinical trials to investigate new therapies for patients with decompensated cirrhosis is complex. The population of patients with decompensated cirrhosis is heterogeneous (i.e., different etiologies, comorbidities and disease severity), leading to the inclusion of diverse populations in clinical trials. In addition, primary endpoints selected for trials that include patients with decompensated cirrhosis are not homogeneous and at times may not be appropriate. This leads to difficulties in comparing results obtained from different trials. Against this background, the LiverHope Consortium organized a meeting of experts, the goal of which was to develop recommendations for the design of clinical trials and to define appropriate endpoints, both for trials aimed at modifying the natural history and preventing progression of decompensated cirrhosis, as well as for trials aimed at managing the individual complications of cirrhosis.
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11
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Bloom P, Wang T, Marx M, Tagerman M, Green B, Arvind A, Ha J, Bloom J, Richter JM. A Smartphone App to Manage Cirrhotic Ascites Among Outpatients: Feasibility Study. JMIR Med Inform 2020; 8:e17770. [PMID: 32876581 PMCID: PMC7495260 DOI: 10.2196/17770] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Ascites is a common, painful, and serious complication of cirrhosis. Body weight is a reliable proxy for ascites volume; therefore, daily weight monitoring is recommended to optimize ascites management. OBJECTIVE This study aims to evaluate the feasibility of a smartphone app in facilitating outpatient ascites management. METHODS In this feasibility study, patients with cirrhotic ascites requiring active management were identified in both inpatient and outpatient settings. Patients were provided with a Bluetooth-connected scale, which transmitted weight data to a smartphone app and then via the internet to an electronic medical record (EMR). Weights were monitored every weekday. In the event of a weight change of ≥5 lbs in 1 week, patients were called and administered a short symptom questionnaire, and providers received an email alert. The primary outcomes of this study were the percentage of enrolled days during which weight data were successfully transmitted to an EMR and the percentage of weight alerts that prompted responses by the provider. RESULTS In this study, 25 patients were enrolled: 12 (48%) were male, and the mean age was 58 (SD 13; range 35-81) years. A total of 18 (72%) inpatients were enrolled. Weight data were successfully transmitted to an EMR during 71.2% (697/979) of the study enrollment days, with technology issues reported on 16.5% (162/979) of the days. Of a total of 79 weight change alerts fired, 41 (52%) were triggered by weight loss and 38 (48%) were by weight gain. Providers responded in some fashion to 66 (84%) of the weight alerts and intervened in response to 45 (57%) of the alerts, for example, by contacting the patient, scheduling clinic or paracentesis appointments, modifying the diuretic dose, or requesting a laboratory workup. Providers responded equally to weight increase and decrease alerts (P=.87). The staff called patients a mean of 3.7 (SD 3.5) times per patient, and the number of phone calls correlated with technology issues (r=0.60; P=.002). A total of 60% (15/25) of the patients chose to extend their participation beyond 30 days. A total of 17 patient readmissions occurred during the study period, with only 4 (24%) related to ascites. CONCLUSIONS We demonstrated the feasibility of a smartphone app to facilitate the management of ascites and reported excellent rates of patient and provider engagement. This innovation could enable early therapeutic intervention, thereby decreasing the burden of morbidity and mortality among patients with cirrhosis.
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Affiliation(s)
- Patricia Bloom
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas Wang
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Madeline Marx
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Michelle Tagerman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Bradley Green
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Ashwini Arvind
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Jasmine Ha
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Judith Bloom
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - James M Richter
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
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12
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Lytvyn Y, Bjornstad P, van Raalte DH, Heerspink HL, Cherney DZI. The New Biology of Diabetic Kidney Disease-Mechanisms and Therapeutic Implications. Endocr Rev 2020; 41:5601424. [PMID: 31633153 PMCID: PMC7156849 DOI: 10.1210/endrev/bnz010] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
Diabetic kidney disease remains the most common cause of end-stage kidney disease in the world. Despite reductions in incidence rates of myocardial infarction and stroke in people with diabetes over the past 3 decades, the risk of diabetic kidney disease has remained unchanged, and may even be increasing in younger individuals afflicted with this disease. Accordingly, changes in public health policy have to be implemented to address the root causes of diabetic kidney disease, including the rise of obesity and diabetes, in addition to the use of safe and effective pharmacological agents to prevent cardiorenal complications in people with diabetes. The aim of this article is to review the mechanisms of pathogenesis and therapies that are either in clinical practice or that are emerging in clinical development programs for potential use to treat diabetic kidney disease.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Department of Medicine, Division of Nephrology, Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Netherlands
| | - Hiddo L Heerspink
- The George Institute for Global Health, Sydney, Australia.,Department of Clinical Pharmacology, University of Groningen, Groningen, Netherlands
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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13
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Zhang M, Wang JX, Chang SQ, Liu XL, Zuo X, Zhou Y. Highly efficient enantioselective synthesis of bispiro[benzofuran-oxindole/benzofuran-chromanone]s through organocatalytic inter-/intramolecular Michael cycloaddition. CHINESE CHEM LETT 2020. [DOI: 10.1016/j.cclet.2019.06.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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14
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Pereira G, Baldin C, Piedade J, Reis V, Valdeolivas T, Victor L, Guimarães L, Duarte J, Veiga Z, Alcântara C, Fernandes F, Pereira JL. Combination and sequential evaluation of acute-on-chronic liver failure (ACLF) and hyponatremia and prognosis in cirrhotic patients. Dig Liver Dis 2020; 52:91-97. [PMID: 31542220 DOI: 10.1016/j.dld.2019.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/27/2019] [Accepted: 08/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Few studies have evaluated whether combination and sequential evaluation of ACLF (acute-on-chronic liver failure) and hyponatremia aids prognosis. AIMS Describe clinical course and determine prognostic capability of assessing ACLF and hyponatremia at specific time-points. METHODS Prospective study with inclusion of 376 patients. ACLF and hyponatremia were evaluated at days 1 and 7 and classified as persistent, transient, de novo or absent. Follow-up was 90 days. RESULTS At inclusion, ACLF was diagnosed in 99 patients. Reversal was observed in 57 patients and was associated with lower creatinine and ACLF grade. De novo ACLF developed in 19 patients, and MELD (model of end-stage liver disease) score and lower albumin were predictive factors. Hyponatremia was present in 76 patients (persistent, transient and de novo in 27, 24 and 25 respectively). ACLF at D7 had the lowest survival compared to transient or no ACLF (21, 57 and 80%, p < 0.0001). Hyponatremia at admission was associated with low survival (35%) whereas survival was higher for de novo or absent cases (70%), p < 0.001. In multivariate analysis ACLF at D7 and hyponatremia at D1 were predictors of survival. CONCLUSION ACLF and hyponatremia are dynamic and evaluation of both conditions at different time-points identifies patients at higher risk of short-term mortality.
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Affiliation(s)
- Gustavo Pereira
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil; Estácio de Sá University, School of Medicine, Rio de Janeiro, Brazil.
| | - Caroline Baldin
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Juliana Piedade
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Vanessa Reis
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Tatiana Valdeolivas
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Lívia Victor
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Lívia Guimarães
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Joana Duarte
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Zulane Veiga
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Camila Alcântara
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - Flávia Fernandes
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
| | - João Luiz Pereira
- Gastroenterology and Hepatology Unit, Bonsucesso Federal Hospital, (Ministry of Health), Rio de Janeiro, Brazil
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15
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Song YX, Lin Y, Yan L, Du DM. An organocatalytic domino Michael addition strategy: construction of bispiro[oxindole-thiazolidinone-hexahydroxanthone]s with five contiguous stereocenters. Org Biomol Chem 2020; 18:7373-7378. [DOI: 10.1039/d0ob01613f] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
An efficient squaramide-catalyzed domino Michael addition for the stereoselective synthesis of bispiro[oxindole-thiazolidinone-hexahydroxanthone]s in good to excellent yields with excellent stereoselectivities was developed.
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Affiliation(s)
- Yong-Xing Song
- School of Chemistry and Chemical Engineering
- Beijing Institute of Technology
- Beijing 100081
- People's Republic of China
| | - Ye Lin
- School of Chemistry and Chemical Engineering
- Beijing Institute of Technology
- Beijing 100081
- People's Republic of China
| | - Li Yan
- Analytical and Testing Center
- Beijing Institute of Technology
- Liangxiang Campus
- Beijing 102488
- People's Republic of China
| | - Da-Ming Du
- School of Chemistry and Chemical Engineering
- Beijing Institute of Technology
- Beijing 100081
- People's Republic of China
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16
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Li M, Bi Z, Huang Z. Impact of Vaptans on Clinical Outcomes in Cirrhosis Patients: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019; 10:1365. [PMID: 31824315 PMCID: PMC6880191 DOI: 10.3389/fphar.2019.01365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/28/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Vaptans have been confirmed to mobilize ascites and improve hyponatremia in cirrhosis patients. However, the effects of vaptans on all-cause mortality, ascites-related complications, and adverse events in cirrhosis patients have not been fully determined. Objectives: To systematically evaluate the impact of vaptans on the clinical outcomes in patients with cirrhosis. Materials and Methods: A systematic review and meta-analysis was performed. The PubMed, Embase, and Cochrane’s Library electronic databases were systematically searched for randomized controlled trials (RCTs) investigating the clinical efficacy of vaptans in cirrhosis patients. The results were pooled with a random-effect model. Results: Eighteen RCTs containing 3,059 cirrhosis patients with ascites and/or hyponatremia were included. Meta-analysis showed that vaptans did not significantly affect the risk of all-cause mortality (RR: 1.02, 95% CI: 0.87 to 1.08, p = 0.83; I2 = 2%), consistent with studies with short-term (< 26 weeks) and long-term (≥ 26 weeks) follow-up durations. Additionally, vaptans did not affect the incidence of variceal bleeding (RR: 0.96, p = 0.86), showed a trend of reduced incidence of hepatic encephalopathy (RR: 0.86, p = 0.09), significantly reduced the incidence of spontaneous bacterial peritonitis (RR: 0.75, p = 0.03), but did not significantly affect the risk of hepatorenal syndrome or renal failure (RR: 1.09, p = 0.36). Vaptans did not affect the incidence of adverse events in cirrhosis patients. Discussion: Treatment with vaptans is not associated with improved survival in cirrhosis patients, although it may reduce the risk of hepatic encephalopathy and spontaneous bacterial peritonitis in these patients. The limitations of the current study include limited number of available studies, small sample sizes of the included studies, variations of baseline patient characteristics, and differences in the dose and duration of vaptans.
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Affiliation(s)
- Miao Li
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhuofang Bi
- Department of Ultrasonography, the Sihui People's Hospital, Zhaoqing, China
| | - Zicheng Huang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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17
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Watson H, Guevara M, Vilstrup H, Ginès P. Improvement of hyponatremia in cirrhosis is associated with improved complex information processing. J Gastroenterol Hepatol 2019; 34:1999-2003. [PMID: 30965392 DOI: 10.1111/jgh.14683] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/21/2019] [Accepted: 04/05/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Hyponatremia, a cause of brain dysfunction and risk factor for hepatic encephalopathy, is frequent in patients with advanced cirrhosis and ascites. The interdependence of liver failure and hyponatremia makes it difficult to separate the effects of each on cognitive function. The objective was to assess whether an increase in plasma sodium in patients with cirrhosis and ascites leads to an improvement in cognitive function. METHODS This is a post-hoc analysis of 250 cirrhosis patients without overt hepatic encephalopathy randomized to receive either placebo or satavaptan, a vasopressin V2 antagonist. The exposure was plasma sodium, and the outcome was the trail-making test (TMT) parts A and B, which assesses speed of information processing, performed before the study starts and after 14 days. The results were analyzed by initial and change to final sodium concentration. RESULTS At entry, the patients with normonatremia exhibited better results on both the TMT-A (median 56 vs 77.5 s for patients with sodium ≤ 130 mmol/L [P = 0.0059]) and the TMT-B (median 127 vs 170 s for patients with sodium ≤ 130 mmol/L [P = 0.0066]), unrelated to age. Improvement of hyponatremia was more common in patients who received satavaptan (59.7%) than placebo (18.5%). Correction of hyponatremia did not shorten the simple TMT-A but markedly improved the complex TMT-B by an average of 20 s compared with 6.5 s in those with continuing hyponatremia (P = 0.02). Liver status measures remained stable during the period reported. CONCLUSIONS These data suggest that improvement of hyponatremia in patients with cirrhosis leads to an increase in the speed of complex information processing.
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Affiliation(s)
- Hugh Watson
- Infectious Diseases Research, Sanofi-Aventis R&D, Marcy l'Etoile, France.,Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
| | - Monica Guevara
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), and Centro de Investigaciones en Red Hepatologia y Digestivas (CIBEReHD), Barcelona, Spain
| | - Hendrik Vilstrup
- Department of Gastroenterology and Hepatology, Aarhus University Hospital, Aarhus, Denmark
| | - Pere Ginès
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), and Centro de Investigaciones en Red Hepatologia y Digestivas (CIBEReHD), Barcelona, Spain
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18
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Enhörning S, Malan L. Copeptin relates to a fatty liver and measures of obesity in a South African population with mixed ethnicities. Endocrine 2019; 65:304-311. [PMID: 31230225 PMCID: PMC6656785 DOI: 10.1007/s12020-019-01977-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Elevated copeptin, a vasopressin marker, is linked to metabolic disease, and obese rats with low-vasopressin concentration had a decreased risk of liver steatosis. We here investigated the association between copeptin and nonalcoholic fatty liver disease (NAFLD) and possible differences in copeptin concentration between ethnicities. METHODS In this cross-sectional study of 361 South Africans (n = 172 African black, 189 = Caucasian) with a mean age of 45 years and 45% men, plasma copeptin was measured and associated with NAFLD according to a validated fatty liver index accounting for measures of BMI, waist, triglycerides, and gamma-glutamyltransferase. RESULTS There was no significant difference in copeptin concentrations between ethnicities after age and gender adjustment (p = 0.24). Increasing copeptin tertile levels were significantly associated with obesity, overweight, and abdominal obesity, respectively, after multivariate adjustment for age, gender, ethnicity, and high HOMA-IR (p = 0.02 for all). Individuals in the second and third copeptin tertile had an increased odds (95% CI) of NAFLD of 1.77 (1.04-3.02) and 2.97 (1.74-5.06), respectively, compared to the bottom tertile (p < 0.001). The association between increasing copeptin tertile and NAFLD remained significant after adjustment for age, gender, ethnicity, high HOMA-IR, self-reported current alcohol intake, and statin treatment (p = 0.01). CONCLUSIONS Elevated plasma copeptin is independently associated with NAFLD in a population with mixed ethnicities, pointing at the pharmacologically modifiable vasopressin system as a new mechanism behind NAFLD.
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Affiliation(s)
- Sofia Enhörning
- Department of Clinical Science, Lund University, Skåne University Hospital, SE 214 28, Malmö, Sweden.
- Department of Endocrinology, Skåne University Hospital, SE 221 85, Lund, Sweden.
| | - Léone Malan
- Hypertension in Africa Research Team (HART), Centre of Excellence, North-West University, Private Bag x6001, Potchefstroom, 2520, South Africa
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19
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Bossen L, Ginès P, Vilstrup H, Watson H, Jepsen P. Serum sodium as a risk factor for hepatic encephalopathy in patients with cirrhosis and ascites. J Gastroenterol Hepatol 2019; 34:914-920. [PMID: 30500090 DOI: 10.1111/jgh.14558] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/28/2018] [Accepted: 11/22/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Hyponatremia is associated with development of hepatic encephalopathy (HE), but the nature of the relationship between serum sodium and HE incidence is unknown. We examined the association between serum sodium, changes in serum sodium, and HE incidence using data from three randomized trials of satavaptan in cirrhosis patients with ascites. METHODS During follow-up, patients were examined for HE, and serum sodium was measured regularly. We used fractional polynomials to estimate the nature of the association between current serum sodium and hazard rate of HE (e.g. with a linear, logarithmic, or exponential slope) and Cox regression to adjust for confounders. Moreover, we examined the association between serum sodium at inclusion and 30-day and 1-year cumulative risk of HE. Finally, we examined the effect of "change in serum sodium since inclusion" on the hazard rate of HE. RESULTS We included 1116 patients of whom 302 developed HE. Median serum sodium at inclusion was 137 (interquartile range, 134-139). The lower the current serum sodium, the higher the rate of HE. Specifically, the confounder-adjusted HE hazard rate increased linearly by 8% (adjusted hazard ratio = 1.08, 95% confidence interval: 1.06-1.10) for every mmol/L decrease in serum sodium over the range of measured values. Current serum sodium had a stronger effect on the HE rate than the changes in serum sodium since inclusion. CONCLUSION The hazard rate of HE development increased by 8% for every mmol/L decrease in serum sodium. Further, current serum sodium had a stronger effect on the HE rate than changes in serum sodium.
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Affiliation(s)
- Lars Bossen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Pere Ginès
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigaciones en Red Hepatologia y Digestivas (CIBEReHD), Barcelona, Spain
| | - Hendrik Vilstrup
- 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
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20
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Liu X, Wei Q, Zuo X, Xu S, Yao Z, Wang J, Zhou Y. Organocatalytic Michael/Michael Cycloaddition Enabled Asymmetric Construction of Hexahydroxanthones with Skeletal Diversity. Adv Synth Catal 2019. [DOI: 10.1002/adsc.201900119] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Xiong‐Li Liu
- College of Pharmaceutical SciencesGuizhou University of Chinese Medicine Guiyang 550025 People's Republic of China
- Guizhou Engineering Center for Innovative Traditional Chinese Medicine and Ethnic MedicineGuizhou University Guiyang 550025 People's Republic of China
| | - Qi‐Di Wei
- Guizhou Engineering Center for Innovative Traditional Chinese Medicine and Ethnic MedicineGuizhou University Guiyang 550025 People's Republic of China
| | - Xiong Zuo
- Guizhou Engineering Center for Innovative Traditional Chinese Medicine and Ethnic MedicineGuizhou University Guiyang 550025 People's Republic of China
| | - Sheng‐Wen Xu
- Guizhou Engineering Center for Innovative Traditional Chinese Medicine and Ethnic MedicineGuizhou University Guiyang 550025 People's Republic of China
| | - Zhen Yao
- Guizhou Engineering Center for Innovative Traditional Chinese Medicine and Ethnic MedicineGuizhou University Guiyang 550025 People's Republic of China
| | - Jun‐Xin Wang
- Guizhou Engineering Center for Innovative Traditional Chinese Medicine and Ethnic MedicineGuizhou University Guiyang 550025 People's Republic of China
| | - Ying Zhou
- College of Pharmaceutical SciencesGuizhou University of Chinese Medicine Guiyang 550025 People's Republic of China
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21
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Macdonald S, Jepsen P, Alrubaiy L, Watson H, Vilstrup H, Jalan R. Quality of life measures predict mortality in patients with cirrhosis and severe ascites. Aliment Pharmacol Ther 2019; 49:321-330. [PMID: 30585338 DOI: 10.1111/apt.15084] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 09/16/2018] [Accepted: 11/14/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe ascites is associated with both a poor health-related quality of life (HRQL) and a mortality in excess of that captured by current prognostic clinical scores. AIM To determine the association between HRQL and mortality in patients with severe ascites. METHODS The HRQL data from previously published randomised controlled trials examining the efficacy of satavaptan in ascites were retrospectively evaluated. RESULTS Of the 496 patients randomised who completed the SF-36, 405 patients had complete datasets and were included in the analysis (difficult-to-treat ascites, n = 164 or refractory ascites, n = 241). Overall, patients reported poor HRQL, in particular the physical component score (PCS) of SF-36. The physical component score (PCS) correlated with the mental component score (MCS) of SF-36 (Spearman rank correlation = 0.68) but not with markers of severity of liver disease. The PCS, but not the MCS, was significantly lower in patients who died (P = 0.01 and P = 0.84, respectively). After confounder-adjustment, the hazard ratio for a 10-point increase in the physical component score was 0.83 (95% CI; 0.72-0.97) for all-cause mortality and 0.84 (95% CI; 0.71-0.99) for cirrhosis-related deaths only, indicating that patients with better physical HRQL live longer on average. CONCLUSIONS Poor physical component score (PCS) of SF-36 is an independent predictor of 12-month mortality in patients with severe ascites independent of current prognostic clinical scores. It holds promise not only in prognostic modelling but also as an endpoint in the evaluation of therapies targeting ascites.
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Affiliation(s)
- Stewart Macdonald
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Hugh Watson
- Infectious Diseases Unit, Sanofi-Aventis R&D, Marcy l'Etoile, France
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
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22
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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.
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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
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23
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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.
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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
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Herrera-Gómez F, Monge-Donaire D, Ochoa-Sangrador C, Bustamante-Munguira J, Alamartine E, Álvarez FJ. Correction of Hyponatremia May Be a Treatment Stratification Biomarker: A Two-Stage Systematic Review and Meta-Analysis. J Clin Med 2018; 7:jcm7090262. [PMID: 30205538 PMCID: PMC6162844 DOI: 10.3390/jcm7090262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 08/29/2018] [Accepted: 09/06/2018] [Indexed: 12/21/2022] Open
Abstract
Changes in serum sodium concentration ([Na+]serum) can permit evaluation of the treatment effect of vasopressin antagonists (vaptans) in patients with worsening heart failure (HF) or cirrhotic ascites; that is, they may act as a treatment stratification biomarker. A two-stage systematic review and meta-analysis were carried out and contextualized by experts in fluid resuscitation and translational pharmacology (registration ID in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42017051440). Meta-analysis of aggregated dichotomous outcomes was performed. Pooled estimates for correction of hyponatremia (normalization or an increase in [Na+]serum of at least 3–5 mEq/L) under treatment with vaptans (Stage 1) and for clinical outcomes in both worsening HF (rehospitalization and/or death) and cirrhotic ascites (ascites worsening) when correction of hyponatremia is achieved (Stage 2) were calculated. The body of evidence was assessed. Correction of hyponatremia was achieved under vaptans (odds ratio (OR)/95% confidence interval (95% CI)/I2/number of studies (n): 7.48/4.95–11.30/58%/15). Clinical outcomes in both worsening HF and cirrhotic ascites improved when correction of hyponatremia was achieved (OR/95% CI/I2/n: 0.51/0.26–0.99/52%/3). Despite the appropriateness of the study design, however, there are too few trials to consider that correction of hyponatremia is a treatment stratification biomarker. Patients with worsening HF or with cirrhotic ascites needing treatment with vaptans, have better clinical outcomes when correction of hyponatremia is achieved. However, the evidence base needs to be enlarged to propose formally correction of hyponatremia as a new treatment stratification biomarker. Markers for use with drugs are needed to improve outcomes related to the use of medicines.
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Affiliation(s)
- Francisco Herrera-Gómez
- Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Avenida Ramón y Cajal, 7, 47005 Valladolid, Spain.
- Nephrology, Hospital Virgen de la Concha-Sanidad de Castilla y León, 49022 Zamora, Spain.
| | - Diana Monge-Donaire
- Intensive Care Medicine, Hospital Virgen de la Concha-Sanidad de Castilla y León, 49022 Zamora, Spain.
| | - Carlos Ochoa-Sangrador
- Research Unit, Hospital Virgen de la Concha-Sanidad de Castilla y León, 49022 Zamora, Spain.
| | - Juan Bustamante-Munguira
- Cardiac Surgery, Hospital Clínico Universitario de Valladolid-Sanidad de Castilla y León, 47003 Valladolid, Spain.
| | - Eric Alamartine
- Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire de Saint-Etienne, 42270 Saint-Priest-en-Jarez, France.
| | - F Javier Álvarez
- Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Avenida Ramón y Cajal, 7, 47005 Valladolid, Spain.
- CEIm Área de Salud Valladolid Este, Hospital Clínico Universitario de Valladolid-Sanidad de Castilla y León, 47003 Valladolid, Spain.
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KASL clinical practice guidelines for liver cirrhosis: Ascites and related complications. Clin Mol Hepatol 2018; 24:230-277. [PMID: 29991196 PMCID: PMC6166105 DOI: 10.3350/cmh.2018.1005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open
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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: 1534] [Impact Index Per Article: 255.7] [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]
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Nagler EV, Haller MC, Van Biesen W, Vanholder R, Craig JC, Webster AC. Interventions for chronic non-hypovolaemic hypotonic hyponatraemia. Cochrane Database Syst Rev 2018; 6:CD010965. [PMID: 29953167 PMCID: PMC6513194 DOI: 10.1002/14651858.cd010965.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic (present > 48 hours) non-hypovolaemic hyponatraemia occurs frequently, can be caused by various conditions, and is associated with shorter survival and longer hospital stays. Many treatments, such as fluid restriction or vasopressin receptor antagonists can be used to improve the hyponatraemia, but whether that translates into improved patient-important outcomes is less certain. OBJECTIVES This review aimed to 1) look at the benefits and harms of interventions for chronic non-hypovolaemic hypotonic hyponatraemia when compared with placebo, no treatment or head-to-head; and 2) determine if benefits and harms vary in absolute or relative terms dependent on the specific compound within a drug class, on the dosage used, or the underlying disorder causing the hyponatraemia. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 1 December 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also screened the reference lists of potentially relevant studies, contacted authors, and screened the websites of regulatory agencies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of any intervention with placebo, no treatment, standard care, or any other intervention in patients with chronic non-hypovolaemic hypotonic hyponatraemia. We also included subgroups with hyponatraemia from studies with broader inclusion criteria (e.g. people with chronic heart failure or people with cirrhosis with or without hyponatraemia), provided we could obtain outcomes for participants with hyponatraemia from the report or the study authors. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. We expressed treatment effects as mean difference (MD) for continuous outcomes (health-related quality of life, length of hospital stay, change from baseline in serum sodium concentration, cognitive function), and risk ratio (RR) for dichotomous outcomes (death, response and rapid increase in serum sodium concentration, hypernatraemia, polyuria, hypotension, acute kidney injury, liver function abnormalities) together with 95% confidence intervals (CI). MAIN RESULTS We identified 35 studies, enrolling 3429 participants. Twenty-eight studies (3189 participants) compared a vasopressin receptor antagonist versus placebo, usual care, no treatment, or fluid restriction. In adults with chronic, non-hypovolaemic hypotonic hyponatraemia, vasopressin receptor antagonists have uncertain effects on death at six months (15 studies, 2330 participants: RR 1.11, 95% CI 0.92 to 1.33) due to risk of selective reporting and serious imprecision; and on health-related quality of life because results are at serious risk of performance, selective reporting and attrition bias, and suffer from indirectness related to the validity of the Short Form Health Survey (SF-12) in the setting of hyponatraemia. Vasopressin receptor antagonists may reduce hospital stay (low certainty evidence due to risk of performance bias and imprecision) (3 studies, 610 participants: MD -1.63 days, 95% CI -2.96 to -0.30), and may make little or no difference to cognitive function (low certainty evidence due to indirectness and imprecision). Vasopressin receptor antagonists probably increase the intermediate outcome of serum sodium concentration (21 studies, 2641 participants: MD 4.17 mmol/L, 95% CI 3.18 to 5.16), corresponding to two and a half as many people having a 5 to 6 mmol/L increase in sodium concentration compared with placebo at 4 to 180 days (moderate certainty evidence due to risk of attrition bias) (18 studies, 2014 participants: RR 2.49, 95% CI 1.95 to 3.18). But they probably also increase the risk of rapid serum sodium correction - most commonly defined as > 12 mmol/L/d (moderate certainty evidence due to indirectness) (14 studies, 2058 participants: RR 1.67, 95% CI 1.16 to 2.40) and commonly cause side-effects such as thirst (13 studies, 1666 participants: OR 2.77, 95% CI 1.80 to 4.27) and polyuria (6 studies, 1272 participants): RR 4.69, 95% CI 1.59 to 13.85) (high certainty evidence). The potential for liver toxicity remains uncertain due to large imprecision. Effects were generally consistent across the different agents, suggesting class effect.Data for other interventions such as fluid restriction, urea, mannitol, loop diuretics, corticosteroids, demeclocycline, lithium and phenytoin were largely absent. AUTHORS' CONCLUSIONS In people with chronic hyponatraemia, vasopressin receptor antagonists modestly raise serum sodium concentration at the cost of a 3% increased risk of it being rapid. To date there is very low certainty evidence for patient-important outcomes; the effects on mortality and health-related quality of life are unclear and do not rule out appreciable benefit or harm; there does not appear to be an important effect on cognitive function, but hospital stay may be slightly shorter, although available data are limited. Treatment decisions must weigh the value of an increase in serum sodium concentration against its short-term risks and unknown effects on patient-important outcomes. Evidence for other treatments is largely absent.Further studies assessing standard treatments such as fluid restriction or urea against placebo and one-another would inform practice and are warranted. Given the limited available evidence for patient-important outcomes, any study should include these outcomes in a standardised manner.
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Affiliation(s)
- Evi V Nagler
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Maria C Haller
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
- Medical University ViennaSection for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent SystemsSpitalgasse 23ViennaAustriaA‐1090
- Ordensklinikum Linz ElisabethinenDepartment of NephrologyFadingerstraße 1LinzAustria4020
| | - Wim Van Biesen
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Raymond Vanholder
- Ghent University HospitalRenal Division, Sector Metabolic and Cardiovascular ConditionsDe Pintelaan 185GhentBelgium9000
- Guidance Body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA)European Renal Best Practice (ERBP)LondonUK
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Angela C Webster
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
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Jiménez JV, Carrillo-Pérez DL, Rosado-Canto R, García-Juárez I, Torre A, Kershenobich D, Carrillo-Maravilla E. Electrolyte and Acid-Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach. Dig Dis Sci 2017; 62:1855-1871. [PMID: 28501971 DOI: 10.1007/s10620-017-4597-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 04/26/2017] [Indexed: 12/17/2022]
Abstract
Electrolyte and acid-base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid-base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid-base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid-base spectrum. Because most electrolyte and acid-base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.
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Affiliation(s)
- José Víctor Jiménez
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Diego Luis Carrillo-Pérez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Rodrigo Rosado-Canto
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - David Kershenobich
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Eduardo Carrillo-Maravilla
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico.
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Bhandari S, Peri A, Cranston I, McCool R, Shaw A, Glanville J, Petrakova L, O'Reilly K. A systematic review of known interventions for the treatment of chronic nonhypovolaemic hypotonic hyponatraemia and a meta-analysis of the vaptans. Clin Endocrinol (Oxf) 2017; 86:761-771. [PMID: 28214374 DOI: 10.1111/cen.13315] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 01/31/2017] [Accepted: 02/15/2017] [Indexed: 01/17/2023]
Abstract
International and national guidelines on the treatment of chronic nonhypovolaemic hypotonic hyponatraemia differ; therefore, we have undertaken this systematic review and meta-analysis to investigate the efficacy and safety of interventions for the treatment of chronic nonhypovolaemic hypotonic hyponatraemia. Following registration of the review protocol with PROSPERO, systematic literature searches were conducted to identify randomized and quasi-randomized controlled trials assessing any degree of fluid restriction or any drug treatment with the aim of increasing serum sodium concentration in patients with chronic nonhypovolaemic hypotonic hyponatraemia. Where appropriate, outcome data were synthesized in a meta-analysis. A total of 45 716 bibliographic records were identified from the searches and 18 trials (assessing conivaptan, lixivaptan, tolvaptan and satavaptan) met the eligibility criteria. Results suggest that all four vasopressin receptor agonists ("vaptans") significantly improve serum sodium concentration. Lixivaptan, satavaptan and tolvaptan were associated with greater rates of response versus placebo. There was no evidence of a difference between each of the vaptans compared with placebo for mortality, discontinuation and rates of hypernatraemia. No RCT evidence of treatments other than the vaptans for hyponatraemia such as oral urea, salt tablets, mannitol, loop diuretics demeclocycline or lithium was identified. Vaptans demonstrated superiority over placebo for outcomes relating to serum sodium correction. Few trials documented the potential benefit of vaptans on change in health-related quality of life as a result of treatment. There was also a lack of high-quality RCT evidence on the comparative efficacy of the vaptans and other treatment strategies for the treatment of chronic nonhypovolaemic hypotonic hyponatraemia.
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Affiliation(s)
- Sunil Bhandari
- Renal and Transplant Medicine, Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School (HYMS), Hull, UK
| | - Alessandro Peri
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Iain Cranston
- Academic Department of Endocrinology and Diabetes, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Rachael McCool
- York Health Economics Consortium, University of York, York, UK
| | - Alison Shaw
- York Health Economics Consortium, University of York, York, UK
| | - Julie Glanville
- York Health Economics Consortium, University of York, York, UK
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Rai N, Singh B, Singh A, Vijayvergiya R, Sharma N, Bhalla A, Singh V. Midodrine and tolvaptan in patients with cirrhosis and refractory or recurrent ascites: a randomised pilot study. Liver Int 2017; 37:406-414. [PMID: 27614145 DOI: 10.1111/liv.13250] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/30/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND Splanchnic arterial vasodilatation and subsequent sodium and water retention play an important role in cirrhotic ascites. Midodrine and tolvaptan have been used separately in these patients. However, there are no reports on the use of combination of midodrine and tolvaptan in the control of ascites. The aim of this study was to evaluate the safety and efficacy of midodrine, tolvaptan and their combination in control of refractory or recurrent ascites in cirrhotics. METHODS Fifty cirrhotic patients with refractory or recurrent ascites were randomised to receive midodrine (n=13), tolvaptan (n=12) or both (n=13) plus standard medical therapy (SMT) or SMT alone (n=12). RESULTS A significant increase in urinary volume and urinary sodium at 1 and 3 months (P<.05) was observed in all groups except SMT. There was no worsening of renal or hepatic function in any group. There was deterioration of model for end-stage liver disease (MELD) in SMT. Midodrine as well as combination of midodrine and tolvaptan but not tolvaptan alone was superior to SMT in control of ascites at 3 months (P<.05). The combination therapy was also superior to midodrine in the control of ascites at 1 month. The morbidity and mortality were similar in all the groups except SMT. CONCLUSIONS The results of this pilot study suggest that midodrine and combination with tolvaptan better controls ascites without any renal or hepatic dysfunction. The combination therapy rapidly controls ascites as compared to midodrine or tolvaptan alone.
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Affiliation(s)
- Nitish Rai
- Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Baljinder Singh
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Akash Singh
- Government Medical College and Hospital, Chandigarh, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Ling Q, Dai H, Zhuang R, Shen T, Wang W, Xu X, Zheng S. Predicting short-term survival after liver transplantation on eight score systems: a national report from China Liver Transplant Registry. Sci Rep 2017; 7:42253. [PMID: 28198820 PMCID: PMC5304182 DOI: 10.1038/srep42253] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 01/08/2017] [Indexed: 12/16/2022] Open
Abstract
To compare the performance of eight score systems (MELD, uMELD, MELD-Na. iMELD, UKELD, MELD-AS, CTP, and mCTP) in predicting the post-transplant mortality, we analyzed the data of 6,014 adult cirrhotic patients who underwent liver transplantation between January 2003 and December 2010 from the China Liver Transplant Registry database. In hepatitis B virus (HBV) group, MELD, uMELD and MELD-AS showed good predictive accuracies at 3-month mortality after liver transplantation; by comparison with other five models, MELD presented the best ability in predicting 3-month, 6-month and 1-year mortality, showing a significantly better predictive ability than UKELD and iMELD. In hepatitis C virus and Alcohol groups, the predictive ability did not differ significantly between MELD and other models. Patient survivals in different MELD categories were of statistically significant difference. Among patients with MELD score >35, a new prognostic model based on serum creatinine, need for hemodialysis and moderate ascites could identify the sickest one. In conclusion, MELD is superior to other score systems in predicting short-term post-transplant survival in patients with HBV-related liver disease. Among patients with MELD score >35, a new prognostic model can identify the sickest patients who should be excluded from waiting list to prevent wasteful transplantation.
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Affiliation(s)
- Qi Ling
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haojiang Dai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Runzhou Zhuang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tian Shen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Abstract
Despite the introduction of multiple new pharmacological agents over the past three decades in the field of heart failure (HF), overall prognosis remains poor. Hyponatremia is prevalent in HF patients and has been suggested as a contributor to poor response to standard therapy. Elevated levels of arginine vasopressin (AVP), a peptide hormone produced in the hypothalamus, play a role in development of hyponatremia, and AVP and its surrogate, copeptin, are related to changes in osmolality, hemodynamics, neuro-hormones as well as in overall outcome in HF patients. Of current pharmacological interest are the selective and non-selective vasopressin receptor antagonists (VRAs), which inhibit vasoconstriction and cardiac remodeling mediated by the V1a receptors in smooth blood vessels, and water retention (increased urine osmolality and decreased water excretion) by increasing aquaporin-2 water channels mediated by the V2 receptors in the renal collecting tubules. The optimal use of VRAs is yet to be determined, especially in patients with congestive HF. Although long-term effects on improvement in mortality have not been shown in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial, the only long-term outcome trial to date, many short-term studies indicate beneficial aquaretic- and hemodynamic-effects of the VRAs. In contrast to loop diuretics, these new agents tend to increase urine flow and the excretion of electrolyte-free water (so-called aquaresis) in patients with HF, without substantial changes in sodium or potassium excretion. This chapter reviews the role of AVP and copeptin in HF, and the treatment potential of VRAs in HF.
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Colson PH, Virsolvy A, Gaudard P, Charrabi A, Corbani M, Manière MJ, Richard S, Guillon G. Terlipressin, a vasoactive prodrug recommended in hepatorenal syndrome, is an agonist of human V1, V2 and V1B receptors: Implications for its safety profile. Pharmacol Res 2016; 113:257-264. [PMID: 27586252 DOI: 10.1016/j.phrs.2016.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/12/2016] [Accepted: 08/27/2016] [Indexed: 12/13/2022]
Abstract
Terlipressin is recommended as a gold standard to treat hepatorenal syndrome complicating liver cirrhosis. It is presented as a specific V1A receptor agonist, beyond its enzymatic conversion into lysine8-Vasopressin (LVP), able to counteract the splanchnic vasodilation. However, the complete pharmacological characterization of this drug with respect to the different vasopressin receptor subtypes is missing. We studied terlipressin intrinsic properties, focusing not only on V1A, but also on other vasopressin receptor subtypes. The experimental studies were conducted on rat and human cellular models. Binding experiments were performed on rat liver membranes and CHO cells transfected with the different human vasopressin receptor subtypes. Agonist status was assessed from inositol phosphate or cyclic AMP assays, and measurement of intracellular calcium variations, performed on cultured vascular smooth muscle cells from rat aorta and human uterine artery and CHO cells. Terlipressin binds to the rat and human V1A receptors with an affinity in the micromolar range, a value 120 fold lower than that of LVP. It induces a rapid and transient intracellular calcium increase, a robust stimulation of phospholipase C but with reduced maximal efficiencies as compared to LVP, indicating a partial V1A agonist property. In addition, terlipressin is also a full agonist of human V2 and V1B receptors, with also a micromomolar affinity. CONCLUSIONS Terlipressin is a non-selective vasopressin analogue, exhibiting intrinsic agonist properties. Its full V2 receptor agonism may result in renal effects potentially aggravating water retention and hyponatremia of cirrhosis.
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Affiliation(s)
- Pascal H Colson
- Institut de Génomique Fonctionnelle, Département d'Endocrinologie, CNRS UMR 5203, INSERM U1191, Université de Montpellier, F-34094 Montpellier, France; Département d'Anesthésie Réanimation Arnaud de Villeneuve, Centre Hospitalier Régional et Universitaire, F-34295 Montpellier, France.
| | - Anne Virsolvy
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Université de Montpellier, F-34295 Montpellier, France.
| | - Philippe Gaudard
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Université de Montpellier, F-34295 Montpellier, France; Département d'Anesthésie Réanimation Arnaud de Villeneuve, Centre Hospitalier Régional et Universitaire, F-34295 Montpellier, France.
| | - Azzouz Charrabi
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Université de Montpellier, F-34295 Montpellier, France.
| | - Maithé Corbani
- Institut de Génomique Fonctionnelle, Département d'Endocrinologie, CNRS UMR 5203, INSERM U1191, Université de Montpellier, F-34094 Montpellier, France.
| | - Maxime J Manière
- Institut de Génomique Fonctionnelle, Département d'Endocrinologie, CNRS UMR 5203, INSERM U1191, Université de Montpellier, F-34094 Montpellier, France.
| | - Sylvain Richard
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Université de Montpellier, F-34295 Montpellier, France.
| | - Gilles Guillon
- Institut de Génomique Fonctionnelle, Département d'Endocrinologie, CNRS UMR 5203, INSERM U1191, Université de Montpellier, F-34094 Montpellier, France.
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Abstract
Antiviral therapeutics with profiles of high potency, low resistance, panserotype, and low toxicity remain challenging, and obtaining such agents continues to be an active area of therapeutic development. Due to their unique three-dimensional structural features, spirooxindoles have been identified as privileged chemotypes for antiviral drug development. Among them, spiro-pyrazolopyridone oxindoles have been recently reported as potent inhibitors of dengue virus NS4B, leading to the discovery of an orally bioavailable preclinical candidate (R)-44 with excellent in vivo efficacy in a dengue viremia mouse model. This review highlights recent advances in the development of biologically active spirooxindoles for their antiviral potential, primarily focusing on the structure-activity relationships (SARs) and modes of action, as well as future directions to achieve more potent analogues toward a viable antiviral therapy.
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Affiliation(s)
- Na Ye
- Chemical Biology Program, Department of Pharmacology and Toxicology, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555, United States
| | - Haiying Chen
- Chemical Biology Program, Department of Pharmacology and Toxicology, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555, United States
| | - Eric A. Wold
- Chemical Biology Program, Department of Pharmacology and Toxicology, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555, United States
| | - Pei-Yong Shi
- Chemical Biology Program, Department of Pharmacology and Toxicology, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555, United States
- Department of Biochemistry & Molecular Biology, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555, United States
- Sealy Center for Structural Biology & Molecular Biophysics, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555, United States
| | - Jia Zhou
- Chemical Biology Program, Department of Pharmacology and Toxicology, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555, United States
- Center for Biodefense and Emerging Infectious Diseases, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555, United States
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Nakagawa A, Atsukawa M, Tsubota A, Kondo C, Okubo T, Arai T, Itokawa N, Narahara Y, Iwakiri K. Usefulness of portal vein pressure for predicting the effects of tolvaptan in cirrhotic patients. World J Gastroenterol 2016; 22:5104-5113. [PMID: 27275103 PMCID: PMC4886386 DOI: 10.3748/wjg.v22.i21.5104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 03/19/2016] [Accepted: 03/30/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To elucidate influencing factors of treatment response, then tolvaptan has been approved in Japan for liquid retention.
METHODS: We herein conducted this study to clarify the influencing factors in 40 patients with decompensated liver cirrhosis complicated by liquid retention. Tolvaptan was administered at a dosage of 7.5 mg once a day for patients with conventional diuretic-resistant hepatic edema for 7 d. At the initiation of tolvaptan, the estimated hepatic venous pressure gradient (HVPG) value which was estimated portal vein pressure was measured using hepatic venous catheterization. We analyzed the effects of tolvaptan and influencing factors associated with treatment response.
RESULTS: Subjects comprised patients with a median age of 65 (range, 40-82) years. According to the Child-Pugh classification, class A was 3 patients, class B was 19, and class C was 18. Changes from the baseline in body weight were -1.0 kg (P = 2.04 × 10-6) and -1.3 kg (P = 1.83 × 10-5), respectively. The median HVPG value was 240 (range, 105-580) mmH2O. HVPG was only significant influencing factor of the weight loss effect. When patients with body weight loss of 2 kg or greater from the baseline was defined as responders, receiver operating characteristic curve analysis showed that the optimal HVPG cutoff value was 190 mmH2O in predicting treatment response. The response rate was 87.5% (7/8) in patients with HVPG of 190 mmH2O or less, whereas it was only 12.5% (2/16) in those with HVPG of greater than 190 mmH2O (P = 7.46 × 10-4). We compared each characteristics factors between responders and non-responders. As a result, HVPG (P = 0.045) and serum hyaluronic acid (P = 0.017) were detected as useful factors.
CONCLUSION: The present study suggests that tolvaptan in the treatment of liquid retention could be more effective for patients with lower portal vein pressure.
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Lizaola B, Bonder A, Tapper EB, Mendez-Bocanegra A, Cardenas A. The Changing Role of Sodium Management in Cirrhosis. ACTA ACUST UNITED AC 2016; 14:274-84. [DOI: 10.1007/s11938-016-0094-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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37
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Huang H, Bihani M, Zhao JCG. Stereoselective synthesis of spirooxindole derivatives using an organocatalyzed tandem Michael–Michael reaction. Org Biomol Chem 2016; 14:1755-63. [DOI: 10.1039/c5ob02348c] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A highly efficient and stereoselective method for the synthesis of functionalized spirooxindole derivatives was realized using enamine catalysis.
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Affiliation(s)
- Huicai Huang
- Department of Chemistry
- University of Texas at San Antonio
- San Antonio
- USA
| | - Manisha Bihani
- Department of Chemistry
- University of Texas at San Antonio
- San Antonio
- USA
| | - John C.-G. Zhao
- Department of Chemistry
- University of Texas at San Antonio
- San Antonio
- USA
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Solà E, Solé C, Ginès P. Management of uninfected and infected ascites in cirrhosis. Liver Int 2016; 36 Suppl 1:109-15. [PMID: 26725907 DOI: 10.1111/liv.13015] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 02/06/2023]
Abstract
Ascites is the most frequent complication of patients with cirrhosis. Ascites is related to increased renal sodium retention as a result of increased activity of the renin-angiotensin-aldosterone system in response to marked vasodilation of the splanchnic circulation. Management of uncomplicated ascites is based on a low-sodium diet and diuretics. However, approximately 10% of patients develop refractory ascites during follow-up, which is associated with a poor prognosis. The treatment of choice in patients with refractory ascites is large-volume paracentesis associated with intravenous albumin. Moreover, patients who develop refractory ascites should be considered as candidates for liver transplantation. Patients with ascites are all at risk of developing spontaneous bacterial peritonitis (SBP). SBP is a common infection in patients with cirrhosis with a risk of mortality of 20%. Empirical antibiotics are the treatment of choice in patients with SBP but differ depending on the acquisition site of infection, because nosocomial infections have a higher risk of being caused by multiresistant bacteria. In addition to antibiotic treatment, all patients with SBP should also receive intravenous albumin. This review summarizes the management of uninfected ascites and SBP in cirrhosis.
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Affiliation(s)
- Elsa Solà
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Reina Sofía de Investigación Nefrológica (IRSIN)
| | - Cristina Solé
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Reina Sofía de Investigación Nefrológica (IRSIN)
| | - Pere Ginès
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Reina Sofía de Investigación Nefrológica (IRSIN)
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Iwamoto T, Maeda M, Hisanaga T, Saeki I, Fujisawa K, Matsumoto T, Hidaka I, Ishikawa T, Takami T, Sakaida I. Predictors of the Effect of Tolvaptan on the Prognosis of Cirrhosis. Intern Med 2016; 55:2911-2916. [PMID: 27746425 PMCID: PMC5109555 DOI: 10.2169/internalmedicine.55.6819] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Objective Tolvaptan was first approved for use for cirrhosis in Japan in September 2013. The aim of the study was to examine the effect of tolvaptan, a vasopressin V2 receptor antagonist, on the prognosis of cirrhosis. Methods The effect of tolvaptan was evaluated in 26 patients with cirrhosis treated at our hospital from September 2013 to April 2015. Results The primary disease was hepatitis C in 20 patients, hepatitis B in 2, nonalcoholic steatohepatitis in 2 and others in 2; and 12 had hepatocellular carcinoma. The Child-Pugh score was 9.7±1.6 and the serum albumin level was 2.53±0.44 g/dL. Body weight decreased from 55.5±11.8 kg before administration to 52.1±14.7 kg after 7 days of tolvaptan treatment. After 7 days, patients with weight loss ≥2 kg (n=16, mean decrease of 4.3±2.3 kg) had significantly lower blood urea nitrogen (24.2±14.4 vs. 36.1±11.4 mg/dL) and serum creatinine (1.1±0.5 vs. 1.5±0.7 mg/dL) levels and decreased urine osmolality 4 h after the administration of tolvaptan (236±96 vs. 364±122 mOsm/kg) compared with patients with weight loss <2 kg (n=10, mean increase of +0.7±2.1 kg) (all p<0.05). The prognosis was significantly better in the group with weight loss ≥2 kg. Conclusion The effect of tolvaptan on the renal function is likely to improve the prognosis of patients with cirrhosis if the drug is started at a stage in which the renal function is maintained.
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Affiliation(s)
- Takuya Iwamoto
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Japan
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Rafat C, Flamant M, Gaudry S, Vidal-Petiot E, Ricard JD, Dreyfuss D. Hyponatremia in the intensive care unit: How to avoid a Zugzwang situation? Ann Intensive Care 2015; 5:39. [PMID: 26553121 PMCID: PMC4639545 DOI: 10.1186/s13613-015-0066-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
Hyponatremia is a common
electrolyte derangement in the setting of the intensive care unit. Life-threatening neurological complications may arise not only in case of a severe (<120 mmol/L) and acute fall of plasma sodium levels, but may also stem from overly rapid correction of hyponatremia. Additionally, even mild hyponatremia carries a poor short-term and long-term prognosis across a wide range of conditions. Its multifaceted and intricate physiopathology may seem deterring at first glance, yet a careful multi-step diagnostic approach may easily unravel the underlying mechanisms and enable physicians to adopt the adequate measures at the patient’s bedside. Unless hyponatremia is associated with obvious extracellular fluid volume increase such as in heart failure or cirrhosis, hypertonic saline therapy is the cornerstone of the therapeutic of profound or severely symptomatic hyponatremia. When overcorrection of hyponatremia occurs, recent data indicate that re-lowering of plasma sodium levels through the infusion of hypotonic fluids and the cautious use of desmopressin acetate represent a reasonable strategy. New therapeutic options have recently emerged, foremost among these being vaptans, but their use in the setting of the intensive care unit remains to be clarified.
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Affiliation(s)
- Cédric Rafat
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,AP-HP, Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France.
| | - Martin Flamant
- AP-HP, Service de Physiologie Rénale, Hôpital Bichat, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM, U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| | - Stéphane Gaudry
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,ECEVE UMR 1123, ECEVE, Paris, France.
| | - Emmanuelle Vidal-Petiot
- AP-HP, Service de Physiologie Rénale, Hôpital Bichat, Paris, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM, U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| | - Jean-Damien Ricard
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM UMR 1137, IAME, Paris, France.
| | - Didier Dreyfuss
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,INSERM UMR 1137, IAME, Paris, France.
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Fukui H. Do vasopressin V2 receptor antagonists benefit cirrhotics with refractory ascites? World J Gastroenterol 2015; 21:11584-11596. [PMID: 26556988 PMCID: PMC4631962 DOI: 10.3748/wjg.v21.i41.11584] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/08/2015] [Accepted: 09/15/2015] [Indexed: 02/06/2023] Open
Abstract
Hyponatremia is a frequent complication of advanced cirrhosis with ascites associated with increased morbidity and mortality. It is caused by an impairment in the renal capacity to eliminate solute-free water and is considered to be related to persistent secretion of vasopressin despite low serum osmolality. This nonosmotic release of vasopressin is mediated by the autonomic nervous system, which senses the underfilling of arterial vascular component. This reduction of effective arterial blood volume is closely related to the development of ascites. Although the short-time effects of vasopressin V2 receptor antagonists (vaptans) on hyponatremia and ascites have been repeatedly reported, their effects on the long-term management of cirrhotic ascites have not been established yet. Considering that their effects on water diuresis and their safety are limited by severe underfilling state of patients, cautious approaches with adequate monitoring are needed to advanced cirrhosis. Proper indication, adequate doses and new possibility of combination therapy should be explored in the future controlled study. As hyponatremia is frequent obstacle to ascites management, judicious combination with low-dose diuretics may decrease the incidence of refractory ascites. Although vaptans show much promise in the treatment of advanced cirrhosis, the problem of high cost should be solved for the future.
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Pathogenesis of solute-free water retention in experimental ascitic cirrhosis: is vasopressin the only culprit? Clin Sci (Lond) 2015; 130:117-24. [PMID: 26519424 DOI: 10.1042/cs20150479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/30/2015] [Indexed: 01/12/2023]
Abstract
Catecholamines trigger proximal tubular fluid retention and reduce renal excretion of solute-free water. In advanced cirrhosis, non-osmotic hypersecretion of vasopressin (antidiuretic hormone or ADH) is considered the cause of dilutional hyponatraemia, but ADH V2 receptor antagonists are not beneficial in long-term treatment of ascites. To test the hypothesis that water retention in experimental ascitic cirrhosis might depend primarily on adrenergic hyper-function, hormonal status, renal function and tubular free-water reabsorption (TFWR) were assessed in six groups of rats with ascitic cirrhosis: rats with cirrhosis due to 13-week CCl4 (carbon tetrachloride) administration (group G1); cirrhotic rats receiving daily diuretics (0.5 mg/kg furosemide plus 2 mg/kg K(+)-canrenoate) from the 11th to the 13th week of CCl4 (G2), diuretics associated with guanfacine oral prodrug (α2A-adrenergic receptor agonist and sympatholytic agent) at 2 (G3), 7 (G4) or 10 (G5) mg/kg, or with SSP-004240F1 (V2 receptor antagonist) at 1 mg/kg (G6). Natriuresis was lower in G1 than in G2, G4 and G6 (all P<0.05). Guanfacine, added to diuretics (i.e. G3 compared with G2), reduced serum noradrenaline from 423±22 to 211±41 ng/l (P<0.05), plasma renin activity (PRA) from 35±8 to 9±2 ng/ml/h (P<0.05) and TFWR from 45±8 to 20±6 μl/min (P<0.01). TFWR correlated with plasma aldosterone (r=0.51, P<0.01) and urinary potassium excretion (r=0.90, P<0.001). In ascitic cirrhosis, reduced volaemia, use of diuretics (especially furosemide) and adrenergic hyper-function cause tubular retention of water. Suitable doses of sympatholytic agents are effective aquaretics.
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Sinha VK, Ko B. Hyponatremia in Cirrhosis--Pathogenesis, Treatment, and Prognostic Significance. Adv Chronic Kidney Dis 2015; 22:361-7. [PMID: 26311597 DOI: 10.1053/j.ackd.2015.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 02/06/2015] [Accepted: 02/12/2015] [Indexed: 01/14/2023]
Abstract
Cirrhosis is characterized by systemic and splanchnic vasodilation that leads to excessive nonosmotic secretion of vasopressin (antidiuretic hormone). Hyponatremia is a common electrolyte abnormality in advanced liver disease that results from the impaired ability of the kidney to excrete solute-free water that leads to "dilutional" hyponatremia-water retention disproportionate to the retention of sodium. Hyponatremia in liver diseases carries the prognostic burden, correlates with the severity of cirrhosis, and, in recent studies, has also been implicated in the pathogenesis of hepatic encephalopathy. The current treatment options are limited to conventional therapies like fluid restriction, and the outcomes are unsatisfactory. Although currently available vasopressin (V2 receptors) antagonists have been shown to increase serum sodium concentrations and improve ascites control, their role in the treatment of hyponatremia in liver disease patients remains questionable because of adverse effect profiles, high cost, and poor data on long-term mortality benefits. More information is needed to argue the benefits vs risks of short-term use of vaptans for correction of hyponatremia especially just hours-to-days before liver transplant.
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44
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Organocatalytic Enantioselective Synthesis of Polysubstituted Spirooxindoles using a Tandem Michael-Michael Reaction. Adv Synth Catal 2015. [DOI: 10.1002/adsc.201500298] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Yan L, Xie F, Lu J, Ni Q, Shi C, Tang C, Yang J. The treatment of vasopressin V2-receptor antagonists in cirrhosis patients with ascites: a meta-analysis of randomized controlled trials. BMC Gastroenterol 2015; 15:65. [PMID: 26054761 PMCID: PMC4460759 DOI: 10.1186/s12876-015-0297-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 05/29/2015] [Indexed: 12/15/2022] Open
Abstract
Background Ascites is the most common complication of cirrhosis. It may lead to the consequence of poor prognosis and the deterioration of quality of life. Asopressin V2 receptor antagonists is a kind of vaptans, and it has been proved to be effective in hyponatremia patients. We conducted a meta-analysis about treatment of vaptans in cirrhosis patients with ascites. Methods Following our selection criteria, we collected a total of 14 studies containing 16 randomized controlled trials (2620 patients) from a series of database about the treatment with vaptans for cirrhosis with ascites patients. The included studies compared the treatment effect of lixivaptan (VPA 985), or RMJ-351647, or satavaptan, or tolvaptan with placebo. Results The included vaptans (asopressin V2 receptor antagonists) showed significant effect of increasing the serum sodium concentration for cirrhosis patients (WMD = 2.11 mmol/L, p < 0.00001). Patients also could acquire significant improvement of ascites, as this kind of aquaretics can significantly reduce ascites patients’ weight (WMD = −1.53, p < 0.00001), abdominal girth (WMD = −2.04, p < 0.00001), and the ratio of worsening ascites (RR = 0.51, p = 0.001). Though the drug did not produce more total adverse events (RR = 1.04, p = 0.09) and the total serious events (RR = 1.04, p = 0.42), the emergence of excessive correction of serum sodium concentrations (>145 mmol/L) was more frequently noted in patients under the employment of vaptans (RR = 2.14, 95 % CI [1.45, 3.16], p = 0.0001). Whether with the administration of vaptans for short-term or long-term, no survival benefit was detected from the selected studies. Conclusions Asopressin V2 receptor antagonists could play an effective and safe role in symptomatic treatment for cirrhosis patients with ascites, especially for refractory ascites patients who presented insufficient response to conventional diuretics.
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Affiliation(s)
- Long Yan
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Feng Xie
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Jiongjiong Lu
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Qingqiang Ni
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Changying Shi
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Caixi Tang
- Hepatobiliary and pancreatic surgery center, Zhuzhou Central Hospital, Zhuzhou, 412007, China.
| | - Jiamei Yang
- Department of Special Treatment and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
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John S, Thuluvath PJ. Hyponatremia in cirrhosis: Pathophysiology and management. World J Gastroenterol 2015; 21:3197-205. [PMID: 25805925 PMCID: PMC4363748 DOI: 10.3748/wjg.v21.i11.3197] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/02/2014] [Accepted: 01/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. The development of ascites in patients with cirrhosis is multi-factorial. Portal hypertension and the associated systemic vasodilation lead to activation of the sodium-retaining neurohumoral mechanisms which include the renin-angiotensin-aldosterone system, sympathetic nervous system and antidiuretic hormone (ADH). The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume resulting in the development of ascites. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and ascites leads to impairment of the kidneys to eliminate solute- free water. This leads to additional compensatory mechanisms including non-osmotic secretion of ADH, also known as arginine vasopressin, further worsening excess water retention and thereby hyponatremia. Hyponatremia is associated with increased morbidity and mortality in patients with cirrhosis, and is an important prognostic marker both before and after liver transplant. The management of hyponatremia in this setting is a challenge as conventional therapy for hyponatremia including fluid restriction and loop diuretics are frequently inefficacious. In this review, we discuss the pathophysiology and various treatment modalities, including selective vasopressin receptor antagonists, for the management of hyponatremia in patients with cirrhosis.
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Buffington MA, Abreo K. Hyponatremia: A Review. J Intensive Care Med 2015; 31:223-36. [PMID: 25592330 DOI: 10.1177/0885066614566794] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 10/24/2014] [Indexed: 01/03/2023]
Abstract
Hyponatremia is the most frequently occurring electrolyte abnormality and can lead to life-threatening complications. This disorder may be present on admission to the intensive care setting or develop during hospitalization as a result of treatment or multiple comorbidities. Patients with acute hyponatremia or symptomatic chronic hyponatremia will likely require treatment in the intensive care unit (ICU). Immediate treatment with hypertonic saline is needed to reduce the risk of permanent neurologic injury. Chronic hyponatremia should be corrected at a rate sufficient to reduce symptoms but not at an excessive rate that would create a risk of osmotic injury. Determination of the etiology of chronic hyponatremia requires analysis of serum osmolality, volume status, and urine osmolality and sodium level. Correct diagnosis points to the appropriate treatment and helps identify risk factors for accelerated correction of the serum sodium level. Management in the ICU facilitates frequent laboratory draws and allows close monitoring of the patient's mentation as well as quantification of urine output. Overly aggressive correction of serum sodium levels can result in neurological injury caused by osmotic demyelination. Therapeutic measures to lower the serum sodium level should be undertaken if the rate increases too rapidly.
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Affiliation(s)
- Mary Ansley Buffington
- LSU Health Shreveport School of Medicine, Nephrology Section of Department of Internal Medicine, Shreveport, LA, USA.
| | - Kenneth Abreo
- LSU Health Shreveport School of Medicine, Nephrology Section of Department of Internal Medicine, Shreveport, LA, USA
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Abstract
Hyponatremia is common in cirrhosis. It mostly occurs in an advanced stage of the disease and is associated with complications and increased mortality. Either hypovolemic or, more commonly, hypervolemic hyponatremia can be seen in cirrhosis. Impaired renal sodium handling due to renal hypoperfusion and increased arginine-vasopressin secretion secondary to reduced effective volemia due to peripheral arterial vasodilation represent the main mechanisms leading to dilutional hyponatremia in this setting. Patients with cirrhosis usually develop slowly progressing hyponatremia. In different clinical contexts, it is associated with neurological manifestations due to increased brain water content, where the intensity is often magnified by concomitant hyperammonemia leading to hepatic encephalopathy. Severe hyponatremia requiring hypertonic saline infusion is rare in cirrhosis. The management of asymptomatic or mildly symptomatic hyponatremia mainly rely on the identification and treatment of precipitating factors. However, sustained resolution of hyponatremia is often difficult to achieve. V2 receptor blockade by Vaptans is certainly effective, but their long-term safety, especially when associated to diuretics given to control ascites, has not been established as yet. As in other conditions, a rapid correction of long-standing hyponatremia can lead to irreversible brain damage. The liver transplant setting represents a condition at high risk for the occurrence of such complications.
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Facciorusso A, Amoruso A, Neve V, Antonino M, Prete VD, Barone M. Role of vaptans in the management of hydroelectrolytic imbalance in liver cirrhosis. World J Hepatol 2014; 6:793-799. [PMID: 25429317 PMCID: PMC4243153 DOI: 10.4254/wjh.v6.i11.793] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/08/2014] [Accepted: 10/10/2014] [Indexed: 02/06/2023] Open
Abstract
Ascites and hyponatremia are the most common complications in patients with liver cirrhosis and develop as a consequence of a severe impairment of liver function and portal hypertension. Increasing evidences support the central role of renal function alterations in the pathogenesis of hydroelectrolytic imbalances in cirrhotic patients, thus implying a dense cross-talk between liver and kidney in the systemic and splanchnic vascular homeostasis in such subjects. Since Arginin Vasopressin (AVP) hyperincretion occurs at late stage of cirrhosis and plays an important role in the development of refractory ascites, dilutional hyponatremia and finally hepato-renal syndrome, selective antagonists of AVP receptors V2 (vaptans) have been recently introduced in the therapeutic algorithm of advanced cirrhotic patients. Despite the promising results of earlier phase-two studies, randomized controlled trials failed to find significant results in terms of efficacy of such drugs both in refractory ascites and hyponatremia. Moreover, concerns on their safety profile arise, due to the number of potentially severe side effects of vaptans in the clinical setting, such as hypernatremia, dehydration, renal impairment, and osmotic demyelination syndrome. More robust data from randomized controlled trials are needed in order to confirm the potential role of vaptans in the management of advanced cirrhotic patients.
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Low-dose tolvaptan for the treatment of dilutional hyponatremia in cirrhosis: a case report and literature review. Case Reports Hepatol 2014; 2014:795261. [PMID: 25383228 PMCID: PMC4208386 DOI: 10.1155/2014/795261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 04/03/2014] [Accepted: 04/15/2014] [Indexed: 11/17/2022] Open
Abstract
Dilutional hyponatremia is common in decompensated cirrhosis and can be successfully treated by tolvaptan, a vasopressin V2-receptor antagonist. Data were lacking regarding the effects of tolvaptan on cirrhotic patients with a Child-Pugh score of >10 and a serum sodium concentration of <120 mmol/L. We report a case of forties man with a 20-year history of chronic hepatitis B presenting with yellow urine and skin. Laboratory tests demonstrated prolonged prothrombin time, markedly elevated total bilirubin, severe hyponatremia, and a Child-Pugh score of >10. The patient was diagnosed with dilutional hyponatremia and was treated with recommended dosage tolvaptan at first. The serum concentration of sodium recover but the patient felt obviously thirsty. As the dosage of tolvaptan was decreased accordingly from 15 mg to 5 mg, the patient still maintained the ideal concentration of serum sodium. This case emphasizes that cirrhotic patient with higher Child-Pugh scores and serum sodium concentration of <120 mmol/L can be treated with lower dose of tolvaptan.
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