[Complications of liver cirrhosis]. Internist (Berl). 2011;52:1061-170; quiz 1061-170;. [PMID: 21611819 DOI: 10.1007/s00108-011-2853-0]

Underfunding of German university-based high-performance medicine exemplified by the treatment of varices in cirrhosis

Facing increasing economization in the health care sector, clinicians have to adapt not only to the ever-growing economic challenges, but also to a patient-oriented health care. Treatment costs are the most important variable for optimizing success when facing scarce human resources, increasing material- and infrastructure costs in general, as well as low revenue flexibility due to flat rates per case in Germany, the so-called Diagnosis-Related Groups (DRG). University hospitals treat many patients with particularly serious illnesses. Therefore, their share of complex and expensive treatments, such as liver cirrhosis, is significantly higher. The resulting costs are not adequately reflected in the DRG flat rate per case, which is based on an average calculation across all hospitals, which increases this economic pressure. Thus, the aim of this manuscript is to review cost and revenue structures of the management of varices in patients with cirrhosis at a university center with a focus on hepatology. For this monocentric study, the data of 851 patients, treated at the Gastroenterology Department of a University Hospital between 2016 and 2020, were evaluated retrospectively and anonymously. Medical services (e.g., endoscopy, radiology, laboratory diagnostics) were analyzed within the framework of activity-based-costing. As part of the cost unit accounting, the individual steps of the treatment pathways of the 851 patients were monetarily evaluated with corresponding applicable service catalogs and compared with the revenue shares of the cost center and cost element matrix of the German (G-) DRG system. This study examines whether university-based high-performance medicine is efficient and cost-covering within the framework of the G-DRG system. We demonstrate a dramatic underfunding of the management of varicose veins in cirrhosis in our university center. It is therefore generally questionable whether and to what extent an adequate care for this patient collective is reflected in the G-DRG system.

Severity of Non-B and Non-C Hepatitis Versus Hepatitis B and C Associated Chronic Liver Disease: A Retrospective, Observational, Comparative Study

Background and objectives

Chronic liver disease (CLD) encompasses a variety of etiologies, and the infectious causes are mainly hepatitis B and hepatitis C virus. Chronic alcohol abuse and non-alcoholic fatty liver disease also have a major contribution to CLD. The Child-Pugh scoring system indicates the probable prognosis and mortality risk of a patient with cirrhosis. The primary objective of this research is to observe the mortality risks of CLD caused by a variety of etiologies mentioned above. The secondary objective is to determine the biochemical markers that are correlating with the severity of the study groups. Another aim was to determine the Model for End-Stage Liver Disease (MELD) scoring of each study group predicting the severity of disease among the Child-Pugh classification.

Materials and methods

We broadly classified the etiologies into two study groups: (1) hepatitis B, C associated CLD (hepatitis B, C­-CLD) and (2) non-hepatitis B, C associated CLD (non-hepatitis B, C-CLD). This study was conducted as a descriptive, retrospective study involving patients admitted to the Gastroenterology Department at Dow University Hospital between July 2019 and December 2019. All patients who met the inclusion criteria were included in the study in order to document their levels of severity markers of CLD. A total of 167 individuals met the inclusion criteria, and the sampling was done through non-probability consecutive methods. All continuous variables were described as mean and standard deviations, which were then compared using an independent sample t-test. The comparison of categorical data was done either using the chi-square test or Fisher’s exact test accordingly. A p-value of <0.05 was considered statistically significant (two-tailed).

Results

The mean age of the study population was 51.83 ± 13.67, with no difference in gender and type of CLD. The frequent co-morbidities (other than CLD) found in the study population were diabetes, hypertension, ischemic heart disease, and chronic kidney disease, with most of them having significant association with non-hepatitis B, C-CLD. Both types of CLD had equal gender proportion (p=0.708). Among the study groups, 56.28% (n=94) had hepatitis B, C-CLD, out of which 18 (19%) belonged to Child-Pugh class A, 36 (38%) to Child-Pugh class B, and 40 (43%) to Child-Pugh class C, whereas 43.72% (n=71) had non-hepatitis B, C-CLD, comprising of 13% (n=10) of Child-Pugh class A patients, 42% (n=31) of Child-Pugh class B patients, and 44% (n=32) of Child-Pugh class C patients (p=0.631). Bilirubin levels (p=0.055), serum creatinine (p=0.201), and International normalized ratio (INR) are found higher in non-hepatitis B, C-CLD (p=0.312), whereas thrombocytopenia was more likely to be associated with hepatitis B, C-CLD (p=0.205). Hyponatremia was slightly associated with non-hepatitis B, C-CLD (p=0.281). The mean MELD score was comparable among the two study groups in both Child-Pugh classes A and B, but in Child-Pugh class C it was significantly higher in non-hepatitis B, C-CLD patients as compared to hepatitis B, C­-CLD (p=0.006).

Conclusion

Non-hepatitis B, C-CLD was proved to be milder in Child-Pugh class A as compared to hepatitis B, C-CLD, but its mortality risk increases with severity, as mean MELD score was found significantly higher in Child-Pugh class C. Our research was able to identify severe biochemical markers in both types of CLD.

Relationship Between Portal HTN and Cirrhosis as a Cause for Diabetes

Our aim was to explore the relationship between liver cirrhosis (LC), portal hypertension (PH), and diabetes mellitus (DM). LC displayed hemodynamic alterations reflected by signs and symptoms of hypertension and hyperdynamic circulation. Portal hypertension also caused splenomegaly because of the blood flow into the spleen from the portal vessels and portal flow. The alcoholic cirrhosis displayed abnormal values (AST, ALT, AST/ALT, albumin, ammonia, bilirubin, blood platelet, erythrocytes, glucose, Hb, international normalized ratio (INR), PT, prothrombin index (PI), thymol test, white blood cell (WBC) count), which demonstrated the presence of portal hypertension, ascites, DM, infection, and coagulopathy. The evaluation of liver enzymes and other laboratories data helped to determine the severity of the condition and prognosis. Diabetes appeared to be less affecting the prognosis of patients with cirrhosis than LC itself, showing that hepatocellular failure was largely responsible for patients’ mortality rather than diabetes and its complications. Patients displayed a BMI correlating obesity, although affected by concomitant diseases that commonly cause a severe weight loss. The elevated BMI in this case was accentuated by the presence of ascitic fluid, which is responsible for the increase in weight and the inaccurate BMI evaluation. Ascites affect patients’ recovery from liver diseases. Obese patients with cirrhosis can be related to have a large amount of ascites and that physicians should be expecting to notice changes in their BMI pre- and postoperatively, subsequently making a prior classification as obese inappropriate. Disease severity could be assessed through the evaluation of PH stage, which was characterized by a significant depletion of WBC and as well as platelet counts.

Bone marrow mesenchymal stem cells for treatment of liver cirrhosis

Liver disease is a frequently occurring disease worldwide. In China, the incidence of hepatitis and liver cirrhosis is high, and has increased year by year. The progression of chronic liver disease can lead to upper gastrointestinal bleeding, liver cancer and other malignant diseases, posing a serious threat to the health and quality of life of patients. Before progression to liver cirrhosis, choosing an effective treatment method can reverse the disease, improve the prognosis and reduce mortality. Bone marrow mesenchymal stem cells (BMSCs) are the most popular seed cells in the development of new methods for treating cirrhosis. They can not only differentiate into hepatocytes in vivo, but also reduce the inflammatory response, inhibit cell apoptosis, improve liver function and so on. BMSCs are expected to be a new strategy for the treatment of liver cirrhosis and liver failure.

[Management of decompensated liver cirrhosis in the intensive care unit]

Liver cirrhosis is the end-stage of long-standing chronic liver diseases. The occurrence of complications from liver cirrhosis increases the mortality risk, but the prognosis can be improved by optimal management in the intensive care unit (ICU). Defined diagnostic algorithms allow the etiology and presence of typical complications upon presentation to the ICU to be identified. Acute variceal bleeding requires endoscopic intervention, vasoactive drugs, antibiotics, supportive intensive care measures and, where necessary, urgent transjugular intrahepatic portosystemic shunt (TIPS) procedure. Spontaneous bacterial peritonitis needs to be diagnosed and immediately treated in patients with ascites. Hepatorenal syndrome should be treated by albumin and terlipressin. In case of respiratory failure, differential diagnosis should not only consider pneumonia, pulmonary embolism and cardiac failure, but also hepatic hydrothorax, portopulmonary hypertension and hepatopulmonary syndrome. The feasibility of liver transplantation should be always discussed in patients with decompensated cirrhosis. Artificial liver support devices may only serve as a bridging procedure until transplant.

The etiology, diagnosis and prevention of liver cirrhosis: part 1 of a series on liver cirrhosis

BACKGROUND

Cirrhosis of the liver is the end stage of chronic liver disease. Among the many liver disorders that can lead to cirrhosis, some progress rapidly (years) and others more slowly (decades). In Germany, cirrhosis is often a consequence of fatty liver disease due to alcoholism or other causes, but can also be caused by hepatitis B and hepatitis C. Cirrhosis is more common in overweight persons and smokers. The underlying causes of cirrhosis determine its rate of progression and are the focus of preventive efforts and treatment. The prevalence of cirrhosis in Germany is rising; it now ranks among the top 20 causes of death in the country.

METHODS

This article is based on a selective review of pertinent literature, including reviews and current guidelines.

RESULTS

Strictly speaking, cirrhosis is a pathological diagnosis; it is, nevertheless, usually diagnosed clinically, by history, physical examination (e.g., cutaneous signs of liver disease), ancillary testing (e.g., ultrasonography, transient elastography) and laboratory analyses (e,g., APRI, which is the quotient of the GOT concentration and the platelet count). There are no laboratory cutoff values for the diagnosis of cirrhosis. Early detection of chronic liver disease, followed by individually tailored, risk-adapted treatment, is the best way to prevent it. Esophagogastroduodenoscopy can be performed early on to assess the risk of variceal bleeding. In most patients, the progression of fibrosis can be averted by early detection and appropriate treatment.

CONCLUSION

Screening for chronic liver disease should include history and physical examination, serum transaminase measurement, upper abdominal ultrasonography, and, in some cases, transient elastography.