Ascites

Predictive value of serum albumin levels on cancer survival: a prospective cohort study

Background

Serum albumin levels and cancer mortality are closely related, yet large-sample studies encompassing a broad spectrum of cancer types are lacking.

Methods

This study encompassed patients diagnosed with cancer across the continuous 10 cycles of NHANES surveys from 1999 to 2018. The study population was stratified into two groups based on median albumin levels (≤ 4.2g/dL and > 4.2 g/dL) or cancer aggressiveness (well-survived cancers and poorly-survived cancers). Survival rates were estimated using the Kaplan-Meier method. The Cox proportional hazards model was employed to evaluate the association between serum albumin levels and cancer mortality. Restricted cubic spline (RCS) analysis was conducted to assess the nonlinear relationship between serum albumin levels and the risk of cancer mortality.

Results

Kaplan-Meier curves demonstrated that patients with albumin levels ≤ 4.2 g/dL exhibited lower survival rates compared to those with levels > 4.2 g/dL, irrespective of cancer aggressiveness. Following adjustment for confounders, decreased albumin levels were associated with an elevated risk of cancer mortality across all groups [all cancers, HR (95%CI) = 2.03(1.73, 2.37); well survived cancers, HR (95%CI) = 1.78(1.38, 2.32); and poorly survived cancers, HR (95%CI) = 1.99(1.64, 2.42)]. RCS analyses revealed a stable nonlinear negative association between albumin levels and cancer mortality in all groups, regardless of confounder adjustment.

Conclusion

Low serum albumin levels predict higher cancer mortality. Furthermore, a nonlinear negative association was observed between serum albumin levels and the risk of cancer mortality.

Possible use of 2D shear wave liver elastography in new-onset ascites evaluation

BACKGROUND

No data on the use of 2D shear wave elastography exists regarding the evaluation of the new-onset ascites causality.

AIMS

To determine whether 2D shear wave elastography can help in the non-invasive assessment of the new-onset ascites cause. To assess the applicability of liver stiffness measured by 2D shear wave elastography using Esaote MyLab Nine apparatus in patients with ascites.

METHODS

In 52 consecutive patients with new-onset ascites (January 2020 to October 2021), liver stiffness using 2D shear wave elastography was prospectively measured. The reliable measurements were used for further analysis. Relevant clinical and laboratory data was collected.

RESULTS

The calculated liver stiffness measurement cut-off value of 14.4 kPa held 94% accuracy, 100% sensitivity, and 83% specificity when determining ascites with serum ascites albumin gradient ≥11 g/L. Reliable 2D shear wave elastography success rate was 84%.

CONCLUSIONS

2D shear wave elastography may potentially be used to differentiate transudative from exudative ascites, especially in patients with portal hypertension and peritoneal carcinomatosis.

Okadaic Acid Is at Least as Toxic as Dinophysistoxin-1 after Repeated Administration to Mice by Gavage

Okadaic acid (OA) and its analogues cause diarrhetic shellfish poisoning (DSP) in humans, and risk assessments of these toxins require toxicity equivalency factors (TEFs), which represent the relative toxicities of analogues. However, no human death by DSP toxin has been reported, and its current TEF value is based on acute lethality. To properly reflect the symptoms of DSP, such as diarrhea without death, the chronic toxicity of DSP toxins at sublethal doses should be considered. In this study, we obtained acute oral LD50 values for OA and dinophysistoxin-1 (DTX-1) (1069 and 897 μg/kg, respectively) to set sublethal doses. Mice were treated with sublethal doses of OA and DTX-1 for 7 days. The mice lost body weight, and the disease activity index and intestinal crypt depths increased. Furthermore, these changes were more severe in OA-treated mice than in the DTX-1-treated mice. Strikingly, ascites was observed, and its severity was greater in mice treated with OA. Our findings suggest that OA is at least as toxic as DTX-1 after repeated oral administration at a low dose. This is the first study to compare repeated oral dosing of DSP toxins. Further sub-chronic and chronic studies are warranted to determine appropriate TEF values for DSP toxins.

Epidemiology of liver cirrhosis and associated complications: Current knowledge and future directions

Cirrhosis causes a heavy global burden. In this review, we summarized up-to-date epidemiological features of cirrhosis and its complications. Recent epidemiological studies reported an increase in the prevalence of cirrhosis in 2017 compared to in 1990 in both men and women, with 5.2 million cases of cirrhosis and chronic liver disease occurring in 2017. Cirrhosis caused 1.48 million deaths in 2019, an increase of 8.1% compared to 2017. Disability-adjusted life-years due to cirrhosis ranked 16th among all diseases and 7th in people aged 50-74 years in 2019. The global burden of hepatitis B virus and hepatitis C virus-associated cirrhosis is decreasing, while the burden of cirrhosis due to alcohol and nonalcoholic fatty liver disease (NAFLD) is increasing rapidly. We described the current epidemiology of the major complications of cirrhosis, including ascites, variceal bleeding, hepatic encephalopathy, renal disorders, and infections. We also summarized the epidemiology of hepatocellular carcinoma in patients with cirrhosis. In the future, NAFLD-related cirrhosis will likely become more common due to the prevalence of metabolic diseases such as obesity and diabetes, and the prevalence of alcohol-induced cirrhosis is increasing. This altered epidemiology should be clinically noted, and relevant interventions should be undertaken.

Hepatic lymphatic vascular system in health and disease

In recent years, significant advances have been made in the study of lymphatic vessels with the identification of their specific markers and the development of research tools that have accelerated our understanding of their role in tissue homeostasis and disease pathogenesis in many organs. Compared to other organs, the lymphatic system in the liver is understudied despite its obvious importance for hepatic physiology and pathophysiology. In this review, we describe fundamental aspects of the hepatic lymphatic system and its role in a range of liver-related pathological conditions such as portal hypertension, ascites formation, malignant tumours, liver transplantation, congenital liver diseases, non-alcoholic fatty liver disease, and hepatic encephalopathy. The article concludes with a discussion regarding the modulation of lymphangiogenesis as a potential therapeutic strategy for liver diseases.

Metabolomic Analysis Uncovers Lipid and Amino Acid Metabolism Disturbance During the Development of Ascites in Alcoholic Liver Disease

Ascites is one of the most common complications of cirrhosis, and there is a dearth of knowledge about ascites-related pathologic metabolism. In this study, 122 alcoholic liver disease (ALD) patients, including 49 cases without ascites, 18 cases with mild-ascites, and 55 cases with large-ascites (1) were established according to the International Ascites Club (2), and untargeted metabolomics coupled with pattern recognition approaches were performed to profile and extract metabolite signatures. A total of 553 metabolites were uniquely discovered in patients with ascites, of which 136 metabolites had been annotated in the human metabolome database. Principal component analysis (PCA) analysis was used to further identify 21 ascites-related fingerprints. The eigenmetabolite calculated by reducing the dimensions of the 21 metabolites could be used to effectively identify those ALD patients with or without ascites. The eigenmetabolite showed a decreasing trend during ascites production and accumulation and was negatively related to the disease progress. These metabolic fingerprints mainly belong to the metabolites in lipid metabolism and the amino acid pathway. The results imply that lipid and amino acid metabolism disturbance may play a critical role in the development of ascites in ALD patients and could be a potent prognosis marker.

Ascites development is associated with worse outcome in patients after kidney transplantation

BACKGROUND

We provide detailed analysis and outcomes in patients post-kidney transplant (KT) developing ascites, which has never been categorically reported.

METHODS

Ascites was identified by ICD9/10 codes and detailed chart review in patients post-KT from 01/2004-06/2019. The incidence of patient death and graft loss were determined per 100-person-years, and the incidence rate ratio was obtained.

RESULTS

Of 3329 patients receiving KT, 83 (2.5%) patients had new-onset ascites, of whom 58% were male, 21% blacks, and 29% whites. Seventy-five percentage were on hemodialysis. Patients were maintained primarily on tacrolimus and mycophenolate for immunosuppression. Only 14% of patients with ascites had the appropriate diagnostic workup. There was a trend toward an increased mortality in patients with ascites (incidence rate ratio, IRR [95% CI]: 1.8 [0.92, 3.19], p = .06), and a significantly higher incidence of graft loss (IRR: 5.62 [3.97, 7.76], p < .001), compared with non-ascites patients. When classified by ascites severity, determined by imaging, moderate/severe ascites patients had the worst clinical outcomes, with a mortality of 32% and graft failure in 57%, compared with 9% and 10%, respectively, in those without ascites.

CONCLUSION

In this large cohort employing stepwise analysis of ascites post-KT, worse outcomes were noted, dictating the need for optimized management to improve clinical outcomes.

Paraphenylenediamine and related chemicals as allergens responsible for allergic contact dermatitis

INTRODUCTION

Paraphenylenediamine (PPDA) is a chemical with strong sensitizing properties used for dyeing of hair and textiles. Paraphenylenediamine can cross-react, resulting in allergy to other related compounds. The prevalence of PPDA sensitization varies widely. The objectives were to assess the frequency of positive patch test reactions to PPDA and related chemicals among patients with allergic contact dermatitis (ACD) and to analyze them regarding their clinical pattern, occupation and cross-reactions.

MATERIAL AND METHODS

The sociodemographic and clinical data of patients with positive patch tests to PPDA, N-isopropyl-N-phenyl-4-phenylenediamine (IPPD), ethylenediamine (EDA), triethylenetetramine (TETA) and toluene-2,5-diamine (TDA) were analyzed. The frequency, strength and cross-reactions with other chemicals were assessed.

RESULTS

Of 4087 ACD patients patch-tested between 2006 and 2015, positive reactions to PPDA and other amines were found in 166 (4.1%). The occupational character of PPDA allergy was established in 34.3% of patients. Personal history of atopy was reported by 36.7% of patients. In 98% of those examined, allergy presented as ACD, most frequently affecting hands. Hypersensitivity to PPDA was diagnosed in 77.1%, to IPPD in 20.5%, to TDA in 6%, to TETA in 1.2%, and to EDA in 0.6% of cases. The patients with an extremely strong PPDA reaction significantly more frequently showed reactions to other para group chemicals, especially to benzocaine.

CONCLUSIONS

Paraphenylenediamine was a major cause of contact allergy of diverse clinical picture more often affecting women, especially with atopy. Every fifth PPDA-allergic person exhibited hypersensitivity to other related compounds. Strong reactions to PPDA increased the risk of cross-reactions.

Pretransplant ascites and encephalopathy and their influence on survival and liver graft rejection in alcoholic cirrhosis disease

INTRODUCTION

The Child-Pugh and model for end-stage liver disease (MELD) scores are widely used to predict the outcomes of liver transplant (LT). Both have similar prognostic values in most cases, although their benefits might differ in some specific conditions. The aim of our study was to analyze the influence of pre-transplant ascites and encephalopathy in post-transplant liver rejection development and survival in alcohol cirrhosis (AC) patients undergoing LT to determine the usefulness of the Child-Pugh score for the assessment of prognosis in such patients.

MATERIAL AND METHODS

Two hundred and eighty-one AC patients, classified according to viral infections and pre-transplant complications, were analyzed. Acute (AR) and chronic (CR) liver rejections and Child-Pugh, MELD and albumin-bilirubin (ALBI) scores were studied in all cases.

RESULTS

Similar AC rejection percentages were observed in ascites or encephalopathy groups (18.5% and 16.5%, p = 0.735), although a higher but not statistically significant AC rate was observed in patients with grade III ascites (p = 0.777) and with grade II encephalopathy (p = 0.089). Chronic rejection was only developed by 9.1% of AC patients, regardless of the presence of ascites (6.2%) or encephalopathy (5.5%). The presence of ascites and encephalopathy complications did not seem to influence post-transplant survival. Neither the Child-Pugh nor the ALBI score can be considered the best for predicting patient survival in the short or long term.

CONCLUSIONS

Ascites and encephalopathy do not seem to influence AC or CR in patient survival, regardless of the presence of viral infections, so in our study neither the Child-Pugh nor ALBI score seems to be the best score to predict the outcomes of these patients.

Ascites and Hepatorenal Syndrome

Ascites occurs in up to 70% of patients during the natural history of cirrhosis. Management of uncomplicated ascites includes sodium restriction and diuretic therapy, whereas that for refractory ascites (RA) is regular large-volume paracentesis with transjugular intrahepatic portosystemic shunt being offered in appropriate patients. Renal impairment occurs in up to 50% of patients with RA with type 1 hepatorenal syndrome (HRS) being most severe. Liver transplant remains the definitive treatment of eligible candidates with HRS, whereas combined liver and kidney transplant should be considered in patients requiring dialysis for more than 4 to 6 weeks or those with underlying chronic kidney disease.

An update on the pathogenesis and clinical management of cirrhosis with refractory ascites

Ascites commonly complicates cirrhosis, becoming refractory to treatment with diuretics and sodium restriction in approximately 10% of patients. Pathogenesis of refractory ascites (RA) is multifactorial, the common final pathway being renal hypoperfusion and avid sodium retention. Refractory ascites has a negative prognostic implication in the natural history of cirrhosis. Management of RA include sodium restriction and regular large volume paracentesis (LVP) with albumin infusions, preventing paracentesis-induced circulatory dysfunction. In appropriate setting, transjugular intrahepatic porto-systemic shunt (TIPS) can be considered. Ascites clearance with TIPS can lead to nutritional improvement, avoiding sarcopenia. Liver transplantation (LT) remains the definitive treatment for eligible candidates. Areas covered: Our review summarizes current updates on pathogenesis and clinical management of RA including potential future therapeutic options such as the automated slow-flow ascites pump, chronic outpatient albumin infusion and cell-free and concentrated ascites reinfusion therapy. Expert commentary: Standard of care in patients with RA include LVP with albumin replacement and prompt referral for LT where indicated. Other novel therapeutic options on the horizon include automated low-flow ascites pump and cell-free, concentrated albumin reinfusion therapy.

Soluble Myeloid Triggering Receptor Expressed on Myeloid Cell 1 Might Have More Diagnostic Value for Bacterial Ascites than C-reactive Protein

The timely and accurate diagnosis of ascites is of great significance for early treatment and prognostication. This study explored the value of soluble myeloid triggering receptor expressed on myeloid cell 1 (sTREM-1) and C-reactive protein (CRP) for assessing ascites. A total of 133 patients with ascites who received treatment at the Affiliated Hospital of Taishan Medical University between September 2015 and September 2017 were retrospectively analyzed. The ascites in 22, 45, 33 and 33 patients were tuberculous, bacterial, tumorous, and transudative, respectively. Healthy volunteers (n=30) who received a health examination at the same hospital during the same period constituted the control group. Before treatment, both ascitic sTREM-1 and CRP showed significant differences among the ascites subgroups (P<0.001), with the highest levels in the bacterial subgroup. Serum sTREM-1 and CRP also showed significant differences among the groups. A correlation analysis showed a positive correlation between sTREM-1 and CRP. ROC curves of the bacterial subgroup showed that when the optimal cutoff point was set to 20.2, the sensitivity, specificity, positive predictive value, and negative predictive value of the serum sTREM-1 index were 0.933, 0.955, 0.914, and 0.965, respectively. sTREM-1 may provide more diagnostic value than CRP for the diagnosis of bacterial ascites.

Tolvaptan treatment improves survival of cirrhotic patients with ascites and hyponatremia

Background

Although tolvaptan treatment improves hyponatremia, only few studies have investigated whether tolvaptan actually benefits the survival of cirrhotic patients. This study evaluated the impact of tolvaptan on six-month survival of decompensated cirrhotic patients with and without hyponatremia.

Methods

Two hundred forty-nine decompensated cirrhotic patients with or without hyponatremia were enrolled in a multicenter cohort study. Patients were divided into two groups according to receiving either tolvaptan or placebo treatment for 7-day. Subsequently, the patients were followed up for 6 months.

Results

Two hundred thirty patients, including 98 with hyponatremia (tolvaptan vs. placebo: 69 vs. 29) finished the study. Tolvaptan did not alter serum sodium levels and survival outcome of decompensated cirrhotic patients without hyponatremia. However, tolvaptan treatment remarkably improved serum sodium levels and six-month survival in patients with hyponatremia. Following tolvaptan treatment, serum sodium levels were restored to normal in 63.8% of patients, whereas in patients receiving placebo, only 36.2% showed the same effect (P < 0.05). Compared to a six-month survival rate of 68.97% in patients receiving placebo, the survival rate in tolvapatan-treated patients was 89.94% (P < 0.05). Furthermore, six-month survival rate in the tolvaptan-treated hyponatremia patients with resolved serum sodium was 81.32%, whereas the survival in those with unresolved serum sodium was only 24% (P < 0.05).

Conclusions

Tolvaptan improves short term survival in most decompensated cirrhotic hyponatremia patients with resolved serum sodium.

Trials registration

Clinical trial one: ClinicalTrials.gov ID:NCT00664014, Registered on April 14, 2008.

Clinical trial two: ClinicalTrials.gov ID:NCT01349335, Registered on March 5, 2010.

Clinical trial three: ClinicalTrials.gov ID:NCT01349348, Registered on May 4, 2011.

Right Atrium Invasion of Tumor Thrombus from Hepatocellular Carcinoma Incidentally Found on Transthoracic Echocardiogram

Hepatocellular carcinoma (HCC) is a highly aggressive malignancy in which tumor thrombus can invade portal and hepatic veins in late stages. However, an antemortem diagnosis of right atrial invasion by tumor thrombus is very rare and confers a poor prognosis. We report a patient with antemortem diagnosis of tumor thrombus in the right atrium incidentally found by transthoracic echocardiogram which was later confirmed with CT scan of abdomen with IV contrast. The patient was also noted to have an acute increase in alpha-fetoprotein (AFP). Our case suggests the importance of imaging studies and monitoring AFP levels in patients with long standing HCC.

Long-evolution ascites in a patient with constrictive pericarditis

Constrictive pericarditis (CP) is an uncommon disease resulting from chronic pericardial inflammation, fibrosis and calcification. Once there are atypical forms of presentation, with subtle or nonexistent cardiorespiratory symptoms, diagnosis may be challenging and difficult. Recurrent ascites in patients with congestive hepatopathy due to constrictive pericarditis is common and, in most cases, reversible after pericardiectomy. Nevertheless, development of persistent liver dysfunction may be a long-term complication. The present work describes a 23 years old man with growth delay, dyspnoea and long evolution ascites, whose exhaustive etiological investigation led to diagnosis. Afterwards the patient underwent elective surgery with symptom and general condition improvement. Ascites differential diagnosis and its association with constrictive pericarditis are briefly reviewed in this article.

Risk Factors for Intractable Ascites After Adult-to-Adult Living Donor Liver Transplantation Using Left Lobe

Background

Intractable ascites is one of the causes of graft loss after adult-to-adult living donor liver transplantation (LDLT) using a small graft. Identification of factors associated with increasing posttransplant ascites has important implications for prevention and treatment.

Methods

All 59 consecutive adult patients who underwent left lobe LDLT without portal inflow modulation between October 2002 and February 2016 were prospectively enrolled. Factors associated with the average daily amount of ascites for 2 weeks after LDLT were assessed.

Results

The median daily amount of ascites during the 2 weeks was 1052 mL (range, 52-3480 mL). Although 16 of the 59 patients developed intractable ascites, exceeding 1500 mL daily (massive ascites group), the remaining 43 patients produced less than 1500 mL of ascites daily (nonmassive ascites group). The presence of pretransplant ascites (P = 0.001), albumin (P = 0.011), albumin/globulin ratio (P = 0.026), cold ischemia time (P = 0.004), operation time (P = 0.022), and pretransplant portal vein pressure (PVP) (P = 0.047) differed significantly between the 2 groups. Neither posttransplant PVP nor portal vein flow differed between the 2 groups. The variables associated with intractable ascites that remained significant after logistic regression analysis were pretransplant PVP (P = 0.047) and cold ischemia time (P = 0.049). After appropriate fluid resuscitation for intractable ascites, 58 (98%) of the 59 recipients were discharged from hospital after removal of the indwelling drains.

Conclusions

It is important to shorten the scold ischemia time to reduce massive ascites after LDLT. Pretransplant portal hypertension is more closely associated with ascites production than posttransplant hemodynamic status.

Pancreas Adenocarcinoma: Ascites, Clinical Manifestations, and Management Implications

BACKGROUND

Ascites develops in a subset of patients with pancreatic adenocarcinoma (PAC) at presentation or as the disease advances. Limited data exist on the prognostic importance of malignant ascites in PAC. Our hypothesis is that this information will provide an understanding of the natural history and facilitate management decisions.

METHODS

We conducted a retrospective analysis of 180 patients treated at Memorial Sloan Kettering Cancer Center diagnosed between January 1, 2009 and December 31, 2014, with PAC and with ascites either at presentation or that developed during the disease course.

RESULTS

For the 180 patients, the overall survival was 15 months. The time from diagnosis to ascites presentation was 11 months, and the survival time after ascites development was 1.8 months (range, 1.6-2.3 months; 95% confidence interval). Of 62 patients (34%) who had ascitic fluid analyzed, 36 (58%) had positive cytology. Fifty-one (82%) patients had a serum ascites albumin gradient ≥ 1, and 11 (18%) had serum ascites albumin gradient < 1. Sixty-four (36%) patients had their ascites managed solely by serial paracenteses. A total of 116 patients required a catheter; of these, 108 (93%) had a Tenckhoff catheter, 4 (3%) a Pleurx catheter, 4 (3%) a pigtail catheter, and 1 (1%) a Denver catheter. Eight (7%) patients required 2 catheters to be placed, and in 6 (5%), Tenckhoff catheters had to be removed. The main observed complications were spontaneous bacterial peritonitis in 7 (11%) managed with paracenteses versus 26 (23%) who had a catheter placed, catheter malfunction in 8 (7%), and acute renal failure in 6 (3%). After ascites development, 79 (44%) patients received active anti-cancer therapy, and 101 (56%) patients were managed with supportive care alone.

CONCLUSIONS

In patients with PAC who presented with or developed ascites, serial paracenteses and indwelling catheters are common methods used for providing symptomatic relief. The complication rate was higher with indwelling catheters, primarily related to infection (eg, bacterial peritonitis). Overall, ascites has a significantly negative prognostic import with a short median survival.

The Hepatic Lymphatic Vascular System: Structure, Function, Markers, and Lymphangiogenesis

The lymphatic vascular system has been minimally explored in the liver despite its essential functions including maintenance of tissue fluid homeostasis. The discovery of specific markers for lymphatic endothelial cells has advanced the study of lymphatics by methods including imaging, cell isolation, and transgenic animal models and has resulted in rapid progress in lymphatic vascular research during the last decade. These studies have yielded concrete evidence that lymphatic vessel dysfunction plays an important role in the pathogenesis of many diseases. This article reviews the current knowledge of the structure, function, and markers of the hepatic lymphatic vascular system as well as factors associated with hepatic lymphangiogenesis and compares liver lymphatics with those in other tissues.

Safety and efficacy of long-term tolvaptan therapy for decompensated liver cirrhosis

AIM

Recently, the short-term efficacy of the vasopressin V2 receptor antagonist tolvaptan for the treatment of ascites in cirrhosis was reported. However, the long-term effects remain unknown. Here, we report the clinical features of decompensated cirrhosis treated using long-term tolvaptan therapy, and evaluate its safety and efficacy.

METHODS

Fifty-five cirrhotic patients hospitalized due to ascites, despite receiving appropriate diuretic treatment, were treated with tolvaptan. We excluded 35 patients due to liver transplant (20.0%), death (28.6%), poor general status (14.3%), improved ascites (5.7%) or other reasons (31.4%). In 20 cases treated with tolvaptan for 6 months, total body water (TBW) and extracellular fluids (ECW) were measured using bioelectric impedance analysis (BIA) with an InBody720.

RESULTS

The median age of the 20 patients was 64 years (range, 48-90), and 60% were male. The etiology of cirrhosis included hepatitis C (45%), alcohol-induced (20%) and other (35%). The percentage of patients with Child-Pugh class A, B and C was 0%, 40% and 60%, respectively. Biochemical findings revealed that serum creatinine levels and estimated glomerular filtration rate were not affected during 6 months of treatment with tolvaptan, and there was no renal disturbance. The median serum sodium levels were increased from 138 to 139 mEq/L, but serious adverse events related to renal and liver function were not observed. Data also revealed that long-term treatment reduced the BIA-estimated ECW/TBW ratio.

CONCLUSION

Long-term tolvaptan treatment was a safe and effective treatment for decompensated cirrhosis.

Gender, Age, Etiology, and Complications in Liver Transplant Candidates

Liver cirrhosis is the end stage of chronic liver disease (CLD), which is characterized by the appearance of fibrosis and regenerated nodules. It can be caused by different etiological factors. The only therapeutic modality is liver transplantation. The objective of this study was to describe the basic demographic characteristics, etiology, and complications of CLD in liver transplant candidates in patients of both genders. Autoimmune chronic disease was significantly more frequent in females (p = .022), whereas alcoholic liver disease was more frequent in males (p = .038). There was no difference between gender in other causes of CLD. Ascites was significantly higher in males (p = .041), whereas for other complications there was no difference between genders. Candidates for liver transplantation of different genders are different in the frequency of autoimmune and alcoholic liver disease, and the frequency of ascites. Frequency of other etiologies and complications does not relate to gender.

Presentation and complications associated with cirrhosis of the liver

OBJECTIVE

To provide an understanding of the detrimental impact of cirrhosis and its complications, strengths and weaknesses of current treatment options for the management of these complications, and new developments in this rapidly changing field.

RESEARCH DESIGN AND METHODS

Relevant publications were identified via PubMed and Cochrane databases, with additional references obtained by reviewing bibliographies from selected articles.

RESULTS

Cirrhosis, a progressive liver disease, is characterized by fibrosis caused by chronic liver injury. Liver fibrosis impairs hepatic function and causes structural changes that result in portal hypertension. Most patients with cirrhosis remain asymptomatic until they develop decompensated cirrhosis. At this stage, patients experience complications associated with portal hypertension (i.e., the abnormal increase in portal vein pressure), including ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy (HE), hepatorenal syndrome, portopulmonary hypertension, or variceal bleeding. In addition, intestinal microbial translocation in patients with cirrhosis might also cause SBP and HE. Because the survival rate for patients with cirrhosis substantially decreases once complications develop, the key goals in treating patients with cirrhosis include both managing the underlying liver disease and preventing and treating related complications. In patients with compensated cirrhosis, the management strategy is to prevent variceal bleeding and other complications that can lead to decompensated cirrhosis. Patients with decompensated cirrhosis are typically referred for liver transplantation, and the main focus of pre-transplant management is to eliminate the cause of cirrhosis (e.g., excess alcohol consumption, hepatitis virus) and prevent the recurrence of each decompensating complication.

CONCLUSIONS

Although substantial progress has been made to prevent the complications and mortality associated with cirrhosis, liver transplantation in combination with resolution of the etiology of cirrhosis remains the only curative option for most patients. Emerging therapies such as anti-fibrotic agents hold promise in potentially halting or reversing the progression of cirrhosis, even in patients with decompensated cirrhosis.

Palliative care for patients with end-stage liver disease

Liver disease results in over four million physician visits and over 750,000 hospitalizations per year in the USA. Those with chronic liver disease frequently progress to cirrhosis, end-stage liver disease (ESLD), and death. Patients with ESLD experience numerous complications, including muscle cramps, confusion (hepatic encephalopathy), protein calorie malnutrition, muscle wasting, fluid overload (ascites, edema), bleeding (esophagogastric variceal hemorrhage), infection (spontaneous bacterial peritonitis), fatigue, anxiety, and depression. Despite significant improvements in palliation of these complications, patients still suffer reduced quality of life and must confront the fact that their disease will often inexorably progress to death. Liver transplantation is a valid option in this setting, increasing the duration of survival and palliating many of the symptoms. However, many patients die waiting for an organ or are not candidates for transplantation due to comorbid illness. Others receive a transplant but succumb to complications of the transplant itself. Patients and families must struggle with simultaneously hoping for a cure while facing a life-threatening illness. Ideally, the combination of palliative care with life-sustaining therapy can maximize the patients' quality and quantity of life. If it becomes clear that life-sustaining therapy is no longer an option, these patients are then already in a system to help them with end-of-life care.

Management of refractory hepatic hydrothorax

PURPOSE OF REVIEW

Treatment of hepatic hydrothorax is challenging because of its rapid symptomatic recurrence. This review will focus on potential therapeutic approaches to hepatic hydrothorax.

RECENT FINDINGS

Hepatic hydrothorax is refractory to salt restriction and diuretics in approximately 25% of cases. Primary management options for these patients include serial thoracenteses, transjugular intrahepatic portosystemic shunt (TIPS) placement, and insertion of an indwelling pleural catheter (IPC). Response rate to TIPS, being the first choice whenever possible, is about 80%. IPC is emerging as a feasible alternative in patients who require frequent therapeutic thoracenteses, particularly if TIPS is contraindicated. Pleurodesis is not advocated because of the low likelihood of a pleural symphysis owing to the rapid re-accumulation of pleural fluid. The only cure for hepatic hydrothorax, a defined complication of end-stage liver disease, is liver transplantation.

SUMMARY

No single treatment option for refractory hepatic hydrothorax is ideal. However, in patients with contraindications to or who are awaiting liver transplantation, TIPS seems the most beneficial therapy, whereas IPC promises to be an alternative second-line consideration.

Clinical efficacy of tolvaptan for treatment of refractory ascites in liver cirrhosis patients

AIM

To evaluate the efficacy and safety of tolvaptan to treat refractory ascites in decompensated liver cirrhosis patients with or without further complications, such as hepatorenal syndrome and/or hepatocellular carcinoma.

METHODS

Thirty-nine patients (mean age 55 years, males: 32) with decompensated liver cirrhosis and refractory ascites were enrolled. All patients received a combination of tolvaptan (15 mg/d for 5-14 d) and diuretics (40-80 mg/d of furosemide and 80-160 mg/d of spironolactone). The etiology of cirrhosis included hepatitis B (69.2%), hepatitis C (7.7%) and alcohol-induced (23.1%). Changes in the urine excretion volume, abdominal circumference and edema were assessed. The serum sodium levels were also measured, and adverse events were recorded. A follow-up assessment was conducted 1 mo after treatment with tolvaptan.

RESULTS

Tolvaptan increased the mean urine excretion volume (1969.2 ± 355.55 mL vs 3410.3 ± 974.1 mL, P < 0.001), and 89.7% of patients showed improvements in their ascites, 46.2% of whom showed significant improvements. The overall efficacy of tolvaptan in all patients was 89.7%; the efficacies in patients with hepatocellular carcinoma and hepatorenal syndrome were 84.2% and 77.8%, respectively. The incidence of hyponatremia was 53.8%. In patients with hyponatremia, the serum sodium levels increased after tolvaptan treatment (from 128.1 ± 4.22 mEq/L vs 133.1 ± 3.8 mEq/L, P < 0.001). Only mild drug-related adverse events, including thirst and dry mouth, were observed.

CONCLUSION

Tolvaptan is a promising aquaretic for the treatment of refractory ascites in patients with decompensated liver cirrhosis.

Safety and efficacy of the PleurX catheter for the treatment of malignant ascites

BACKGROUND

Malignant ascites is a common complication seen in association with various types of neoplastic processes. Due to high recurrence rates, patients may require multiple paracenteses, which have associated complications such as increased risk of bleeding, infection, pain, and volume and electrolyte depletion.

OBJECTIVE

This study evaluated the management of malignant ascites by placement of the PleurX® tunneled catheter system at a single center.

METHODS

This was a retrospective study of 38 patients who underwent PleurX catheter placement for refractory malignant ascites between February 2006 and March 2012 at our institution. Pretreatment characteristics and outcome measures were reported using descriptive statistics.

RESULTS

The population included 21 males and 17 females with a mean age of 60.6 years (range, 36-79 years) diagnosed with metastatic disease from a variety of primary malignancies, the most common of which was pancreatic cancer (10 patients). In 84% of patients (32/38) who were not lost to follow-up, mean survival time was 40.7 days (range 4-434 days). Technical success rate of catheter placement was 100%.

CONCLUSIONS

The PleurX catheter can be used to manage malignant ascites in severely ill patients with metastatic cancer, with a high rate of procedural success and a low incidence of potentially serious adverse events, infections, or catheter-related complications.

Mathematical model of blood and interstitial flow and lymph production in the liver

We present a mathematical model of blood and interstitial flow in the liver. The liver is treated as a lattice of hexagonal ‘classic’ lobules, which are assumed to be long enough that end effects may be neglected and a two-dimensional problem considered. Since sinusoids and lymphatic vessels are numerous and small compared to the lobule, we use a homogenized approach, describing the sinusoidal and interstitial spaces as porous media. We model plasma filtration from sinusoids to the interstitium, lymph uptake by lymphatic ducts, and lymph outflow from the liver surface. Our results show that the effect of the liver surface only penetrates a depth of a few lobules’ thickness into the tissue. Thus, we separately consider a single lobule lying sufficiently far from all external boundaries that we may regard it as being in an infinite lattice, and also a model of the region near the liver surface. The model predicts that slightly more lymph is produced by interstitial fluid flowing through the liver surface than that taken up by the lymphatic vessels in the liver and that the non-peritonealized region of the surface of the liver results in the total lymph production (uptake by lymphatics plus fluid crossing surface) being about 5 % more than if the entire surface were covered by the Glisson–peritoneal membrane. Estimates of lymph outflow through the surface of the liver are in good agreement with experimental data. We also study the effect of non-physiological values of the controlling parameters, particularly focusing on the conditions of portal hypertension and ascites. To our knowledge, this is the first attempt to model lymph production in the liver. The model provides clinically relevant information about lymph outflow pathways and predicts the systemic response to pathological variations.