Ascites and renal functional abnormalities in cirrhosis. Pathogenesis and treatment

Diagnostic accuracy of the attenuation value in abdominal contrast enhanced dynamic multi-detector-row computed tomography for esophageal varices in patients with liver cirrhosis

Purpose

To investigate whether the attenuation value obtained by subtracting the CT value obtained from abdominal dynamic contrast enhanced (ADCE)-MDCT imaging of the equilibrium phase from the value obtained from that of the portal phase in hepatic parenchyma is useful in distinguishing normal liver from liver cirrhosis (LC) and to predict the development of esophageal varices (EVs) in patients with LC.

Materials and methods

We assigned 72 outpatients to group A (n = 45; normal liver) and group B (n = 27; LC), who underwent ADCE-MDCT. The attenuation value and CT value of the hepatic parenchymal portal and equilibrium phase were compared, and the correlation between attenuation value and biomarkers (ALB, T-bil, PLT, FIB-4, APRI, and AAR) was investigated. Furthermore, we investigated differences in the attenuation value, FIB-4, APRI, and AAR between the two subgroups of group B [without EVs (group a) and with EVs (group b)]. We performed receiver operating characteristic (ROC) analysis of the attenuation value, FIB-4, APRI, and, AAR for subgroup a vs b and evaluated the diagnostic accuracy.

Results

Significant differences were observed between groups A and B in all items. The attenuation value correlated with ALB, T-bil, PLT, FIB-4, and APRI. Only attenuation value showed a significant difference between groups a and b. The best cut-off attenuation value, FIB-4, APRI, and AAR for predicting EVs, according to ROC analysis was 13.4 HU, 6.8, 1.9, and 1.5.

Conclusions

Attenuation value can be useful to quantitatively classify normal liver and LC and to predict EVs in patients with LC.

TIPS for management of portal-hypertension-related complications in patients with cirrhosis

Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites: Review and Update of the Literature

Ascites is the most common complication of cirrhosis, impairs quality of life, and carries a poor prognosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated therapy for refractory ascites and is superior at reducing the accumulation of fluid compared with paracentesis. More recent evidence has shown that TIPS also provides an improved transplant-free survival compared with paracentesis. To maximize the clinical efficacy and survival advantage, proper patient selection is crucial. While current guidelines recommend that elective TIPS for ascites should be performed only in patients with MELD ≤ 18, recent literature suggests that elective TIPS safely and effectively controls ascites and potentially provides a survival advantage in patients with higher MELD scores (≤ 24). The evolution of these findings likely represents the combination of improved medical management of cirrhotic patients, improved devices, and a better knowledge of selection criteria for potential TIPS patients. This article will review the pathophysiology and management of ascites, with a focus on the evidence supporting TIPS placement for refractory ascites.

Prognostic Value of AIMS65 Score in Cirrhotic Patients with Upper Gastrointestinal Bleeding

Introduction. Unlike Rockall scoring system, AIMS65 is based only on clinical and laboratory features. In this study we investigated the correlation between the AIMS65 score and Endoscopic Rockall score, in cirrhotic and noncirrhotic patients. Methods. This is a retrospective study of patients admitted with overt UGIB and undergoing esophagogastroduodenoscopy (EGD). AIMS65 and Rockall scores were calculated at the time of admission. We investigated the correlation between both scores along with stigmata of bleed seen on endoscopy. Results. A total of 1255 patients were studied. 152 patients were cirrhotic while 1103 patients were noncirrhotic. There was significant correlation between AIMS65 and Total Rockall scores in patients of both groups. There was significant correlation between AIMS65 score and Endoscopic Rockall score in noncirrhotics but not cirrhotics. AIMS65 scores in both cirrhotic and noncirrhotic groups were significantly higher in patients who died from UGIB than in patients who did not. Conclusion. We observed statistically significant correlation between AIMS65 score and length of hospitalization and mortality in noncirrhotic patients. We found that AIMS65 score paralleled the endoscopic grading of lesion causing UGIB in noncirrhotics. AIMS65 score correlated only with mortality but not the length of hospitalization or endoscopic stigmata of bleed in cirrhotics.

Systemic vascular resistance in cirrhosis: a predictor of severity?

Background

The aim of this study was to investigate whether systemic vascular resistance (SVR) correlates with validated prospective scoring systems such as Model for End-stage Liver Disease (MELD) and its modifications.

Methods

Patients with cirrhosis, who were admitted to hospital with decompensation (as defined by development of ascites, hepatic encephalopathy, and variceal bleeding) and underwent echocardiography were included in this study. Laboratory data required for computing MELD score, serum bilirubin, serum creatinine, international normalized ratio, and serum sodium were collected for every patient. We tabulated hemodynamic and echocardiography parameters that enabled calculation of SVR. We analyzed the correlation between SVR and each of the individual prognostic scores.

Results

A total of 771 patients with a diagnosis of decompensated cirrhosis were included in the study. Two hundred and sixty-two patients were found to have a low sodium level (<135 mEq/L) and 509 were found to have a normal sodium level (>135 mEq/L). In the patients with hyponatremia, we found statistically significant inverse correlations between SVR and validated liver severity models. However, these correlations were not seen in patients with normonatremia.

Conclusion

We observed a statistically significant inverse correlation between SVR and all the validated liver disease severity models used in this study among patients with hyponatremia but not in those with normonatremia.

[Hyponatremia in liver cirrhosis: pathogenesis and treatment]

Hyponatremia is the most common electrolyte disorder in patients with cirrhosis. This disorder can be a result of substantial loss of extracellular fluid "hypotonic or hypovolemic hyponatremia" or develop in the context of an increase in extracellular fluid volume and in the absence of major sodium losses; this situation occurs in patients with advanced cirrhosis and is known as "dilutional or hypervolemic hyponatremia". In dilutional or hypervolemic hyponatremia, serum sodium concentration is reduced, plasma volume is increased (although the effective plasma volume is decreased due to marked arterial vasodilation in the splanchnic circulation) and extracellular fluid volume is increased, with ascites and edema in the absence of signs of dehydration. This is a result of the marked deterioration in renal excretion of solute-free water, leading to disproportionate water retention in relation to sodium retention. Hypotonic hyponatremia represents 10% of all hyponatremias in patients with cirrhosis. Since hypervolemic hyponatremia is by far the most frequent form of this disorder, the present chapter will concentrate specifically on hypervolemic hyponatremia in cirrhosis.

A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome

BACKGROUND & AIMS

Hepatorenal syndrome (HRS) type 1 is a progressive functional renal failure in subjects with advanced liver disease. The aim of this study was to evaluate the efficacy and safety of terlipressin, a systemic arterial vasoconstrictor, for cirrhosis type 1 HRS.

METHODS

A prospective, randomized, double-blind, placebo-controlled clinical trial of terlipressin was performed. Subjects with type 1 HRS were randomized to terlipressin (1 mg intravenously every 6 hours) or placebo plus albumin in both groups. The dose was doubled on day 4 if the serum creatinine (SCr) level did not decrease by 30% of baseline. Treatment was continued to day 14 unless treatment success, death, dialysis, or transplantation occurred. Treatment success was defined by a decrease in SCr level to </=1.5 mg/dL for at least 48 hours by day 14 without dialysis, death, or relapse of HRS type 1.

RESULTS

Fifty-six subjects were randomized to each arm. Treatment success with terlipressin was double that with placebo (25% vs 12.5%, P = .093). SCr level improved from baseline to day 14 on terlipressin (-0.7 mg/dL) as compared with placebo (0 mg/dL), P < .009. Terlipressin was superior to placebo for HRS reversal (34% vs 13%, P = .008), defined by decrease in SCr level </=1.5 mg/dL. Overall and transplantation-free survival was similar between study groups; HRS reversal significantly improved survival at day 180. One nonfatal myocardial infarction occurred with terlipressin, but the total adverse event rate was similar to placebo.

CONCLUSIONS

Terlipressin is an effective treatment to improve renal function in HRS type 1.

Effect of chronic administration of sildenafil on sodium retention and on the hemodynamic complications associated with liver cirrhosis in the rat

Previous studies demonstrated increased phosphodiesterase-5 (PDE5) activity and expression in the kidneys of rats with liver cirrhosis. Acute intravenous administration of PDE5 inhibitors enhanced sodium excretion in these rats. The aim of the present study was to examine the effects of chronic administration of sildenafil on renal sodium handling and hemodynamics in rats with liver cirrhosis. Male Sprague-Dawley rats underwent bile-duct ligation and excision or sham operation and were housed in metabolic cages throughout the study. Body weight, food intake, water intake and urine volume were measured daily, and plasma samples were obtained twice weekly. Fourteen days following surgery sildenafil or its vehicle (dimethylsulfoxide) were administered (20 mg/kg subcutaneously 3 times/day). Two weeks later, systemic hemodynamics were measured under general anesthesia. Sildenafil enhanced the systemic vasodilatation associated with liver cirrhosis and reduced the arterial pressure. There was no reduction in the glomerular filtration rate, however. Despite these hemodynamic changes, sildenafil prevented the decrease in sodium excretion observed in the bile-duct-ligated group receiving vehicle and markedly increased fractional sodium excretion relative to the other groups. These results suggest that chronic sildenafil administration may help prevent or ameliorate sodium retention in cirrhosis, but that hemodynamic adverse effects may ensue.

The changes in renal function after a single dose of intravenous furosemide in patients with compensated liver cirrhosis

BACKGROUND

Patients with compensated Child-A cirrhosis have sub clinical hypovolemia and diuretic treatment could result in renal impairment.

AIM

To evaluate the changes in renal functional mass as reflected by DMSA uptake after single injection of intravenous furosemide in patients with compensated liver cirrhosis.

METHODS

Eighteen cirrhotic patients were divided in two groups; eight patients (group 1, age 56 +/- 9.6 yrs, Gender 5M/3F, 3 alcoholic and 5 non alcoholic) were given low intravenous 40 mg furosemide and ten other patients (group 2, age 54 +/- 9.9, Gender 6M/4F, 4 alcoholic and 6 non alcoholic) were given high 120 mg furosemide respectively. Renoscintigraphy with 100MBq Of Tc 99 DMSA was given intravenously before and 90 minutes after furosemide administration and SPECT imaging was determined 3 hours later. All patients were kept under low sodium diet (80mEq/d) and all diuretics were withdrawn for 3 days. 8-hours UNa exertion, Calculated and measured Creatinine clearance (CCT) were performed for all patients.

RESULTS

Intravenous furosemide increased the mean renal DMSA uptake in 55% of patients with compensated cirrhosis and these changes persist up to three hours after injection. This increase was at the same extent in either low or high doses of furosemide. (From 12.8% +/- 3.8 to 15.2% +/- 2.2, p < 0.001 in Gr I as compared to 10.6% +/- 4.6 to 13.5% +/- 3.6 in Gr 2, p < 0.001). In 8 patients (45%, 3 pts from Gr 1 and 5 pts from Gr 2) DMSA uptake remain unchanged. The mean 8 hrs UNa excretion after intravenous furosemide was above 80 meq/l and was higher in Gr 2 as compared to Gr 1 respectively (136 +/- 37 meq/l) VS 100 +/- 36.6 meq/l, P = 0.05). Finally, basal global renal DMSA uptake was decreased in 80% of patients; 22.5 +/- 7.5% (NL > 40%), as compared to normal calculated creatinine clearance (CCT 101 +/- 26), and measured CCT of 87 +/- 30 cc/min (P < 0.001).

CONCLUSION

A single furosemide injection increases renal functional mass as reflected by DMSA in 55% of patients with compensated cirrhosis and identify 45% of patients with reduced uptake and who could develop renal impairment under diuretics. Whether or not albumin infusion exerts beneficial effect in those patients with reduced DMSA uptake remains to be determined.

The influence of continuous seven-day elevated intra-abdominal pressure in the renal perfusion in cirrhotic rats

Since hepatorenal syndrome is a functional renal failure due to renal ischemia in cirrhotics with refractory ascites, we investigated whether increased intra-abdominal pressure (IAP) impairs the renal function and perfusion in cirrhotic portal hypertensive rats. Eight groups of 32 rats each were studied, including 4 control and 4 CCl(4) cirrhotic groups. These were subdivided into two groups each, with and without an increased IAP, and further subdivided into groups of rats with and without NO inhibition. IAP was increased to 20 mm Hg for 7 consecutive days by means of an intraperitoneally placed balloon filled with water. The animals were studied in normal conditions and after inhibition of NO synthesis. Changes in mean arterial pressure and renal microcirculation by means of femoral artery catheterization and laser-Doppler technique, respectively, were recorded. Venous samples for determination of plasma renin-aldosterone activity, biochemical parameters of liver and renal function, and plasma nitrite/nitrate levels as an index of NO synthesis were drawn. Cirrhotic rats showed decreased renal microcirculation (P = 0.05), while elevated IAP produced a further decrease (P = 0.01). Renin-aldosterone levels found increased (P = 0.001) in cirrhotics, and elevated IAP produced a further increase (P = 0.01] in both groups. Inhibition of NO synthesis resulted in a nonsignificant decrease in both renal microcirculation and renin-aldosterone levels in all experimental groups. Liver and renal function was found to be impaired in cirrhotics, but increased IAP had a nonsignificant further functional impairment in both organs. In conclusion, chronically elevated IAP in cirrhotic rats is associated with an increase in renin-aldosterone levels and significant impairment of renal perfusion.

Characterisation of portal hypertension models by microspheres in anaesthetised rats: a comparison of liver flow

Several portal hypertensive animal models are available and frequently used for haemodynamic studies. The portal venous inflows, measured with microspheres in pentobarbital anaesthetised rats, are compared here. The partial portal vein ligation model is characterised by a high portal venous inflow, together with extensive portal systemic shunting, at the cost of portal sinusoidal flow. In carbon tetrachloride-induced micronodular cirrhosis, portal sinusoidal flow, which reaches liver parenchyma, is high, and this is more pronounced in the presence of ascites. In bile duct ligation and excision-induced cirrhosis, an increase in liver weight was not equally followed by an increase in portal sinusoidal flow, pointing to a relatively underperfused liver.

Hepatorenal syndrome

Hepatorenal syndrome is a functional renal failure that occurs in cirrhotic patients with advanced liver disease and ascites. The diagnostic criteria and clinical types of this syndrome have recently been revised. Hepatorenal syndrome is caused by marked hypoperfusion of the kidney as the result of renal vasoconstriction, which is thought to be the extreme manifestation of an underfilling of the arterial circulation. This circulatory dysfunction is the consequence of arterial vasodilation in the splanchnic circulation. Liver transplantation is the best treatment for HRS, but its applicability is low because of the short survival of these patients. New therapies, such as the use of systemic vasoconstrictors or TIPS, seem promising, but prospective investigations are needed to delineate their role in the management of cirrhotic patients with HRS.