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Jacob S, Nguyen JH, El-Sayed Ahmed MM, Makey IA, Haddad OK, Thomas M, Sareyyupoglu B, Pham SM, Landolfo KP. Combined cardiac surgery procedures and liver transplant: a single-center experience. Gen Thorac Cardiovasc Surg 2022; 70:714-720. [PMID: 35146597 DOI: 10.1007/s11748-022-01783-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/27/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Morbidity and mortality rates associated with liver transplant are high for patients with concomitant heart disease. Traditionally, such cases were considered contraindications for transplant. The objective of our study was to assess the outcome of combined surgical approaches. METHODS A prospectively maintained database was analyzed of patients undergoing cardiac surgery and liver transplant at our institution. Twelve identified patients underwent combined cardiac operation and liver transplant. A control group was created (n = 24) with the same selection criteria. RESULTS Median patient age was 64.94 years in the combined group vs 63.80 in the control, and in both groups, 58% were male. Left ventricular ejection fraction (0.60), body mass index (30.1), and median (range) score of the Model for End-stage Liver Disease (18 [9-33]) were the same in both groups. The cardiac operations combined with liver transplant were coronary artery bypass grafting, valve replacement procedures, and ascending thoracic aortic aneurysm repair. Piggyback liver transplant was performed for all patients. Survival periods of 1, 5, and 10 years for control vs combined cases were 90 vs 62%, 79 vs 55%, and 70 vs 45%, respectively (P = 0.03). CONCLUSION Concomitant cardiac procedure and liver transplant is a valid treatment option and should be considered with risk stratification criteria of the patient with end-stage liver disease and cardiac surgical pathologic characteristics.
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Affiliation(s)
- Samuel Jacob
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA.
| | - Justin H Nguyen
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Magdy M El-Sayed Ahmed
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA
| | - Ian A Makey
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA
| | - Osama K Haddad
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA.,Division of Transplant Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Basar Sareyyupoglu
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA
| | - Kevin P Landolfo
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida, 32224, USA.,Division of Transplant Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Miño Bernal JF, López Morales E, Sandino NJ, Molano Franco D. Cirrosis hepática o falla hepática crónica agudizada: definición y clasificación. REPERTORIO DE MEDICINA Y CIRUGÍA 2022. [DOI: 10.31260/repertmedcir.01217372.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La cirrosis se considera el estadio crónico e irreversible de la lesión hepática. Su etiología es diversa y abarca causas como las infecciones víricas, tóxicos como el alcohol, medicamentos, patologías autoinmunes y otras. La descompensación de la cirrosis hepática es consecuencia de cambios fisiopatológicos que se dan con el tiempo como ascitis, peritonitis bacteriana espontánea, hemorragia del tubo digestivo, síndrome hepatorrenal, encefalopatía hepática o hipertensión portopulmonar, mientras que la falla hepática crónica agudizada debe considerarse como una entidad que debe diferenciarse de la anterior, ya que es una falla multiorgánica de curso rápido, por lo regular en pacientes hospitalizados en unidad de cuidado intensivo, a menudo secundaria a desencadenantes como estados de choque. El clínico debe identificarlas para su abordaje y evaluación. El método actual adecuado para estadificar esta entidad es el puntaje CLIFF SOFA, que evalúa la mortalidad a 28 y 90 días, permitiendo intervenciones adecuadas en cada caso.
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3
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Liu XQ, Zhang XY, Ying Y, Zheng JM, Sun J, Zhang WH, Zhang JM, Huang YX. The role of prophylactic antibiotics in hepatitis B virus-related acute-on-chronic liver failure patients at risk of bacterial infection: a retrospective study. Infect Dis Poverty 2021; 10:44. [PMID: 33789759 PMCID: PMC8011196 DOI: 10.1186/s40249-021-00830-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/19/2021] [Indexed: 12/13/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) is characterized by an excessive systemic inflammatory response and organ failure and has high mortality. Bacterial infections (BIs) worsen the clinical course of ACLF and carry a poor prognosis in ACLF patients. The efficacy of third-generation cephalosporins has been challenged in recent years. The aim of this study was to characterize the difference between ACLF patients with and without BIs and to provide a reference for medical intervention. Methods A total of 140 patients with hepatitis B virus-related ACLF (HBV-ACLF) hospitalized at the Department of Infectious Diseases, Huashan Hospital, Fudan University (Shanghai, China) between May 2013 and January 2020 were enrolled. Mann-Whitney U test was used to compare the baseline characteristics of HBV-ACLF patients with and without BIs. Univariate and multivariate analyses were performed to find predictors of BIs. The characteristics of BIs and the role of prophylactic antibiotics were profiled. Results A total of 97 episodes of BIs occurred in patients during the course of HBV-ACLF. Patients with and without BIs differed in clinical characteristics. The incidence of BIs showed a positive correlation with the ACLF grade (P = 0.003) and the clinical course (P = 0.003). The 90-day transplant-free survival of patients with BIs was lower than those without BIs (P < 0.0001). Patients administered prophylactic antibiotics showed a lower incidence of BIs and had a higher transplant-free survival probability than those who did not (P = 0.046). No statistical differences in antibiotic efficacy between third-generation and other antibiotics were observed (P = 0.108). Conclusions BIs affected the clinical course and prognosis of patients with HBV-ACLF. Prophylactic antibiotics were of potential clinical importance in the prevention of BIs and improving the clinical course and prognosis in HBV-ACLF patients. Third-generation cephalosporins were qualified for use in antibiotic prophylaxis. ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00830-7.
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Affiliation(s)
- Xiao-Qin Liu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China
| | - Xue-Yun Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China
| | - Yue Ying
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China
| | - Jian-Ming Zheng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China
| | - Jian Sun
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China
| | - Wen-Hong Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China
| | - Ji-Ming Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China
| | - Yu-Xian Huang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China.
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A Stepwise Evaluation of Hepatitis B Virus-Related Acute-on-Chronic Liver Failure to Optimize the Indication for Urgent Liver Transplantation. Dig Dis Sci 2021; 66:284-295. [PMID: 32140946 DOI: 10.1007/s10620-020-06149-x] [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: 09/29/2019] [Accepted: 02/13/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a dynamic but reversible disease. AIM We aimed to clarify whether the change in Chinese Group on the Study of Severe Hepatitis B-ACLF (COSSH-ACLF) grade in HBV-ACLF patients can be used to predict prognosis, and to explore the appropriate conditions for performing urgent liver transplantation. METHODS We assessed the COSSH-ACLF grades of HBV-ACLF patients at different time points from June 2013 to May 2019 at Huashan Hospital in Shanghai, China, and analyzed the relationship between the change in grade and patient prognosis. RESULTS A total of 207 HBV-ACLF patients were enrolled, of which 79 underwent urgent liver transplantation. Their COSSH-ACLF grades were calculated at diagnosis, 3-7 days after diagnosis, and on the final day. Most of the final ACLF grades were consistent with their corresponding grades at days 3-7 after diagnosis (62.5%), while only 44.5% were in accordance with the initial grades at diagnosis. In patients who had a poor prognosis (initial ACLF-3 and ACLF-2 or -3 at days 3-7), the 28-day survival rate was 93.3% in those who underwent transplantation and 6.8% in those who did not (P < 0.0001). However, in patients who had a good prognosis (ACLF-0 or ACLF-1 at days 3-7), the 28-day survival rate was 100% in transplanted patients and 91.5% in non-transplanted patients (P = 0.236). CONCLUSIONS Reevaluation of the COSSH-ACLF grade 3-7 days after diagnosis could potentially show an indication for urgent liver transplantation.
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Karagozian R, Bhardwaj G, Wakefield DB, Verna EC. Acute kidney injury is associated with higher mortality and healthcare costs in hospitalized patients with cirrhosis. Ann Hepatol 2020; 18:730-735. [PMID: 31175020 DOI: 10.1016/j.aohep.2019.03.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 03/09/2019] [Accepted: 02/09/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES AKI is known to be associated with increased risk of mortality, however limited information is available on how AKI impacts healthcare costs and resource utilization in hospitalized patients with cirrhosis. Previous studies have had variable definitions of AKI, resulting in inconsistent reporting of the true impact of AKI in patients with cirrhosis. METHODS Data from the Nationwide Inpatient Sample (NIS) which contains data from 44 states and 4378 hospitals, accounting for over 7 million discharges were analyzed. The inclusion data were all discharges in the 2012 NIS dataset with a discharge diagnosis of cirrhosis. RESULTS A total of 32,605 patients were included in the analysis, incidence of AKI was 12.12% in patients with cirrhosis. Crude mortality was much higher for patients with cirrhosis and AKI (14.9% vs. 1.8%, OR 9.42, p<0.001) than for patients without AKI. In addition, mean LOS was longer (8.5 vs. 4.3 days, p<0.001) and median total hospital charges were higher for patients with AKI ($43,939 vs. $22,270, p<0.001). In multivariate logistic regression, controlling for covariates and mortality risk score, sepsis, ascites and SBP were predictors of AKI. CONCLUSIONS AKI is relatively common in hospitalized patients with cirrhosis. Presence of AKI results in significantly higher inpatient mortality as well as LOS and resource utilization. Median hospitalization cost was twice as high in AKI patients. Early identification of patients at high risk for AKI should be implemented to reduce mortality and contain costs. Prognosis could be enhanced by utilizing biomarkers which could rapidly detect AKI.
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Affiliation(s)
- Raffi Karagozian
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, United States.
| | - Gaurav Bhardwaj
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Dorothy B Wakefield
- Center for Public Health and Health Policy, UConn Health, Farmington, CT, United States; St Francis Hospital & Medical Center, Hartford, CT, United States
| | - Elizabeth C Verna
- New York Presbyterian-Columbia University Medical Center, New York, NY, United States
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Impact of cardiac function, refractory ascites and beta blockers on the outcome of patients with cirrhosis listed for liver transplantation. J Hepatol 2020; 72:463-471. [PMID: 31622697 DOI: 10.1016/j.jhep.2019.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/27/2019] [Accepted: 10/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Whether non-selective beta blockers (NSBBs) are deleterious in patients with end-stage cirrhosis and refractory ascites has been widely debated. We hypothesized that only the subset of patients on the liver transplant waiting list who had impaired cardiac performance would be at increased risk of mortality if receiving NSBBs. METHODS This study included 584 consecutive patients with cirrhosis evaluated for transplantation between 1999 and 2014. All patients had right heart catheterization with hemodynamic measurements at evaluation. Fifty percent received NSBBs. Refractory ascites was present in 33%. Cardiac performance was assessed by left ventricular stroke work index (LVSWI). Waiting list mortality without liver transplantation was explored using competing risk analysis. RESULTS LVSWI was significantly lower in patients with refractory ascites. In multivariate analysis using competing risk, refractory ascites, NSBBs and LVSWI were associated with waiting list mortality in the whole population, with a statistically significant interaction between NSBBs and LVSWI. The most discriminant value of LVSWI was 64.1 g-m/m2. In the final model, refractory ascites (subdistribution hazard ratio 1.52; 95% CI1.01-2.28; p = 0.0083) and treatment by NSBBs with LVSWI <64.1 g-m/m2 (subdistribution hazard ratio 1.96; 95% CI 1.32-2.90; p = 0.0009) were significantly associated with waiting list mortality, taking into account serum sodium and the model for end-stage liver disease score. CONCLUSIONS This study suggests that compromised cardiac performance is more common in patients with refractory ascites and that NSBBs are deleterious in cirrhotic patients with compromised cardiac performance. These results highlight the prognostic value of cardiac function in patients with end-stage cirrhosis. LAY SUMMARY There are still controversies concerning the impact of non-selective beta blockers on outcomes in patients with decompensated cirrhosis, especially in those with refractory ascites. In this study of 584 cirrhotic patients evaluated for liver transplantation, who underwent right heart catheterization, we have shown that global cardiac performance measured by left ventricular stroke work index is lower in patients with refractory ascites. Administration of non-selective beta blockers in patients with compromised cardiac performance may increase waiting list mortality. These results highlight the prognostic value of global cardiac performance in patients with end-stage cirrhosis.
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Ding X, Yu Y, Chen M, Wang C, Kang Y, Lou J. Causative agents and outcome of spontaneous bacterial peritonitis in cirrhotic patients: community-acquired versus nosocomial infections. BMC Infect Dis 2019; 19:463. [PMID: 31122192 PMCID: PMC6533661 DOI: 10.1186/s12879-019-4102-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 05/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is a serious complication and common cause of death in patients with liver cirrhosis. This study was conducted to compare the microbiological characteristics, drug resistance, and treatment outcomes for nosocomial SBP and community-acquired SBP. Methods A retrospective study was performed on 334 patients with culture-positive SBP at Beijing Youan Hospital, China, between January 2012 and December 2016. The medical records for these patients were reviewed, and their clinical and laboratory data were analyzed. Results A total of 155 (46.4%) patients with nosocomial SBP and 179 (53.6%) with community-acquired SBP were included in this study. From the patients’ ascitic fluids, 334 pathogenic strains, including 178 Gram-negative bacterial strains, 138 Gram-positive bacterial strains and 18 other microbial strains were isolated. E. coli was the major pathogen (24.3%), followed by Klebsiella pneumoniae (12.0%) and Enterococcus faecium (10.5%). The proportion of Enterococcus was significantly higher in the patients with nosocomial SBP (6.1% vs. 27.7%, P < 0.001) than in the patients with community-acquired SBP. The main pathogens isolated from the nosocomial infections were significantly more resistant to the first-line recommended drug. Compared with community-acquired SBP, nosocomial SBP had a poorer outcome (36.8% vs. 24.6%; P = 0.016). The independent predictors for 30-day mortality included nosocomial infection, Child-Pugh classification, hepatocellular carcinoma, renal failure and hepatic encephalopathy. Conclusion Gram-negative bacteria were the major pathogens involved in SBP in the cirrhotic patients. The strains isolated from the patients with nosocomial SBP displayed higher drug resistance than those isolated from patients with community-acquired SBP. Compared with community-acquired SBP, nosocomial SBP had a poorer outcome. When choosing drug treatments, the acquisition site of infection and the local epidemiological situation should be taken into account.
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Affiliation(s)
- Xiurong Ding
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Yanhua Yu
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Ming Chen
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Chen Wang
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Yanfang Kang
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Jinli Lou
- Department of Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
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8
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Heidari R, Mandegani L, Ghanbarinejad V, Siavashpour A, Ommati MM, Azarpira N, Najibi A, Niknahad H. Mitochondrial dysfunction as a mechanism involved in the pathogenesis of cirrhosis-associated cholemic nephropathy. Biomed Pharmacother 2019; 109:271-280. [DOI: 10.1016/j.biopha.2018.10.104] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 10/17/2018] [Accepted: 10/20/2018] [Indexed: 12/12/2022] Open
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Wu T, Li J, Shao L, Xin J, Jiang L, Zhou Q, Shi D, Jiang J, Sun S, Jin L, Ye P, Yang L, Lu Y, Li T, Huang J, Xu X, Chen J, Hao S, Chen Y, Xin S, Gao Z, Duan Z, Han T, Wang Y, Gan J, Feng T, Pan C, Chen Y, Li H, Huang Y, Xie Q, Lin S, Li L, Li J. Development of diagnostic criteria and a prognostic score for hepatitis B virus-related acute-on-chronic liver failure. Gut 2018; 67:2181-2191. [PMID: 28928275 DOI: 10.1136/gutjnl-2017-314641] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The definition of acute-on-chronic liver failure (ACLF) based on cirrhosis, irrespective of aetiology, remains controversial. This study aimed to clarify the clinicopathological characteristics of patients with hepatitis B virus-related ACLF (HBV-ACLF) in a prospective study and develop new diagnostic criteria and a prognostic score for such patients. DESIGN The clinical data from 1322 hospitalised patients with acute decompensation of cirrhosis or severe liver injury due to chronic hepatitis B (CHB) at 13 liver centres in China were used to develop new diagnostic and prognostic criteria. RESULTS Of the patients assessed using the Chronic Liver Failure Consortium criteria with the exception of cirrhosis, 391 patients with ACLF were identified: 92 with non-cirrhotic HBV-ACLF, 271 with cirrhotic HBV-ACLF and 28 with ACLF with cirrhosis caused by non-HBV aetiologies (non-HBV-ACLF). The short-term (28/90 days) mortality of the patients with HBV-ACLF were significantly higher than those of the patients with non-HBV-ACLF. Total bilirubin (TB) ≥12 mg/dL and an international normalised ratio (INR) ≥1.5 was proposed as an additional diagnostic indicator of HBV-ACLF, and 19.3% of patients with an HBV aetiology were additionally diagnosed with ACLF. The new prognostic score (0.741×INR+0.523×HBV-SOFA+0.026×age+0.003×TB) for short-term mortality was superior to five other scores based on both discovery and external validation studies. CONCLUSIONS Regardless of the presence of cirrhosis, patients with CHB, TB ≥12 mg/dL and INR ≥1.5 should be diagnosed with ACLF. The new criteria diagnosed nearly 20% more patients with an HBV aetiology with ACLF, thus increasing their opportunity to receive timely intensive management.
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Affiliation(s)
- Tianzhou Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiang Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li Shao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiaojiao Xin
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Longyan Jiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qian Zhou
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dongyan Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jing Jiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Suwan Sun
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Linfeng Jin
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ping Ye
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lingling Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yinyun Lu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianrong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaowei Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiajia Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaorui Hao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuemei Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaojie Xin
- Department of Liver and Infectious Diseases, No. 302 Hospital of Chinese People's Liberation Army, Beijing, China
| | - Zhiliang Gao
- Department of Liver and Infectious Diseases, The Third Affiliated Hospital, Sun YAT-SEN University, Guangzhou, China
| | - Zhongping Duan
- Department of Liver and Infectious Diseases, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Tao Han
- Department of Liver and Infectious Diseases, Tianjin Third Central Hospital, Tianjin, China
| | - Yuming Wang
- Department of Liver and Infectious Diseases, The First Hospital Affiliated of The Third Military Medical University, Chongqing, China
| | - Jianhe Gan
- Department of Liver and Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Tingting Feng
- Department of Liver and Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chen Pan
- Department of Liver and Infectious Diseases, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Yongping Chen
- Department of Liver and Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hai Li
- Department of Gastroenterology, Renji Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Huang
- Department of Liver and Infectious Diseases, Xiangya Hospital Central South University, Changsha, China
| | - Qing Xie
- Department of Liver and Infectious Diseases, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shumei Lin
- Department of Liver and Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Abstract
Decompensated liver cirrhosis has a dismal prognosis, with an overall survival of 2-4 years, which is worse than for many oncological diseases. Albumin is an important tool in the management of patients with cirrhosis, since it decreases for less than half the risk for post-paracentesis cardiocirculatory dysfunction and mortality associated with spontaneous bacterial infection, as well as, it triplicates the response to terlipressin in patients with hepatorenal syndrome. Recently, research on albumin has been a hot topic, with important new insights such as the characterization of the pleiotropic effects of albumin (which surpass its oncotic properties) and the concept of effective albumin concentration. In fact, patients with liver cirrhosis present posttranslational modifications on albumin that compromises its function. Those modified albumin forms were proved to have prognostic value and its knowledge may change the paradigm of albumin treatment. In this review, we critically summarize the latest evidence on the potential benefits of albumin in patients with end-stage liver disease.
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Affiliation(s)
- Joana R Carvalho
- Department of Gastroenterology and Hepatology, Hospital Santa Maria, Lisbon, Portugal
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11
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Multiple bacterial infections increase the risk of hepatic encephalopathy in patients with cirrhosis. PLoS One 2018; 13:e0197127. [PMID: 29746564 PMCID: PMC5945008 DOI: 10.1371/journal.pone.0197127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 04/26/2018] [Indexed: 02/07/2023] Open
Abstract
Objective Patients with liver cirrhosis (LC) are at increased risk for bacterial infections. It is not fully understood how exposure to infections induces further development of hepatic encephalopathy (HE). This study estimated risks of infection associated with HE among patients with LC. Methods A nested case-control study of 14,428 adult patients with LC was performed using the population-based Longitudinal Health Insurance Database 2000 in Taiwan. Cases were cirrhotic patients who developed HE during follow-up. Controls were matched to each case by age at LC diagnosis (±2 years), sex, Charlson Comorbid index score, year of LC, and follow-up time with a 1:1 ratio. A multivariate logistic regression model was used to determine and compare the odds of developing HE based on exposure to various risk factors, including site of infection, cirrhosis-related complications, Helicobacter pylori eradication therapy, and peptic ulcer bleeding. Patient survival was evaluated using the time-dependent Cox regression model. Results Cirrhotic patients with HE (n = 714) and without HE (n = 714) were matched to compare risks. Infections and more frequent yearly infections were significantly associated with increased risk of HE. Independent predictors of HE included spontaneous bacterial peritonitis (aOR, 5.13; 95% CI, 3.03–8.69), sepsis (aOR, 2.54; 95% CI, 1.82–-3.53), and biliary tract infection (aOR, 2.03; 95% CI, 1.2–3.46), controlling for confounders. Conclusion Frequent infections are associated with increased risk of HE in cirrhotic patients. More frequent exposure to infection increases the risk of HE and mortality rates. Appropriate prevention of infection and the use of antibiotics for cirrhotic patients at risk for HE are needed.
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The effect of albumin administration on renal dysfunction after experimental surgical obstructive jaundice in male rats. JOURNAL OF TAIBAH UNIVERSITY FOR SCIENCE 2018. [DOI: 10.1016/j.jtusci.2015.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Lee JM, Lee JH, Kim ES, Lee JM, Yoo IK, Kim SH, Choi HS, Keum B, Seo YS, Jeen YT, Lee HS, Chun HJ, Um SH, Kim CD. The safety and effectiveness of 2-liter polyethylene glycol plus ascorbic acid in patients with liver cirrhosis: A retrospective observational study. Medicine (Baltimore) 2017; 96:e9011. [PMID: 29390432 PMCID: PMC5758134 DOI: 10.1097/md.0000000000009011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The safety of bowel-cleansing agents is an important issue in clinical practice, especially in patients with chronic diseases. Although the safety and efficacy of polyethylene glycol (PEG) has been investigated in many studies, few studies on PEG plus ascorbic acid exist. In this study, we compared the safety of 2 bowel-cleansing agents for patients with liver cirrhosis: 2-liter PEG (2 L PEG) plus ascorbic acid versus 4-liter PEG (4 L PEG). We performed a retrospective study on colonoscopy in patients with liver cirrhosis. Patients referred for colonoscopy were divided into 2 groups: 2 L PEG plus ascorbic acid (n = 105) and 4 L PEG (n = 61). Safety was assessed by comparing the clinical factors and laboratory findings as follows: blood biochemistry, electrolytes, weight change, and bowel-cleansing quality. Serum electrolytes, laboratory findings, and body weight showed no significant change between the 2 groups. There was no significant change in clinical factors before and after bowel preparation in the PEG group or the PEG plus ascorbic acid group. The acceptability and compliance of patients was better in the 2 L PEG plus ascorbic acid than the 4 L PEG group. In subgroup analysis, patients with compensated or decompensated cirrhosis showed no increased risk of electrolyte imbalances after bowel preparation. Child-Pugh scores did not influence the outcome after bowel cleansing. Successful cleansing was mostly achieved in both groups. Our analysis showed that of the use of 2 L PEG plus ascorbic acid could be a safe choice for colonoscopy in patients with liver cirrhosis.
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Musso CG, Juarez R, Glassock RJ. Water, electrolyte, acid–base, and trace elements alterations in cirrhotic patients. Int Urol Nephrol 2017; 50:81-89. [DOI: 10.1007/s11255-017-1614-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/02/2017] [Indexed: 12/20/2022]
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15
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Han EC, Ryoo SB, Park JW, Yi JW, Oh HK, Choe EK, Ha HK, Park BK, Moon SH, Jeong SY, Park KJ. Oncologic and surgical outcomes in colorectal cancer patients with liver cirrhosis: A propensity-matched study. PLoS One 2017; 12:e0178920. [PMID: 28586376 PMCID: PMC5460849 DOI: 10.1371/journal.pone.0178920] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/22/2017] [Indexed: 02/06/2023] Open
Abstract
The management of colorectal cancer in patients with liver cirrhosis requires a thorough understanding of both diseases. This study evaluated the effect of liver cirrhosis on oncologic and surgical outcomes and prognostic factors in colorectal cancer patients. Fifty-five consecutive colorectal cancer patients with liver cirrhosis underwent colorectal resection (LC group). Using a prospectively maintained database, these patients were matched 1:4 using propensity scoring with R programming language, package "MatchIt" and "optmatch" by sex, age, cancer location, and tumor stage with 220 patients without liver cirrhosis (non-LC group), resulting in 275 patients. The 5-year overall survival (OS) was significantly worse in the LC group than in the non-LC group (46.7% vs. 76.2% respectively, P < 0.001); however, the 5-year proportion of recurrence free (PRF) rates were similar (73.1% vs. 84.5% respectively, P = 0.094). On multivariate analysis of the LC group, tumor-node-metastasis (TNM) stage ≥III disease, venous invasion, and a model for end-stage liver disease plus serum sodium (MELD-Na) score >10 were prognostic factors for OS. However, the OS was not different between the LC group with MELD-Na score ≤10 and the non-LC group (5-year OS rate, TNM stage ≤II, 85.7 vs 89.5%, p = 0.356; TNM stage ≥III, 41.1 vs 66.2%, p = 0.061). Colorectal cancer patients with liver cirrhosis have poorer OS compared to those without liver cirrhosis; however, the PRF rates are similar. It might be due to the mortality from the liver, and surgical treatment should be actively considered for patients with MELD-Na score <10.
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Affiliation(s)
- Eon Chul Han
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Wook Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eun Kyung Choe
- Seoul National University Hospital Gangnam Center, Seoul, Korea
| | - Heon-Kyun Ha
- Department of Surgery, Seonam University College of Medicine Myongji Hospital, Goyang, Gyeonggi Province, Korea
| | - Byung Kwan Park
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Sang Hui Moon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Soliman AM, Mohamed AS, Marie MAS. Echinochrome pigment attenuates diabetic nephropathy in the models of type 1 and type 2 diabetes. DIABETES MELLITUS 2016. [DOI: 10.14341/dm8039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background. The main complication of diabetes mellitus is diabetic nephropathy in both types, which is a main reason for renal failure. Echinochrome substance present in sea urchin shells and spines and possesses high antioxidant activity.Aim. is to evaluate the ability of Ech to suppress the progression of diabetic complication in kidney.Materials and methods. Thirty-six male Wistar albino rats were divided into two main groups, type 1 diabetes mellitus and type 2 diabetes mellitus. Both groups divided into control, diabetic and echinochrome subgroups. Type 1 diabetes was induced by single dose of streptozotocin (60 mg/kg, i.p), while type 2 was induced by high fat diet for 4 weeks before the injection with streptozotocin (30 mg/kg, i.p). The treated groups were administrated by echinochrome (1mg/kg body weight in 10% DMSO) daily for 4 weeks.Results. Echinochrome groups showed reduction in the concentrations of glucose, malondialdehyde, urea, uric acid and creatinine. While it caused general increase in glutathione-S-transferase, superoxide dismutase, catalase, glutathione reduced, nitric oxide and creatinine clearance. The histopathological investigation showed clear improvement in the kidney architecture.Conclusion. Administration of echinochrome improves renal function and ameliorates renal histopathological changes possibly by improvement of glucose metabolism and inhibition of lipid peroxidation process.
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Kumbasar A, Navdar M, Ataoglu E, Uzunhasan I, Ergen K, Poturoglu S, Basinoglu F, Yilmaz F, Yenigun M, Sar F, Tanriverdi O. N-Terminal pro-B-Type Natriuretic Peptide Levels are Linked with Modified Child-Pugh Classification in Patients with Nonalcoholic Cirrhosis [NT-ProBNP and Liver Cirrhosis]. Cell Biochem Biophys 2016; 75:111-117. [PMID: 27914003 DOI: 10.1007/s12013-016-0773-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 11/25/2016] [Indexed: 01/21/2023]
Abstract
Excess N-terminal pro-brain natriuretic peptide secretion has been linked to cirrhosis in previously studies. The relationship of plasma N-terminal pro-brain natriuretic peptide levels and cardiac dysfunction determined by echocardiography were investigated in patients with nonalcoholic cirrhosis and a control group of chronic hepatitis. This study was designed as a cross-sectional study. Thirty-two men and thirty-three women who gave informed consent who were followed-up for chronic liver failure were enrolled. All patients gave clinical history, physical examination was carried out and information about ongoing medication has been obtained. Serum N-terminal pro-brain natriuretic peptide level was measured in all patients. The same cardiologist determined ejection fraction, end-diastolic left ventricular diameter, interventricular septum, and posterior wall on transthoracic echocardiography. Patients with extensive liver disease according to Child-Pugh classification from A to C had increasing N-terminal pro-brain natriuretic peptide levels in association (P < .001). According to the Child-Pugh classification there were no significant difference between groups for echocardiographic measurements (P > .05). N-terminal pro-brain natriuretic peptide may be an important marker for cardiac dysfunction in patients with chronic liver failure in accordance with Child-Pugh stage.
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Affiliation(s)
- Abdulbaki Kumbasar
- Clinic of Internal Medicine, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Mehtap Navdar
- Clinic of Internal Medicine, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Esra Ataoglu
- Clinic of Internal Medicine, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Isil Uzunhasan
- Department of Cardiology, Istanbul University Institute of Cardiology, Istanbul, Turkey
| | - Kadir Ergen
- Clinic of Internal Medicine, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Sule Poturoglu
- Department of Gastroenterohepatology, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Filiz Basinoglu
- Clinic of Biochemistry, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Fatih Yilmaz
- Clinic of Internal Medicine, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Yenigun
- Clinic of Internal Medicine, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Fuat Sar
- Clinic of Internal Medicine, Haseki Education and Research Hospital, Istanbul, Turkey
| | - Ozgur Tanriverdi
- Department of Internal Medicine, Trakya University Faculty of Medicine, Edirne, Turkey.
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Abd El-Latif AAEA, Sayed AA, Soliman AM, Fahmy SR. Exploration of the therapeutic potential effect of Sepia officinalis in animal model of sepsis induced by cecal ligation and puncture. Injury 2016; 47:2709-2717. [PMID: 27743598 DOI: 10.1016/j.injury.2016.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 10/05/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The present investigation explored the therapeutic potential effect of Sepia officinalis body tissue (SOBT) and Sepia officinalis polysaccharide (SOP) extracts, in animal model of sepsis [induced by cecal ligation and puncture (CLP)]. MATERIALS AND METHODS Experimental animals were divided into 4 groups, Group 1: Sham control rats. Group 2: Septic rats. Group 3: Septic rats treated with methanolic extract of Sepia officinalis body tissue (SOBT) (500mg/kg body weight) for 2days. Group 4: Septic rats treated with Sepia officinalis polysaccharide (SOP) extract (200mg/kg body weight) for 2days. RESULTS The antioxidant activity of SOBT and SOP was proven by DPPH test. CLP-induced liver and kidney toxicities showed by an increase in the ALAT, ASAT, γGT, ALP, creatinine, BUN and uric acid concentrations in serum. Moreover, CLP-induced oxidative stress in liver and kidney evidenced by the increase of MDA levels, decrease in GSH concentrations and decrease in the enzymatic antioxidants (SOD, CAT, GST). In addition, CLP caused decrease in CYP1A2 content in liver. CONCLUSIONS Our findings demonstrate the therapeutic efficacy of SOBT and SOP in liver and kidney disorders. Therefore this study suggests that SOBT and SOP could be a potential therapeutic agents for sepsis treatment.
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Affiliation(s)
| | - Amany Ahmed Sayed
- Zoology Department, Faculty of Science, Cairo University, 12613, Giza, Egypt.
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Boyer TD, Sanyal AJ, Wong F, Frederick RT, Lake JR, O'Leary JG, Ganger D, Jamil K, Pappas SC. Terlipressin Plus Albumin Is More Effective Than Albumin Alone in Improving Renal Function in Patients With Cirrhosis and Hepatorenal Syndrome Type 1. Gastroenterology 2016; 150:1579-1589.e2. [PMID: 26896734 DOI: 10.1053/j.gastro.2016.02.026] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 02/09/2016] [Accepted: 02/10/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Hepatorenal syndrome type 1 (HRS-1) in patients with cirrhosis and ascites is a functional, potentially reversible, form of acute kidney injury characterized by rapid (<2 wk) and progressive deterioration of renal function. Terlipressin is a synthetic vasopressin analogue that acts, via vascular vasopressin V1 receptors, as a systemic vasoconstrictor. We performed a phase 3 study to evaluate the efficacy and safety of intravenous terlipressin plus albumin vs placebo plus albumin in patients with HRS-1. METHODS Adult patients with cirrhosis, ascites, and HRS-1 (based on the 2007 International Club of Ascites criteria of rapidly deteriorating renal function) were assigned randomly to groups given intravenous terlipressin (1 mg, n = 97) or placebo (n = 99) every 6 hours with concomitant albumin. Treatment continued through day 14 unless the following occurred: confirmed HRS reversal (CHRSR, defined as 2 serum creatinine [SCr] values ≤1.5 mg/dL, at least 40 hours apart, on treatment without renal replacement therapy or liver transplantation) or SCr at or above baseline on day 4. The primary end point was the percentage of patients with confirmed CHRSR. Secondary end points included the incidence of HRS reversal (defined as at least 1 SCr value ≤1.5 mg/dL while on treatment), transplant-free survival, and overall survival. The study was performed at 50 investigational sites in the United States and 2 in Canada, from October 2010 through February 2013. RESULTS Baseline demographic/clinical characteristics were similar between groups. CHRSR was observed in 19 of 97 patients (19.6%) receiving terlipressin vs 13 of 99 patients (13.1%) receiving placebo (P = .22). HRS reversal was achieved in 23 of 97 (23.7%) patients receiving terlipressin vs 15 of 99 (15.2%) receiving placebo (P = .13). SCr decreased by 1.1 mg/dL in patients receiving terlipressin and by only 0.6 mg/dL in patients receiving placebo (P < .001). Decreases in SCr and survival were correlated (r(2) = .882; P < .001). Transplant-free and overall survival were similar between groups. A significantly greater proportion of patients with CHRSR who received terlipressin survived until day 90 than patients who did not have CHRSR after receiving terlipressin (P < .001); this difference was not observed in patients who did vs did not have CHRSR after receiving placebo (P = .28). There were similar numbers of adverse events in each group, but patients in the terlipressin group had more ischemic events. CONCLUSIONS Terlipressin plus albumin was associated with greater improvement in renal function vs albumin alone in patients with cirrhosis and HRS-1. Patients had similar rates of HRS reversal with terlipressin as they did with albumin. ClinicalTrials.gov no: NCT01143246.
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Affiliation(s)
- Thomas D Boyer
- Department of Medicine, University of Arizona, Tucson, Arizona.
| | - Arun J Sanyal
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R Todd Frederick
- Department of Medicine, California Pacific Medical Center, San Francisco, California
| | - John R Lake
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - Daniel Ganger
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - Khurram Jamil
- Ikaria Therapeutics, LLC, a Mallinckrodt Company, Hampton, New Jersey
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Kim JH, Jeon YD, Jung IY, Ahn MY, Ahn HW, Ahn JY, Ku NS, Han SH, Choi JY, Ahn SH, Song YG, Han KH, Kim JM. Predictive Factors of Spontaneous Bacterial Peritonitis Caused by Gram-Positive Bacteria in Patients With Cirrhosis. Medicine (Baltimore) 2016; 95:e3489. [PMID: 27124049 PMCID: PMC4998712 DOI: 10.1097/md.0000000000003489] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is typically caused by gram-negative bacteria. However, the number of SBP cases due to gram-positive bacteria is steadily increasing. To date, little is known about the predictive factors involved in SBP infections.We performed a retrospective cohort study of patients (>18 years) with SBP due to gram-positive and -negative bacteria who were enrolled from January 2006 to December 2013 at Severance Hospital in Seoul, Korea where the incidences of hepatitis B virus associated chronic liver disease, cirrhosis, and hepatocellular carcinoma are high. Only the 1st SBP episode for each patient within the study period was included in our analysis.We identified 77 patients with cirrhosis and SBP. Of these, 27 patients (35%) had gram-positive bacterial infections and 50 patients (65%) had gram-negative bacterial infections. Our univariate analysis revealed that an early stage of cirrhosis (P = 0.004), lower creatinine level (P = 0.011), lower Sequential Organ Failure Assessment (SOFA) score (P = 0.001), lower Model for End-Stage Liver Disease score (P = 0.005), and use of systemic antibiotics within 30 days before SBP diagnosis (P = 0.03) were significantly associated with gram-positive bacterial infections. Our multivariate analysis indicated that the use of systemic antibiotics within 30 days before SBP diagnosis (odds ratio, 3.94; 95% CI, 1.11-13.96; P = 0.033) and a lower SOFA score (odds ratio, 0.56; 95% CI, 0.37-0.86; P = 0.007) were independent predictive factors of SBP caused by gram-positive bacterial infections in patients with cirrhosis. However, we did not observe a statistically significant difference in the 28-day mortality between the gram-positive and -negative bacterial infection groups (40.7% vs 46.0%, respectively; P = 0.407).In this study, the incidence rate of SBP caused by gram-positive bacteria in patients with cirrhosis was similar to the rates reported in recently published studies. Furthermore, the use of systemic antibiotics within 30 days before SBP diagnosis and a lower SOFA score were significantly associated with SBP caused by gram-positive bacteria in patients with cirrhosis.
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Affiliation(s)
- Jung Ho Kim
- From the Department of Internal Medicine (JHK, YDJ, IYJ, MYA, HWA, JYA, NSK, SHH, JYC, SHA, YGS, KHH, JMK); and AIDS Research Institute, Severance Hospital (YDJ, MYA, HWA, JYA, NSK, SHH, JYC, YGS, JMK), Yonsei University College of Medicine, Seoul, Republic of Korea
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Fernández-Varo G, Oró D, Cable EE, Reichenbach V, Carvajal S, de la Presa BG, Wiśniewski K, Ginés P, Harris G, Jiménez W. Vasopressin 1a receptor partial agonism increases sodium excretion and reduces portal hypertension and ascites in cirrhotic rats. Hepatology 2016; 63:207-16. [PMID: 26403564 DOI: 10.1002/hep.28250] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 09/20/2015] [Indexed: 12/30/2022]
Abstract
UNLABELLED Patients and rats with cirrhosis and ascites have portal hypertension and circulatory dysfunction. Synthetic arginine vasopressin (AVP) receptor agonists able to induce systemic and mesenteric vasoconstriction have shown their usefulness in reducing portal pressure (PP) in this condition. We assessed the potential therapeutic value of a new V1 a -AVP receptor partial agonist with a preferential splanchnic vasoconstrictor effect (FE 204038) in rats with cirrhosis and ascites. The hemodynamic effects of cumulative intravenous doses of FE 204038, terlipressin, or vehicle were investigated. Mean arterial pressure and PP were continuously recorded and cardiac output and systemic vascular resistance (SVR) assessed at 30-minute intervals for 90 minutes. Urine volume, urine osmolality, and urinary excretion of sodium and creatinine were measured in basal conditions and following twice-daily subcutaneous doses of FE 204038 or vehicle. PP, mean arterial pressure, cardiac output, SVR, and ascites volume were also measured after 6 days. The expression of an array of vasoactive genes was assessed in the thoracic aorta and the mesenteric circulation of control rats and rats with cirrhosis and ascites. FE 204038 dose-dependently decreased PP, did not modify mean arterial pressure, and increased SVR. The effect of the V1a -AVP receptor partial agonist on PP was associated with an improvement in urine volume and urinary excretion of sodium during the first day of treatment. SVR was higher and cardiac output and ascites volume were lower in rats with cirrhosis and ascites treated with FE 204038. V1a -AVP receptor expression in rats with cirrhosis and ascites was markedly enhanced in the mesenteric circulation compared to the thoracic aorta. CONCLUSION FE 204038 increases sodium excretion and reduces portal hypertension and ascites in experimental cirrhosis. V1a -AVP receptor partial agonism could be a useful pharmacological treatment in decompensated patients with cirrhosis.
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Affiliation(s)
- Guillermo Fernández-Varo
- Biochemistry and Molecular Genetics Service, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain.,Department Ciencies Fisiologiques I, University of Barcelona, Barcelona, Spain
| | - Denise Oró
- Biochemistry and Molecular Genetics Service, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | | | - Vedrana Reichenbach
- Biochemistry and Molecular Genetics Service, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Silvia Carvajal
- Biochemistry and Molecular Genetics Service, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Bernardino González de la Presa
- Biochemistry and Molecular Genetics Service, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | | | - Pere Ginés
- Liver Unit, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | | | - Wladimiro Jiménez
- Biochemistry and Molecular Genetics Service, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain.,Department Ciencies Fisiologiques I, University of Barcelona, Barcelona, Spain
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Hand WR, Whiteley JR, Epperson TI, Tam L, Crego H, Wolf B, Chavin KD, Taber DJ. Hydroxyethyl starch and acute kidney injury in orthotopic liver transplantation: a single-center retrospective review. Anesth Analg 2015; 120:619-626. [PMID: 25036375 DOI: 10.1213/ane.0000000000000374] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent complication of orthotopic liver transplantation (OLT). Hepatic failure pathophysiology and intraoperative events contribute to AKI after OLT. Colloids are routinely used to maintain intravascular volume during OLT. Recent evidence has implicated 6% hydroxyethyl starch (HES) (130/0.4) with AKI in critically ill patients. METHODS We performed a retrospective cross-sectional analysis of electronic anesthesia records, surgical dictations, and perioperative laboratory results. Postoperative AKI incidence was determined by RIFLE (Risk Injury Failure Loss End-Stage) criteria. AKI was staged into Risk, Injury, and Failure based on change in serum creatinine from preoperative baseline to peak level by postoperative day 7. Uni- and multivariate analysis was used to evaluate the association between type of intraoperative colloid administered and AKI. RESULTS One hundred seventy-four adult patients underwent OLT and had complete records for review. Of these, 50 received only 5% albumin, 25 received both 5% albumin and HES, and 99 received only HES. Albumin-only, albumin and HES, and HES-only groups were otherwise homogeneous based on patient characteristics and intraoperative variables. There was a statistically significant linear-by-linear association between type of colloid(s) administered and AKI (Rifle Criteria-Injury Stage). Patients administered HES were 3 times more likely to develop AKI within 7 days after OLT compared with albumin (adjusted odds ratio 2.94, 95% confidence interval, 1.13-7.7, P = 0.027). The linear trend between colloidal use (5% albumin only versus albumin/HES versus HES only, ranked ordering) and "injury" was statistically significant (P = 0.048). A propensity-matched analysis also showed a significant difference in the incidence of AKI between the patients receiving albumin compared with HES (P = 0.044). CONCLUSIONS Patients receiving 6% HES (130/0.4) likely had an increased odds of AKI compared with patients receiving 5% albumin during OLT. These retrospective findings are consistent with recent clinical trials that found an association between 6% HES (130/0.4) and renal injury in critically ill patients.
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Affiliation(s)
- William R Hand
- From the *Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina; †Georgetown University School of Medicine, Washington, DC; ‡Medical University of South Carolina, Charleston, South Carolina; and §Department of Public Health Sciences and ‖Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina
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John S, Thuluvath PJ. Hyponatremia in cirrhosis: Pathophysiology and management. World J Gastroenterol 2015; 21:3197-205. [PMID: 25805925 PMCID: PMC4363748 DOI: 10.3748/wjg.v21.i11.3197] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/02/2014] [Accepted: 01/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. The development of ascites in patients with cirrhosis is multi-factorial. Portal hypertension and the associated systemic vasodilation lead to activation of the sodium-retaining neurohumoral mechanisms which include the renin-angiotensin-aldosterone system, sympathetic nervous system and antidiuretic hormone (ADH). The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume resulting in the development of ascites. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and ascites leads to impairment of the kidneys to eliminate solute- free water. This leads to additional compensatory mechanisms including non-osmotic secretion of ADH, also known as arginine vasopressin, further worsening excess water retention and thereby hyponatremia. Hyponatremia is associated with increased morbidity and mortality in patients with cirrhosis, and is an important prognostic marker both before and after liver transplant. The management of hyponatremia in this setting is a challenge as conventional therapy for hyponatremia including fluid restriction and loop diuretics are frequently inefficacious. In this review, we discuss the pathophysiology and various treatment modalities, including selective vasopressin receptor antagonists, for the management of hyponatremia in patients with cirrhosis.
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New Insight Into Volume Overload and Hepatorenal Syndrome in Cirrhosis "the Hepatorenal Reflex Hypothesis". Am J Med Sci 2014; 348:244-8. [DOI: 10.1097/maj.0000000000000268] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Thiele GB, da Silva OM, Fayad L, Lazzarotto C, Ferreira MDA, Marconcini ML, Dantas-Corrêa EB, Schiavon LDL, Narciso-Schiavon JL. Clinical and laboratorial features of spontaneous bacterial peritonitis in southern Brazil. SAO PAULO MED J 2014; 132:205-10. [PMID: 25055065 PMCID: PMC10496729 DOI: 10.1590/1516-3180.2014.1324698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/07/2013] [Accepted: 08/15/2013] [Indexed: 12/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Spontaneous bacterial peritonitis (SBP) is a severe complication that occurs in 8-27% of hospitalized patients with liver cirrhosis and ascites, with high mortality rates. This study aimed to identify the clinical characteristics associated with SBP. DESIGN AND SETTING Cross-sectional study, conducted in a public university. METHODS The study consecutively included individuals with liver cirrhosis and ascites between September 2009 and March 2012. Forty-five patients were included: mean age 53.2 ± 12.3 years, 82.2% male, 73.8% Caucasian, mean Model of End-stage Liver Disease (MELD) score of 19.5 ± 7.2, and 33.3% with SBP. The subjects were divided into two groups: SBP and controls. RESULTS Comparison between individuals with SBP and controls showed that those with SBP had lower mean prothrombin activity time (36.1 ± 16.0% versus 47.1 ± 17.2%; P = 0.044) and lower median serum-ascites albumin gradient (SAAG) (1.2 versus 1.7, P = 0.045). There was a tendency towards higher mean MELD in the SBP group, not significant (22.2 ± 7.6 versus 17.9 ± 6.7; P = 0.067). There was a strong positive correlation between the neutrophil count in ascitic fluid and serum leukocyte count (r = 0.501; P = 0.001) and a negative correlation between the neutrophil count in ascitic fluid with prothrombin activity time (r = -0.385; P = 0.011). CONCLUSION A few characteristics are associated with the presence of SBP, especially liver dysfunction, SAAG and peripheral leukocytosis.
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Affiliation(s)
- Gabriela Bicca Thiele
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Otávio Marcos da Silva
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Leonardo Fayad
- MD. Resident in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - César Lazzarotto
- MD, MSc. Resident in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | | | - Maíra Luciana Marconcini
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Esther Buzaglo Dantas-Corrêa
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Leonardo de Lucca Schiavon
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Janaína Luz Narciso-Schiavon
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
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Hemodynamic phenotype of the failing Fontan in an adult population. Am J Cardiol 2013; 112:1943-7. [PMID: 24075283 DOI: 10.1016/j.amjcard.2013.08.023] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 08/01/2013] [Accepted: 08/01/2013] [Indexed: 12/12/2022]
Abstract
Fontan failure can occur even with normal systolic ventricular function and often in the context of significant liver disease. We hypothesized that Fontan failure is hemodynamically distinct from traditional heart failure and characterized by low systemic vascular resistance (SVR) index and preserved cardiac index. Twenty-seven symptomatic adult Fontan (SAF) patients who underwent catheterization from 2001 to 2011 constituted our study group. Fifty-four predominantly asymptomatic pediatric Fontan (PF) patients who underwent catheterization during the same period were randomly selected to perform a control:case cohort analysis. Clinical comparisons were made between the 2 groups. The adults were more symptomatic than the PF cohort (New York Heart Association classes I and II or III and IV: 48% or 52% [SAF] vs 94% or 6% [PF], respectively, p <0.01). SAF versus PF mean catheterization findings were central venous pressure 18 ± 6 versus 14 ± 3 mm Hg (p <0.01), SVR index 1,680 ± 368 versus 1,960 ± 550 dyn s/cm(5)/m(2) (p = 0.02), and cardiac index 2.7 ± 0.8 versus 2.8 ± 0.7 L/min/m(2) (p = 0.25). By imaging, the SAF cohort demonstrated a greater incidence of abnormal liver texture changes (96% vs 75%, p = 0.04) and nodularity (77% vs 42%, p = 0.02). In conclusion, adult patients with failing Fontan circulation had a lower SVR index and similar cardiac index compared with the pediatric cohort. Liver disease in the adults was more advanced. Our data suggest that Fontan failure is a distinct circulatory derangement with hemodynamic features similar to portal hypertension, albeit with limited ability to augment cardiac output.
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Miyazaki T, Fujiki H, Yamamura Y. Tolvaptan, an orally active non-peptide arginine vasopressin V2 receptor antagonist, reduces ascites in rats with chronic liver injury. Hepatol Res 2013; 43:1224-30. [PMID: 23413814 DOI: 10.1111/hepr.12073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/06/2013] [Accepted: 01/10/2013] [Indexed: 02/08/2023]
Abstract
AIM This is a non-clinical, proof of concept study, showing that tolvaptan has efficacy in reducing ascites in chronic liver injury, using a rat model induced by repeated dimethylnitrosamine (DMNA) injection. METHODS A rat model of chronic liver injury was induced by 10 mg/kg of repeated i.p. injection with DMNA for 6-9 weeks. Tolvaptan was administrated to rats that showed obvious and stable ascites, and abdominal circumference was evaluated as a surrogate marker of ascites volume. Rats were placed in metabolic cages with free access to food and water to collect urine over a 24-h period. RESULTS Oral tolvaptan (1 and 3 mg/kg) promoted a remarkable diuretic effect, decreasing bodyweight and abdominal circumference in a dose-dependent manner. Plasma sodium concentration was increased by tolvaptan due to the large amount of free-water excretion following tolvaptan administration. CONCLUSION Tolvaptan had therapeutic efficacy in the reduction of ascites in rats with chronic liver injury. These results are consistent with the clinical data showing tolvaptan has therapeutic implications in the reduction of ascites in patients with decompensated cirrhosis.
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Affiliation(s)
- Toshiki Miyazaki
- First Institute of New Drug Discovery, Otsuka Pharmaceutical, Tokushima, Japan
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The effect of infections on the mortality of cirrhotic patients with hepatic encephalopathy. Epidemiol Infect 2013; 141:2671-8. [PMID: 23433300 DOI: 10.1017/s0950268813000186] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cirrhotic patients are prone to having infections, which may aggravate hepatic encephalopathy (HE). However, the effect of infections on mortality in HE cirrhotic patients is not well described. The National Health Insurance Database, derived from the Taiwan National Health Insurance Programme, was used to identify 4150 adult HE cirrhotic patients hospitalized between 1 January 2004 and 31 December 2004. Nine hundred and eighty-five patients (23.7%) had one or more co-existing infections during their hospitalization. After Cox proportional hazard regression modelling adjusted by the patients' gender, age, and medical comorbidity disorders, the hazard ratios (HRs) in HE patients with infections for 30-day, 30- to 90-day, and 90-day to 1-year mortalities were 1.66 [95% confidence interval (CI) 1.42-1.94], 1.51 (95% CI 1.23-1.85) and 1.34 (95% CI 1.13-1.58), respectively. Compared to the non-infection group, the HRs of pneumonia, spontaneous bacterial peritonitis, urinary tract infection, sepsis without specific focus (SWSF), cellulitis, and biliary tract infection were 2.11, 1.48, 1.06, 2.21, 1.06, and 0.78, respectively, for 30-day mortality; 1.82, 1.22, 0.93, 2.24, 0.31, and 2.82, respectively, for 30- to 90-day mortality; and 2.03, 0.82, 1.24, 1.64, 1.14, and 0.60, respectively, for 90-day to 1-year mortality for HE cirrhotic patients. We conclude that infections increase the mortality of HE cirrhotic patients, especially pneumonia and SWSF.
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Belcher JM, Garcia-Tsao G, Sanyal AJ, Bhogal H, Lim JK, Ansari N, Coca SG, Parikh CR. Association of AKI with mortality and complications in hospitalized patients with cirrhosis. Hepatology 2013; 57:753-62. [PMID: 22454364 PMCID: PMC3390443 DOI: 10.1002/hep.25735] [Citation(s) in RCA: 261] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Accepted: 03/16/2012] [Indexed: 12/15/2022]
Abstract
UNLABELLED Acute kidney injury (AKI) is a common and devastating complication in patients with cirrhosis. However, the definitions of AKI employed in studies involving patients with cirrhosis have not been standardized, lack sensitivity, and are often limited to narrow clinical settings. We conducted a multicenter, prospective observational cohort study of patients with cirrhosis and AKI, drawn from multiple hospital wards, utilizing the modern acute kidney injury network (AKIN) definition and assessed the association between AKI severity and progression with in-hospital mortality. Of the 192 patients who were enrolled and included in the study, 85 (44%) progressed to a higher AKIN stage after initially fulfilling AKI criteria. Patients achieved a peak severity of AKIN stage 1, 26%, stage 2, 24%, and stage 3, 49%. The incidence of mortality, general medical events (bacteremia, pneumonia, urinary tract infection), and cirrhosis-specific complications (ascites, encephalopathy, spontaneous bacterial peritonitis) increased with severity of AKI. Progression was significantly more common and peak AKI stage higher in nonsurvivors than survivors (P < 0.0001). After adjusting for baseline renal function, demographics, and critical hospital- and cirrhosis-associated variables, progression of AKI was independently associated with mortality (adjusted odds ratio = 3.8, 95% confidence interval 1.3-11.1). CONCLUSION AKI, as defined by AKIN criteria, in patients with cirrhosis is frequently progressive and severe and is independently associated with mortality in a stage-dependent fashion. Methods for earlier diagnosis of AKI and its progression may result in improved outcomes by facilitating targeted and timely treatment of AKI.
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Affiliation(s)
- Justin M. Belcher
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
| | - Guadalupe Garcia-Tsao
- Clinical Epidemiology Research Center, VAMC, West Haven, CT,Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA-Connecticut Healthcare System, West Haven, CT
| | - Arun J. Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Harjit Bhogal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Joseph K. Lim
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT
| | - Naheed Ansari
- Division of Nephrology, Department of Internal Medicine, Jacobi Medical Center, South Bronx, NY
| | - Steven G. Coca
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
| | - Chirag R. Parikh
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
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Kakazu E, Kondo Y, Shimosegawa T. The Relationship between Renal Dysfunction and Abnormalities of the Immune System in Patients with Decompensated Cirrhosis. ISRN GASTROENTEROLOGY 2012; 2012:123826. [PMID: 23326675 PMCID: PMC3541637 DOI: 10.5402/2012/123826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 12/06/2012] [Indexed: 12/15/2022]
Abstract
In patients with advanced cirrhosis, not only hepatocellular carcinoma but also bacterial infections, such as spontaneous bacterial peritonitis (SBP) or pneumonia, are frequent clinical complications in such immune-compromised patients. These pathologies often progress to renal dysfunction, especially hepatorenal syndrome (HRS). The central pathology of HRS is splanchnic arterial vasodilation and hyperpermeability followed by bacterial translocation (BT). BT induces a severe inflammatory response in the peritoneal lymphoid tissue, with the activation of the immune systems and the long-lasting production of vasoactive mediators that can impair the circulatory function and cause renal failure. Recent studies report that the plasma amino acid imbalance appeared to be related to an abnormality of the immune system in patients with decompensated cirrhosis. This paper can provide a new approach for future studies of the pathology in cirrhotic patients with renal dysfunction.
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Affiliation(s)
- Eiji Kakazu
- Division of Gastroenterology, Tohoku University Hospital, 1-1 Seiryo, Aobaku, Sendai 980-8574, Japan
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Abstract
BACKGROUND Clinical trials suggest that terlipressin improves renal function in hepatorenal syndrome, but the evidence concerning mortality is equivocal. OBJECTIVES To assess the beneficial and harmful effects of terlipressin alone or with albumin versus placebo, no intervention or albumin for hepatorenal syndrome. SEARCH METHODS Eligible trials were identified through electronic (The Cochrane Library, MEDLINE, EMBASE and Science Citation Index databases) and manual searches until January 2012. SELECTION CRITERIA Randomised clinical trials involving patients with type 1 or type 2 hepatorenal syndrome were included irrespective of publication status or language. DATA COLLECTION AND ANALYSIS The review authors independently extracted data from trial reports and undertook correspondence with the authors. Primary outcome measures included mortality, reversal of hepatorenal syndrome and adverse events. Intention-to-treat, random-effects model meta-analyses were performed and results were expressed as risk ratios (RR) with 95% confidence intervals (CI), and the I(2) statistic provided a measure of intertrial heterogeneity. Subgroup, sensitivity, regression and sequential analyses were performed. MAIN RESULTS We identified six randomised clinical trials. All had high risk of bias. Five trials assessed terlipressin (with albumin in three trials) versus no intervention (with albumin in three trials) and one trial assessed terlipressin versus albumin. Data from five randomised trials on terlipressin alone (one trial) or terlipressin and albumin (four trials) were included in the review. In total, 74 of 155 (47.7%) patients randomised to terlipressin alone or terlipressin with albumin versus 98 of 154 (63.6%) patients randomised to no intervention, placebo or albumin died. Random-effects model meta-analysis found that terlipressin reduced mortality (RR 0.76, 95% CI 0.61 to 0.95). The results were stable when repeated with trials on terlipressin plus albumin, trials on patients with type 2 hepatorenal syndrome, and trials with a low risk of selection bias. No evidence of bias or small study effects were identified in regression analyses. In a trial sequential analysis on mortality, the cumulative Z curve approached but did not cross the monitoring boundary suggesting that the results were not stable to adjustment for sparse data and multiple comparisons. Analyses of the remaining outcome measures found that terlipressin and albumin increased the number of patients with reversal of hepatorenal syndrome as well as adverse events, including cardiovascular and gastrointestinal symptoms. AUTHORS' CONCLUSIONS Terlipressin may reduce mortality and improve renal function in patients with type 1 hepatorenal syndrome. Whether the evidence is strong enough to support the intervention for clinical practice could be debated due to the results of the trial sequential analyses. However, the outcome measures assessed are objective, which reduces the risk of bias.
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Affiliation(s)
- Lise Lotte Gluud
- Department of InternalMedicine, Gentofte UniversityHospital, Hellerup,Denmark.
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Rai R, Nagral S, Nagral A. Surgery in a patient with liver disease. J Clin Exp Hepatol 2012; 2:238-46. [PMID: 25755440 PMCID: PMC3940091 DOI: 10.1016/j.jceh.2012.05.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 05/15/2012] [Indexed: 12/12/2022] Open
Abstract
Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease.
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Key Words
- ABG, arterial blood gas
- ASA, American Society of Anesthesiologists
- Anesthesia
- BNP, brain natriuretic peptide
- COPD, chronic obstructive pulmonary disease
- CTP, Child–Turcotte–Pugh
- CVP, central venous pressure
- Child–Pugh score
- FDP, fibrin degradation products
- FFP, fresh frozen plasma
- HPS, hepatopulmonary syndrome
- ICG, indocyanine green
- ICU, intensive care unit
- INR, international normalized ratio
- MELD, model for end-stage liver disease
- NSAID, nonsteroidal anti-inflammatory drug
- PICD, paracentesis-induced circulatory dysfunction
- PT, prothrombin time
- PTT, partial thromboplastin time
- SBP, spontaneous bacterial peritonitis
- TEG, thromboelastogram
- TIPS, transjugular intrahepatic portosystemic shunt
- cirrhosis
- coagulopathy
- hepatic
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Affiliation(s)
- Rakesh Rai
- Department of HPB Surgery and Liver Transplantation, Fortis Hospital, Mulund, Mumbai, India
| | - Sanjay Nagral
- Department of Surgical Gastroenterology, Jaslok Hospital, Mumbai, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital, Mumbai, India,Address for correspondence: Aabha Nagral, Department of Gastroenterology, Jaslok Hospital, 7, Snehasagar, Prabhanagar, Prabhadevi, Mumbai - 400025, India.
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Toshima T, Shirabe K, Yoshiya S, Muto J, Ikegami T, Yoshizumi T, Maehara Y. Outcome of hepatectomy for hepatocellular carcinoma in patients with renal dysfunction. HPB (Oxford) 2012; 14:317-24. [PMID: 22487069 PMCID: PMC3384851 DOI: 10.1111/j.1477-2574.2012.00452.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES There are few reports on the efficacy of hepatectomy for hepatocellular carcinoma (HCC) in patients with renal dysfunction (RD). This study aimed to clarify the validity of hepatectomy for treating HCC in RD patients, and to compare postoperative courses in RD and non-RD patients. METHODS The clinical features of 722 HCC patients who underwent curative hepatectomy between 1986 and 2009 were retrospectively reviewed. Seventeen patients (2.4%) with preoperative serum creatinine levels of >2.0 mg/dl were defined as the RD group, and, of these, seven who did not receive preoperative haemodialysis were defined as borderline patients. Clinicopathological characteristics and postoperative outcomes were compared between the RD group (n= 17) and the non-RD group (n= 705). The postoperative courses of borderline patients were reviewed in detail. RESULTS Overall survival (P= 0.177) and disease-free survival (P= 0.942) after hepatectomy did not differ significantly between the groups. Incidences of massive ascites (35.3% vs. 14.3%; P= 0.034) and pleural effusion (52.9% vs. 17.6%; P= 0.001), defined as massive effusion (ME), were significantly higher in the RD group than in the non-RD group. Hypoalbuminaemia (≤2.8 g/dl; P= 0.031), heavy blood loss (≥1000 ml; P= 0.012) and intraoperative blood transfusion (P= 0.007) were risk factors for ME. Among the borderline patients, serum creatinine values were not increased immediately after surgery and four patients underwent haemodialysis. CONCLUSIONS Preoperative hypoalbuminaemia, heavy blood loss and blood transfusion are independent risk factors for ME in RD patients. Preoperative improvement of anaemia and reduction of blood loss by meticulous surgical techniques may prevent ME in RD patients who require hepatectomy for HCC.
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Affiliation(s)
- Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan.
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Gallach M, Pérez J, Vergara M, Olivé G, Miquel M, Casas M, Gil M, Dalmau B, Sánchez J, Dosal A, Moreno L, Alavedra E, Gené E. [Spontaneous visits to the emergency service and hepatology day hospital by patients with liver cirrhosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:599-604. [PMID: 22037093 DOI: 10.1016/j.gastrohep.2011.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 06/30/2011] [Accepted: 07/01/2011] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Because of the current overload of emergency services, new units, such as day units, have had to be created. Liver cirrhosis (LC) is a chronic disease with frequent decompensations requiring medical attention. The aim of this study was to compare differences between emergency consultations in a hepatology day hospital (HDH) and in an emergency service (ES) among patients with LC. METHODS AND MATERIAL We performed an observational prospective study. All patients with LC attending the HDH or ES from September 2007 to August 2008 were asked to complete a questionnaire. Demographic, clinical, and radiological variables were collected. RESULTS There were 743 consultations, of which 62% involved the HDH. The mean age was 65±12 years, and the male/female ratio was 2:3. The most frequent diagnosis in the ES was hepatic encephalopathy (26.2% ES versus 6% HDH, p<0.001) followed by upper gastrointestinal hemorrhage (17.7% ES versus 0.6% HDH, p<0.001), while the most frequent diagnosis in the HDH was ascites (66.2% HDH versus 22.7% ES, p<0.001). The tests performed were as follows: blood analysis: 95% ES versus 60% HDH (p<0.01); radiology: 71% ES versus 11% HDH (p<0.01) and paracentesis: 51% ES versus 74% HDH (p<0.01). The mean length of stay in the ES was 21.3±121.5 hours compared with 3.3±2.4 hours in the HDH (p<0.001). A total of 53% of patients attended in the ES were hospitalized compared with 12% of those attended in the HDH (p<0.05). CONCLUSION Patients with LC preferentially attend the HDH, where fewer tests are performed and the length of stay is shorter. The care provided in the HDH is appropriate and efficient.
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Affiliation(s)
- Marta Gallach
- Servicio de Aparato Digestivo, Hospital de Sabadell, Barcelona, España.
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Lim YS. [Prediction of post-operative mortality in patients with cirrhosis: growth of child to MELD]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 57:333-4. [PMID: 21694483 DOI: 10.4166/kjg.2011.57.6.333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Laleman W, Verbeke L, Meersseman P, Wauters J, van Pelt J, Cassiman D, Wilmer A, Verslype C, Nevens F. Acute-on-chronic liver failure: current concepts on definition, pathogenesis, clinical manifestations and potential therapeutic interventions. Expert Rev Gastroenterol Hepatol 2011; 5:523-37; quiz 537. [PMID: 21780899 DOI: 10.1586/egh.11.47] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In recent years, acute-on-chronic liver failure has been recognized as a specific clinical form of liver failure associated with cirrhosis. The syndrome refers to an acute deterioration of liver function and subsequently of other end organs over a period of weeks following a precipitating event in a patient with previously well- or reasonably well-compensated cirrhosis. These precipitating events include either an indirect (e.g., variceal hemorrhage, sepsis) or a direct (e.g., drug-induced) hepatotoxic factor. The short-term mortality for this condition is more than 50%. At present, considerable efforts are ongoing to better characterize the syndrome, to gain further insight into its pathophysiology and to optimize therapy. This article aims to highlight the current concepts of these various aspects.
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Affiliation(s)
- Wim Laleman
- Department of Liver and Biliopancreatic disorders, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium.
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Abstract
PURPOSE OF REVIEW Circulatory abnormalities in cirrhosis include hyperdynamic circulation and cirrhotic cardiomyopathy. The extent of circulatory abnormalities is further exaggerated in acute-on-chronic liver failure (ACLF). The mechanism remains unclear and management also needs to be evaluated. RECENT FINDINGS The predominant mechanism of ACLF is thought to be a systemic inflammatory reaction. Cardiovascular-active factors such as tumor necrosis factor and nitric oxide are increased and cortisol is decreased; the former further dilates the vasculature and the latter decreases the sensitivity to vasoconstrictors. The exaggerated vasodilatation further decreases the cardiac afterload. However, no study has yet demonstrated the benefit of vasodilators/vasoconstrictors in the management of ACLF. Standard medical treatment in this setting is associated with high mortality. Patients treated with molecular adsorbent recirculating system (MARS) had improved serum levels of inflammatory mediators such as tumor necrosis factor alpha and interleukin-6, but this was not associated with improved survival. Liver transplantation eventually reverses the cardiovascular abnormalities. SUMMARY Circulatory abnormalities are exaggerated in ACLF. The predominant mechanism is a systemic inflammatory reaction. Modalities such as MARS improve serum markers of inflammation, but not survival. Liver transplantation is the definitive treatment of the cardiovascular abnormalities of ACLF.
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Hemodynamic effects of 3 months of therapy with midodrine in cirrhotic patients with and without ascites. EGYPTIAN LIVER JOURNAL 2011. [DOI: 10.1097/01.elx.0000398638.27770.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Sadik KW, Laibstain S, Northup PG, Kashmer D, Schmitt TM, Bonatti HJR. Closure of ascites leaks with fibrin glue injection in patients with end-stage liver disease. J Laparoendosc Adv Surg Tech A 2011; 21:609-14. [PMID: 21612447 DOI: 10.1089/lap.2010.0476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ascites leaks (AL) in patients with end-stage liver disease (ESLD) are associated with significant morbidity and mortality regardless if they are medically or surgically managed. PATIENTS AND METHODS In a pilot study, 14 ESLD patients with AL underwent treatment with fibrin glue injection around the leak after failing conservative therapy. The end point of this study was the cessation of AL in the short term and the maintenance of a leak-free abdomen in the long term, allowing for medical optimization of the patients. RESULTS Median age of the 10 men and 4 women was 50 (range 26-67) years. Underlying ESLDs were chronic hepatitis C (n=5), alcoholic LD (n=2), cryptogenic cirrhosis (n=2), and miscellaneous (n=5). There were six leaking incisions posthernia repair (three umbilical and three inguinal), two leaking/ruptured umbilical hernias, four leaking paracentesis sites, one leaking Jackson-Pratt (JP) drain canal, and one leaking laparoscopic trocar site. Average AL volume per day was 1000 (range 400-2000) mL. All leaks were immediately resolved with a 3-5 mL fibrin glue injection. Five recurred and required a second injection (four within 24 hours). Mental status improved in 7 patients (West Haven Criteria: grade II to I [n=6], grade III to I [n=1]). Median model of end-stage liver disease scores improved from 23 (range 8-33) to 20 (range 14-26). There were no infections, bleeds, or other injection-related complications. Average follow-up for these patients was 441.6 days (range 2-852). Five patients underwent liver transplant (LT) median 15 (range 4-270) days postinjection; 2 of them died. Another 3 patients died (2 from sepsis and 1 from metastatic cancer). CONCLUSION Fibrin glue injection for the control of AL is a simple and safe bedside procedure that quickly controls AL, allowing for patient recovery in anticipation of further care.
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Affiliation(s)
- Karim W Sadik
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Abstract
Patients with critical illness are heterogeneous, with differing physiologic requirements over time. Goal-directed therapy in the emergency room demonstrates that protocolized care could result in improved outcomes. Subsequent studies have confirmed benefit with such a "bundle-based approach" in the emergency room and in preoperative and postoperative scenarios. However, this cannot be necessarily extrapolated to the medium-term and long-term care pathway of the critically ill patient. It is likely that the development of mitochondrial dysfunction could result in goal-directed types of approaches being detrimental. Equally, arterial pressure aims are likely to be considerably different as the patient's physiology moves toward "hibernation." The agents we utilize as sedative and pressor agents have considerable effects on immune function and the inflammatory profile, and should be considered as part of the total clinical picture. The role of gut failure in driving inflammation is considerable, and the drive to feed enterally, regardless of aspirate volume, may be detrimental in those with degrees of ileus, which is often a difficult diagnosis in the critically ill. The pathogenesis of liver dysfunction may be, at least in part, related to venous engorgement that will contribute toward portal hypertension and gut edema. This, in association with loss of the hepatosplanchnic buffer response, it is likely to contribute to venous pooling in the abdominal cavity, impaired venous return, and decreased central blood volumes. Therapies such as those used in "small-for-size syndrome" may have a role in the chronic stages of septic vascular failure.
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Kalambokis GN, Pappas K, Baltayiannis G, Katsanou A, Tsianos EV. Effects of terlipressin on water excretion after oral water load test in nonazotemic cirrhotic patients with ascites without hyponatremia. Scand J Gastroenterol 2010; 45:1509-15. [PMID: 20695722 DOI: 10.3109/00365521.2010.510576] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Impaired water excretion is a major prognostic factor in decompensated cirrhotic patients. We investigated if terlipressin improves water excretion after a water load test in nonazotemic cirrhotic patients with ascites without hyponatremia. METHODS Fifteen patients (Child-Pugh B/C: 6/9) were studied after an oral water intake of 20 ml/kg within 40 min and water excretion over 5 h was measured at baseline: day 1, and after a bolus infusion (2 mg) of terlipressin: day 3. Mean arterial pressure (MAP) before and after water loading on day 1, and MAP, cardiac output (CO), and systemic vascular resistance (SVR) before and 1 h after terlipressin infusion on day 3, were evaluated. The 5-h creatinine clearance (ClCre), diuresis, and sodium excretion were also evaluated in each study day. RESULTS The water load excreted on day 1 was significantly correlated with Child-Pugh score, ClCre, sodium excretion, and SVR. The water load excreted and diuresis increased significantly after terlipressin infusion in the 12 patients that completed the study (48.3±3.3% vs. 39.5±4.9%; p=0.001 and 2.51±0.21 vs. 2.06±0.29 ml/min; p=0.001, respectively); significant increases in ClCre and sodium excretion, a significant decrease in CO and significant increases in MAP and SVR were also noted. The changes in the percentage of water load excreted were significantly correlated with the changes in SVR and ClCre. CONCLUSIONS Terlipressin increases water excretion during a water load test in nonazotemic cirrhotic patients without hyponatremia, suggesting that the administration of arterial vasoconstrictors could influence the prognosis of these patients.
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Affiliation(s)
- Georgios N Kalambokis
- 1st Division of Internal Medicine and Hepato-Gastroenterology Unit, University Hospital, Ioannina, Greece
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Fernández-Varo G, Melgar-Lesmes P, Casals G, Pauta M, Arroyo V, Morales-Ruiz M, Ros J, Jiménez W. Inactivation of extrahepatic vascular Akt improves systemic hemodynamics and sodium excretion in cirrhotic rats. J Hepatol 2010; 53:1041-8. [PMID: 20800923 DOI: 10.1016/j.jhep.2010.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 05/06/2010] [Accepted: 05/31/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Increased activity of the vascular Akt/eNOS signaling pathway is involved in the hemodynamic and renal complications developed by patients and rats with cirrhosis and ascites. This occurs in the setting of impaired Akt/eNOS activity within the cirrhotic liver. Here we assessed the feasibility of selectively inhibiting vascular eNOS without further impairing the intrahepatic activity of this enzyme. Ultimately, we sought to determine whether endothelial transduction of a constitutively inactive mutant of Akt (AA-Akt) improves circulatory function and sodium excretion in cirrhotic rats with ascites. METHODS First, we administered recombinant adenoviruses that encode the β-galactosidase gene (β-gal) to 5 control rats and 5 cirrhotic rats with ascites and analyzed their tissue distribution by chemiluminescence. Next, urine samples were obtained from 18 cirrhotic rats with ascites and then the animal randomly received saline or adenoviruses containing the β-gal or the AA-Akt genes. Following a 24-h urine collection period, hemodynamic studies were performed and tissue samples were obtained to analyze Akt and eNOS expressions. RESULTS No β-gal activity was detected in the liver of cirrhotic rats compared to that of controls. This was paralleled by increased β-gal activity in other territories such as the thoracic aorta. AA-Akt transduction improved systemic hemodynamics, splanchnic perfusion pressure and renal excretory function in comparison with cirrhotic rats transduced with β-gal adenoviruses or receiving saline. Moreover, the AA-Akt transgene did not modify portal pressure. CONCLUSIONS Inactivation of extrahepatic vascular Akt and the concomitant decrease in nitric oxide expression ameliorate systemic hemodynamics and renal excretory function in experimental cirrhosis.
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Affiliation(s)
- G Fernández-Varo
- Biochemistry and Molecular Genetics Service, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
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Huo YM, Hua R, Chen W, Sun YW. Clinical study on pulmonary diffusion function in patients with chronic liver disease. J Dig Dis 2010; 11:291-8. [PMID: 20883425 DOI: 10.1111/j.1751-2980.2010.00452.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the influence of chronic liver disease (CLD) on pulmonary diffusion function. METHODS Arterial blood gas analysis, pulmonary function test, contrast-enhanced transthoracic echocardiography and technetium macro-aggregated albumin scanning were performed in 50 cirrhotic patients who underwent surgery on portal hypertension and liver transplantation. The severity of chronic liver disease (CLD) was evaluated by Child-Pugh-Turcotte (CPT) categorization and model for end stage liver disease (MELD) score from October 2008 to July 2009 in our surgical department and organ transplantation center. RESULTS A-aDO(2) was increased with the aggravation of liver dysfunction. The pulmonary diffusion capacity for carbon monoxide (DLCO) differed significantly among the three groups, which was (90.8 ± 7.3)% in CPT A group, (82.8 ± 10.8)% in CPT B group, and (73.5 ± 8.3)% in CPT C group. A-aDO(2) correlated positively with CPT (r= 0.581, P= 0.000) as well as the MELD score (r= 0.696, P= 0.000), whereas DLCO was negatively correlated with CPT (r=-0.630, P= 0.000) and the MELD score (r=-0.708, P= 0.000). CONCLUSION DLCO can be useful in the detection of pulmonary vascular abnormality of CLD. The MELD score may be a better criterion than the CPT score in assessing intrapulmonary vascular damage of CLD patients.
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Affiliation(s)
- Yan Miao Huo
- Department of General Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, China
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Serum Vasopressin Concentrations During Orthotopic Liver Transplantation. Transplant Proc 2010; 42:2594-8. [DOI: 10.1016/j.transproceed.2010.04.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Revised: 02/13/2010] [Accepted: 04/21/2010] [Indexed: 11/23/2022]
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Abstract
OBJECTIVES Renal failure is common in cirrhosis frequently due to hepatorenal syndrome (HRS). Terlipressin and albumin improve renal function with a trend to prolong survival in HRS, but prognostic factors with therapy have been poorly studied. METHODS Forty-five cirrhotics seen consecutively in a single centre with renal failure defined as oliguria/anuria and/or rising creatinine and no response to volume loading, without intrinsic renal disease, sepsis, gastrointestinal bleeding [median Child-Pugh score 12(8-14)/Model for End-Stage Liver Disease 29(10-40)], had intravenous terlipressin and albumin and were audited retrospectively classified into three groups: group 1 HRS type 1 (15), group 2 HRS type 2 (11) and group 3(19): not fulfilling HRS 1 or 2 criteria. Baseline median creatinine was 1.7 (0.9-5.46) mg/dl and 30 (67%) had creatinine greater than 1.5 mg/dl. All 45 patients had initial colloid/albumin and 31 continued terlipressin (2-4 mg/day) for a median 8 (2-76) days. RESULTS Improvement in serum creatinine occurred in 23 (51%) [(1.3 mg/dl (0.6-3.9)] compared with baseline [1.7 mg/dl (0.92-3.75)] (P<0.001). In the multivariate analysis a greater reduction in creatinine between baseline and day 4 (95% confidence interval, odds ratio: 0.25) was associated with improved survival at 6 weeks. CONCLUSION Albumin and terlipressin improve renal failure in the absence of sepsis in cirrhosis independently of whether HRS criteria are fulfilled or not. Improvement at 4 days of therapy is associated with better survival. Randomized studies are needed for oliguria and rising creatinine in cirrhotics even if HRS criteria are not fulfilled.
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Rogers GB, Russell LE, Preston PG, Marsh P, Collins JE, Saunders J, Sutton J, Fine D, Bruce KD, Wright M. Characterisation of bacteria in ascites--reporting the potential of culture-independent, molecular analysis. Eur J Clin Microbiol Infect Dis 2010; 29:533-41. [PMID: 20238135 DOI: 10.1007/s10096-010-0891-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 02/15/2010] [Indexed: 02/07/2023]
Abstract
Spontaneous bacterial peritonitis (SBP) is a severe complication of liver disease. A significant proportion of patients have culture-negative ascites, despite having similar signs, symptoms and mortality to those with SBP. Therefore, empirical antibiotic treatment for infection is often started without knowledge of the causative organisms. Here, we investigated the potential of molecular techniques to provide rapid and accurate characterisation of the bacteria present in ascitic fluid. Ascites samples were obtained from 29 cirrhotic patients undergoing clinically indicated therapeutic paracentesis. Bacterial content was determined by terminal restriction fragment length polymorphism (T-RFLP) analysis, quantitative polymerase chain reaction (PCR) and 16S ribosomal clone sequence analysis. Bacterial signal was detected in all samples, compared to three out of ten using standard methods. Bacterial loads ranged from 5.5 x 10(2) to 5.4 x 10(7) cfu/ml, with a mean value of 1.9 x 10(6) cfu/ml (standard deviation +/- 9.6 x 10(6) cfu/ml). In all but one instance, bacterial species identified by culture were also confirmed by molecular analyses. Preliminary data presented here suggests that culture-independent, molecular analyses could provide rapid characterisation of the bacterial content of ascites fluid, providing a basis for the investigation of SBP development and allowing early and targeted antibiotic intervention.
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Affiliation(s)
- G B Rogers
- Molecular Microbiology Research Group, PSD, King's College London, London, UK.
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Laleman W. Hemodynamic effects of albumin dialysis in patients with liver failure: for better or for worse? Ther Apher Dial 2009; 13:384-92. [PMID: 19788454 DOI: 10.1111/j.1744-9987.2009.00756.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Liver failure, irrespective of is cause, is frequently associated with multi-organ dysfunction, including hemodynamic instability, and renal and cerebral insufficiency. As a result of the combined impact of these complications, liver failure carries an exceptionally high risk of mortality. A central role in the etiopathogenesis of different end-organ manifestations, as well as in the aggravation of the underlying liver failure, has been attributed to the hyperdynamic (hypotensive) state, which is characterized by a reduced systemic vascular resistance and mean arterial pressure, as well as an increased cardiac index, heart rate, and total plasma volume. Since the accumulation of toxins due to the decreased detoxification capacity by the failing liver is considered vital herein, the emergence of extracorporeal liver support has provided a rational basis for the potential reversal of these phenomena. The present article critically reviews data with regard to the hemodynamic effects of artificial liver support in the context of liver failure. Although these are scarce for acute liver failure, several uncontrolled series and small randomized trials have clearly documented that artificial liver support is able to improve both portal hypertension and the associated systemic circulatory dysfunction in patients with acute-on-chronic liver failure. The molecular basis for these effects have been related to temporary changes and/or elimination in endogenous vasoactive substances, improved albumin binding capacity, or restoration of oxidative stress-mediated damage to albumin.
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Affiliation(s)
- Wim Laleman
- Department of Hepatology, University Hospital Gasthuisberg, Catholic University Leuven, Leuven, Belgium.
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Møller S, Krag A, Madsen JL, Henriksen JH, Bendtsen F. Pulmonary dysfunction and hepatopulmonary syndrome in cirrhosis and portal hypertension. Liver Int 2009; 29:1528-37. [PMID: 19725890 DOI: 10.1111/j.1478-3231.2009.02103.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pulmonary dysfunction including the hepatopulmonary syndrome (HPS) is an important complication to cirrhosis and portal hypertension. However, the precise relation to liver dysfunction and the prevalence of HPS are unclear. AIMS We therefore aimed to assess (i) the prevalence of HPS in consecutive alcoholic cirrhotic patients, (ii) the degree of pulmonary dysfunction in relation to liver function and (iii) the response of a 100% oxygen test on cardiopulmonary and peripheral oxygenation. METHODS Fifty patients with cirrhosis and 12 matched healthy controls were entered in this study. All underwent haemodynamic and pulmonary investigations [lung diffusing capacity for carbon monoxide (DLCO), contrast-enhanced echocardiography and detection of extrapulmonary shunt fraction]. A 100% oxygen test was performed with the assessment of arterial oxygen tension (PaO(2)), the alveolar-arterial oxygen gradient (AaPO(2)) and peripheral transcutaneous oxygen tension (tcPO(2)). RESULTS The prevalence of HPS was 10%. PaO(2) and DLCO were reduced in 32 and 72% and AaPO(2), was increased in 60% of the patients respectively. DLCO correlated with indicators of liver dysfunction (galactose elimination capacity, P<0.01, indocyanine green clearance, P<0.001), portal hypertension (post-sinusoidal resistance, P<0.01) and central hypovolaemia (central and arterial blood volume, P<0.01). After 100% oxygen inhalation, the changes in PaO(2), AaPO(2), tcPO(2) and heart rate were abnormal in the patients compared with controls (P<0.02). CONCLUSIONS Pulmonary dysfunction in alcoholic cirrhosis is common and relates to different aspects of liver dysfunction, whereas the prevalence of HPS is low. The haemodynamic response to oxygen inhalation is clearly impaired and HPS and pulmonary dysfunction seem to be caused by different pathophysiological mechanisms.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Copple BL, Bustamante JJ, Welch TP, Kim ND, Moon JOK. Hypoxia-inducible factor-dependent production of profibrotic mediators by hypoxic hepatocytes. Liver Int 2009; 29:1010-21. [PMID: 19302442 PMCID: PMC3111079 DOI: 10.1111/j.1478-3231.2009.02015.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS During the development of liver fibrosis, mediators are produced that stimulate cells in the liver to differentiate into myofibroblasts and to produce collagen. Recent studies demonstrated that the transcription factor, hypoxia-inducible factor-1alpha (HIF-1alpha), is critical for upregulation of profibrotic mediators, such as platelet-derived growth factor-A (PDGF-A), PDGF-B and plasminogen activator inhibitor-1 (PAI-1) in the liver, during the development of fibrosis. What remains unknown is the cell type-specific regulation of these genes by HIF-1alpha in liver cell types. Accordingly, the hypothesis was tested that HIF-1alpha is activated in hypoxic hepatocytes and regulates the production of profibrotic mediators by these cells. METHODS In this study, hepatocytes were isolated from the livers of control and HIF-1alpha- or HIF-1beta-deficient mice and exposed to hypoxia. RESULTS Exposure of primary mouse hepatocytes to 1% oxygen stimulated nuclear accumulation of HIF-1alpha and upregulated PAI-1, vascular endothelial cell growth factor and the vasoactive peptides adrenomedullin-1 (ADM-1) and ADM-2. In contrast, the levels of PDGF-A and PDGF-B mRNAs were unaffected in these cells by hypoxia. Exposure of HIF-1alpha-deficient hepatocytes to 1% oxygen only partially prevented upregulation of these genes, suggesting that other hypoxia-regulated transcription factors, such as HIF-2alpha, may also regulate these genes. In support of this, HIF-2alpha was activated in hypoxic hepatocytes, and exposure of HIF-1beta-deficient hepatocytes to 1% oxygen completely prevented upregulation of PAI-1, vascular endothelial cell growth factor and ADM-1, suggesting that HIF-2alpha may also contribute to upregulation of these genes in hypoxic hepatocytes. CONCLUSIONS Collectively, our results suggest that HIFs may be important regulators of profibrotic and vasoactive mediators by hypoxic hepatocytes.
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Affiliation(s)
- Bryan L. Copple
- Department of Pharmacology, Toxicology, and Experimental Therapeutics, University of Kansas Medical Center, Kansas City, KS 66160
| | - Juan J. Bustamante
- Department of Pharmacology, Toxicology, and Experimental Therapeutics, University of Kansas Medical Center, Kansas City, KS 66160
| | - Timothy P. Welch
- Department of Pharmacology, Toxicology, and Experimental Therapeutics, University of Kansas Medical Center, Kansas City, KS 66160
| | - Nam Deuk Kim
- Department of Pharmacology, Toxicology, and Experimental Therapeutics, University of Kansas Medical Center, Kansas City, KS 66160, School of Pharmacy, Pusan National University, Busan 609-735, South Korea
| | - Jeon-OK Moon
- Department of Pharmacology, Toxicology, and Experimental Therapeutics, University of Kansas Medical Center, Kansas City, KS 66160, School of Pharmacy, Pusan National University, Busan 609-735, South Korea
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Operative risks of digestive surgery in cirrhotic patients. ACTA ACUST UNITED AC 2009; 33:555-64. [PMID: 19481892 DOI: 10.1016/j.gcb.2009.03.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 03/25/2009] [Indexed: 12/13/2022]
Abstract
Digestive surgery in cirrhotic patients has long been limited to the treatment of disorders related to the liver disease (portal hypertension, hepatocellular carcinoma and umbilical hernia). The improvement in cirrhotic patient management has allowed an increase in surgical procedures for extrahepatic indications. The aim of this study was to evaluate the operative risks of such surgical procedures. Extrahepatic surgery in cirrhotic patients is associated with high mortality and morbidity. Emergency surgery, gastrointestinal tract opening (esophagus, stomach and colon), <30 g/L serum albumin, transaminase levels more than three times the upper limit of normal, ascites, and intraoperative transfusions are the main risk factors for postoperative death. In Child A patients, the operative risk of elective surgery is moderate and surgical indications are not altered by the presence of cirrhosis. The laparoscopic approach should be recommended because of the potentially lower morbidity. In Child C patients, operative mortality is often higher than 40%; surgical indications must remain exceptional and non operative management has to be preferred. In Child B patients, preoperative improvement of liver function is mandatory for lower risk surgery.
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