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Takahashi S, Terai H, Hoshino M, Tsujio T, Suzuki A, Namikawa T, Kato M, Matsumura A, Takayama K, Toyoda H, Tamai K, Ohyama S, Hori Y, Yabu A, Nakamura H. Risk factors of the poor long-term prognosis of osteoporotic vertebral fractures: A multicenter cohort study. J Orthop Surg (Hong Kong) 2021; 29:2309499021994969. [PMID: 33626975 DOI: 10.1177/2309499021994969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The presence of existing osteoporotic vertebral fracture (OVF) increases the mortality risk. However, the influence of the characteristics of OVF is unclear. This study aimed to investigate the influence of new OVF on patients' long-term prognosis using our past cohort study. METHOD This is an extension study of our cohort study carried out between 2005 and 2007. In the present extension study, of 420 patients, 197 whose contact information was available at the 6-month follow-up were included in the telephone survey in 2018. Five patients refused to participate in the survey, and 82 could not be contacted. Eventually, 110 patients were enrolled. Of the Demographic data, radiological findings, medical history, and clinical outcome were investigated at injury onset and at the 6-month follow-up. A proportional hazard model was used to investigate the risk factors for mortality. RESULTS Among 110 patients, 33 died. Male sex and low body mass index (BMI <18.5 kg/m2) were significant risk factors for mortality [hazard ratio (HR) = 6.40, 1.01-40.50; 5.24, 1.44-19.04, respectively]. The history of stroke and liver disease increased the risk of mortality (HR = 13.37, 1.93-92.7; 6.62, 1.15-38.14, respectively). As regards radiological findings, local kyphosis progression per 1° or ≥7° were significant risk factors of mortality (HR = 1.20, 1.06-1.36; 5.38, 1.81-16.03, respectively). CONCLUSIONS A telephone survey at 12 years after the occurrence of OVF analyzed risk factors for mortality and showed that a progression of local kyphosis in fractures between injury onset and 6 months after injury was a risk factor of poor prognosis.
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Affiliation(s)
- Shinji Takahashi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Masatoshi Hoshino
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Tadao Tsujio
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Shiraniwadai Ikoma City, Nara, Japan
| | - Akinobu Suzuki
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Takashi Namikawa
- Department of Orthopaedic Surgery, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Minori Kato
- Department of Orthopaedic Surgery, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Akira Matsumura
- Department of Orthopaedic Surgery, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Kazushi Takayama
- Department of Orthopaedic Surgery, Seikeikai Hospital, Sakai City, Osaka, Japan
| | - Hiromitsu Toyoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Koji Tamai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Shoichiro Ohyama
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Yusuke Hori
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Akito Yabu
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka, Japan
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Current Indications and Long-Term Outcomes of Surgical Portosystemic Shunts in Adults. J Gastrointest Surg 2021; 25:1437-1444. [PMID: 32424687 DOI: 10.1007/s11605-020-04643-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/03/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical portosystemic shunts are rare. We reviewed indications, operative details, and outcomes of patients undergoing surgical portosystemic shunt procedures. METHODS We retrospectively reviewed clinical data of consecutive patients between 1997 and 2018 from a single institution. Clinical characteristics and outcomes were compared between two groups: patients with portomesenteric venous thrombosis (PMVT) vs those with cirrhosis. Endpoints included 30-day mortality, shunt-related complications, patency, and survival. RESULTS There were 99 patients, 45 male and 54 female, with a mean age of 46 ± 18 years, enrolled in the study. There were 63 patients (63%) with PMVT and 36 patients (36%) with cirrhosis. Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for more diabetes among those with cirrhosis (p < 0.05). There were no significant differences in procedural metrics and intra-procedure complications between groups, except that patients with PMVT underwent more non-selective shunts than those with cirrhosis (63% vs. 30%, p < 0.001). There were two 30-day deaths (2%), with no difference in mortality and MAEs between groups. On univariate analysis, cholangiopathy and PMVT were associated with graft thrombosis (HR = 9.22, 95% CI 1.22-70.27) while race, smoking, cardiac comorbidity, type of operative shunt, configuration of the shunt, and use of conduit were not (p > 0.05). Patients with PMVT had significantly lower 1-, 5-, and 10-year primary (77%, 71%, and 71% vs. 97%, p = 0.009) and secondary patency (88%, 76%, and 72% vs. 96%, p = 0.027) compared with those with cirrhosis. The 1-, 5-, and 10-year survival rates were 94%, 84%, and 61% for patients with PMVT compared with 88%, 58%, and 26% for those with cirrhosis (non-adjusted HR 0.40, 95% CI 0.19-0.84, p = 0.01, age-adjusted HR 0.51, 95% CI 0.24-1.09, p = 0.08). The survival of patients with PMVT without liver disease trended higher than those with liver disease; however, when adjusted for age, the survival gap narrowed, and the difference was not statistically significant (p = 0.19), survival being lowest for those with PMVT and liver disease. CONCLUSIONS Surgical portosystemic shunts are safe and effective for symptom relief in selected patients with portal hypertension. The odds of graft thrombosis is 9 times higher in patients with PMVT. Overall survival is similar in patients with PMVT or cirrhosis.
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Zettervall SL, Schermerhorn ML. Reply. J Vasc Surg 2021; 73:1840. [PMID: 33894901 DOI: 10.1016/j.jvs.2020.12.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Sara L Zettervall
- Division of Vascular Surgery, University of Washington, Seattle, Wash
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
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Nagappa B, Ramalingam A, Rastogi A, Dubey S, Thomas SS, Gupta E, Sarin SK. Number needed to screen to prevent progression of liver fibrosis to cirrhosis at primary health centers: An experience from Delhi. J Family Med Prim Care 2021; 10:1412-1418. [PMID: 34041187 PMCID: PMC8140251 DOI: 10.4103/jfmpc.jfmpc_1441_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/17/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Early diagnosis has been a bottleneck in the care of chronic liver disease patients and can be addressed by Community-based screening for liver fibrosis using non-invasive diagnostic techniques. OBJECTIVES The study aimed to determine the prevalence of liver fibrosis and the number needed to screen (NNS) to prevent the progression of fibrosis, among adults visiting urban Primary Health Centres (PHC). METHODS A facility-based cross-sectional study was conducted from May 2018 to April 2019 in 72 randomly chosen PHCs using a mobile screening van. A pre-tested questionnaire was used to collect relevant history from adult patients and patient attenders. A venous blood sample was collected for biochemical markers and Transient Elastography was also done to measure Liver stiffness (LSM). LSM ≥6.0 kPa was taken as the cut-off for detecting liver fibrosis. Lifestyle modifications and alcohol cessations were considered as interventions for non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) respectively, to calculate NNS. RESULTS 7624 participants were recruited in the study with a mean age of 46 ± 12 years. Around 35.5% of participants had liver fibrosis and 3% had cirrhosis. Nearly 4% had ALD and 30% had NAFLD. NNS for preventing progression of fibrosis for ALD and NAFLD was 12 and 29 respectively. NNS was least among obese, diabetes and hypertensive participants. CONCLUSION One-third of adults visiting urban PHCs had significant liver fibrosis. Low NNS to prevent the progression of fibrosis to cirrhosis among alcohol users and other high-risk groups, substantiates the need for screening among these groups.
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Affiliation(s)
- Bharathnag Nagappa
- Department of Epidemiology, Institute of Liver and Biliary Sciences, Delhi, India
| | - Archana Ramalingam
- Department of Epidemiology, Institute of Liver and Biliary Sciences, Delhi, India
| | - Aayushi Rastogi
- Department of Epidemiology, Institute of Liver and Biliary Sciences, Delhi, India
| | - Shantanu Dubey
- Assistant Head Operations (Medical), Institute of Liver and Biliary Sciences, Delhi, India
| | - Sherin Sarah Thomas
- Department of Biochemistry (Metabolic Medicine and Immunopathology), Institute of Liver and Biliary Sciences, Delhi, India
| | - Ekta Gupta
- Department of Virology, Institute of Liver and Biliary Sciences, Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology and Director, Institute of Liver and Biliary Sciences, Delhi, India
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Pye A, Khan S, Whitehouse T, Turner AM. Personalizing liver targeted treatments and transplantation for patients with alpha-1 antitrypsin deficiency. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2020. [DOI: 10.1080/23808993.2021.1862648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Anita Pye
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sheeba Khan
- University Hospital Birmingham NHS FT, Birmingham, UK
| | | | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Zettervall SL, Dansey K, Swerdlow NJ, Soden P, Evenson A, Schermerhorn ML. Aspartate transaminase to platelet ratio index and Model for End-Stage Liver Disease scores are associated with morbidity and mortality after endovascular aneurysm repair among patients with liver dysfunction. J Vasc Surg 2020; 72:904-909. [PMID: 31964569 DOI: 10.1016/j.jvs.2019.10.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 10/26/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Liver cirrhosis dramatically increases morbidity and mortality after open surgical procedures and is often a contraindication to open repair of abdominal aortic aneurysms. However, limited data have evaluated the effect of liver disease on outcomes after endovascular repair of aortic aneurysms. METHODS The National Surgical Quality Improvement Program was used to evaluate all nonemergent endovascular aneurysm repairs (EVARs) from 2005 to 2016. The aspartate transaminase to platelet ratio index is a sensitive, noninvasive screening tool used to screen for liver disease and was calculated for all patients. A value >0.5 was used to identify those with significant liver fibrosis. Demographics, comorbidities, and 30-day outcomes were then compared between patients with and patients without fibrosis. Additional analysis was then completed to assess the effect of increasing Model for End-Stage Liver Disease (MELD) score on 30-day outcomes. Multivariable regression was used to account for differences in baseline factors. RESULTS EVAR was performed on 18,484 patients including 2286 with liver fibrosis and 16,198 without. Patients with liver fibrosis had an increased 30-day mortality (1.5% vs 2.4%; P < .01) and significantly higher rates of major morbidities including return to the operating room, pulmonary complications, transfusion, and discharge other than home. After multivariable analysis, patients with liver fibrosis had a significant increase in 30-day mortality (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.1), return to the operating room (OR, 1.5; 95% CI, 1.2-1.8), pulmonary complications (OR, 1.6; 95% CI, 1.2-2.0), transfusion (OR, 1.7; 95% CI, 1.5-2.0), and discharge other than home (OR, 1.5; 95% CI, 1.3-1.8). In further analysis, mortality also increased in a stepwise fashion with increasing MELD score (MELD <10, 1.3%; MELD 10-15, 2.3%; MELD >15, 4.7%; P < .01), as did major complications (MELD <10, 7%; MELD 10-15, 11%; MELD >15, 15%; P < .01). These increases persisted in adjusted analysis. CONCLUSIONS Liver fibrosis significantly increases mortality and major morbidity after EVAR. The aspartate transaminase to platelet ratio index and MELD score should be used for preoperative risk stratification. Moreover, current 30-day morbidity and mortality rates among patients with MELD scores >10 exceed 5%, which is higher than the annual rupture risk for aneurysms <6 cm. Therefore, an increased size threshold of >6 cm may be warranted before EVAR in patients with liver fibrosis.
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Affiliation(s)
- Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Kirsten Dansey
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Peter Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Amy Evenson
- Division of Transplantation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Yoon H, Song KJ, Shin SD, Ro YS, Hong KJ, Park JH. Effect of serum albumin level on hospital outcomes in out-of-hospital cardiac arrest. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919849786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Background: Serum albumin has been known as a strong predictive value of mortality in various disease conditions, severe burns, major surgeries, stroke, myocardial infarction, etc. But little is known for the effect of serum albumin level on out-of-hospital cardiac arrest patients. Objectives: This study aimed to investigate the effect of serum albumin level on the outcome of out of hospital cardiac arrest. Methods: This study was a prospective hospital-based patient cohort study, conducted during January to December 2014 at 27 emergency departments in Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance project. The albumin was measured immediately after arrival to the emergency department during cardiopulmonary resuscitation, and albumin was categorized into two groups, group < 3.5 g/dL group and ⩾ 3.5 g/dL group. The primary outcome was a good neurological recovery at discharge (cerebral performance category scale 1 or 2). Multivariable logistic regression was used for adjusting for confounders. Results: During the study period, 1616 out-of-hospital cardiac arrest patients with presumed cardiac etiology were enrolled, and the total of 1013 patients were analyzed in this study. A total 452 (44.6%) patients had serum albumin level less than 3.5 g/dL. The serum albumin ⩾ 3.5 g/dL group showed better neurological outcomes than the serum albumin < 3.5 g/dL group: 18.5% versus 4.0%, and ⩾ 3.5 g/dL group had higher survival discharge rates than the < 3.5 g/dL group: 23.9% versus 9.1% (p < 0.01). After adjusting for potential covariates, patients with serum albumin ⩾ 3.5 g/dL had a higher odds of good neurological recovery (adjusted odds ratio: 2.94 (95% confidence interval: [1.57, 5.49])), and higher survival to discharge (adjusted odds ratio: 1.74 (95% confidence interval: [1.10, 2.76])). Conclusion: Low serum albumin levels are associated with a worse neurologic outcome in patients with out-of-hospital cardiac arrest.
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Affiliation(s)
- Hanna Yoon
- Department of Emergency Medicine, Boramae Medical Center, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Boramae Medical Center, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Boramae Medical Center, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
| | - Ki Jeong Hong
- Department of Emergency Medicine, Boramae Medical Center, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, Boramae Medical Center, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
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Subramanian KKK, Tandon M, Pandey CK, Jain P. Patients with Cirrhosis of Liver Operated for Non-transplant Surgery: A Retrospective Analysis. J Clin Transl Hepatol 2019; 7:9-14. [PMID: 30944813 PMCID: PMC6441638 DOI: 10.14218/jcth.2018.00043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/15/2018] [Accepted: 01/09/2019] [Indexed: 12/22/2022] Open
Abstract
Background and Aims: Patients with cirrhosis of the liver have high mortality after surgery. We investigated the mortality in patients with cirrhosis of the liver who underwent surgery other than liver transplant and applied the Mayo clinic model to predict mortality and compare with the observed mortality. We also studied the association of the observed mortality with the Child-Turcotte-Pugh (CTP) class and the model for end-stage liver disease (MELD) and model for end-stage liver disease-sodium (MELD-Na) scores. Methods: The electronic records database of our hospital was accessed to analyze the data of 133 cirrhotic patients who underwent various surgeries under general anesthesia from October 2009 to June 2017. The Mayo risk score was applied to each and used to calculate predicted mortality; the MELD and MELD-Na scores were also calculated. Telephonic interview was performed with the patients and or their relative to ascertain survival or time of death after surgery, when the information was not available from the hospital records. Results: The all-cause observed mortality rates at postoperative days 30 and 90 and at 1 year were 12%, 20.3% and 26.3% respectively. The area under the receiver operating characteristic curve values for the Mayo model as a predictor of 30-day, 90-day and 1-year mortality were 0.836, 0.828 and 0.744 respectively. Good correlation was seen for observed mortality with CTP class and with MELD and MELD-Na scores. Conclusions: The Mayo model for predicting postoperative mortality in patients with cirrhosis of the liver demonstrated good correlation in this study. The strength of prediction of mortality by Mayo risk score calculation was similar at postoperative days 30 and 90 but decreased at 1-year after the surgery. Good correlation was seen for the observed mortality with MELD, MELD-Na and CTP scores.
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Affiliation(s)
| | - Manish Tandon
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, New Delhi, India
- *Correspondence to: Manish Tandon, Department of Anaesthesiology, Institute of Liver and Biliary Sciences, D-1, Vasant kunj, New Delhi, India. Tel: +91-9871437478, Fax: +91-1146300010, E-mail:
| | - Chandra Kant Pandey
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Department of Research, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
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Abstract
BACKGROUND Cirrhotic cardiomyopathy is characterized by an attenuated contractile response to stress. Long-term exposure of β-adrenergic receptors to persistently high levels of catecholamines has been implicated in its pathogenesis. We hypothesized that β-blockade with metoprolol could reverse the changes in heart function and morphology in cirrhotic cardiomyopathy. PATIENTS AND METHODS In this prospective randomized trial, we included 78 patients aged between 18 and 60 years with abnormal cardiac output response under dobutamine stress echocardiography, without primary cardiac disease or a history of alcohol intake. Patients were assigned randomly to receive metoprolol or placebo for 6 months. The primary endpoint was the improvement in cardiac output response to stress, measured by an increase in the left ventricle stroke volume more than 30%. RESULTS Three (7.3%) patients in the metoprolol group and nine (24.3%) patients in the placebo group showed improved stroke volume (P=0.057). Diastolic dysfunction was found in two (4.8%) patients before and in five (15.6%) patients after therapy in the metoprolol group, and in 10 (27%) patients before and nine (31%) patients after therapy in the placebo group (P=0.67). After treatment, no echocardiography parameter of morphology was significantly different between metoprolol or placebo groups. No significant differences were observed in noradrenaline, plasma renin activity, and troponin levels between groups. Cirrhosis-related clinical events, including hospitalizations and mortality, were not significantly different between the two groups. Six months of therapy with β-blocker did not ameliorate heart function and morphology in patients with cirrhotic cardiomyopathy.
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Oh S, Han G, Kim B, Shoda J. Regular Exercise as a Secondary Practical Treatment for Nonalcoholic Fatty Liver Disease. EXERCISE MEDICINE 2018. [DOI: 10.26644/em.2018.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Mukherjee PS, Vishnubhatla S, Amarapurkar DN, Das K, Sood A, Chawla YK, Eapen CE, Boddu P, Thomas V, Varshney S, Hidangmayum DS, Bhaumik P, Thakur B, Acharya SK, Chowdhury A. Etiology and mode of presentation of chronic liver diseases in India: A multi centric study. PLoS One 2017; 12:e0187033. [PMID: 29073197 PMCID: PMC5658106 DOI: 10.1371/journal.pone.0187033] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/12/2017] [Indexed: 12/27/2022] Open
Abstract
There is a paucity of health policy relevant data for chronic liver disease from India, impeding formulation of an interventional strategy to address the issue. A prospective, multicentric study to delineate the etiology and clinical profile of chronic liver disease in India is reported here. A centrally coordinated and monitored web-based data repository was developed (Feb, 2010 to Jan, 2013) and analyzed. Eleven hospitals from different parts of India participated. Data were uploaded into a web based proforma and monitored by a single centre according to a standardized protocol. 1.28% (n = 266621) of all patients (n = 20701383) attending the eleven participating hospitals of India had liver disease. 65807 (24·68%) were diagnosed for the first time (new cases). Of these, 13014 (19·77%, median age 43 years, 73% males) cases of chronic liver disease were finally analyzed. 33.9% presented with decompensated cirrhosis. Alcoholism (34·3% of 4413) was the commonest cause of cirrhosis while Hepatitis B (33·3%) was predominant cause of chronic liver disease in general and non-cirrhotic chronic liver disease (40·8% out of 8163). There was significant interregional differences (hepatitis C in North, hepatitis B in East and South, alcohol in North-east, Non-alcoholic Fatty Liver Disease in West) in the predominant cause of chronic liver disease. Hepatitis B (46·8% of 438 cases) was the commonest cause of hepatocellular Cancer.11·7% had diabetes. Observations of our study will help guide a contextually relevant liver care policy for India and could serve as a framework for similar endeavor in other developing countries as well.
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Affiliation(s)
| | - Sreenivas Vishnubhatla
- Department of Biostatistics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | | | - Kausik Das
- Department of Hepatology, School of Digestive and liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Yogesh K. Chawla
- Department of Hepatology, Post Graduate Institute of Medical Sciences, Chandigarh, India
| | | | - Prabhakar Boddu
- Department of Gastroenterology, Osmania General Hospital, Afzalgunj, Hyderabad, Telangana, India
| | - Varghese Thomas
- Department of Gastroenterology, Calicut Medical College, Kozhikode, Kerala, India
| | - Subodh Varshney
- Department of Surgical Gastroenterology, Bhopal Memorial Hospital and Research Centre, Bhopal, Madhya Pradesh, India
| | | | - Pradip Bhaumik
- Department of medicine, Agartala Govt Medical College, Agartala, Tripura, India
| | - Bhaskar Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Abhijit Chowdhury
- Department of Hepatology, School of Digestive and liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, India
- Indian Institute of Liver and Digestive Sciences, Sitala (East), Jagadishpur, Sonarpur, 24 Pgs(S), Kolkata, India
- * E-mail:
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De Vincentis A, Pennazza G, Santonico M, Vespasiani-Gentilucci U, Galati G, Gallo P, Zompanti A, Pedone C, Antonelli Incalzi R, Picardi A. Breath-print analysis by e-nose may refine risk stratification for adverse outcomes in cirrhotic patients. Liver Int 2017; 37:242-250. [PMID: 27496750 DOI: 10.1111/liv.13214] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/02/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS The spectrum of volatile organic compounds in the exhaled breath (breath-print, BP) has been shown to characterize patients with cirrhosis and with worse hepatic function. However, the association of different BPs with clinically relevant outcomes has not been described yet. Hence, we aimed to evaluate the association between BPs, mortality and hospitalization in cirrhotic patients and to compare it with that of the "classical" prognostic indices (Child-Pugh Classification [CPC] and MELD). METHODS Eighty-nine cirrhotic patients (M/F 59/30, mean age 64.8 ± 11.3, CPC A/B/C 37/33/19) were recruited and followed up for a median time of 23 months. Clinical and biochemical data were collected. Breath collection and analysis were obtained through Pneumopipe® and BIONOTE e-nose respectively. RESULTS Four different BP clusters (A, B, C, D) were identified. BP clusters A and D were associated with a significantly increased risk of mortality (HR 2.9, 95% confidence intervals [CI] 1.5-5.6) and hospitalization (HR 2.6, 95% CI 1.4-4.6), even in multiple adjusted models including CPC and MELD score (adjusted [a]HR 2.8, 95% CI 1.1-7.0 for mortality and aHR 2.2, 95% CI 1.1-4.2 for hospitalization). CPC C maintained the strongest association with both mortality (aHR 17.6, 95% CI 1.8-174.0) and hospitalization (aHR 12.4, 95% CI 2.0-75.8). CONCLUSIONS This pilot study demonstrates that BP clusters are associated with significant clinical endpoints (mortality and hospitalization) even independently from "classical" prognostic indices. Even though further studies are warranted on this topic, our findings suggest that the e-nose may become an adjunctive aid to stratify the risk of adverse outcomes in cirrhotic patients.
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Affiliation(s)
- Antonio De Vincentis
- Clinical Medicine and Hepatology Department, Campus Bio-Medico University, Rome, Italy
| | - Giorgio Pennazza
- Center for Integrated Research - CIR, Unit of Electronics for Sensor Systems, Campus Bio-Medico University, Rome, Italy
| | - Marco Santonico
- Center for Integrated Research - CIR, Unit of Electronics for Sensor Systems, Campus Bio-Medico University, Rome, Italy
| | | | - Giovanni Galati
- Clinical Medicine and Hepatology Department, Campus Bio-Medico University, Rome, Italy
| | - Paolo Gallo
- Clinical Medicine and Hepatology Department, Campus Bio-Medico University, Rome, Italy
| | - Alessandro Zompanti
- Center for Integrated Research - CIR, Unit of Electronics for Sensor Systems, Campus Bio-Medico University, Rome, Italy
| | - Claudio Pedone
- Chair of Geriatrics, Unit of Respiratory Pathophysiology, Campus Bio-Medico University, Rome, Italy
| | - Raffaele Antonelli Incalzi
- Chair of Geriatrics, Unit of Respiratory Pathophysiology, Campus Bio-Medico University, Rome, Italy.,San Raffaele- Cittadella della Carità Foundation, Taranto, Italy
| | - Antonio Picardi
- Clinical Medicine and Hepatology Department, Campus Bio-Medico University, Rome, Italy
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Suchartlikitwong S, Lapumnuaypol K, Rerknimitr R, Werawatganon D. Epidemiology of upper gastrointestinal bleeding and Helicobacter pylori infection: review of 3,488 Thai patients. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0901.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The current epidemiology of upper gastrointestinal bleeding (UGIB) in Thailand is poorly understood and the reported prevalence of Helicobacter pylori infection is outdated.
Objectives
To investigate the etiologies of UGIB and prevalence of H. pylori infection in Thailand, including its association with UGIB.
Methods
We retrieved information regarding patients attending the endoscopic unit of King Chulalongkorn Memorial Hospital from June 2007 to January 2013. A database search using keywords “upper gastrointestinal bleeding” and “iron deficiency” was used. From 4,454 diagnoses, after exclusion criteria, 3,488 patients (2,042 male (58.5%) and 1,446 female (41.5%); mean age 63.3 ± 15.94 years, range 13–103 years) were included.
Results
The three most common causes of UGIB were peptic ulcer (38.2%), nonulcer-mucosal lesions (23.4%), and esophageal-related causes (20.4%). The 5 year-incidence of H. pylori was 25%–30%. The overall prevalence was 27%. The prevalence of H. pylori infection was found to decrease with age from 43.8% at <40 years to 21.7% at >79 years old. H. pylori infection was significantly associated with duodenal and gastroduodenal ulcers. Cirrhosis and nonulcer-mucosal lesions were significantly unrelated to H. pylori infection. Patients with concurrent cirrhosis with peptic ulcer were found to be negative for H. pylori infection.
Conclusion
Peptic ulcer is the leading cause of UGIB in Thailand. However, its incidence is declining. Patients who presented to hospital with UGIB were older, compared with those a decade ago. H. pylori infection plays an important role in UGIB and its incidence was stable during the past 5 years.
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Affiliation(s)
| | - Kamolyut Lapumnuaypol
- Department of Internal Medicine, Faculty of Medicine , Chulalongkorn University , Bangkok 10330 , Thailand
| | - Rungsun Rerknimitr
- Department of Internal Medicine, Faculty of Medicine , Chulalongkorn University , Bangkok 10330 , Thailand
| | - Duangporn Werawatganon
- Department of Physiology, Faculty of Medicine , Chulalongkorn University , Bangkok 10330 , Thailand
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The Royal Free Hospital-Nutritional Prioritizing Tool Is an Independent Predictor of Deterioration of Liver Function and Survival in Cirrhosis. Dig Dis Sci 2016; 61:1735-43. [PMID: 26725059 DOI: 10.1007/s10620-015-4015-z] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/16/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Malnutrition might affect survival and severity of complications in cirrhotic patients. However, adequate evaluation of the nutritional status is a difficult task since the common assessment tools are either inappropriate or too complicated. A simpler method could evaluate the patient's risk for malnutrition instead of the nutritional status itself. This study evaluated the prediction of clinical deterioration and transplant-free survival in patients with chronic liver disease by two nutritional risk scores. METHODS In 84 cirrhotic patients, Nutritional Risk Screening (NRS), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), and the chronic liver disease questionnaire have been assessed. These patients were evaluated at a second time point after a median observation time of 500 days. Another cohort of 64 patients was collected to validate the findings. RESULTS Of the included patients, 67.7 % were male with a median age of 57 years and a median Child score of 9. RFH-NPT classified 50.7 % of the patients as high-risk patients, and NRS assessed 44.6 % of the patients as moderate- to high-risk patients. RFH-NPT correlated with clinical deterioration, severity of disease (Child score, MELD score), and clinical complications such as ascites, hepatorenal syndrome, and episodes of hepatic encephalopathy. RFH-NPT was an independent predictor of clinical deterioration and transplant-free survival. Furthermore, improvement in RFH-NPT within 500 days was associated with improved survival. CONCLUSION Assessing the patients' risk for malnutrition by RFH-NPT may be a useful predictor of disease progression and outcome for patients with chronic liver disease.
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Kim TH, Um SH, Yim SY, Seo YS, Yim HJ, Jeen YT, Lee HS, Chun HJ, Kim CD, Ahn H, Lee Y. The risk of perioperative adverse events in patients with chronic liver disease. Liver Int 2015; 35:713-23. [PMID: 24620863 DOI: 10.1111/liv.12529] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 03/09/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Chronic liver disease is a common comorbidity in surgery. To assess post-operative morbidity and mortality in relation to progression of chronic liver disease and to identify the risk factors. METHODS Six hundred and nine consecutive patients with chronic liver disease who underwent surgery were classified into two groups: non-cirrhotic (n = 363) and cirrhotic (n = 246). Randomly selected patients without underlying liver disease who underwent surgery were used as control group (n = 148). RESULTS The occurrence of major post-operative complications was higher in the non-cirrhotic group than in the control group (11.8% vs. 6.1%, P = 0.051); age, type of surgery and serum albumin level were independent predictors for post-operative morbidity. The frequency of significant post-operative liver damage (14.9% vs. 12.2%, P = 0.920) and mortality (0.6% vs. 0.7%, P = 0.871) did not differ between the two groups. The cirrhotic group had markedly higher incidences of post-operative mortality (10.2%), major complications (32.5%) and significant liver damage (43.1%) than the control and non-cirrhotic groups (all P < 0.001). Type of surgery, Child-Pugh score and model for end-stage liver disease score were independently associated with post-operative morbidity and mortality in patients with cirrhosis. Specific data regarding post-operative morbidity and mortality were presented according to progression of liver disease and type of surgery. CONCLUSION Non-cirrhotic chronic liver diseases were associated with higher risk of post-operative morbidity, particularly in cases of major surgery, older age and hypoalbuminaemia. Cirrhosis further increased the risk, even death, depending on degree of hepatic decompensation and type of surgery.
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Affiliation(s)
- Tae Hyung Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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van der Meer AJ, Hansen BE, Fattovich G, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, Duarte-Rojo A, Manns MP, Ieluzzi D, Zeuzem S, Hofmann WP, de Knegt RJ, Veldt BJ, Janssen HLA. Reliable prediction of clinical outcome in patients with chronic HCV infection and compensated advanced hepatic fibrosis: a validated model using objective and readily available clinical parameters. Gut 2015; 64:322-31. [PMID: 24815676 DOI: 10.1136/gutjnl-2013-305357] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Reliable tools to predict long-term outcome among patients with well compensated advanced liver disease due to chronic HCV infection are lacking. DESIGN Risk scores for mortality and for cirrhosis-related complications were constructed with Cox regression analysis in a derivation cohort and evaluated in a validation cohort, both including patients with chronic HCV infection and advanced fibrosis. RESULTS In the derivation cohort, 100/405 patients died during a median 8.1 (IQR 5.7-11.1) years of follow-up. Multivariate Cox analyses showed age (HR=1.06, 95% CI 1.04 to 1.09, p<0.001), male sex (HR=1.91, 95% CI 1.10 to 3.29, p=0.021), platelet count (HR=0.91, 95% CI 0.87 to 0.95, p<0.001) and log10 aspartate aminotransferase/alanine aminotransferase ratio (HR=1.30, 95% CI 1.12 to 1.51, p=0.001) were independently associated with mortality (C statistic=0.78, 95% CI 0.72 to 0.83). In the validation cohort, 58/296 patients with cirrhosis died during a median of 6.6 (IQR 4.4-9.0) years. Among patients with estimated 5-year mortality risks <5%, 5-10% and >10%, the observed 5-year mortality rates in the derivation cohort and validation cohort were 0.9% (95% CI 0.0 to 2.7) and 2.6% (95% CI 0.0 to 6.1), 8.1% (95% CI 1.8 to 14.4) and 8.0% (95% CI 1.3 to 14.7), 21.8% (95% CI 13.2 to 30.4) and 20.9% (95% CI 13.6 to 28.1), respectively (C statistic in validation cohort = 0.76, 95% CI 0.69 to 0.83). The risk score for cirrhosis-related complications also incorporated HCV genotype (C statistic = 0.80, 95% CI 0.76 to 0.83 in the derivation cohort; and 0.74, 95% CI 0.68 to 0.79 in the validation cohort). CONCLUSIONS Prognosis of patients with chronic HCV infection and compensated advanced liver disease can be accurately assessed with risk scores including readily available objective clinical parameters.
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Affiliation(s)
- Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Jordan J Feld
- Liver Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Heiner Wedemeyer
- Departments of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Jean-François Dufour
- Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Andres Duarte-Rojo
- Liver Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael P Manns
- Departments of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | | | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - W Peter Hofmann
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands Liver Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Haflidadottir S, Jonasson JG, Norland H, Einarsdottir SO, Kleiner DE, Lund SH, Björnsson ES. Long-term follow-up and liver-related death rate in patients with non-alcoholic and alcoholic related fatty liver disease. BMC Gastroenterol 2014; 14:166. [PMID: 25260964 PMCID: PMC4182763 DOI: 10.1186/1471-230x-14-166] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/23/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Few studies have compared the prognosis and liver-related mortality in patients with NAFLD (nonalcoholic fatty liver disease) and AFLD (alcoholic fatty liver disease). We aimed to investigate the etiology and liver-related mortality of patients with liver biopsy verified fatty liver disease in a population based setting. METHODS In this retrospective study, all patients who underwent a liver biopsy 1984-2009 at the National University Hospital of Iceland were identified through a computerized pathological database with the code for fatty liver. Only patients with NAFLD and AFLD were included and medical records reviewed. The patients were linked to the Hospital Discharge Register, the Causes of Death Registry and Centre for Addiction Medicine. RESULTS A total of 151 had NAFLD and 94 AFLD with median survival of 24 years and 20 years, respectively (p = NS). A total of 10/151 (7%) patients developed cirrhosis in the NAFLD group and 19/94 (20%) in AFLD group (p = 0.03). The most common cause of death in the NAFLD group was cardiovascular disease (48%). Liver disease was the most common cause of death in the AFLD group (36%), whereas liver-related death occurred in 7% of the NAFLD group. The mean liver-related death rate among the general population during the study period was 0.1% of all deaths. There was a significantly worse survival for patients in the AFLD group compared to the NAFLD group after adjusting for gender, calendar year of diagnosis and age at diagnosis (HR 2.16, p = 0.009). The survival for patients with moderate to severe fibrosis was significantly worse than for patients with mild fibrosis after adjusting for gender, calendar year of diagnosis and age at diagnosis (HR 2.09, p = 0.01). CONCLUSIONS Patients with fatty liver disease showed a markedly higher risk of developing liver-related death compared to the general population. The AFLD group had higher liver-related mortality and had a worse survival than the NAFLD group. Patients with more severe fibrosis at baseline showed a worse survival than patients with none or mild fibrosis at baseline.
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Affiliation(s)
| | | | | | | | | | | | - Einar S Björnsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital of Iceland, Hringbraut 11D, 101 Reykjavik, Iceland.
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Abstract
Patients with cirrhosis who experience hepatic decompensation, such as the development of ascites, SBP, variceal hemorrhage, or hepatic encephalopathy, or who develop HCC, are at a higher risk of mortality. Management should be focused on the prevention of recurrence of complications, and these patients should be referred for consideration of liver transplantation.
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Affiliation(s)
- Iris W Liou
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Box 356175, Seattle, WA 98195-6175, USA.
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Predictors of health-related quality of life in outpatients with cirrhosis: results from a prospective cohort. HEPATITIS RESEARCH AND TREATMENT 2013; 2013:479639. [PMID: 24490061 PMCID: PMC3896069 DOI: 10.1155/2013/479639] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 11/21/2013] [Accepted: 11/24/2013] [Indexed: 02/07/2023]
Abstract
Background. Cirrhosis may lead to a poor health-related quality of life (HRQOL), which should be taken into consideration when addressing the cirrhotic outpatient. Methods. Prospective cohort study evaluating predictors of HRQOL in outpatients with cirrhosis. Patients with overt hepatic encephalopathy at baseline were excluded. HRQOL was evaluated at baseline using the six point Chronic Liver Disease Questionnaire. Predictors of low quality of life scores (<4 points) and mortality were analyzed using multivariable logistic regression. Results. In total, 92 patients were included (mean age 61 years, 59% male). Nineteen patients died (mean duration of follow-up 20 months). The mean Child-Pugh score was 6.9. Twenty percent had a poor HRQOL judged by the Chronic Liver Disease Questionnaire score and 45% had covert hepatic encephalopathy. The only predictors of poor HRQOL were the Child-Pugh score (β=0.45;P = 0.013), nonalcoholic etiology of cirrhosis (β=−2.34;P = 0.009), and body mass index (β=−0.20;P = 0.023). The body mass index predicted poor HRQOL independently of the presence of ascites and albumin level. Conclusions. The body mass index was associated with a low HRQOL. This suggests that malnutrition may be an important target in the management of patients with cirrhosis.
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Molecular mechanisms of ursodeoxycholic acid toxicity & side effects: ursodeoxycholic acid freezes regeneration & induces hibernation mode. Int J Mol Sci 2012; 13:8882-8914. [PMID: 22942741 PMCID: PMC3430272 DOI: 10.3390/ijms13078882] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/03/2012] [Accepted: 07/06/2012] [Indexed: 12/14/2022] Open
Abstract
Ursodeoxycholic acid (UDCA) is a steroid bile acid approved for primary biliary cirrhosis (PBC). UDCA is reported to have “hepato-protective properties”. Yet, UDCA has “unanticipated” toxicity, pronounced by more than double number of deaths, and eligibility for liver transplantation compared to the control group in 28 mg/kg/day in primary sclerosing cholangitis, necessitating trial halt in North America. UDCA is associated with increase in hepatocellular carcinoma in PBC especially when it fails to achieve biochemical response (10 and 15 years incidence of 9% and 20% respectively). “Unanticipated” UDCA toxicity includes hepatitis, pruritus, cholangitis, ascites, vanishing bile duct syndrome, liver cell failure, death, severe watery diarrhea, pneumonia, dysuria, immune-suppression, mutagenic effects and withdrawal syndrome upon sudden halt. UDCA inhibits DNA repair, co-enzyme A, cyclic AMP, p53, phagocytosis, and inhibits induction of nitric oxide synthatase. It is genotoxic, exerts aneugenic activity, and arrests apoptosis even after cellular phosphatidylserine externalization. UDCA toxicity is related to its interference with drug detoxification, being hydrophilic and anti-apoptotic, has a long half-life, has transcriptional mutational abilities, down-regulates cellular functions, has a very narrow difference between the recommended (13 mg/kg/day) and toxic dose (28 mg/kg/day), and it typically transforms into lithocholic acid that induces DNA strand breakage, it is uniquely co-mutagenic, and promotes cell transformation. UDCA beyond PBC is unjustified.
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Wiegand J, Kühne M, Pradat P, Mössner J, Trepo C, Tillmann HL. Different patterns of decompensation in patients with alcoholic vs. non-alcoholic liver cirrhosis. Aliment Pharmacol Ther 2012; 35:1443-50. [PMID: 22530565 DOI: 10.1111/j.1365-2036.2012.05108.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 03/24/2012] [Accepted: 04/03/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND The histological pattern of fibrosis in liver cirrhosis varies in different chronic liver diseases, and hepatic decompensation may be differentiated in consequences of fibrosis (i.e. ascites, variceal bleeding) or in lack of function (i.e. jaundice) resulting in aetiology-specific variable morbidity and mortality. AIM To evaluate patterns of hepatic decompensation in relation to the aetiology of liver cirrhosis. METHODS Two different cohorts were retrospectively evaluated between 2002 and 2007. Cohort A was for hypothesis generation and consisted of 220 cirrhotic patients. To confirm the initial observations a second cohort B (n = 217) was analysed. The different patterns of hepatic decompensation evaluated were ascites, jaundice, encephalopathy, variceal bleeding, spontaneous bacterial peritonitis, hepatorenal syndrome or hepatocellular carcinoma. Furthermore, we analysed survival in relation to pattern of decompensation in alcoholic vs. non-alcoholic liver disease. RESULTS Alcoholics were more frequently hospitalised for ascites (cohort A: 81.4% vs. 65.4%, P = 0.016; cohort B 71.3% vs. 58.5%, P = 0.085). In contrast, non-alcoholics presented with higher rates of hepatocellular carcinoma (cohort A: 23.1% vs. 11.9%, P = 0.046; cohort B 38.6% vs. 22.5%, P = 0.018). There were no significant differences in jaundice, variceal bleeding, hepatorenal syndrome or encephalopathy. Survival was significantly impaired in non-alcoholic cirrhosis once ascites occurred (P = 0.003), whereas ascites did not predict higher mortality in patients with alcoholic cirrhosis. CONCLUSIONS Ascites is the leading initial pattern of decompensation in alcoholic cirrhosis whereas hepatocellular carcinoma dominates in non-alcoholics. Non-alcoholics developing ascites show a poor survival.
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Affiliation(s)
- J Wiegand
- Universitätsklinikum Leipzig, Klinik und Poliklinik für Gastroenterologie und Rheumatologie, Germany
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Long-term clinical course of decompensated alcoholic cirrhosis: a prospective study of 165 patients. J Clin Gastroenterol 2011; 45:906-11. [PMID: 21814145 DOI: 10.1097/mcg.0b013e3182284e13] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prognosis of decompensated alcoholic cirrhosis is based mainly on studies that included patients with different severities of liver disease and did not recognize either hepatitis C virus epidemic or changes in clinical management of cirrhosis. AIM To define the long-term course after the first hepatic decompensation in alcoholic cirrhosis. METHODS Prospective inclusion at the start point of decompensated cirrhosis of 165 consecutive patients with alcoholic cirrhosis without known hepatocellular carcinoma hospitalized from January 1998 to December 2001 was made. Follow-up was maintained until death or the end of the observation period (April 1, 2010). RESULTS The patients were followed for 835.75 patient years. Median age was 56 years (95% confidence interval: 54-58). Baseline Child-Pugh score was 9 (95% CI: 8-9), and model for end-stage liver disease (MELD) was 13.8 (95% CI: 12.5-14.7). Ascites was the most frequent first decompensation (51%). During follow-up, 99 (60%) patients were abstinent, hepatocellular carcinoma developed in 18 (11%) patients, and 116 patients died (70%). Median overall survival was 61 months (95% CI: 48-74). Median survival probability after onset of hepatic encephalopathy (HE) was only 14 months (95% CI: 5-23). Age, baseline MELD, albumin, development of HE, and persistence of alcohol use were independently correlated with mortality. CONCLUSIONS Patients with alcoholic cirrhosis show a high frequency of complications. The low mortality rate in our cohort of patients probably reflects the improvement in the management of patients with cirrhosis; it is mainly influenced by baseline MELD, age, HE development, and continued abstinence. Patients who develop HE should be considered for hepatic transplantation.
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Mirza MS. Obesity, Visceral Fat, and NAFLD: Querying the Role of Adipokines in the Progression of Nonalcoholic Fatty Liver Disease. ISRN GASTROENTEROLOGY 2011; 2011:592404. [PMID: 21991518 PMCID: PMC3168494 DOI: 10.5402/2011/592404] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 05/01/2011] [Indexed: 12/13/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of clinicopathologic conditions ranging from steatosis alone to nonalcoholic steatohepatitis (NASH), with varying risks for progression to cirrhosis and hepatocellular carcinoma. There is mounting evidence that NAFLD not only complicates obesity, but also perpetuates its metabolic consequences. Critical event that leads to progressive liver injury in NAFLD is unknown. Obesity reflects a generalized proinflammatory state with its increased inflammatory markers like C reactive protein, IL-6, IL-8, IL-10, PAI-1, TNF-α, and hepatocyte growth factor. The elevated production of these adipokines is increasingly considered to be important in the development of diseases linked to obesity and the metabolic syndrome. Disordered cytokine production is likely to play a role in the pathogenesis of NAFLD. There is no effective treatment for NAFLD, though weight loss may halt disease progression and revert histological changes, the underlying mechanism remaining elusive. All stages of the disease pathway from prevention, early identification/diagnosis, and treatment require an understanding of the pathogenesis of liver injury in NAFLD.
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Affiliation(s)
- M. S. Mirza
- SpR Surgery, Ninewells Hospital, 65 Lister Court, Dundee DD2 1UY, UK
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Alsultan MA, Alrshed RS, Aljumah AA, Baharoon SA, Arabi YM, Aldawood AS. In-hospital mortality among a cohort of cirrhotic patients admitted to a tertiary hospital. Saudi J Gastroenterol 2011; 17:387-90. [PMID: 22064336 PMCID: PMC3221112 DOI: 10.4103/1319-3767.87179] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND/AIM To determine the mortality rate in a cohort of hospitalized patients with cirrhosis and examine their resuscitation status at admission. MATERIALS AND METHODS A retrospective chart review was conducted of patients with cirrhosis who were admitted to a tertiary care hospital in Riyadh, Saudi Arabia, from January 1, 2009, to December 31, 2009. RESULTS We reviewed 226 cirrhotic patients during the study period. The hospital mortality rate was 35%. A univariate analysis revealed that worse outcomes were seen in patients with advanced age or who had worse child-turcotte-pugh (CPT) scores, worse model for end-stage liver disease (MELD) scores, low albumin and high serum creatinine. Using a multivariate analysis, we found that advanced age (P=0.004) and high MELD (P=0.001) scores were independent risk factors for the mortality of cirrhotic patients. The end-of-life decision were made in 34% of cirrhotic patients, and the majority of deceased patients were "no resuscitation" status (90% vs. 4%, P<0.001). CONCLUSIONS The relatively high mortality in cirrhotic patients admitted for care in a tertiary hospital, Saudi Arabia was comparable to that reported in the literature. Furthermore, end-of-life discussions should be addressed early in the hospitalization of cirrhotic patients.
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Affiliation(s)
- Mohammad A. Alsultan
- Department of Intensive Care Medicine and Emergency Medicine, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Rashed S. Alrshed
- Vice-president of King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Salim A. Baharoon
- Department of Intensive Care Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen M. Arabi
- Department of Intensive Care, King Saud Bin Abdulaziz University for Health Sciences,, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz S. Aldawood
- Department of Intensive Care, King Saud Bin Abdulaziz University for Health Sciences,, King Abdulaziz Medical City, Riyadh, Saudi Arabia,Address for correspondence: Dr. Abdulaziz S. Aldawood, Department of Intensive Care, King Saud Bin Abdulaziz University for Health Sciences and King Abdulaziz Medical City, Riyadh, Saudi Arabia. E-mail:
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Frazier TH, Stocker AM, Kershner NA, Marsano LS, McClain CJ. Treatment of alcoholic liver disease. Therap Adv Gastroenterol 2011; 4:63-81. [PMID: 21317995 PMCID: PMC3036962 DOI: 10.1177/1756283x10378925] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Alcoholic liver disease (ALD) remains a major cause of liver-related mortality in the US and worldwide. The correct diagnosis of ALD can usually be made on a clinical basis in conjunction with blood tests, and a liver biopsy is not usually required. Abstinence is the hallmark of therapy for ALD, and nutritional therapy is the first line of therapeutic intervention. The role of steroids in patients with moderate to severe alcoholic hepatitis is gaining increasing acceptance, with the caveat that patients be evaluated for the effectiveness of therapy at 1 week. Pentoxifylline appears to be especially effective in ALD patients with renal dysfunction/hepatorenal syndrome. Biologics such as specific anti-TNFs have been disappointing and should probably not be used outside of the clinical trial setting. Transplantation is effective in patients with end-stage ALD who have stopped drinking (usually for ≥6 months), and both long-term graft and patient survival are excellent.
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Affiliation(s)
- Thomas H. Frazier
- Department of Internal Medicine and Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
| | - Abigail M. Stocker
- Department of Internal Medicine and Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
| | - Nicole A. Kershner
- Department of Internal Medicine and Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
| | - Luis S. Marsano
- Department of Internal Medicine and Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
- Louisville Veterans Affairs Medical Center, Louisville, KY, USA
- University of Louisville Alcohol Research Center, Louisville, KY, USA
| | - Craig J. McClain
- Department of Medicine (Division of Gastroenterology, Hepatology and Nutrition), Pharmacology and Toxicology UofL Alcohol Research Center University of Louisville School of Medicine Louisville VAMC 505 S. Hancock St., Rm 503 Clinical and Translational Research Building Louisville, KY 40202, USA
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Gunnarsdottir SA, Olsson R, Olafsson S, Cariglia N, Westin J, Thjódleifsson B, Björnsson E. Liver cirrhosis in Iceland and Sweden: incidence, aetiology and outcomes. Scand J Gastroenterol 2010; 44:984-93. [PMID: 19437344 DOI: 10.1080/00365520902912571] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objectives of this study were to investigate the incidence, aetiology and mortality of liver cirrhosis in Iceland and in Gothenburg in Sweden. Further objectives were prognosis in relation to different aetiologies and to evaluate the relationship between alcohol consumption in these countries and the incidence of alcoholic cirrhosis in recent decades. The incidence and mortality of liver cirrhosis in Iceland has been reported to be the lowest in the Western world. There are very few data on aetiology, incidence and prognosis among cirrhotics in Sweden. MATERIAL AND METHODS All patients diagnosed with liver cirrhosis in Gothenburg (600,000 inhabitants) and Iceland (300,000 inhabitants) during the period 1994-2003 were included. RESULTS A total of 918 patients in Gothenburg and 98 in Iceland were identified. The annual incidence in Gothenburg was 15.3+/-2.4/100,000 compared to 3.3+/-1.2/100,000 in Iceland (p<0.0001). In Gothenburg, 69% were male and in Iceland 52% (p<0.001). In Gothenburg, 50% of the patients had alcoholic cirrhosis compared to 29% in Iceland (p<0.0001). In Gothenburg, the patients had a higher Child-Pugh score (9.0) (SD 2.5) compared to Iceland (7.3) (SD 2.7) (p<0.0001). There was no difference in survival between patients with alcoholic liver disease and those with other aetiologies. CONCLUSIONS The incidence of liver cirrhosis is low in Iceland, i.e. 24% of the incidence in Gothenburg, due to the lower incidence of alcoholic and hepatitis C cirrhosis in Iceland. No increasing trends in the incidence of cirrhosis in these two countries were observed during the study period.
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Affiliation(s)
- Steingerdur Anna Gunnarsdottir
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Cirrhotic patients with a transjugular intrahepatic portosystemic shunt undergoing major extrahepatic surgery. J Clin Gastroenterol 2009; 43:574-9. [PMID: 19169145 DOI: 10.1097/mcg.0b013e31818738ef] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A transjugular intrahepatic portosystemic shunt (TIPS) can potentially reduce the risk of perioperative complications in cirrhotic patients undergoing surgery but experience is limited. The aim of our study was to assess the clinical outcomes in consecutive cirrhotic patients with a patent TIPS undergoing major extrahepatic surgery. METHODS Between July 1992 and January 2007, 25 cirrhotic patients with a patent TIPS underwent abdominal or cardiothoracic surgery at a single center. Preoperative laboratory and clinical features and postoperative outcomes were reviewed. RESULTS Mean subject age was 49+/-12 years. The TIPS was placed at a median of 20 days before surgery (range, 1 to 2338 d). In 19 patients, the TIPS had been previously placed for management of refractory ascites or bleeding varices whereas in 6 patients, the TIPS was specifically placed for portal decompression before planned surgery. The mean hepatic venous pressure gradient was significantly reduced from 19.6+/-5.5 to 8.7+/-2.9 mm Hg post-TIPS (P<0.001). The mean preoperative Model for End Stage Liver Disease (MELD) score was 15+/-7.6 and Child-Turcotte-Pugh scores were A (8%), B (64%), and C (28%). Nineteen abdominal and 6 cardiothoracic surgeries were performed under emergent (32%) or urgent (24%) circumstances. Postoperatively, severe ascites developed in 29% and encephalopathy in 17%. The median postoperative intensive care unit and hospital stay were 1 day (range, 0 to 26 d) and 7 days (0 to 32 d), respectively. During a median follow-up of 33 months, actuarial 1-year patient survival was 74%. The 3 patients (12%) who died during their hospitalization all had MELD scores > or = 25 and required emergency surgery. CONCLUSIONS Portal decompression via TIPS may allow selected cirrhotic patients to safely undergo major surgery with an acceptable rate of short-term morbidity and mortality.
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Gane E. Predicting outcome in patients with cirrhosis following acute decompensation: can we do better? J Gastroenterol Hepatol 2008; 23:1163-5. [PMID: 18699975 DOI: 10.1111/j.1440-1746.2008.05540.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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30
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Kooby DA, Egnatashvili V, Graiser M, Delman KA, Kauh J, Wood WC, Staley III CA. Changing management and outcome of hepatocellular carcinoma: Evaluation of 501 patients treated at a single comprehensive center. J Surg Oncol 2008; 98:81-8. [DOI: 10.1002/jso.21049] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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McCaughan GW, Omata M, Amarapurkar D, Bowden S, Chow WC, Chutaputti A, Dore G, Gane E, Guan R, Hamid SS, Hardikar W, Hui CK, Jafri W, Jia JD, Lai MY, Wei L, Leung N, Piratvisuth T, Sarin S, Sollano J, Tateishi R. Asian Pacific Association for the Study of the Liver consensus statements on the diagnosis, management and treatment of hepatitis C virus infection. J Gastroenterol Hepatol 2007; 22:615-33. [PMID: 17444847 DOI: 10.1111/j.1440-1746.2007.04883.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
OBJECTIVE To review present knowledge of the influence of hepatic steatosis in liver surgery as derived from experimental and clinical studies. SUMMARY BACKGROUND DATA Hepatic steatosis is the most common chronic liver disease in the Western world, and it is associated with obesity, diabetes, and metabolic syndrome. Fatty accumulation affects hepatocyte homeostasis and potentially impairs recovery of steatotic livers after resection. This is reflected clinically in increased mortality and morbidity after liver resection in patients with any grade of steatosis. Because of the epidemic increase of obesity, hepatic steatosis will play an even more significant role in liver surgery. METHODS A literature review was performed using MEDLINE and key words related to experimental and clinical studies concerning steatosis. RESULTS Experimental studies show the increased vulnerability of steatotic livers to various insults, attributed to underlying metabolic and pathologic derangements induced by fatty accumulation. In clinical studies, the severity of steatosis has an important impact on patient outcome and mortality. Even the mildest form of steatosis increases the risk of postoperative complications. CONCLUSIONS Hepatic steatosis is a major factor determining patient outcome after surgery. Further research is needed to clarify the clinical relevance of all forms and severity grades of steatosis for patient outcome. Standardized grading and diagnostic methods need to be used in future clinical trials to be able to compare outcomes of different studies.
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Affiliation(s)
- Reeta Veteläinen
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
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Krige JEJ, Kotze UK, Bornman PC, Shaw JM, Klipin M. Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices. Ann Surg 2006; 244:764-70. [PMID: 17060770 PMCID: PMC1856595 DOI: 10.1097/01.sla.0000231704.45005.4e] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis. SUMMARY BACKGROUND DATA Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy. METHODS Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24-87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565 upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded. RESULTS Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1-174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3-198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death. CONCLUSION Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.
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Affiliation(s)
- Jake E J Krige
- Department of Surgery, University of Cape Town Health Sciences Faculty, Anzio Road, Observatory 7925, Cape Town, South Africa.
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Soultati AS, Dourakis SP, Alexopoulou A, Deutsch M, Vasilieva L, Archimandritis AJ. Predicting utility of a model for end stage liver disease in alcoholic liver disease. World J Gastroenterol 2006; 12:4020-5. [PMID: 16810751 PMCID: PMC4087713 DOI: 10.3748/wjg.v12.i25.4020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To validate the statistic utility of both the Maddrey Discriminant Function score and the Model for End-Stage Liver Disease as predictors of short term (30 d and 90 d) mortality in patients with alcoholic hepatitis and to assess prognostic factors among clinical characteristics and laboratory variables of patients with alcoholic hepatitis.
METHODS: Thirty-four patients with the diagnosis of alcoholic hepatitis admitted to Hippokration University Hospital of Athens from 2000 to 2005 were assessed in the current retrospective study and a statistical analysis was conducted.
RESULTS: 30- and 90-d mortality rates were reported at 5.9% (2/34) and 14.7% (5/34), respectively. Significant correlation was demonstrated for the Model for End-Stage Liver Disease (P30 = 0.094, P90 = 0.046) and the Maddrey Discriminant Function score (P30 = 0.033, P90 = 0.038) with 30- and 90-d mortality whereas a significant association was also established for alanine aminotransferase (P = 0.057), fibrin degradation products (P = 0.048) and C-reactive protein (P = 0.067) with 90-d mortality. For 30-d mortality the Area Under the Curve was 0.969 (95%CI: 0.902-1.036, P = 0.028) for the Model for End-Stage Liver Disease score and 0.984 (95%CI: 0.942-1.027, P = 0.023) for the Maddrey Discriminant Function score with the optimal cut off point of 30.5 (sensitivity 1, specificity 0.937) and 108.68 (sensitivity 1, specificity 0.969), respectively. Accordingly, for 90-d mortality the Area Under the Curve was 0.762 (95%CI: 0.559-0.965, P = 0.065) for the Model for End-Stage Liver Disease score and 0.752 (95%CI: 0.465-1.038, P = 0.076) for the Maddrey Discriminant Function score with the optimal cut off point of 19 (sensitivity 0.6, specificity 0.6) and 92 (sensitivity 0.6, specificity 0.946), respectively. The observed Kaplan Meier survival rates for different score-categories were compared with log-rank tests and higher score values were correlated with a lower survival.
CONCLUSION: Equivalency of the Model for End-Stage Liver Disease and the Maddrey Discriminant Function score is implied by the current study, verified by the plotted Receiver Operative Curves and the estimated survival rates. A statistically significant utility of C-reactive protein, fibrin degradation products and alanine aminotransferase as independent predictors of 90-d mortality has also been verified.
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Affiliation(s)
- Aspasia S Soultati
- 2nd Department of Internal Medicine, University of Athens Medical School, Hippokration General Hospital, Greece
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Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL. Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 2005; 242:244-51. [PMID: 16041215 PMCID: PMC1357730 DOI: 10.1097/01.sla.0000171327.29262.e0] [Citation(s) in RCA: 229] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We sought to determine the ability of the Model for End-Stage Liver Disease (MELD) score to predict 30-day postoperative mortality for patients with cirrhosis undergoing nontransplant surgical procedures. SUMMARY BACKGROUND DATA The Child-Pugh class historically has been used by clinicians to assist in management decisions involving patients with cirrhosis. However, this classification scheme has a number of limitations. Recently, MELD was introduced. It has been shown to be highly predictive of mortality in a variety of clinical scenarios. METHODS Adult patients with a diagnosis of cirrhosis undergoing nontransplant surgical procedures between January 1, 1996, and January 1, 2002, at a single center were analyzed. The preoperative MELD score was calculated for all patients, and the MELD's performance in predicting 30-day mortality was determined using multivariate regression techniques. RESULTS A total of 140 surgical procedures were identified and analyzed. The 30-day mortality rate was 16.4%. The mean admission MELD score for the patients who died (23.3, 95% confidence interval 19.6-27.0) was significantly different from those patients surviving beyond 30 days (16.9, 15.6-18.2), P = 0.0003. The c-statistic for MELD score predicting 30-day mortality was 0.72. Further subgroup analysis of 67 intra-abdominal surgeries showed an in-hospital mortality of 23.9%. The mean MELD score for patients dying (24.8, 20.4-29.3) was significantly different from survivors (16.2, 14.2-18.2), P = 0.0001. The c-statistic for this subgroup was 0.80. CONCLUSIONS The MELD score, as an objective scale of disease severity in patients with cirrhosis, shows promise as being a useful preoperative predictor of surgical mortality risk.
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Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
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Murray KF, Carithers RL. AASLD practice guidelines: Evaluation of the patient for liver transplantation. Hepatology 2005; 41:1407-32. [PMID: 15880505 DOI: 10.1002/hep.20704] [Citation(s) in RCA: 498] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Karen F Murray
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA 98195-6174, USA
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Haktanir A, Cihan BS, Celenk C, Cihan S. Value of Doppler sonography in assessing the progression of chronic viral hepatitis and in the diagnosis and grading of cirrhosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:311-321. [PMID: 15723843 DOI: 10.7863/jum.2005.24.3.311] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the value of Doppler sonography in assessing the progression of chronic viral hepatitis and in the diagnosis and grading of cirrhosis. METHODS Abdominal sonographic and liver Doppler studies were performed in 3 groups: 36 patients with chronic viral hepatitis, 63 patients with cirrhosis, and 30 control subjects with no evidence of liver disease. A series of Doppler indices of hepatic vascularity, including portal vein velocity, portal vein pulsatility score, flow volume of the portal vein, resistive and pulsatility indices of the hepatic artery, modified hepatic index, hepatic vascular index, waveform of the hepatic vein, and focal acceleration of flow, were measured and correlated with liver and spleen size, portal and splenic vein diameter, and presence of ascites and collateral vessels. These indices were compared across the 3 study groups and within the patient groups with respect to presence of inflammation, fibrosis, and steatosis, as determined by histologic evaluation. RESULTS The most useful indices were portal vein velocity, the modified hepatic index, and nontriphasic flow in the hepatic vein, which were helpful in distinguishing patients from control subjects. Hepatic vascular and modified hepatic indices were useful for differential diagnosis of cirrhosis and chronic viral hepatitis. However, all measurements were limited in their ability to determine the severity of chronic hepatitis. CONCLUSIONS Doppler sonography is sensitive to hemodynamic alterations resulting from inflammation and fibrosis, and if sonography is the study of choice to follow the progression of hepatitis, it will not be adequate without Doppler imaging. Doppler sonography has high diagnostic accuracy in cirrhosis despite some false-positive conditions. However, it has a limited role in clinical grading.
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Affiliation(s)
- Alpay Haktanir
- Department of Radiology, Ondokuz Mayis University Medical Faculty, Samsun, Turkey.
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Mills SJ, Harrison SA. Comparison of the natural history of alcoholic and nonalcoholic fatty liver disease. Curr Gastroenterol Rep 2005; 7:32-6. [PMID: 15701296 DOI: 10.1007/s11894-005-0063-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Fatty liver disease represents a common clinical entity. It is classically divided into alcoholic fatty liver disease (AFLD) and nonalcoholic fatty liver disease (NAFLD). Whereas AFLD occurs in as many as 10 million Americans, NAFLD represents the most common chronic liver disease and is the most common cause of liver enzyme abnormalities in the United States. Both diseases encompass the clinical spectrum of steatosis, steatohepatitis, and cirrhosis. Although they are histologically indistinct, AFLD and NAFLD follow different clinical courses. This article compares the natural history of these diseases.
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Affiliation(s)
- Shane J Mills
- Department of Medicine, Gastroenterology and Hepatology Service, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234-6200, USA
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Lin OS, Keeffe EB, Sanders GD, Owens DK. Cost-effectiveness of screening for hepatocellular carcinoma in patients with cirrhosis due to chronic hepatitis C. Aliment Pharmacol Ther 2004; 19:1159-72. [PMID: 15153169 DOI: 10.1111/j.1365-2036.2004.01963.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND Screening for hepatocellular carcinoma in cirrhotic patients using abdominal ultrasonography and alpha-foetoprotein levels is widely practiced. AIM To evaluate its cost-effectiveness using a Markov decision model. METHODS Several screening strategies with abdominal ultrasonography or computerized tomography and serum alpha-foetoprotein at 6-12-month intervals in 40-year-old patients with chronic hepatitis C and compensated cirrhosis were simulated from a societal perspective, resulting in discounted costs per quality-adjusted life-year saved. Extensive sensitivity analysis was performed. RESULTS For the least efficacious strategy, annual alpha-foetoprotein/ultrasonography, the incremental cost-effectiveness ratio (vs. no screening) was $23 043/quality-adjusted life-year. Biannual alpha-foetoprotein/annual ultrasonography, the most commonly used strategy in the United States, was more efficacious, with a cost-effectiveness ratio of $33 083/quality-adjusted life-year vs. annual alpha-foetoprotein/ultrasonography. The most efficacious strategy, biannual alpha-foetoprotein/ultrasonography, resulted in a cost-effectiveness ratio of $73 789/quality-adjusted life-year vs. biannual alpha-foetoprotein/annual ultrasonography. Biannual alpha-foetoprotein/annual computerized tomography screening resulted in a cost-effectiveness ratio of $51 750/quality-adjusted life-year vs. biannual alpha-foetoprotein/annual ultrasonography screening. CONCLUSIONS Screening for hepatocellular carcinoma is as cost-effective as other accepted screening protocols. Of the strategies evaluated, biannual alpha-foetoprotein/annual ultrasonography gives the most quality-adjusted life-year gain while still maintaining a cost-effectiveness ratio <$50 000/quality-adjusted life-year. Biannual alpha-foetoprotein/annual computerized tomography screening may be cost-effective.
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Affiliation(s)
- O S Lin
- Gastroenterology Section, Virginia Mason Medical Center, Seattle, WA, USA.
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40
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Lin MH, Wu PY, Tsai ST, Lin CL, Chen TW, Hwang SJ. Hospice palliative care for patients with hepatocellular carcinoma in Taiwan. Palliat Med 2004; 18:93-9. [PMID: 15046405 DOI: 10.1191/0269216304pm851oa] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death in Taiwan. In order to delineate the unique demographic features and clinical profile of terminal HCC, we conducted a retrospective study in a hospital-based hospice in Taiwan. Of a total of 991 terminally ill cancer patients (654 men and 337 women, mean age 66.1 years) admitted to our palliative care unit during a three-year period, 110 patients (11.1%) were diagnosed as having HCC (93 men and 17 women, mean age 60.5 years). The most common metastatic sites were bone and lung. Eighty-five HCC patients (77.3%) also had associated liver cirrhosis. The most common symptoms of HCC patients upon admission to the hospice ward were pain, fatigue or weakness, anorexia/vomiting, peripheral edema, cachexia, and ascites. Hypoalbuminemia, anemia, hyponatremia and jaundice were common laboratory abnormalities. Eighty-four patients (76.4%) required opiates for pain management. Upper gastrointestinal bleeding or varices bleeding developed in 76 patients (69.1%). Ninety-four patients (85.5%) died at the hospital, and the overall median survival time at hospice ward was 12 days. Because of more severe underlying portal hypertension and deteriorated liver function, terminal HCC patients with decompensated liver cirrhosis (Child-Pugh class C) had a significantly higher prevalence of peripheral edema, ascites, dyspnea, jaundice, thrombocytopenia, and stage III-IV hepatic encephalopathy than noncirrhotic or Child-Pugh class A and B terminal HCC patients. Symptoms and signs resulting from these portal hypertensions frequently complicated the symptomatic management of terminal HCC patients in the hospice ward. The treatment of these complications is mostly empirical in hospice ward, where intensive laboratory or diagnostic tests are usually not performed. In conclusion, symptoms and signs of terminally ill HCC patients in hospice are unique and should be managed appropriately.
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Affiliation(s)
- Ming-Hwai Lin
- Division of Hospice Palliative Care, Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Affiliation(s)
- Stephen F Stewart
- Centre for Liver Research, Medical School, Framlington Place, Newcastle upon Tyne NE2 4HH, UK
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Abstract
Alcoholic liver disease (ALD) remains a major cause of morbidity and mortality worldwide. For example, the Veterans Administration Cooperative Studies reported that patients with cirrhosis and superimposed alcoholic hepatitis had a 4-year mortality of >60%. Interactions between acetaldehyde, reactive oxygen and nitrogen species, inflammatory mediators and genetic factors appear to play prominent roles in the development of ALD. The cornerstone of therapy for ALD is lifestyle modification, including drinking and smoking cessation and losing weight, if appropriate. Nutrition intervention has been shown to play a positive role on both an inpatient and outpatient basis. Corticosteroids are effective in selected patients with alcoholic hepatitis and pentoxifylline appears to be a promising anti-inflammatory therapy. Some complementary and alternative medicine agents, such as milk thistle and S-adenosylmethionine, may be effective in alcoholic cirrhosis. Treatment of the complications of ALD can improve quality of life and, in some cases, decrease short-term mortality.
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Affiliation(s)
- Gavin Arteel
- University of Louisville Medical Center, Building A, Room 1319, Louisville, KY 40292, USA
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43
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Botero RC, Lucey MR. Organ allocation: model for end-stage liver disease, Child-Turcotte-Pugh, Mayo risk score, or something else. Clin Liver Dis 2003; 7:715-27, ix. [PMID: 14509535 DOI: 10.1016/s1089-3261(03)00052-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The discovery of a single test of liver function has been a goal of hepatologists for many years. The great complexity of the liver and its many diverse functions, however, has prevented such an accomplishment. An analogy can be made with the way one currently uses liver tests where several individual tests are combined into a profile. This article presents evidence that confirms the same concept: Only by combining several clinical and laboratory measures can we predict the prognosis of liver disease patients. End-stage liver disease and pediatric end-stage liver disease models are valuable additions to the prognostic armamentarium; however, these models are not perfect and some important indications for liver transplant today cannot be included because their main issue is not disease severity.
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Affiliation(s)
- Rafael Claudino Botero
- Section of Gastroenterology and Hepatology, University of Wisconsin School of Medicine-Madison Medical School, H6/516 CSC, 600 Highland Avenue, Madison, WI 52792, USA
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Prieto M, Clemente G, Casafont F, Cuende N, Cuervas-Mons V, Figueras J, Grande L, Herrero JI, Jara P, Mas A, de la Mata M, Navasa M. [Consensus document on indications for liver transplantation. 2002]. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:355-75. [PMID: 12809573 DOI: 10.1016/s0210-5705(03)70373-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- M Prieto
- Servicio de Medicina Digestiva. Hospital Universitario La Fe. Valencia. España
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Abstract
Fatty liver disease that develops in the absence of alcohol abuse is recognized increasingly as a major health burden. This report summarizes the presentations and discussions at a Single Topic Conference held September 20-22, 2002, and sponsored by the American Association for the Study of Liver Diseases. The conference focused on fatty liver disorders. Estimates based on imaging and autopsy studies suggest that about 20% to 30% of adults in the United States and other Western countries have excess fat accumulation in the liver. About 10% of these individuals, or fully 2% to 3% of adults, are estimated to meet current diagnostic criteria for nonalcoholic steatohepatitis (NASH). Sustained liver injury leads to progressive fibrosis and cirrhosis in a fraction, possibly up to one third, of those with NASH, and NASH may be a cause of cryptogenic cirrhosis. NASH is now a significant health issue for obese children as well, leading to cirrhosis in some. The diagnostic criteria for NASH continue to evolve and rely on the histologic findings of steatosis, hepatocellular injury (ballooning, Mallory bodies), and the pattern of fibrosis. Generally recognized indications for biopsy include establishing the diagnosis and staging of the injury, but strict guidelines do not exist. Liver enzymes are insensitive and cannot be used reliably to confirm the diagnosis or stage the extent of fibrosis. Older age, obesity, and diabetes are predictive of fibrosis. The pathogenesis of NASH is multifactorial. Insulin resistance may be an important factor in the accumulation of hepatocellular fat, whereas excess intracellular fatty acids, oxidant stress, adenosine triphosphate (ATP) depletion, and mitochondrial dysfunction may be important causes of hepatocellular injury in the steatotic liver. Efforts are underway to refine the role of insulin resistance in NASH and determine whether improving insulin sensitivity pharmacologically is an effective treatment. An altered lifestyle may be a more effective means of improving insulin sensitivity. The research agenda for the future includes establishing the role of insulin resistance and abnormal lipoprotein metabolism in NASH, determining the pathogenesis of cellular injury, defining predisposing genetic abnormalities, identifying better noninvasive predictors of disease, and defining effective therapy.
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Sørensen HT, Thulstrup AM, Mellemkjar L, Jepsen P, Christensen E, Olsen JH, Vilstrup H. Long-term survival and cause-specific mortality in patients with cirrhosis of the liver: a nationwide cohort study in Denmark. J Clin Epidemiol 2003; 56:88-93. [PMID: 12589875 DOI: 10.1016/s0895-4356(02)00531-0] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mortality from cirrhosis of the liver has been examined in few long-term follow-up studies. In the Danish National Registry of Patients, 1982-1989, we identified a cohort of 10,154 patients with liver cirrhosis and divided them according to the etiology of their liver disease. Causes of death were identified in the Danish Death Registry, 1982-1993. We estimated relative survival and standardized mortality ratios by comparing with the mortality in the general population. The 10-year relative survival was worse in patients with alcoholic cirrhosis (34%) or nonspecified cirrhosis (32%) than in patients with primary biliary cirrhosis (58%) or chronic hepatitis (66%). The standardized mortality ratio for all causes of death combined was 12-fold increased, 5-fold excluding cirrhosis-related causes. Mortality in all disease categories was increased, even in those not traditionally related to cirrhosis. In conclusion, patients with cirrhosis of the liver face reduced life expectancy due to several causes of death.
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Affiliation(s)
- Henrik Toft Sørensen
- Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, Nørrebrogade 44, DK-8000 Aarhus C, Denmark.
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Merli M, Nicolini G, Angeloni S, Riggio O. Malnutrition is a risk factor in cirrhotic patients undergoing surgery. Nutrition 2002; 18:978-86. [PMID: 12431721 DOI: 10.1016/s0899-9007(02)00984-x] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cirrhotic patients may become candidates for elective and emergency surgery. This may be due to conditions requiring operations such as cholecystectomy, herniotomy, or gastrointestinal malignancies, more common in cirrhotics when compared with the general population, or to complications of the liver disease such as resectable hepatocellular carcinomas or surgical portosystemic shunts to treat portal hypertension. It has been estimated that 10% of cirrhotics undergo at least one operative procedure during the final 2 y of their lives. Many studies have documented a high risk of morbidity and mortality associated with surgical procedures in these patients, and several factors influencing the postoperative outcome have been identified. Malnutrition, which is frequently encountered in cirrhotic patients, has been shown to have an important impact on the surgical risk. A poor nutrition status also has been associated with a higher risk of complications and mortality in patients undergoing liver transplantation. Few data are available concerning the perioperative nutrition support in surgical cirrhotic patients. The results of these studies are sometimes encouraging in reporting that the nutrition therapy may improve the clinical outcome in cirrhotic patients undergoing general surgery and/or liver transplantation. The limited number of patients and their heterogeneity, however, do not allow definitive conclusions, and more research on this issue is needed.
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Affiliation(s)
- Manuela Merli
- II Gastroenterology, Department of Clinical Medicine, University of Rome "La Sapienza,", Rome, Italy. manuela.merli@uniroma l.it
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Biggins SW, Beldecos A, Rabkin JM, Rosen HR. Retransplantation for hepatic allograft failure: prognostic modeling and ethical considerations. Liver Transpl 2002; 8:313-22. [PMID: 11965573 DOI: 10.1053/jlts.2002.31746] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Retransplantation already accounts for 10% of all liver transplants performed, and this percentage is likely to increase as patients live long enough to develop graft failure from recurrent disease. Overall, retransplantation is associated with significantly diminished survival and increased costs. This review summarizes the current causes of graft failure after primary liver transplant, prognostic models that can identify the subset of patients for retransplantation with outcomes comparable to primary transplantation, and ethical considerations in this setting, i.e., outcomes-based versus urgency-based approaches.
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Affiliation(s)
- Scott W Biggins
- Department of Medicine, Portland Veterans Affairs Medical Center and Oregon Health Sciences University, Portland, OR 97207, USA
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de Bruyn G, Graviss EA. A systematic review of the diagnostic accuracy of physical examination for the detection of cirrhosis. BMC Med Inform Decis Mak 2001; 1:6. [PMID: 11806763 PMCID: PMC64783 DOI: 10.1186/1472-6947-1-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2001] [Accepted: 12/18/2001] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We conducted a review of the diagnostic accuracy of clinical examination for the diagnosis of cirrhosis. The objectives were: to identify studies assessing the accuracy of clinical examination in the detection of cirrhosis; to summarize the diagnostic accuracy of reported physical examination findings; and to define the effects of study characteristics on estimates of diagnostic accuracy. METHODS Studies were identified through electronic literature search of MEDLINE (1966 to 2000), search of bibliographic references, and contact with authors. Studies that evaluated indicants from physical examination of patients with known or suspected liver disease undergoing liver biopsy were included. Qualitative data on study characteristics were extracted. Two-by-two tables of presence or absence of physical findings for patients with and without cirrhosis were created from study data. Data for physical findings reported in each study were combined using Summary Receiver Operating Characteristic (SROC) curves or random effects modeling, as appropriate. RESULTS Twelve studies met inclusion criteria, including a total of 1895 patients, ranging in age from 3 to 90 years. Most studies were conducted in referral populations with elevated aminotransferase levels. Ten physical signs were reported in three or more studies and ten signs in only a single study. Signs for which there was more study data were associated with high specificity (range 75-98%), but low sensitivity (range 15-68%) for histologically-proven cirrhosis. CONCLUSIONS Physical findings are generally of low sensitivity for the diagnosis of cirrhosis, and signs with higher specificity represent decompensated disease. Most studies have been undertaken in highly selected populations.
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Affiliation(s)
- Guy de Bruyn
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Edward A Graviss
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
- Department of Pathology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
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Abstract
PURPOSE Since 1970, the rate of death from cirrhosis has decreased progressively, in part thanks to better handling of complications (preventive and curative treatment of gastric bleeding, prevention of infections and treatment of ascitis). The goal of this study was to examine the evolution in causes of death among cirrhotics. METHODS We identified all of the patients who died among those cirrhotics hospitalized at the Alençon Hospital during the period covered by the study, from January 1, 1993 to December 31, 1998. We examined the age of death of these cirrhotics, their causes of death, and also studied and compared this data with causes of death cited in the literature of the 1980s. Finally, we examined the prevalence of each cause of death in relation to the age of death of each patient. RESULTS Our results show that 347 cirrhotics were hospitalized at the Alençon Hospital during the period covered by the study, and 186 of these patients died. These deaths resulted from hepatocarcinoma in 22% of cases, gastric bleeding in 12% of cases, and liver cell failure at a terminal stage in 21% of cases. In 31% of cases, the cause was unrelated to cirrhosis, and in 13% of cases the cause was unknown. The death rate from hepatocarcinoma increased according to the patients' age, while the death rate from gastric bleeding decreased according to age. CONCLUSION We have noted, in comparison with Saunders in 1981 that there was a significant increase in extrahepatic causes of death and a significant decrease in deaths from liver cell failure. Percentages of the other causes of death do not show any variation, in spite of new techniques of detection and treatment.
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Affiliation(s)
- S Anacréon
- Centre hospitalier, BP 354, 61014 Alençon, France.
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