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Pose E, Piano S, Juanola A, Ginès P. Hepatorenal Syndrome in Cirrhosis. Gastroenterology 2024; 166:588-604.e1. [PMID: 38246506 DOI: 10.1053/j.gastro.2023.11.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 01/23/2024]
Abstract
Hepatorenal syndrome (HRS) is a form of kidney dysfunction that characteristically occurs in liver cirrhosis. It is characterized by a marked impairment of kidney function in response to circulatory and hemodynamic alterations that occur in advanced stages of liver cirrhosis, aggravated by systemic inflammation and bacterial translocation. The classical definitions of the types of HRS have been recently revisited and 2 forms of HRS have been redefined: the acute form, referred to as acute kidney injury (HRS-AKI), and the chronic form, referred to as chronic kidney disease. HRS-AKI is one of the most severe forms of AKI in patients with cirrhosis and it consists of an abrupt impairment of kidney function, frequently triggered by an infection, appearing in the setting of advanced decompensated cirrhosis. Differential diagnosis with other causes of AKI is crucial because HRS-AKI requires a specific treatment. Differential diagnosis with AKI-acute tubular necrosis may be challenging and kidney biomarkers may be useful in this setting. Treatment of HRS-AKI is based on the administration of vasoconstrictor drugs in combination with volume expansion with albumin. Prognosis of HRS-AKI is poor, and the ideal definitive treatment consists of liver transplantation or simultaneous liver-kidney transplantation. HRS-AKI has a big impact on patients' quality of life. Management of HRS-AKI remains challenging in specific situations such as alcohol-associated hepatitis or metabolic-associated steatotic liver disease cirrhosis. Developing preventive measures for HRS-AKI, improving its early identification, discovering new biomarkers for differential diagnosis, and improving the response to therapy are some of the unmet needs in the field of HRS-AKI.
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Affiliation(s)
- Elisa Pose
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Adrià Juanola
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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Asada S, Namisaki T, Kaji K, Takaya H, Kubo T, Akahane T, Kawaratani H, Nishimura N, Takeda S, Masuda H, Shibamoto A, Inoue T, Iwai S, Tomooka F, Tsuji Y, Fujinaga Y, Kitagawa K, Mitoro A, Sato S, Matsumoto M, Yoshiji H. VWF/ADAMTS13 Ratio as a Potential Predictive Biomarker for Acute Kidney Injury Onset in Cirrhosis. Dig Dis Sci 2024; 69:851-869. [PMID: 38244124 DOI: 10.1007/s10620-023-08257-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024]
Abstract
AIM We investigated the von Willebrand factor to ADAMTS13 ratio (von Willebrand factor [VWF]:Ag/ADAMTS13:AC) as a potential biomarker for the outcomes of acute kidney injury (AKI) in liver cirrhosis (LC). METHODS This retrospective cross-sectional study included patients with LC who developed AKI (AKI group: n = 91) and patients with LC who did not develop AKI [non-AKI (NAKI) group, n = 91] as a control group. Plasma levels of the von Willebrand factor antigen (Ag) and ADAMTS13 activity (AC) were measured in patients with AKI or NAKI. Moreover, risk factors for onset of AKI, AKI-associated 90-day mortality, and poor AKI treatment response were identified. RESULTS The AKI group had a significantly higher VWF:Ag/ADAMTS13:AC than the NAKI group. Values of VWF:Ag/ADAMTS13:AC ≥ 5.7 were identified as risk factors for AKI onset in patients with LC (odds ratio [OR] 2.56; 95% CI 1.26-4.99; p < 0.001). Among patients with AKI, values of VWF:Ag/ADAMTS13:AC ≥ 9.0 were identified as risk factors for 90-day mortality (OR 6.83; 95% CI 2.32-20.10; p < 0.001). Cumulative survival was significantly lower in those with high (≥ 9.0) than in those with low (< 9.0) VWF:Ag/ADAMTS13:AC. Furthermore, values of VWF:Ag/ADAMTS13:AC ≥ 7.4 were identified as risk factors for poor treatment response (OR 4.2; 95% CI 1.39-12.70; p < 0.001). The treatment response rates were significantly higher in those with low (< 7.4) VWF:Ag/ADAMTS13:AC than in those with high (≥ 7.4) VWF:Ag/ADAMTS13:AC. CONCLUSION VWF:Ag/ADAMTS13:AC potentially predicts the onset, prognosis, and treatment response of AKI in patients with LC.
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Affiliation(s)
- Shohei Asada
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan.
| | - Kosuke Kaji
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Hiroaki Takaya
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Takahiro Kubo
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Takemi Akahane
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Hideto Kawaratani
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Norihisa Nishimura
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Soichi Takeda
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Hiroyuki Masuda
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Akihiko Shibamoto
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Takashi Inoue
- Department of Evidence-Based Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Satoshi Iwai
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Fumimasa Tomooka
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Yuki Tsuji
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Yukihisa Fujinaga
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Koh Kitagawa
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Akira Mitoro
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Shinya Sato
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Masanori Matsumoto
- Department of Hematology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
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Trebicka J, Garcia-Tsao G. Controversies regarding albumin therapy in cirrhosis. Hepatology 2023:01515467-990000000-00524. [PMID: 37540192 DOI: 10.1097/hep.0000000000000521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/26/2023] [Indexed: 08/05/2023]
Abstract
Albumin is the most abundant protein in the human body and is synthetized exclusively by the liver. Therefore, serum albumin levels are reduced in acute and/or chronic liver disease. In cirrhosis, low levels of albumin predict the outcome. In advanced cirrhosis, the quality of albumin is decreased due to high oxidative stress and a proinflammatory state. Therefore, the administration of i.v. albumin would seem to be of pathophysiological relevance and benefit. Yet, the questions that remain are who, when, how much, and how often. While albumin infusion is recommended after large-volume paracentesis, at diagnosis of spontaneous bacterial peritonitis, in acute kidney injury, and in hepatorenal syndrome, the amount and schedule of albumin to be administered require refinement, particularly given complications related to volume overload that have become increasingly apparent. Other indications for albumin such as infections other than spontaneous bacterial peritonitis, hyponatremia, HE, prevention of poor outcomes in hospitalized, and in outpatients with cirrhosis are still debated. The results of studies in these settings are either negative, controversial, or inconclusive. This sheds some doubts regarding the use of albumin as a "one size fits all" strategy. The indication and patient selection are crucial and not always intuitive. The amount and frequency also seem to play a role in the success or failure of albumin. This review will critically discuss the evidence and underline areas where there are indications for albumin use and others where evidence is still insufficient and will have to await the development/results of randomized controlled trials.
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Affiliation(s)
- Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Münster, Germany
- European Foundation for Study of Chronic Liver Failure, EASL-CLIF-Consortium, Barcelona, Spain
- Department of Gastroenterology and Hepatology, University of Southern Denmark, Odense, Denmark
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Department of Medicine, Yale University, New Haven, Connecticut, USA
- Digestive Diseases Section, Department of Medicine, VA-CT Healthcare System, West Haven, Connecticut, USA
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Amer K, Flikshteyn B, Lingiah V, Tafesh Z, Pyrsopoulos NT. Mechanisms of Disease and Multisystemic Involvement. Clin Liver Dis 2023; 27:563-579. [PMID: 37380283 DOI: 10.1016/j.cld.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
- Kamal Amer
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Ben Flikshteyn
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Vivek Lingiah
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Zaid Tafesh
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 53, Newark, NJ 07101-1709, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 536, Newark, NJ 07101-1709, USA.
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Mandorfer M, Aigner E, Cejna M, Ferlitsch A, Datz C, Gräter T, Graziadei I, Gschwantler M, Hametner-Schreil S, Hofer H, Jachs M, Loizides A, Maieron A, Peck-Radosavljevic M, Rainer F, Scheiner B, Semmler G, Reider L, Reiter S, Schoder M, Schöfl R, Schwabl P, Stadlbauer V, Stauber R, Tatscher E, Trauner M, Ziachehabi A, Zoller H, Fickert P, Reiberger T. Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV). Wien Klin Wochenschr 2023:10.1007/s00508-023-02229-w. [PMID: 37358642 DOI: 10.1007/s00508-023-02229-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/15/2023] [Indexed: 06/27/2023]
Abstract
The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.
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Affiliation(s)
- Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Elmar Aigner
- First Department of Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Manfred Cejna
- Department of Radiology, LKH Feldkirch, Feldkirch, Austria
| | - Arnulf Ferlitsch
- Department of Internal Medicine I, KH Barmherzige Brüder Wien, Vienna, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tilmann Gräter
- Department of Radiology, Medical University of Graz, Graz, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, KH Hall in Tirol, Hall, Austria
| | - Michael Gschwantler
- Division of Gastroenterology and Hepatology, Department of Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Stephanie Hametner-Schreil
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University of Innbsruck, Innsbruck, Austria
| | - Andreas Maieron
- Department of Internal Medicine II, University Hospital St. Pölten, St. Pölten, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Florian Rainer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Reider
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Silvia Reiter
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Maria Schoder
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Rainer Schöfl
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rudolf Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Tatscher
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Alexander Ziachehabi
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Heinz Zoller
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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Gambino C, Piano S, Stenico M, Tonon M, Brocca A, Calvino V, Incicco S, Zeni N, Gagliardi R, Cosma C, Zaninotto M, Burra P, Cillo U, Basso D, Angeli P. Diagnostic and prognostic performance of urinary neutrophil gelatinase-associated lipocalin in patients with cirrhosis and acute kidney injury. Hepatology 2023; 77:1630-1638. [PMID: 36125403 PMCID: PMC10113003 DOI: 10.1002/hep.32799] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Acute kidney injury (AKI) commonly occurs in patients with decompensated cirrhosis. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) could help discriminate between different etiologies of AKI. The aim of this study was to investigate the use of uNGAL in (1) the differential diagnosis of AKI, (2) predicting the response to terlipressin and albumin in patients with hepatorenal syndrome-AKI (HRS-AKI), and (3) predicting in-hospital mortality in patients with AKI. APPROACH AND RESULTS One hundred sixty-two consecutive patients with cirrhosis and AKI were included from 2015 to 2020 and followed until transplant, death, or 90 days. Standard urinary markers and uNGAL were measured. Data on treatment, type, and resolution of AKI were collected. Thirty-five patients (21.6%) had prerenal AKI, 64 (39.5%) HRS-AKI, 27 (16.7%) acute tubular necrosis-AKI (ATN-AKI), and 36 (22.2%) a mixed form of AKI. Mean values of uNGAL were significantly higher in ATN-AKI than in other types of AKI (1162 ng/ml [95% CI 423-2105 ng/ml] vs. 109 ng/ml [95% CI 52-192 ng/ml]; p < 0.001). uNGAL showed a high discrimination ability in predicting ATN-AKI (area under the receiver operating characteristic curve, 0.854; 95% CI 0.767-0.941; p < 0.001). The best-performing threshold was found to be 220 ng/ml (sensitivity, 89%; specificity, 78%). The same threshold was independently associated with a higher risk of nonresponse (adjusted OR [aOR], 6.17; 95% CI 1.41-27.03; p = 0.016). In multivariable analysis (adjusted for age, Model for End-Stage Liver Disease, acute-on-chronic liver failure, leukocytes, and type of AKI), uNGAL was an independent predictor of in-hospital mortality (aOR, 1.74; 95% CI 1.26-2.38; p = 0.001). CONCLUSIONS uNGAL is an adequate biomarker for making a differential diagnosis of AKI in cirrhosis and predicting the response to terlipressin and albumin in patients with HRS-AKI. In addition, it is an independent predictor of in-hospital mortality.
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Affiliation(s)
- Carmine Gambino
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Matteo Stenico
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Alessandra Brocca
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Simone Incicco
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Nicola Zeni
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Roberta Gagliardi
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Chiara Cosma
- Laboratory Medicine Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Daniela Basso
- Laboratory Medicine Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
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Yewale RV, Ramakrishna BS, Venugopal G, Doraiswami BV, Rajini K. Urine neutrophil gelatinase-associated lipocalin as a biomarker of acute kidney injury and prognosis in decompensated chronic liver disease: A prospective study. Indian J Gastroenterol 2023; 42:106-117. [PMID: 36763249 PMCID: PMC9913035 DOI: 10.1007/s12664-022-01312-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 11/08/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) heralds deterioration in patients with decompensated chronic liver disease (DCLD). Serum creatinine (sCr), a component of the model for end-stage liver disease-sodium (MELD-Na) prognostic score, has limitations in patients with DCLD. We evaluated the prognostic role of urine neutrophil gelatinase-associated lipocalin (NGAL) in DCLD and its ability to sub-type AKI. METHODS Total 147 consecutive patients hospitalized between June 2018 and June 2020 for complications of DCLD were evaluated. Urine NGAL was estimated and demographic, clinical and biochemical parameters recorded at baseline. Participants were followed up till the end of study period or mortality, whichever came earlier. Primary outcomes included all-cause mortality and time to death after index hospitalization. Secondary outcomes included the presence and type of AKI, need for intensive care unit (ICU) stay, length of ICU/hospital stay, in-hospital mortality, development of new-onset/recurrent AKI and recurrent hospitalization after index admission. RESULTS Urine NGAL was highest in acute tubular necrosis (ATN), lowest in pre-renal azotemia (PRA) and intermediate in hepatorenal syndrome (HRS-AKI). Urine NGAL (p = 0.0208) was superior to sCr (p = 0.0388) and inferior to fractionated excretion of sodium (FENa) (p = 0.0013) in stratifying AKI. A cut-off of 203.9 ng/mL discriminated between HRS and PRA with sensitivity 77.8% and specificity 68.7%. Urine NGAL correlated with MELD-Na score, need for ICU stay, in-hospital mortality and mortality at three and six months. Two-year survival was significantly lower in patients with urine NGAL > 205 ng/mL. Addition of log-urine-NGAL score did not improve predictive performance of MELD-Na. CONCLUSION Urine NGAL could identify AKI sub-types and correlated with short-term clinical outcomes, including mortality.
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Affiliation(s)
- Rohan Vijay Yewale
- SIMS Institute of Gastroenterology, Hepatobiliary Sciences and Transplantation, SRM Institutes for Medical Science, 1 Jawaharlal Nehru Road, Chennai, 600 026, India.
| | - Balakrishnan Siddartha Ramakrishna
- SIMS Institute of Gastroenterology, Hepatobiliary Sciences and Transplantation, SRM Institutes for Medical Science, 1 Jawaharlal Nehru Road, Chennai, 600 026, India
| | - Giriprasad Venugopal
- SIMS Institute of Gastroenterology, Hepatobiliary Sciences and Transplantation, SRM Institutes for Medical Science, 1 Jawaharlal Nehru Road, Chennai, 600 026, India
| | - Babu Vinish Doraiswami
- SIMS Institute of Gastroenterology, Hepatobiliary Sciences and Transplantation, SRM Institutes for Medical Science, 1 Jawaharlal Nehru Road, Chennai, 600 026, India
| | - Kayalvizhi Rajini
- SIMS Institute of Gastroenterology, Hepatobiliary Sciences and Transplantation, SRM Institutes for Medical Science, 1 Jawaharlal Nehru Road, Chennai, 600 026, India
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El-Makarem MAERA, Mahmoud YZ, Moussa MM, El-Saghir SMM, Keryakos HKH. Do old urinary biomarkers have a place in the new definition of hepatorenal syndrome in the Egyptian cirrhotic patients? A single-center experience. EGYPTIAN LIVER JOURNAL 2022. [DOI: 10.1186/s43066-022-00185-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hepatorenal syndrome is still a diagnosis of exclusion despite new classification.
Aims
To validate the accuracy of urinary neutrophil gelatinase-associated lipocalin, interleukin-18, and kidney injury molecule-1 in the new diagnostic criteria of hepatorenal syndrome in Egyptian patients with hepatitis C virus-related liver cirrhosis using serum creatinine as a gold standard test for acute kidney injury.
Methods
One-hundred twenty cirrhotic patients with ascites were recruited and divided into two groups depending on the presence or absence of renal impairment, and 40 age- and sex-matched cirrhotic patients without ascites used as controls participated in the study. Urinary biomarkers were measured and compared with conventional biomarkers used to assess kidney function (serum creatinine, estimated glomerular filtration rate).
Results
The mean urinary neutrophil gelatinase-associated lipocalin, interleukin-18, and kidney injury molecule-1 were statistically significantly higher in patients with hepatorenal syndrome and were found to be helpful in the early detection with cutoff values of 125 ng/ml, 34.8 pg/ml, and 3.1 pg/ml, respectively.
Conclusions
Urinary neutrophil gelatinase-associated lipocalin, interleukin-18, and kidney injury molecule-1 levels are higher in patients with cirrhotic ascites complicated by HRS-AKI using the new definition of HRS, but IL-18 has lower sensitivity and specificity for the prediction of HRS-AKI as compared to NGAL and KIM-1.
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9
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Portal hypertension in cirrhosis: Pathophysiological mechanisms and therapy. JHEP Rep 2021; 3:100316. [PMID: 34337369 PMCID: PMC8318926 DOI: 10.1016/j.jhepr.2021.100316] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/19/2021] [Accepted: 05/12/2021] [Indexed: 12/14/2022] Open
Abstract
Portal hypertension, defined as increased pressure in the portal vein, develops as a consequence of increased intrahepatic vascular resistance due to the dysregulation of liver sinusoidal endothelial cells (LSECs) and hepatic stellate cells (HSCs), frequently arising from chronic liver diseases. Extrahepatic haemodynamic changes contribute to the aggravation of portal hypertension. The pathogenic complexity of portal hypertension and the unsuccessful translation of preclinical studies have impeded the development of effective therapeutics for patients with cirrhosis, while counteracting hepatic and extrahepatic mechanisms also pose a major obstacle to effective treatment. In this review article, we will discuss the following topics: i) cellular and molecular mechanisms of portal hypertension, focusing on dysregulation of LSECs, HSCs and hepatic microvascular thrombosis, as well as changes in the extrahepatic vasculature, since these are the major contributors to portal hypertension; ii) translational/clinical advances in our knowledge of portal hypertension; and iii) future directions.
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Key Words
- ACE2, angiogenesis-converting enzyme 2
- ACLF, acute-on-chronic liver failure
- AT1R, angiotensin II type I receptor
- CCL2, chemokine (C-C motif) ligand 2
- CCl4, carbon tetrachloride
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- Dll4, delta like canonical Notch ligand 4
- ECM, extracellular matrix
- EUS, endoscopic ultrasound
- FXR
- FXR, farnesoid X receptor
- HCC, hepatocellular carcinoma
- HRS, hepatorenal syndrome
- HSC
- HSCs, hepatic stellate cells
- HVPG, hepatic venous pressure gradient
- Hsp90, heat shock protein 90
- JAK2, Janus kinase 2
- KO, knockout
- LSEC
- LSEC, liver sinusoidal endothelial cells
- MLCP, myosin light-chain phosphatase
- NET, neutrophil extracellular trap
- NO
- NO, nitric oxide
- NSBB
- NSBBs, non-selective beta blockers
- PDE, phosphodiesterase
- PDGF, platelet-derived growth factor
- PIGF, placental growth factor
- PKG, cGMP-dependent protein kinase
- Rho-kinase
- TIPS
- TIPS, transjugular intrahepatic portosystemic shunt
- VCAM1, vascular cell adhesion molecule 1
- VEGF
- VEGF, vascular endothelial growth factor
- angiogenesis
- eNOS, endothelial nitric oxide synthase
- fibrosis
- liver stiffness
- statins
- β-Arr2, β-arrestin 2
- β1-AR, β1-adrenergic receptor
- β2-AR, β2-adrenergic receptor
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10
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Abstract
Liver cirrhosis is a major healthcare problem. Acute decompensation, and in particular its interplay with dysfunction of other organs, is responsible for the majority of deaths in patients with cirrhosis. Acute decompensation has different courses, from stable decompensated cirrhosis over unstable decompensated cirrhosis to pre-acute-on-chronic liver failure and finally acute-on-chronic liver failure, a syndrome with high short-term mortality. This review focuses on the recent developments in the field of acute decompensation and acute-on-chronic liver failure.
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Affiliation(s)
- Philip Ferstl
- Department for Internal Medicine I, University Hospital, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Jonel Trebicka
- Department for Internal Medicine I, University Hospital, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany; European Foundation for the Study of Chronic Liver Failure, Travesera de Gracia 11, 08021 Barcelona, Spain.
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11
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Thalji L, Thalji NM, Heimbach JK, Ibrahim SH, Kamath PS, Hanson A, Schulte PJ, Haile DT, Kor DJ. Renal Function Parameters and Serum Sodium Enhance Prediction of Wait-List Outcomes in Pediatric Liver Transplantation. Hepatology 2021; 73:1117-1131. [PMID: 32485002 DOI: 10.1002/hep.31397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 05/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Reliance on exception points to prioritize children for liver transplantation (LT) stems from concerns that the Pediatric End-Stage Liver Disease (PELD) score underestimates mortality. Renal dysfunction and serum sodium disturbances are negative prognosticators in adult LT candidates and various pediatric populations, but are not accounted for in PELD. We retrospectively evaluated the effect of these parameters in predicting 90-day wait-list death/deterioration among pediatric patients (<12 years) listed for isolated LT in the United States between February 2002 and June 2018. APPROACH AND RESULTS Among 4,765 patients, 2,303 (49.3%) were transplanted, and 231 (4.8%) died or deteriorated beyond transplantability within 90 days of listing. Estimated glomerular filtration rate (eGFR) (hazard ratio [HR] 1.09 per 5-unit decrease, 95% confidence interval [CI] 1.06-1.10) and dialysis (HR 7.24, 95% CI 3.57-14.66) were univariate predictors of 90-day death/deterioration (P < 0.001). The long-term benefit of LT persisted in patients with renal dysfunction, with LT as a time-dependent covariate conferring a 2.4-fold and 17-fold improvement in late survival among those with mild and moderate-to-severe dysfunction, respectively. Adjusting for PELD, sodium was a significant nonlinear predictor of outcome, with 90-day death/deterioration risk increased at both extremes of sodium (HR 1.20 per 1-unit decrease below 137 mmol/L, 95% CI 1.16-1.23; HR per 1-unit increase above 137 mmol/L 1.13, 95% CI 1.10-1.17, P < 0.001). A multivariable model incorporating PELD, eGFR, dialysis, and sodium demonstrated improved performance and superior calibration in predicting wait-list outcomes relative to the PELD score. CONCLUSIONS Listing eGFR, dialysis, and serum sodium are potent, independent predictors of 90-day death/deterioration in pediatric LT candidates, capturing risk not accounted for by PELD. Incorporation of these variables into organ allocation systems may highlight patient subsets with previously underappreciated risk, augment ability of PELD to prioritize patients for transplantation, and ultimately mitigate reliance on nonstandard exceptions.
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Affiliation(s)
- Leanne Thalji
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
| | | | | | - Samar H Ibrahim
- Department of PediatricsDivision of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Patrick S Kamath
- Department of MedicineDivision of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Andrew Hanson
- Division of Biomedical StatisticsMayo ClinicRochesterMN
| | | | - Dawit T Haile
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
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12
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Rey R. M, Delgado AF, De Zubiria A, Pinto R, De la Hoz-Valle JA, Pérez-Riveros ED, Ardila G, Sierra-Arango F. Prevalence and short-term outcome of hepatorenal syndrome: A 9-year experience in a high-complexity hospital in Colombia. PLoS One 2020; 15:e0239834. [PMID: 33079947 PMCID: PMC7575105 DOI: 10.1371/journal.pone.0239834] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 09/14/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND & AIMS Hepatorenal syndrome is a rare entity that is part of the complications of liver cirrhosis in its more severe stages. Without treatment, its mortality rate increases significantly. Terlipressin is considered to be the therapy of choice until the need of a liver transplant. The aim is to determine its prevalence, define patients' characteristics, triggers and 90-day survival, according to the type of managements established. METHOD This was a retrospective cohort study conducted in Colombia. It included patients with cirrhosis and acute kidney injury who met hepatorenal syndrome criteria, reaching 28 patients from 2007 to 2015. Groups were categorized according the type of hepatorenal syndrome and treatment. Demographic and trigger factors were evaluated to characterize the population. Treatment outcomes with terlipressin vs norepinephrine were analyzed up to a 90-day survival, using log Rank test. Continuous variables needed Student's T and Mann Whitney's U tests and categorical variables, Chi2 test. A value of p <0.05 and a power of 85% was considered. The data was analyzed in the SPSS version 23 software. RESULTS 117 patients with cirrhosis developed renal injury; of these 23.9% were diagnosed with Hepatorenal Syndrome (67.8% type1; 32.1% type2). The presence of ascites was 100% in HRS2 and 84% in HRS1 (p = 0.296). The main trigger in both types was paracentesis greater than 5 liters in the last 4 weeks (39.3%). In total, 35% of the patients received renal replacement therapy and 14% underwent a hepatic transplant. Type 1 was more frequent (63% received terlipressin; 21% norepinephrine). The total complete response was 36% (Type2 66.6% vs. Type1 18.7%) (p = 0.026). In contrast, the overall mortality was of 67.8% at 90-day of follow-up (89.4% Type1 vs. 22% Type2) (p = <0.001). We found a lower mortality rate in patients treated with terlipressin than treated with norepinephrine (p = 0.006). CONCLUSION There is scarce clinical and epidemiological information about this condition in Colombia. A significant difference between the two drugs cannot be stipulated due to the limitation in the sample size of our study. The general mortality at a 90-day follow-up was high, being higher in patients with HRS1. While the results of this study are suggestive of clinical information for HRS patients in the Colombian population, they should also be interpreted with caution, therefore further multicenter studies should be performed.
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Affiliation(s)
- Margarita Rey R.
- Gastroenterology and Digestive Endoscopy Section, Fundación Santa Fe de Bogotá, Bogota, Colombia
- Internal Medicine Department, Fundación Santa Fe de Bogotá, Bogota, Colombia
- School of Medicine, Universidad de Los Andes, Fundación Santa Fe de Bogotá, Bogota, Colombia
- * E-mail:
| | - Andrés F. Delgado
- Internal Medicine Department, Fundación Santa Fe de Bogotá, Bogota, Colombia
- Transplant Service Department, Fundación Santa Fe de Bogotá, Bogota, Colombia
| | - Alejandra De Zubiria
- Internal Medicine Department, Fundación Santa Fe de Bogotá, Bogota, Colombia
- School of Medicine, Universidad de Los Andes, Fundación Santa Fe de Bogotá, Bogota, Colombia
| | - Renzo Pinto
- Gastroenterology and Digestive Endoscopy Section, Fundación Santa Fe de Bogotá, Bogota, Colombia
- Internal Medicine Department, Fundación Santa Fe de Bogotá, Bogota, Colombia
- School of Medicine, Universidad de Los Andes, Fundación Santa Fe de Bogotá, Bogota, Colombia
| | - José A. De la Hoz-Valle
- Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogota, Colombia
| | - Erika D. Pérez-Riveros
- Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogota, Colombia
| | - Gerardo Ardila
- Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogota, Colombia
| | - Fernando Sierra-Arango
- Gastroenterology and Digestive Endoscopy Section, Fundación Santa Fe de Bogotá, Bogota, Colombia
- Internal Medicine Department, Fundación Santa Fe de Bogotá, Bogota, Colombia
- School of Medicine, Universidad de Los Andes, Fundación Santa Fe de Bogotá, Bogota, Colombia
- Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogota, Colombia
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13
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Kumar U, Kumar R, Jha SK, Jha AK, Dayal VM, Kumar A. Short-term mortality in patients with cirrhosis of the liver and acute kidney injury: A prospective observational study. Indian J Gastroenterol 2020; 39:457-464. [PMID: 33175368 DOI: 10.1007/s12664-020-01086-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 08/03/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Renal failure is a common and severe complication of cirrhosis and confers poor prognosis. Serum creatinine is the most practical biomarker of renal function. Serum creatinine estimation in cirrhosis of the liver is affected by decreased formation, increased tubular secretion, increased volume of distribution, and interference by elevated bilirubin. Studies on the prognosis of cirrhotic patients using creatinine kinetics as a definition of acute kidney injury (AKI) proposed by the International Ascites Club are limited. METHODS In this single-center prospective observational study, decompensated cirrhotics with AKI defined by the International Ascites Club as the rise of serum creatinine ≥ 0.3 mg/dL within 48 h of admission or increase of serum creatinine ≥ 50% from stable baseline creatinine over the previous 3 months were followed and assessed for the development of complications during hospital course and in-hospital and 30-day mortality. RESULTS AKI developed in 142 out of 499 (28.45%) patients with cirrhosis. Twenty patients were excluded. The most common etiology of cirrhosis was alcohol (n = 64, 52%), and ascites was present in 115 (94%) patients. Eighty-two (67.21%) patients presented with AKI at the time of admission. Thirty-day mortality was 46.72% (57/122 patients). Hepatorenal syndrome had the highest mortality followed by AKI related to infection. Presence of jaundice and hepatic encephalopathy (HE) was associated with poor survival with adjusted hazard ratio of 3.54 and 2.17, respectively. On bivariate logistic regression analysis, jaundice, HE, type of AKI, AKI stage at maximum creatinine, bilirubin, serum glutamic oxaloacetic transaminase (SGOT), international normalized ratio (INR), and Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were predictors of mortality (p < 0.05). Sensitivity, specificity, and accuracy of MELD > 29 and CTP score > 11 were 75.44%, 82%, and 78.70% and 66.67%, 81.54%, and 74.60%, respectively for predicting 30-day mortality. CONCLUSION Development of AKI as defined by the International Ascites Club in cirrhosis confers high short-term mortality. Jaundice, HE, AKI stage, creatinine at enrollment, bilirubin, CTP, and MELD score were the predictors of mortality. Bullet points of the study highlights What is already known? • Renal failure is a common and severe complication of cirrhosis. • Serum creatinine is the most practical biomarker of renal function but it has many limitations in cirrhotic patients. • Creatinine kinetics-based definition of acute kidney injury (AKI) was proposed by the International Ascites Club. What is new in this study? • Short-term mortality (30 days) in decompensated cirrhotic patients with AKI as defined by the International Ascites Club using creatinine kinetics was high. • AKI due to hepatorenal syndrome (HRS) has the highest short-term (30 days) mortality followed by AKI due to infection in decompensated cirrhosis. • Detection of AKI using creatinine kinetics-based definition may prompt an early appropriate intervention. What are the future clinical and research implications of study findings? • Creatinine kinetics-based definition of AKI diagnose renal injury at an earlier stage; an appropriate intervention should be initiated at the earliest in these patients to improve patient survival.
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Affiliation(s)
- Uday Kumar
- Patna Medical College, Patna 800 001, India
| | - Ravikant Kumar
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India.
| | - Sanjeev Kumar Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
| | - Ashish Kumar Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
| | - Vishwa Mohan Dayal
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
| | - Amarendra Kumar
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
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14
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Pietrukaniec M, Migacz M, Żak-Gołąb A, Olszanecka-Glinianowicz M, Chudek J, Duława J, Holecki M. Could KIM-1 and NGAL levels predict acute kidney injury after paracentesis? - preliminary study. Ren Fail 2020; 42:853-859. [PMID: 32808849 PMCID: PMC7472504 DOI: 10.1080/0886022x.2020.1801468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background Kidney dysfunction is a common complication in patients with severe liver cirrhosis. There is a need for discovery and validation of novel biomarkers for earlier AKI detection. The aim of this study was to determine if tubular injury markers: NGAL and KIM-1 could be helpful in the early diagnosis of AKI in patients undergoing therapeutic paracentesis. Methods This preliminary study included 24 adult patients diagnosed with liver cirrhosis who had been hospitalized due to massive ascites requiring paracentesis. Pre- and post-paracentesis plasma samples were taken from each patient and biomarkers were measured. Results Before paracentesis, the levels of serum and urinary NGAL were similar between patients and controls; while urinary KIM-1 was markedly increased in liver cirrhotic patients (0.76 vs. 0.24 ng/ml; respectively). Although urinary NGAL levels in AKI patients were 5-time greater than in non-AKI subgroup, the difference did not reach statistical significance (13.2 vs 1.5 pg/mL, p = 0.06). Serum NGAL level, post-procedure, was 3 times greater in AKI subgroup. Conclusion Kidney injury markers, especially serum NGAL, may be useful for the early detection of AKI. However, further research is required to determine if biomarkers of kidney injury may help identify patients with cirrhosis who would most likely benefit from early AKI prevention and treatment.
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Affiliation(s)
- Marta Pietrukaniec
- Department of Internal, Autoimmune and Metabolic Diseases, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland
| | - Maciej Migacz
- Department of Internal, Autoimmune and Metabolic Diseases, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland
| | - Agnieszka Żak-Gołąb
- Department of Internal, Autoimmune and Metabolic Diseases, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Jerzy Chudek
- Department of Internal Diseases and Oncological Chemotherapy, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland
| | - Jan Duława
- Department of Internal and Autoimmune Diseases, School of Health Science, Medical University of Silesia, Katowice, Poland
| | - Michał Holecki
- Department of Internal, Autoimmune and Metabolic Diseases, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland
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15
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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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16
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Scarpellini E, Luigiano C, Svegliati-Baroni G, Dumitrascu D, Larussa T, Santori V, Luzza F, Abenavoli L. Liver Cirrhosis Complications Management at the Emergency Department. Rev Recent Clin Trials 2020; 15:331-338. [PMID: 32493202 DOI: 10.2174/1574887115666200603160816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/16/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Liver cirrhosis (LC) of any origin has always been a source of several emergencies for physicians working at the Emergency Department (ER). LC patients can present with several complications that are sometimes difficult to recognize and treat. Thus, we reviewed the literature evidence for the diagnosis and management of several LC related emergencies. METHODS We conducted a search on the main medical databases for papers, reviews, metanalyses, case series, and RCTs using the following keywords and their associations: liver cirrhosis, variceal hemorrhage, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepato-renal syndrome, emergency. RESULTS Main LC emergencies are upper gastrointestinal hemorrhage, decompensated ascites and spontaneous bacterial peritonitis, hepatic encephalopathy, hepato-renal syndrome. Their management is partly medical and interventional. Very often, the final cure of some complications, such as hepato-renal syndrome, is represented by liver transplantation. CONCLUSION Although LC prevalence is going to fall in the following years, due to HBV and HCV optimized treatments, its complications represent a significant admission percentage at the ER and challenge for physicians' skills.
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Affiliation(s)
- Emidio Scarpellini
- Internal Medicine Unit, "Madonna del Soccorso" General Hospital, San Benedetto del Tronto, Italy
| | | | - Gianluca Svegliati-Baroni
- Gastroenterology Clinic, "Riuniti University Hospital", Polytechnics University of Marche, Ancona, Italy
| | - Dan Dumitrascu
- Gastroenterology Unit, Cluj University, Cluj-Napoca, Romania
| | - Tiziana Larussa
- Department of Health Sciences, University "Magna Græcia", Catanzaro, Italy
| | - Valeria Santori
- Gastroenterology Clinic, "Riuniti University Hospital", Polytechnics University of Marche, Ancona, Italy
| | - Francesco Luzza
- Department of Health Sciences, University "Magna Græcia", Catanzaro, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, University "Magna Græcia", Catanzaro, Italy
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17
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Acute kidney injury: prediction, prognostication and optimisation for liver transplant. Hepatol Int 2020; 14:167-179. [DOI: 10.1007/s12072-020-10018-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/25/2020] [Indexed: 12/14/2022]
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18
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Israelsen M, Dahl EK, Madsen BS, Wiese S, Bendtsen F, Møller S, Fialla AD, Jensen BL, Krag A. Dobutamine reverses the cardio-suppressive effects of terlipressin without improving renal function in cirrhosis and ascites: a randomized controlled trial. Am J Physiol Gastrointest Liver Physiol 2020; 318:G313-G321. [PMID: 31841026 DOI: 10.1152/ajpgi.00328.2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney injury and hepatorenal syndrome (HRS) are frequent complications in patients with cirrhosis and ascites. First-line treatment is terlipressin, which reverses HRS in ~40% of patients but also lowers cardiac output (CO). We aimed to investigate whether reversing the cardio-suppressive effect of terlipressin with the β-adrenoceptor agonist dobutamine would increase CO and thereby increase the glomerular filtration rate (GFR). We randomized 25 patients with cirrhosis, ascites, and impaired renal function (2:2:1): group A received terlipressin followed by the addition of dobutamine; group B received dobutamine and terlipressin as monotherapies; and group C received placebo. Renal and cardiac functions were assessed during 8 clearance periods of 30 min, and concentrations of vasoactive hormones were measured. Dobutamine as a monotherapy increased CO (1.03 L/min, P < 0.01) but had no significant effects on GFR. Renin (P < 0.05), angiotensin II (P < 0.005), and aldosterone (P < 0.05) increased after dobutamine infusion. Terlipressin as a monotherapy improved GFR (18.9 mL·min-1·m-2, P = 0.005) and mean arterial pressure (MAP) (14 mmHg, P = 0.001) but reduced CO (-0.92 L/min, P < 0.005) and renin (P < .005). A combined treatment of dobutamine and terlipressin had a positive effect on CO (1.19 L/min, P < 0.05) and increased renin (P < 0.005), angiotensin II (P < 0.005), and aldosterone (P < 0.05), but it had no significant effects on MAP or GFR. Dobutamine reversed the cardio-suppressive effect of terlipressin in cirrhosis, ascites, and impaired renal function. However, dobutamine reduced peripheral vascular resistance, activated renin-angiotensin-aldosterone system, and did not improve GFR compared with terlipressin as a monotherapy. Therefore, dobutamine cannot be recommended in cirrhosis and ascites.NEW & NOTEWORTHY This study shows that the cardio-suppressive effects of the vasopressin receptor agonist terlipressin can be reversed by dobutamine. This is a novel observation in patients with decompensated cirrhosis. Furthermore, we show that dobutamine reduced the peripheral vascular resistance and activated the renin-angiotensin system, whereas renal function was not further improved by terlipressin alone.
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Affiliation(s)
- Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Emilie Kristine Dahl
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Bjørn Stæhr Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Signe Wiese
- Gastro Unit, Copenhagen University Hospital Hvidovre, Denmark.,Center for Functional and Diagnostic Imaging and Research, Department of Clinical Physiology and Nuclear Medicine 260, Faculty of Health Sciences Hvidovre Hospital, University of Copenhagen, Denmark
| | | | - Søren Møller
- Center for Functional and Diagnostic Imaging and Research, Department of Clinical Physiology and Nuclear Medicine 260, Faculty of Health Sciences Hvidovre Hospital, University of Copenhagen, Denmark
| | - Annette Dam Fialla
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Boye L Jensen
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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19
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Yan X, Shao R, Wang Y, Mao X, Lei J, Zhang L, Zheng J, Liu A, Zhao H, Gao F, Wang J, Li P, Yao S, Xu M, Xu J, Liu D, Mi Y, Gong X, Ye J, Deng M, Dang T, Ji J, Shao C, Liu C, Gu Y, Wu Y, Wang F, Teng G, Li X, Qi X, Ju S, Qi X. Functional magnetic resonance imaging-based assessment of terlipressin vs. octreotide on renal function in cirrhotic patients with acute variceal bleeding (CHESS1903): study protocol of a multicenter randomized controlled trial. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:586. [PMID: 31807567 PMCID: PMC6861789 DOI: 10.21037/atm.2019.09.141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute variceal bleeding is one of the critical complications in patients with liver cirrhosis. Severe renal vasoconstriction in consequence of low peripheral vascular resistance triggers the reduction of glomerular filtration rate (GFR), and thus induces acute kidney injury (AKI)/hepato-renal syndrome (HRS). Terlipressin and octreotide have been used in the management of cirrhotic patients with variceal bleeding. Also, terlipressin has been recommended as the international first-line pharmacological therapy for the treatment of HRS. In addition, the use of renal functional magnetic resonance imaging (fMRI) has become increasingly prevalent in research and clinical applications. However, the renal function-protective effect of terlipressin and octreotide and the value of fMRI in monitoring renal function remains unclear in patients with cirrhosis undergoing acute variceal bleeding. METHODS This is a multicenter, randomized controlled trial (RCT). Participants will be 1:1 assigned randomly into either terlipressin or octreotide groups. Sixty participants with clinically and/or pathologically diagnosed cirrhosis and active gastroesophageal variceal bleeding (GVB) will be recruited in several sites in China. Participants will receive either the treatment of terlipressin or octreotide after assigned into each group. The primary end point for the trial is the renal function. The secondary end points are (I) renal perfusion; (II) renal blood oxygenation; (III) failure to control bleeding; (IV) intra-hospital rebleeding; (V) intra-hospital mortality; (VI) adverse events (AE); (VII) overall survival. Statistical analysis including multivariate Cox regression, Kaplan-Meier analysis with log-rank test, etc. will be conducted. DISCUSSION The study will provide new insight into the protection of renal function in the process of the treatment of variceal bleeding in patients with cirrhosis. TRIAL REGISTRATION NUMBER NCT04028323.
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Affiliation(s)
- Xinwen Yan
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
- Department of Hepatology Unit and Infectious Diseases, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Ruoyang Shao
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
- Department of Hepatology Unit and Infectious Diseases, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yuancheng Wang
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China
| | - Xiaorong Mao
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Junqiang Lei
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Liting Zhang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Jianjun Zheng
- Department of Radiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, China
| | - Aimin Liu
- Department of Gastroenterology, Fuling Central Hospital of Chongqing City, Chongqing 404000, China
| | - Huimin Zhao
- CHESS Working Party, Xingtai People’s Hospital, Xingtai 054031, China
| | - Fengxiao Gao
- CHESS Working Party, Xingtai People’s Hospital, Xingtai 054031, China
| | - Jitao Wang
- CHESS Working Party, Xingtai People’s Hospital, Xingtai 054031, China
| | - Ping Li
- CHESS Working Party, Tianjin Second People’s Hospital, Tianjin 300192, China
| | - Shengjuan Yao
- CHESS Working Party, Tianjin Second People’s Hospital, Tianjin 300192, China
| | - Ming Xu
- Department of Gastroenterology, Guangdong Second Provincial General Hospital, Guangzhou 510317, China
| | - Jian Xu
- Department of Hepatology & Translation Medicine, Fuling Center Hospital of Chongqing City, Chongqing 404000, China
| | - Dengxiang Liu
- CHESS Working Party, Xingtai People’s Hospital, Xingtai 054031, China
| | - Yuqiang Mi
- CHESS Working Party, Tianjin Second People’s Hospital, Tianjin 300192, China
| | - Xijun Gong
- Department of Radiology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Jun Ye
- Department of Hepatology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Mingming Deng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Tong Dang
- Inner Mongolia Institute of Digestive Diseases, The Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014040, China
| | - Jiansong Ji
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Affiliated Lishui Hospital of Zhejiang University, The Central Hospital of Zhejiang Lishui, Lishui 323000, China
| | - Chuxiao Shao
- Department of Hepatobiliary and Pancreatic Surgery, The Fifth Affiliated Hospital of Wenzhou Medical University, Affiliated Lishui Hospital of Zhejiang University, The Central Hospital of Zhejiang Lishui, Lishui 323000, China
| | - Chao Liu
- CHESS Working Party, Hospital of Chengdu Office, People’s Government of Tibet Autonomous Region, Chengdu 610041, China
| | - Ye Gu
- Department of Gastroenterology, The Sixth Peoples Hospital of Shenyang, Shenyang 110006, China
| | - Yunhong Wu
- CHESS Working Party, Hospital of Chengdu Office, People’s Government of Tibet Autonomous Region, Chengdu 610041, China
| | - Fengmei Wang
- CHESS Working Party, Tianjin Second People’s Hospital, Tianjin 300192, China
| | - Gaojun Teng
- Department of Interventional Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China
| | - Xun Li
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110000, China
| | - Shenghong Ju
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
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20
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Huelin P, Solà E, Elia C, Solé C, Risso A, Moreira R, Carol M, Fabrellas N, Bassegoda O, Juanola A, de Prada G, Albertos S, Piano S, Graupera I, Ariza X, Napoleone L, Pose E, Filella X, Morales-Ruiz M, Rios J, Fernández J, Jiménez W, Poch E, Torres F, Ginès P. Neutrophil Gelatinase-Associated Lipocalin for Assessment of Acute Kidney Injury in Cirrhosis: A Prospective Study. Hepatology 2019; 70:319-333. [PMID: 30810244 DOI: 10.1002/hep.30592] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/12/2019] [Indexed: 12/14/2022]
Abstract
Kidney biomarkers appear to be useful in differential diagnosis between acute tubular necrosis (ATN) and other types of acute kidney injury (AKI) in cirrhosis, particularly hepatorenal syndrome (HRS-AKI). Distinction is important because treatment is different. However, kidney biomarkers are still not used in clinical practice. The aim of the current study was to investigate the accuracy of several biomarkers in differential diagnosis of AKI and in predicting kidney outcome and patient survival. This was a prospective study of 320 consecutive cases of AKI in patients hospitalized for decompensated cirrhosis. Evaluation of AKI was made with a diagnostic algorithm that included identification and removal/treatment of precipitating factors and albumin administration (1 g/kg for 2 days) to patients with AKI stage 1B or greater. Urinary neutrophil gelatinase-associated lipocalin (NGAL), monomeric NGAL (mNGAL), interleukin-18, and standard biomarkers were measured at diagnosis and on days 3, 7, and 14. Of the 320 cases, 153 were hypovolemia-induced AKI (48%), 93 were HRS-AKI (29%), 39 were ATN (12%), and 35 were due to miscellaneous causes (11%). Among all biomarkers, urinary NGAL measured at day 3 had the greatest accuracy for differential diagnosis between ATN and other types of AKI (area under the receiver operating characteristic curve, 0.87; 95% confidence interval, 0.78-0.95). The cutoff with the best predictive accuracy for ATN diagnosis was 220 µg/g creatinine. Progression of AKI during hospitalization was associated with persistently high NGAL levels, and NGAL was an independent predictive factor of AKI progression. Likewise, NGAL was also an independent predictive factor of 28-day mortality together with Model for End-Stage Liver Disease score. Conclusion: These results support the use of NGAL in clinical practice within the context of a diagnostic algorithm for differential diagnosis of AKI and outcome prediction in cirrhosis.
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Affiliation(s)
- Patricia Huelin
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Elsa Solà
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Chiara Elia
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Cristina Solé
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Alessandro Risso
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Rebeca Moreira
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Marta Carol
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Núria Fabrellas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Octavi Bassegoda
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Adrià Juanola
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Gloria de Prada
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Sonia Albertos
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Salvatore Piano
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Isabel Graupera
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Xavier Ariza
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Laura Napoleone
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Xavier Filella
- Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Manuel Morales-Ruiz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - José Rios
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Barcelona, Catalonia, Spain.,Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Javier Fernández
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
| | - Wladimiro Jiménez
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Esteban Poch
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Servei de Nefrologia, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Ferran Torres
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Barcelona, Catalonia, Spain.,Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
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21
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Wong F, Reddy KR, O’Leary JG, Tandon P, Biggins SW, Garcia-Tsao G, Maliakkal BJ, Lai JC, Fallon MB, Vargas HE, Subramanian R, Thuluvath PJ, Kamath PS, Thacker L, Bajaj JS. Impact of Chronic Kidney Disease on Outcomes in Cirrhosis. Liver Transpl 2019; 25:870-880. [PMID: 30908855 PMCID: PMC11075743 DOI: 10.1002/lt.25454] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 03/01/2019] [Indexed: 02/07/2023]
Abstract
We hypothesize that the prevalence of chronic kidney disease (CKD) among patients with cirrhosis has increased due to the increased prevalence of CKD-associated comorbidities, such as diabetes. We aimed to assess the characteristics of hospitalized patients with cirrhosis with CKD and its impact on renal and patient outcomes. The North American Consortium for the Study of End-Stage Liver Disease (NACSELD) prospectively enrolled nonelectively admitted patients with cirrhosis and collected data on demographics, laboratory results, in-hospital clinical course, and postdischarge 3-month outcomes. CKD positive (CKD+) patients, defined as having an estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease-4 variable formula) of ≤60 mL/minute for >3 months, were compared with chronic kidney disease negative (CKD-) patients for development of organ failures, hospital course, and survival. There were 1099 CKD+ patients (46.8% of 2346 enrolled patients) who had significantly higher serum creatinine (2.21 ± 1.33 versus 0.83 ± 0.21 mg/dL in the CKD- group) on admission, higher prevalence of nonalcoholic steatohepatitis cirrhosis etiology, diabetes, refractory ascites, and hospital admissions in the previous 6 months compared with the CKD- group (all P < 0.001). Propensity matching (n = 922 in each group) by Child-Pugh scores (9.78 ± 2.05 versus 9.74 ± 2.04, P = 0.70) showed that CKD+ patients had significantly higher rates of superimposed acute kidney injury (AKI; 68% versus 21%; P < 0.001) and eventual need for dialysis (11% versus 2%; P < 0.001) than CKD- patients. CKD+ patients also had more cases of acute-on-chronic liver failure as defined by the NACSELD group, which was associated with reduced 30- and 90-day overall survival (P < 0.001 for both). A 10 mL/minute drop in eGFR was associated with a 13.1% increase in the risk of 30-day mortality. In conclusion, patients with CKD should be treated as a high-risk group among hospitalized patients with cirrhosis due to their poor survival, and they should be monitored carefully for the development of superimposed AKI.
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Affiliation(s)
- Florence Wong
- Toronto General Hospital, University of Toronto, Toronto,
Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - Leroy Thacker
- Department of Statistics, Commonwealth University of
Virginia, Richmond, VA
| | - Jasmohan S. Bajaj
- Commonwealth University of Virginia and McGuire VA
Medical Center, Richmond, VA
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22
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Ostermann M, Liu K, Kashani K. Fluid Management in Acute Kidney Injury. Chest 2019; 156:594-603. [PMID: 31002784 DOI: 10.1016/j.chest.2019.04.004] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/24/2019] [Accepted: 04/04/2019] [Indexed: 01/02/2023] Open
Abstract
Correction of intravascular hypovolemia is a key component of the prevention and management of acute kidney injury (AKI), but excessive fluid administration is associated with poor outcomes, including the development and progression of AKI. There is growing evidence that fluid administration should be individualized and take into account patient characteristics, nature of the acute illness and trajectories, and risks and benefits of fluids. Existing data support the preferential use of buffered solutions for fluid resuscitation of patients at risk of AKI who do not have hypochloremia. There is a limited role for albumin, and starches should be avoided. Fluids should only be administered until intravascular hypovolemia has been corrected and euvolemia has been achieved using the minimum amount of fluid required to achieve and maintain euvolemia. Oliguria alone should not be viewed as a trigger for fluid administration. If fluid overload occurs, fluid therapy needs to be discontinued, and fluid removal using diuretic agents or extracorporeal therapies should be considered.
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Affiliation(s)
- Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, England.
| | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, NY
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23
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Jansen C, Trebicka J. Editorial: diastolic dysfunction seems not to be decisive for survival after transjugular intrahepatic portosystemic stent-shunt. Aliment Pharmacol Ther 2019; 49:1101-1102. [PMID: 30920049 DOI: 10.1111/apt.15221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Christian Jansen
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, University Clinic Frankfurt, Frankfurt, Germany.,European Foundation for Study of Chronic Liver Failure, Barcelona, Spain.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Institute of Bioengineering Catalunya, Barcelona, Spain
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24
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Abraldes JG, Trebicka J, Chalasani N, D’Amico G, Rockey DC, Shah VH, Bosch J, Garcia-Tsao G. Prioritization of Therapeutic Targets and Trial Design in Cirrhotic Portal Hypertension. Hepatology 2019; 69:1287-1299. [PMID: 30318607 PMCID: PMC11090176 DOI: 10.1002/hep.30314] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/10/2018] [Indexed: 12/12/2022]
Abstract
Portal hypertension (PH) is the main driver of cirrhosis decompensation, the main determinant of death in patients with cirrhosis. PH results initially from increased intrahepatic vascular resistance. Subsequently, increased inflow from splanchnic vasodilation and increased cardiac output lead to a further increase in portal pressure (PP). Reducing PP in cirrhosis results in better outcomes. Removing the cause of cirrhosis might improve PP. However, this is a slow process and patients may continue to be at risk of decompensation. Additionally, for some chronic liver diseases, such as nonalcoholic fatty liver disease (NAFLD), etiological treatments are not yet available. Therefore, there is a need to develop better therapies specifically aimed at reducing PP. For over 35 years, the mainstay of such therapy has been the use of nonselective beta-blockers (NSBBs) that act by reducing portal venous inflow. Recently, many drugs (mainly targeting intrahepatic mechanisms) have shown promise in preclinical and early clinical studies and may act alone or synergistically with NSBBs in reducing PP in cirrhosis. The objective of this position paper is to propose a novel framework for the design of clinical trials (phase 1, 2, and 3) in patients with cirrhosis and PH and to prioritize targets and pharmacological therapies in this setting. We have focused the discussion on patients with compensated cirrhosis. The paper summarizes discussions held at The American Association for the Study of Liver Diseases (AASLD) Industry Colloquium in January 2018, with the participation of clinical and translational investigators, regulatory professionals, and industry partners.
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Affiliation(s)
- Juan G. Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Department of Medicine, CEGIIR, University of Alberta, Edmonton, Canada
| | - Jonel Trebicka
- Translational Hepatology, Department of Internal Medicine I, University Clinic Frankfurt, Frankfurt, Germany
- European Foundation for the Study of Chronic Liver Failure, Institute for Bioengineering of Catalonia, Barcelona, Spain
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | | | - Don C. Rockey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Jaime Bosch
- Swiss Liver Group, University Clinic for Visceral Medicine and Surgery (UVCM), Inselspital, University of Bern, Bern, Switzerland
- Hospital Clinic-IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Yale University School of Medicine; VA-CT Healthcare System, New Haven/West Haven, CT
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25
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Patil V, Jain M, Venkataraman J. Paracentesis-induced acute kidney injury in decompensated cirrhosis - prevalence and predictors. Clin Exp Hepatol 2019; 5:55-59. [PMID: 30915407 PMCID: PMC6431093 DOI: 10.5114/ceh.2019.83157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 09/13/2018] [Indexed: 12/22/2022] Open
Abstract
AIM OF THE STUDY A subgroup of cirrhotic patients undergoing therapeutic paracentesis develop acute kidney injury (AKI) despite adequate colloidal replacement.The aim of the study was to determine the prevalence and predictors of paracentesis-induced AKI in cirrhotic patients with normal baseline renal parameters and adequate colloidal replacement. MATERIAL AND METHODS This prospective, observational analytical study was undertaken between April 2015 and April 2017. All patients undergoing therapeutic paracentesis were enrolled as per inclusion and exclusion criteria. Based on Acute Kidney Injury Network (AKIN) criteria for AKI, comparative analysis was performed between those developing and not developing AKI for demography, renal parameters, frequency and quantity of paracentesis per session. Univariate and multivariate regression analyses were performed to determine the predictors of AKI. RESULTS Altogether, 177 patients underwent 859 therapeutic paracenteses. Ninety-four paracentesis sessions resulted in an AKI (10.9%). The median number of paracenteses was 10 (range 1-25) and the median volume of fluid drained per paracentesis was 6 l (1-20 l). In univariate analysis, younger age (p < 0.02), higher MELD (Model For End-Stage Liver Disease) score (p < 0.0001), CTP (Child-Turcotte-Pugh) class C (p < 0.017) and prior history of renal dysfunction (p < 0.0001) were significantly associated with AKI. For each liter of fluid drained, the risk of AKI increased by 1.24 times. Frequency of paracentesis did not influence the AKI. In multivariate logistic regression, the significant predictors of AKI were past renal dysfunction, a higher MELD and volume of fluid tapped at paracentesis. CONCLUSIONS Post-paracentesis AKI occurs in 10.9% of cases, despite adequate colloid replacement. For each 1 l of fluid drained during paracentesis, the risk of AKI increased by 1.24 times.
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26
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Rho-kinase inhibitor coupled to peptide-modified albumin carrier reduces portal pressure and increases renal perfusion in cirrhotic rats. Sci Rep 2019; 9:2256. [PMID: 30783172 PMCID: PMC6381202 DOI: 10.1038/s41598-019-38678-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/07/2019] [Indexed: 02/07/2023] Open
Abstract
Rho-kinase (ROCK) activation in hepatic stellate cells (HSC) is a key mechanism promoting liver fibrosis and portal hypertension (PTH). Specific delivery of ROCK-inhibitor Y-27632 (Y27) to HSC targeting mannose-6-phosphate-receptors reduces portal pressure and fibrogenesis. In decompensated cirrhosis, presence of ascites is associated with reduced renal perfusion. Since in cirrhosis, platelet-derived growth factor receptor beta (PDGFRβ) is upregulated in the liver as well as the kidney, this study coupled Y27 to human serum albumin (HSA) substituted with PDGFRβ-recognizing peptides (pPB), and investigated its effect on PTH in cirrhotic rats. In vitro collagen contraction assays tested biological activity on LX2 cells. Hemodynamics were analyzed in BDL and CCl4 cirrhotic rats 3 h, 6 h and 24 h after i.v. administration of Y27pPBHSA (0.5/1 mg/kg b.w). Phosphorylation of moesin and myosin light chain (MLC) assessed ROCK activity in liver, femoral muscle, mesenteric artery, kidney and heart. Three Y27 molecules were coupled to pPBHSA as confirmed by HPLC/MS, which was sufficient to relax LX2 cells. In vivo, Y27pPBHSA-treated rats exhibited lower portal pressure, hepatic vascular resistance without effect on systemic vascular resistance, but a tendency towards lower cardiac output compared to non-treated cirrhotic rats. Y27pPBHSA reduced intrahepatic resistance by reduction of phosphorylation of moesin and MLC in Y27pPBHSA-treated cirrhotic rats. Y27pPBHSA was found in the liver of rats up to 6 hours after its injection, in the HSC demonstrated by double-immunostainings. Interestingly, Y27pPBHSA increased renal arterial flow over time combined with an antifibrotic effect as shown by decreased renal acta2 and col1a1 mRNA expression. Therefore, targeting the ROCK inhibitor Y27 to PDGFRβ decreases portal pressure with potential beneficial effects in the kidney. This unique approach should be tested in human cirrhosis.
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Jansen C, Schröder A, Schueler R, Lehmann J, Praktiknjo M, Uschner FE, Schierwagen R, Thomas D, Monteiro S, Nickenig G, Strassburg CP, Meyer C, Arroyo V, Hammerstingl C, Trebicka J. Left Ventricular Longitudinal Contractility Predicts Acute-on-Chronic Liver Failure Development and Mortality After Transjugular Intrahepatic Portosystemic Shunt. Hepatol Commun 2019; 3:340-347. [PMID: 30984902 PMCID: PMC6444053 DOI: 10.1002/hep4.1308] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
Acute deterioration of liver cirrhosis (e.g., infections, acute-on-chronic liver failure [ACLF]) requires an increase in cardiac contractility. The insufficiency to respond to these situations could be deleterious. Left ventricular global longitudinal strain (LV-GLS) has been shown to reflect left cardiac contractility in cirrhosis better than other parameters and might bear prognostic value. Therefore, this retrospective study investigated the role of LV-GLS in the outcome after transjugular intrahepatic portosystemic shunt (TIPS) and the development of ACLF. We included 114 patients (48 female patients) from the Noninvasive Evaluation Program for TIPS and Their Follow-Up Network (NEPTUN) cohort. This number provided sufficient quality and structured follow-up with the possibility of calculating major scores (Child, Model for End-Stage Liver Disease [MELD], Chronic Liver Failure Consortium acute decompensation [CLIF-C AD] scores) and recording of the events (development of decompensation episode and ACLF). We analyzed the association of LV-GLS with overall mortality and development of ACLF in patients with TIPS. LV-GLS was independently associated with overall mortality (hazard ratio [HR], 1.123; 95% confidence interval [CI],1.010-1.250) together with aspartate aminotransferase (HR, 1.009; 95% CI, 1.004-1.014) and CLIF-C AD score (HR, 1.080; 95% CI, 1.018-1.137). Area under the receiver operating characteristic curve (AUROC) analysis for LV-GLS for overall survival showed higher area under the curve (AUC) than MELD and CLIF-C AD scores (AUC, 0.688 versus 0.646 and 0.573, respectively). The best AUROC-determined LV-GLS cutoff was -16.6% to identify patients with a significantly worse outcome after TIPS at 3 months, 6 months, and overall. LV-GLS was independently associated with development of ACLF (HR, 1.613; 95% CI, 1.025-2.540) together with a MELD score above 15 (HR, 2.222; 95% CI, 1.400-3.528). Conclusion: LV-GLS is useful for identifying patients at risk of developing ACLF and a worse outcome after TIPS. Although validation is required, this tool might help to stratify risk in patients receiving TIPS.
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Affiliation(s)
- Christian Jansen
- Department of Internal Medicine I University Clinic Bonn Bonn Germany
| | - Anna Schröder
- Department of Internal Medicine I University Clinic Bonn Bonn Germany
| | - Robert Schueler
- Department of Internal Medicine II University Clinic Bonn Bonn Germany
| | - Jennifer Lehmann
- Department of Internal Medicine I University Clinic Bonn Bonn Germany
| | | | - Frank E Uschner
- Department of Internal Medicine I University Clinic Bonn Bonn Germany.,Department of Internal Medicine I University Clinic Frankfurt Frankfurt Germany
| | | | - Daniel Thomas
- Department of Radiology University Clinic Bonn Bonn Germany
| | - Sofia Monteiro
- Department of Internal Medicine I University Clinic Bonn Bonn Germany.,Department of Internal Medicine Hospital Pedro Hispano, Matosinhos Local Health Unit Matosinhos Portugal
| | - Georg Nickenig
- Department of Internal Medicine II University Clinic Bonn Bonn Germany
| | | | - Carsten Meyer
- Department of Radiology University Clinic Bonn Bonn Germany
| | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure Barcelona Spain
| | | | - Jonel Trebicka
- Department of Internal Medicine I University Clinic Bonn Bonn Germany.,Department of Internal Medicine I University Clinic Frankfurt Frankfurt Germany.,European Foundation for the Study of Chronic Liver Failure Barcelona Spain.,Faculty of Health Sciences University of Southern Denmark Odense Denmark.,Institute of Bioengineering Catalunya Barcelona Spain
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28
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KASL clinical practice guidelines for liver cirrhosis: Ascites and related complications. Clin Mol Hepatol 2018; 24:230-277. [PMID: 29991196 PMCID: PMC6166105 DOI: 10.3350/cmh.2018.1005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open
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29
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Kim MY, Seo YS. [Acute Kidney Injury and Hepatorenal Syndrome]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 72:64-73. [PMID: 30145858 DOI: 10.4166/kjg.2018.72.2.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute kidney injury (AKI) is common in patients with liver cirrhosis, occurring in 13-20% of patients hospitalized with decompensated cirrhosis, and is significantly associated with the prognosis. The development and progression of AKI is an independent predictive factor for mortality in these patients. If AKI develops, the renal function declines progressively even if AKI is improved later, the patients have a poorer prognosis compared to those who have not developed AKI. In addition, in patients without appropriate treatment or no improvement with the initial treatment, AKI often progress to hepatorenal syndrome (HRS), which is associated with significant morbidity and mortality. Therefore, early detection and appropriate management for the development of AKI is very important in these patients. Recently, there have been significant revisions in the diagnostic criteria and treatment of AKI and HRS; this manuscript reviews these changes.
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Affiliation(s)
- Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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30
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Trebicka J, Reiberger T, Laleman W. Gut-Liver Axis Links Portal Hypertension to Acute-on-Chronic Liver Failure. Visc Med 2018; 34:270-275. [PMID: 30345284 PMCID: PMC6189544 DOI: 10.1159/000490262] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Acute-on-chronic liver failure (ACLF) is considered a distinct syndrome in patients with liver disease, with systemic inflammation playing a central role. Portal hypertension (PHT) is also aggravated by inflammation and may subsequently impact the course of ACLF. PHT is more than just an increase in portal pressure in the portal venous system; it aggravates the course of liver disease and, thus, also facilitates the development of acute decompensation and ACLF. A critical mechanistic link between PHT and ACLF might be the gut-liver axis, which is discussed in this review.
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Affiliation(s)
- Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Institute for Bioengineering of Catalonia, Barcelona, Spain
| | - Thomas Reiberger
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Wim Laleman
- Liver and Biliopancreatic Section, Department of Gastroenterology & Hepatology, Hospital Gasthuisberg, K.U. Leuven, Leuven, Belgium
- Laboratory of Hepatology, Department Chronic Diseases, Metabolism & Ageing (CHROMETA), KU Leuven, Leuven, Belgium
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31
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Wang H, Liu A, Bo W, Feng X, Hu Y. Terlipressin in the treatment of hepatorenal syndrome: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e0431. [PMID: 29668606 PMCID: PMC5916651 DOI: 10.1097/md.0000000000010431] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hepatorenal syndrome is a fatal complication of advanced cirrhosis. Terlipressin is the most widely used treatment method, however, the therapy effects remain inconsonant. We aim to systematically assess the safety and efficacy of terlipressin for hepatorenal syndrome. METHODS We conducted a systematic review and meta-analysis. Randomized controlled trials involving terlipressin for hepatorenal syndrome were included in a systematic literature search. Two authors independently assessed the studies for inclusion and extracted the data. A meta-analysis was conducted to estimate the safety and efficacy of terlipressin for hepatorenal syndrome. RESULTS A total of 18 randomized controlled trials including 1011 patients were included. Hepatorenal syndrome reverse rate was 42.0% in the terlipressin group and 26.2% in the non-terlipressin group. Terlipressin had greater hepatorenal syndrome reverse rate and renal function improvement rate than placebo and octreotide in the management of HRS. Comparing to norepinephrine, terlipressin had similar efficacy, but with more adverse events. No significant difference of the efficacy was found between terlipressin and dopamine treatment. The subgroup analysis for type 1 HRS had the above same results, except that the adverse events were not significant different between norepinephrine group and terlipressin group. CONCLUSIONS Terlipressin was superior to placebo and octreotide for reversal of hepatorenal syndrome and improving renal function, but it had no superiority comparing to norepinephrine.
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32
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Koola JD, Davis SE, Al-Nimri O, Parr SK, Fabbri D, Malin BA, Ho SB, Matheny ME. Development of an automated phenotyping algorithm for hepatorenal syndrome. J Biomed Inform 2018; 80:87-95. [PMID: 29530803 PMCID: PMC5920557 DOI: 10.1016/j.jbi.2018.03.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 02/21/2018] [Accepted: 03/07/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Hepatorenal Syndrome (HRS) is a devastating form of acute kidney injury (AKI) in advanced liver disease patients with high morbidity and mortality, but phenotyping algorithms have not yet been developed using large electronic health record (EHR) databases. We evaluated and compared multiple phenotyping methods to achieve an accurate algorithm for HRS identification. MATERIALS AND METHODS A national retrospective cohort of patients with cirrhosis and AKI admitted to 124 Veterans Affairs hospitals was assembled from electronic health record data collected from 2005 to 2013. AKI was defined by the Kidney Disease: Improving Global Outcomes criteria. Five hundred and four hospitalizations were selected for manual chart review and served as the gold standard. Electronic Health Record based predictors were identified using structured and free text clinical data, subjected through NLP from the clinical Text Analysis Knowledge Extraction System. We explored several dimension reduction techniques for the NLP data, including newer high-throughput phenotyping and word embedding methods, and ascertained their effectiveness in identifying the phenotype without structured predictor variables. With the combined structured and NLP variables, we analyzed five phenotyping algorithms: penalized logistic regression, naïve Bayes, support vector machines, random forest, and gradient boosting. Calibration and discrimination metrics were calculated using 100 bootstrap iterations. In the final model, we report odds ratios and 95% confidence intervals. RESULTS The area under the receiver operating characteristic curve (AUC) for the different models ranged from 0.73 to 0.93; with penalized logistic regression having the best discriminatory performance. Calibration for logistic regression was modest, but gradient boosting and support vector machines were superior. NLP identified 6985 variables; a priori variable selection performed similarly to dimensionality reduction using high-throughput phenotyping and semantic similarity informed clustering (AUC of 0.81 - 0.82). CONCLUSION This study demonstrated improved phenotyping of a challenging AKI etiology, HRS, over ICD-9 coding. We also compared performance among multiple approaches to EHR-derived phenotyping, and found similar results between methods. Lastly, we showed that automated NLP dimension reduction is viable for acute illness.
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Affiliation(s)
- Jejo D Koola
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare System Veterans Administration Medical Center, Nashville, TN, USA; Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, CA, USA; Division of Hospital Medicine, Department of Medicine, University of California, San Diego, CA, USA.
| | - Sharon E Davis
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare System Veterans Administration Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Sharidan K Parr
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare System Veterans Administration Medical Center, Nashville, TN, USA; Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel Fabbri
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Bradley A Malin
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Samuel B Ho
- VA San Diego Healthcare System, San Diego, CA, USA; Division of Gastroenterology, Department of Medicine, University of California, San Diego, CA, USA
| | - Michael E Matheny
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare System Veterans Administration Medical Center, Nashville, TN, USA; Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
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33
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The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36:689-698. [DOI: 10.1016/j.ajem.2017.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
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34
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Wang DL, Dai WY, Wang W, Wen Y, Zhou Y, Zhao YT, Wu J, Liu P. Interfering RNA against PKC-α inhibits TNF-α-induced IP 3R1 expression and improves glomerular filtration rate in rats with fulminant hepatic failure. Am J Physiol Renal Physiol 2018; 314:F942-F955. [PMID: 29357415 DOI: 10.1152/ajprenal.00433.2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
We have reported that tumor necrosis factor-α (TNF-α) is critical for reduction of glomerular filtration rate (GFR) in rats with fulminant hepatic failure (FHF). The present study aims to evaluate the underlying mechanisms of decreased GFR during acute hepatic failure. Rats with FHF induced by d-galactosamine plus lipopolysaccharide (GalN/LPS) were injected intravenously with recombinant lentivirus harboring short hairpin RNA against the protein kinase C-α ( PKC-α) gene (Lenti-shRNA-PKC-α). GFR, serum levels of aminotransferases, creatinine, urea nitrogen, potassium, sodium, chloride, TNF-α, and endothelin-1 (ET-1), as well as type 1 inositol 1,4,5-trisphosphate receptor (IP3R1) expression in renal tissue were assessed. The effects of PKC-α silencing on TNF-α-induced IP3R1, specificity protein 1 (SP-1), and c-Jun NH2-terminal kinase (JNK) expression, as well as cytosolic calcium content were determined in glomerular mesangial cell (GMCs) with RNAi against PKC-α. Renal IP3R1 overexpression was abrogated by pre-treatment with Lenti-shRNA-PKC-α. The PKC-α silence significantly improved the compromised GFR, reduced Cr levels, and reversed the decrease in glomerular inulin space and the increase in glomerular calcium content in GalN/LPS-exposed rats. TNF-α treatment increased expression of PKC-α, IP3R1, specificity protein 1 (SP-1), JNK, and p-JNK in GMCs and increased Ca2 + release and binding activity of SP-1 to the IP3R1 promoter. These effects were blocked by transfection of siRNA against the PKC-α gene, and the PKC-α gene silence also restored cytosolic Ca2+ concentration. RNAi targeting PKC-α inhibited TNF-α-induced IP3R1 overexpression and in turn improved compromised GFR in the development of acute kidney injury during FHF in rats.
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Affiliation(s)
- Dong-Lei Wang
- Department of Infectious Diseases, The First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, People's Republic of China
| | - Wen-Ying Dai
- The Sixth People's Hospital of Shenyang, Shenyang City, Liaoning Province, People's Republic of China
| | - Wen Wang
- Department of Infectious Diseases, The First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, People's Republic of China
| | - Ying Wen
- Department of Infectious Diseases, The First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, People's Republic of China
| | - Ying Zhou
- Department of Infectious Diseases, The First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, People's Republic of China
| | - Yi-Tong Zhao
- The Sixth People's Hospital of Shenyang, Shenyang City, Liaoning Province, People's Republic of China
| | - Jian Wu
- Department of Medical Microbiology, Key Laboratory of Medical Molecular Virology, School of Basic Medical Sciences, Fudan University , Shanghai , China.,Shanghai Institute of Liver Diseases, Fudan University , Shanghai , China
| | - Pei Liu
- Department of Infectious Diseases, The First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, People's Republic of China.,The Institute of liver diseases, China Medical University, Shenyang, Liaoning Province, China
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35
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Jansen C, Cox A, Schueler R, Schneider M, Lehmann J, Praktiknjo M, Pohlmann A, Chang J, Manekeller S, Nickenig G, Berlakovich G, Strassburg CP, Hammerstingl C, Staufer K, Trebicka J. Increased myocardial contractility identifies patients with decompensated cirrhosis requiring liver transplantation. Liver Transpl 2018; 24:15-25. [PMID: 28834154 DOI: 10.1002/lt.24846] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/04/2017] [Accepted: 08/03/2017] [Indexed: 01/13/2023]
Abstract
Late allocation of organs for transplant impairs post-liver transplantation (LT) survival. Cardiac dysfunction, especially diastolic and autonomic dysfunction, is frequent and plays an important role in the prognosis of patients with cirrhosis. However, the role of myocardial contractility is unexplored, and its prognostic value is controversially discussed. This study analyses the role of myocardial contractility assessed by speckle tracking echocardiography in LT allocation. In total, 168 patients with cirrhosis (training cohort, 111; validation cohort [VC], 57) awaiting LT in 2 centers were included in this retrospective study. Also, 51 patients from the training and all patients from the VC were transplanted, 36 patients of the training and 38 of the VC were alive at the end of follow-up, and 21 nontransplanted patients died. Contractility of the left ventricle (LV) increased with severity of the Child-Pugh score. Interestingly, higher LV contractility in the training cohort patients, especially in those with Child-Pugh C, was an independent predictor of reduced transplant-free survival. In male patients, the effects on survival of increased left and right ventricular myocardial contractility were more pronounced. Notably, competing risk analysis demonstrated that increased contractility is associated with earlier LT, which could be confirmed in the VC. Importantly, LV myocardial contractility had no impact on survival of patients not receiving LT or on post-LT survival. In conclusion, this study demonstrates for the first time that increased myocardial contractility in decompensated patients identifies patients who require LT earlier, but without increased post-LT mortality. Liver Transplantation 24 15-25 2018 AASLD.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Gabriela Berlakovich
- Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Katharina Staufer
- Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jonel Trebicka
- Departments of Internal Medicine I.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,European Foundation for Study of Chronic Liver Failure, Barcelona, Spain.,Institute of Bioengineering Catalunya, Barcelona, Spain
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36
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Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr 2017; 129:135-158. [PMID: 29063233 PMCID: PMC5674135 DOI: 10.1007/s00508-017-1262-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.
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37
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Cholemic nephropathy - Historical notes and novel perspectives. Biochim Biophys Acta Mol Basis Dis 2017; 1864:1356-1366. [PMID: 28851656 DOI: 10.1016/j.bbadis.2017.08.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/16/2022]
Abstract
Acute kidney injury is common in patients with liver disease and associated with significant morbidity and mortality. Besides bacterial infections, fluid loss, and use of nephrotoxic drugs AKI in liver disease may be triggered by tubular toxicity of cholephiles. Cholemic nephropathy, also known as bile cast nephropathy, supposedly represents a widely underestimated but important cause of renal dysfunction in cholestasic or advanced liver diseases with jaundice. Cholemic nephropathy describes impaired renal function along with characteristic histomorphological changes consisting of intratubular cast formation and tubular epithelial cell injury directed towards distal nephron segments. The underlying pathophysiologic mechanisms are not entirely understood and clear defined diagnostic criteria are still missing. This review aims to summarize (i) the present knowledge on clinical and morphological characteristics of cholemic nephropathy, (ii) available preclinical models, (iii) potential pathomechanisms especially the potential role of bile acids, and (iv) future diagnostic and therapeutic strategies for cholemic nephropathy. This article is part of a Special Issue entitled: Cholangiocytes in Health and Disease edited by Jesus Banales, Marco Marzioni, Nicholas LaRusso and Peter Jansen.
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38
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Wong F, O'Leary JG, Reddy KR, Garcia-Tsao G, Fallon MB, Biggins SW, Subramanian RM, Thuluvath PJ, Kamath PS, Patton H, Maliakkal B, Tandon P, Vargas H, Thacker L, Bajaj JS. Acute Kidney Injury in Cirrhosis: Baseline Serum Creatinine Predicts Patient Outcomes. Am J Gastroenterol 2017; 112:1103-1110. [PMID: 28440305 DOI: 10.1038/ajg.2017.122] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 03/02/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The International Ascites Club (IAC) recently defined Stage 1 acute kidney injury (AKI) for cirrhosis as an acute increase in serum creatinine (SCr) by ≥0.3 mg/dl or by ≥50% in <48 h from a stable value within 3 months. The baseline SCr may influence AKI risk and patient outcomes. The objective of this study is to determine in cirrhosis whether the baseline SCr has any effect on the in-hospital AKI course and patient survival. METHODS North American Consortium for the Study of End-Stage Liver Disease is a consortium of tertiary-care hepatology centers prospectively enroling non-elective cirrhotic inpatients. Patients with different baseline SCr levels (≤0.5, 0.51-1.0, 1.01-1.5, >1.5 mg/dl) were evaluated for the development of AKI, and compared for AKI outcomes and 30-day survival. RESULTS 653 hospitalized cirrhotics (56.7±10years, 64% men, 30% with infection) were included. The incidence of AKI was 47% of enrolled patients. Patients with higher baseline SCr were more likely to develop AKI, with significantly higher delta and peak SCr (P<0.001) than the other groups, more likely to have a progressive AKI course (P<0.0001), associated with a significantly reduced 30-day survival (P<0.0001). Multivariate logistic regression showed that the delta SCr during an AKI episode to be the strongest factor impacting AKI outcomes and survival (P<0.001), with a delta SCr of 0.70 mg/dl having a 68% sensitivity and 80% specificity for predicting 30-day mortality. CONCLUSIONS Admitted cirrhotic patients with higher baseline SCr are at higher risk for in-hospital development of AKI, and more likely to have AKI progression with reduced survival. Therefore, such patients should be closely monitored and treated promptly for their AKI.
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Affiliation(s)
- F Wong
- University of Toronto, Toronto, Ontario, Canada
| | - J G O'Leary
- Baylor University Medical Center, Dallas, Texas, USA
| | - K R Reddy
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - M B Fallon
- Health Science Center, University of Texas, Houston, Texas, USA
| | - S W Biggins
- University of Colorado Denver, Denver, Colorado, USA
| | | | - P J Thuluvath
- Mercy Medical Center &University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - H Patton
- University of California San Diego, San Diego, California, USA
| | - B Maliakkal
- University of Rochester, Rochester, New York, USA
| | - P Tandon
- University of Alberta, Edmonton, Alberta, Canada
| | - H Vargas
- Mayo Clinic, Scottsdale, Arizona, USA
| | - L Thacker
- Biostatisitcs, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - J S Bajaj
- Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
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39
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Krones E, Eller K, Pollheimer MJ, Racedo S, Kirsch AH, Frauscher B, Wahlström A, Ståhlman M, Trauner M, Grahammer F, Huber TB, Wagner K, Rosenkranz AR, Marschall HU, Fickert P. NorUrsodeoxycholic acid ameliorates cholemic nephropathy in bile duct ligated mice. J Hepatol 2017; 67:110-119. [PMID: 28242240 DOI: 10.1016/j.jhep.2017.02.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 02/02/2017] [Accepted: 02/14/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Severe cholestasis may cause cholemic nephropathy that can be modeled in common bile duct ligated (CBDL) mice. We aimed to explore the therapeutic efficacy and mechanisms of norursodeoxycholic acid (norUDCA) in cholemic nephropathy. METHODS In 8-week CBDL mice fed with norUDCA (prior or post CBDL) or chow we evaluated serum urea levels, urine cytology and urinary neutrophil gelatinase associated lipocalin (uNGAL), kidney and liver tissue quantification of fibrosis by hydroxyproline content and gene chip expression looking at key genes of inflammation and fibrosis. Moreover, we comprehensively analysed bile acid profiles in liver, kidney, serum and urine samples. RESULTS NorUDCA-fed CBDL mice had significantly lower serum urea and uNGAL levels and less severe cholemic nephropathy as demonstrated by normal urine cytology, significantly reduced tubulointerstitial nephritis, and renal fibrosis as compared to controls. NorUDCA underwent extensive metabolism to produce even more hydrophilic compounds that were significantly enriched in kidneys. CONCLUSION NorUDCA ameliorates cholemic nephropathy due to the formation of highly hydrophilic metabolites enriched in kidney. Consequently, norUDCA may represent a medical treatment for cholemic nephropathy. LAY SUMMARY The term cholemic nephropathy describes renal dysfunction together with characteristic morphological alterations of the kidney in obstructive cholestasis that can be mimicked by ligation of the common bile duct in mice. Feeding the hydrophilic bile acid norUDCA to bile duct ligated mice leads to a significant amelioration of the renal phenotype due to the formation of highly hydrophilic metabolites enriched in the kidney and may therefore represent a medical treatment for cholemic nephropathy.
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Affiliation(s)
- Elisabeth Krones
- Research Unit for Experimental and Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Kathrin Eller
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Austria
| | | | - Silvia Racedo
- Research Unit for Experimental and Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Alexander H Kirsch
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Bianca Frauscher
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Annika Wahlström
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
| | - Marcus Ståhlman
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
| | - Michael Trauner
- Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Florian Grahammer
- Department of Medicine IV, Medical Center and Faculty of Medicine, University of Freiburg, Germany
| | - Tobias B Huber
- Department of Medicine IV, Medical Center and Faculty of Medicine, University of Freiburg, Germany; BIOSS Center for Biological Signaling Studies, Albert-Ludwigs-University Freiburg, Freiburg, Germany; FRIAS - Freiburg Institute for Advanced Studies and ZBSA - Center for Systems Biology, Albert-Ludwigs-University, Freiburg, Germany
| | - Karin Wagner
- Core Facility Molecular Biology, Center for Medical Research, Medical University Graz, Graz, Austria
| | - Alexander R Rosenkranz
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Hanns-Ulrich Marschall
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
| | - Peter Fickert
- Research Unit for Experimental and Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Austria.
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Sanyal AJ, Boyer TD, Frederick RT, Wong F, Rossaro L, Araya V, Vargas HE, Reddy KR, Pappas SC, Teuber P, Escalante S, Jamil K. Reversal of hepatorenal syndrome type 1 with terlipressin plus albumin vs. placebo plus albumin in a pooled analysis of the OT-0401 and REVERSE randomised clinical studies. Aliment Pharmacol Ther 2017; 45:1390-1402. [PMID: 28370090 PMCID: PMC5434950 DOI: 10.1111/apt.14052] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/28/2016] [Accepted: 02/27/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The goal of hepatorenal syndrome type 1 (HRS-1) treatment is to improve renal function. Terlipressin, a synthetic vasopressin analogue, is a systemic vasoconstrictor used for the treatment of HRS-1, where it is available. AIM To compare the efficacy of terlipressin plus albumin vs. placebo plus albumin in patients with HRS-1. METHODS Pooled patient-level data from two large phase 3, randomised, placebo-controlled studies were analysed for HRS reversal [serum creatinine (SCr) value ≤133 μmol/L], 90-day survival, need for renal replacement therapy and predictors of HRS reversal. Patients received intravenous terlipressin 1-2 mg every 6 hours plus albumin or placebo plus albumin up to 14 days. RESULTS The pooled analysis comprised 308 patients (terlipressin: n = 153; placebo: n = 155). HRS reversal was significantly more frequent with terlipressin vs. placebo (27% vs. 14%; P = 0.004). Terlipressin was associated with a more significant improvement in renal function from baseline until end of treatment, with a mean between-group difference in SCr concentration of -53.0 μmol/L (P < 0.0001). Lower SCr, lower mean arterial pressure and lower total bilirubin and absence of known precipitating factors for HRS were independent predictors of HRS reversal and longer survival in terlipressin-treated patients. CONCLUSIONS Terlipressin plus albumin resulted in a significantly higher rate of HRS reversal vs. albumin alone in patients with HRS-1. Terlipressin treatment is associated with improved renal function. (ClinicalTrials.gov identifier: OT-0401, NCT00089570; REVERSE, NCT01143246).
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Affiliation(s)
- A. J. Sanyal
- Department of MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - T. D. Boyer
- Department of MedicineUniversity of ArizonaTucsonAZUSA
| | - R. T. Frederick
- Department of TransplantationCalifornia Pacific Medical CenterSan FranciscoCAUSA
| | - F. Wong
- Department of MedicineUniversity of TorontoTorontoONCanada
| | - L. Rossaro
- University of California DavisSacramentoCAUSA
| | - V. Araya
- Department of Gastroenterology and HepatologyCentral Bucks Specialists, Ltd.DoylestownPAUSA
| | - H. E. Vargas
- Division of Gastroenterology and HepatologyMayo Clinic ArizonaPhoenixAZUSA
| | - K. R. Reddy
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | | | - S. Escalante
- Ikaria Therapeutics LLC/a Mallinckrodt CompanyHamptonNJUSA
| | - K. Jamil
- Ikaria Therapeutics LLC/a Mallinckrodt CompanyHamptonNJUSA
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Bucsics T, Krones E. Renal dysfunction in cirrhosis: acute kidney injury and the hepatorenal syndrome. Gastroenterol Rep (Oxf) 2017; 5:127-137. [PMID: 28533910 PMCID: PMC5421450 DOI: 10.1093/gastro/gox009] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/08/2017] [Indexed: 02/06/2023] Open
Abstract
Renal dysfunction is a common complication of liver cirrhosis and of utmost clinical and prognostic relevance. Patients with cirrhosis are more prone to developing acute kidney injury (AKI) than the non-cirrhotic population. Pre-renal AKI, the hepatorenal syndrome type of AKI (HRS-AKI, formerly known as 'type 1') and acute tubular necrosis represent the most common causes of AKI in cirrhosis. Correct differentiation is imperative, as treatment differs substantially. While pre-renal AKI usually responds well to plasma volume expansion, HRS-AKI and ATN require different specific approaches and are associated with substantial mortality. Several paradigms, such as the threshold of 2.5 mg/dL for diagnosis of HRS-AKI, have recently been abolished and novel urinary biomarkers are being investigated in order to facilitate early and correct diagnosis and treatment of HRS-AKI and other forms of AKI in patients with cirrhosis. This review summarizes the current diagnostic criteria, as well as pathophysiologic and therapeutic concepts for AKI and HRS-AKI in cirrhosis.
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Affiliation(s)
- Theresa Bucsics
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Krones
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Schneider A, Ostermann M. The AKI glossary. Intensive Care Med 2017; 43:893-897. [PMID: 28365792 DOI: 10.1007/s00134-017-4751-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/27/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Antoine Schneider
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas Hospital, Foundation Hospital, London, SE1 7EH, UK.
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Wong F, Pappas SC, Boyer TD, Sanyal AJ, Bajaj JS, Escalante S, Jamil K. Terlipressin Improves Renal Function and Reverses Hepatorenal Syndrome in Patients With Systemic Inflammatory Response Syndrome. Clin Gastroenterol Hepatol 2017; 15:266-272.e1. [PMID: 27464593 DOI: 10.1016/j.cgh.2016.07.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/24/2016] [Accepted: 07/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with systemic inflammatory response syndrome (SIRS) along with decompensated cirrhosis and renal dysfunction have a poor prognosis and a lower response to treatment. We evaluated the effect of SIRS on the response of hepatorenal syndrome type 1 (HRS-1) to terlipressin. METHODS We performed a retrospective study of data from a trial of the effects of terlipressin (1 mg every 6 hours or placebo with concomitant albumin) in 198 patients with HRS-1, performed at 50 investigational sites in the United States and 2 in Canada from October 2010 through February 2013. We identified patients with 2 or more criteria for SIRS, without untreated infections (28 received terlipressin and 30 received placebo), and patients with less than 2 criteria for SIRS (control subjects). Primary endpoints included HRS reversal (a decrease in serum level of creatinine to ≤1.5 mg/dL), confirmed HRS reversal (defined as 2 serum creatinine levels ≤1.5 mg/dL, ≥ 48 hours apart), and survival for 90 days after treatment. RESULTS Baseline characteristics were similar between groups, apart from slightly higher white blood cell counts and heart rates, and slightly lower serum levels of bicarbonate in patients with SIRS versus without SIRS. HRS was reversed in 42.9% of patients who received terlipressin with SIRS (12/28) versus 6.7% of patients who received placebo (2/30) (P = .0018); confirmed HRS reversal occurred in 32.1% of patients who received terlipressin with SIRS (9/28) versus 3.3% who received placebo (1/30) (P = .0048). A larger proportion of patients with SIRS who received terlipressin survived for 90 days without a transplant (13/28; 46.4%) than patients with SIRS who received placebo (7/30; 23.3%) (P = .076). CONCLUSIONS In an analysis of data from a placebo-controlled study, we found that terlipressin improved renal function and reversed HRS in a higher proportion of patients with HRS-1 and SIRS than patients who received albumin plus placebo. ClincialTrials.gov, number NCT 01143246.
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Affiliation(s)
- Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | | | - Thomas D Boyer
- Department of Medicine, University of Arizona, Tucson, Arizona
| | - Arun J Sanyal
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | | | - Khurram Jamil
- Ikaria Therapeutics LLC/a Mallinckrodt Company, Hampton, New Jersey
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Trebicka J. Emergency TIPS in a Child-Pugh B patient: When does the window of opportunity open and close? J Hepatol 2017; 66:442-450. [PMID: 27984174 DOI: 10.1016/j.jhep.2016.10.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/22/2016] [Accepted: 10/23/2016] [Indexed: 12/14/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of cirrhosis such as variceal bleeding and refractory ascites, but it also bears the risk of liver failure, overt hepatic encephalopathy (HE) and cardiac decompensation. Variceal bleeding may be controlled using endoscopic and medical treatment in patients with compensated cirrhosis; in decompensated patients, however, TIPS improves survival. Therefore, an early TIPS (within 72h or if later, still early after bleeding) might improve the survival of patients by preventing an inflammatory response and bacterial translocation. Both these processes mediate an impaired immunological and hemodynamic response, thereby facilitating the development of acute-on-chronic liver failure (ACLF) and/or death. Similarly, in patients with refractory ascites, TIPS should be used early in treatment to prevent acute kidney injury (AKI) and hepatorenal syndrome (HRS) after precipitating events induced by complications of portal hypertension. Whether TIPS and/or embolization should be used to treat portal vein thrombosis and spontaneous shunts is still a matter of debate and should be further investigated. In summary, the careful selection of patients for TIPS is crucial. New biomarkers, especially those evaluating systemic inflammation and bacterial translocation, might improve the predictive value of established clinical parameters such as bilirubin and overt HE. However, a significant amount of further research must be carried out.
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Affiliation(s)
- Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; Institute of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
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45
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Wong F. Acute kidney injury in liver cirrhosis: new definition and application. Clin Mol Hepatol 2016; 22:415-422. [PMID: 27987536 PMCID: PMC5266339 DOI: 10.3350/cmh.2016.0056] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 09/06/2016] [Indexed: 12/14/2022] Open
Abstract
The traditional diagnostic criteria of renal dysfunction in cirrhosis are a 50% increase in serum creatinine (SCr) with a final value above 1.5 mg/dL. This means that patients with milder degrees of renal dysfunction are not being diagnosed, and therefore not offered timely treatment. The International Ascites Club in 2015 adapted the term acute kidney injury (AKI) to represent acute renal dysfunction in cirrhosis, and defined it by an increase in SCr of 0.3 mg/dL (26.4 µmoL/L) in <48 hours, or a 50% increase in SCr from a baseline within ≤3 months. The severity of AKI is described by stages, with stage 1 represented by these minimal changes, while stages 2 and 3 AKI by 2-fold and 3-fold increases in SCr respectively. Hepatorenal syndrome (HRS), renamed AKI-HRS, is defined by stage 2 or 3 AKI that fulfils all other diagnostic criteria of HRS. Various studies in the past few years have indicated that these new diagnostic criteria are valid in the prediction of prognosis for patients with cirrhosis and AKI. The future in AKI diagnosis may include further refinements such as inclusion of biomarkers that can identify susceptibility for AKI, differentiating the various prototypes of AKI, or track its progression.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Ontario, Canada
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46
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O'Leary JG, Levitsky J, Wong F, Nadim MK, Charlton M, Kim WR. Protecting the Kidney in Liver Transplant Candidates: Practice-Based Recommendations From the American Society of Transplantation Liver and Intestine Community of Practice. Am J Transplant 2016; 16:2516-31. [PMID: 26990924 DOI: 10.1111/ajt.13790] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/18/2016] [Accepted: 03/08/2016] [Indexed: 01/25/2023]
Abstract
Acute kidney injury (AKI) and chronic kidney disease (CKD) are common in patients awaiting liver transplantation, and both have a marked impact on the perioperative and long-term morbidity and mortality of liver transplant recipients. Consequently, we reviewed the epidemiology of AKI and CKD in patients with end-stage liver disease, highlighted strategies to prevent and manage AKI, evaluated the changing liver transplant waiting list's impact on kidney function, delineated important considerations in simultaneous liver-kidney transplant selection, and projected possible future transplant policy changes and outcomes. This review was assembled by experts in the field and endorsed by the American Society of Transplantation Liver and Intestinal Community of Practice and Board of Directors and provides practice-based recommendations for preservation of kidney function in patients with end-stage liver disease.
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Affiliation(s)
- J G O'Leary
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - J Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - F Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - M K Nadim
- Division of Nephology and Hypertension, Department of Medicine, University of Southern California, Los Angeles, CA
| | - M Charlton
- Intermountain Transplant Center, Murray, UT
| | - W R Kim
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, CA
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47
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Association of eNOS Gene Polymorphisms G894T and T-786C with Risk of Hepatorenal Syndrome. Gastroenterol Res Pract 2016; 2016:2579626. [PMID: 27594880 PMCID: PMC4995323 DOI: 10.1155/2016/2579626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/10/2016] [Indexed: 01/13/2023] Open
Abstract
Background. There are no studies investigating the relationship between endothelial nitric oxide synthase (eNOS) gene polymorphisms and hepatorenal syndrome (HRS). Aim. The purpose of this study is to elucidate whether eNOS gene polymorphisms (G894T and T-786C) play a role in the development of type-2 HRS. Methods. This study was carried out in a group of 92 patients with cirrhosis (44 patients with type-2 HRS and 48 without HRS) and 50 healthy controls. Polymorphisms were determined by polymerase chain reaction (PCR) and melting curve analysis. Results. We did not find any significant difference in allele and genotype distributions of the eNOS -T-786C polymorphism among the groups (p = 0.440). However, the frequency of GT (40.9%) and TT (13.6%) genotypes and mutant allele T (34.1%) for the eNOS G894T polymorphism were significantly higher (p < 0.001 and p < 0.001, resp.) in the HRS group than in both the stable cirrhosis (14.6%, 4.2%, and 11.5%, resp.) and the control (22.0%, 2.0%, and 13.0%, resp.) groups. Conclusion. The occurrence of mutant genotypes (GT/TT) and mutant allele T in eNOS -G894T polymorphisms should be considered as a potential risk factor in cirrhotic patients with HRS.
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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: 173] [Impact Index Per Article: 21.6] [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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Pretransplant Type 2 Hepatorenal Syndrome Is Associated With Persistently Impaired Renal Function After Liver Transplantation. Transplantation 2016; 99:1441-6. [PMID: 25643142 DOI: 10.1097/tp.0000000000000557] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Type 2 hepatorenal syndrome (HRS2) is a functional renal impairment complicating end-stage liver disease. Although it is reversible after liver transplantation, long-term posttransplant outcomes in HRS2 patients remain ill-defined. METHODS Retrospective, matched case-control (1:2) study of all adult HRS2 patients transplanted in our institution between 2000 and 2012. The HRS2 patients were identified from our electronic transplant database, and matched with controls for the following variables: age, sex, etiology, diabetes mellitus, and year of transplant. RESULTS Forty-two HRS2 patients were compared to 83 controls. At the time of transplant, HRS2 patients had an estimated glomerular filtration rate of 41 ± 1 mL/min per 1.73 m. The HRS2 patients had greater intraoperative packed red blood cell transfusion (P = 0.002), and longer intensive care unit (P = 0.01) as well as total hospital length of stay (P = 0.03). Reversal of HRS2 occurred in 88.1% patients, 5.7 ± 0.5 days after transplantation. Although HRS2 patients had lower initial exposure to calcineurin inhibitors, a greater proportion of HRS2 patients had chronic kidney disease stage 3 (CKD3) at 3 (53.8% vs 28.4%; P = 0.007) and 12 months (59.5% vs 38.2%; P = 0.03) compared to controls. One-year survival was similar between the 2 groups (log-rank P = 0.82). On multivariate analysis, pretransplant HRS2 was associated with CKD3 at 3 (odds ratio, 3.73; 95% confidence interval, 1.54-9.03; P = 0.004) and 12 months (odds ratio, 3.23; 95% confidence interval, 1.37-7.64; P = 0.007) after transplantation. CONCLUSIONS Liver transplantation reverses HRS2 in the majority of patients with survival outcomes comparable to matched controls, despite longer stays in intensive care unit and in hospital. Pretransplant HRS2 is associated with early posttransplant CKD3, despite calcineurin-inhibitor minimization.
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Ishida T, Kotani H, Miyao M, Kawai C, Jemail L, Abiru H, Tamaki K. Renal Impairment with Sublethal Tubular Cell Injury in a Chronic Liver Disease Mouse Model. PLoS One 2016; 11:e0146871. [PMID: 26752420 PMCID: PMC4713438 DOI: 10.1371/journal.pone.0146871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/25/2015] [Indexed: 02/07/2023] Open
Abstract
The pathogenesis of renal impairment in chronic liver diseases (CLDs) has been primarily studied in the advanced stages of hepatic injury. Meanwhile, the pathology of renal impairment in the early phase of CLDs is poorly understood, and animal models to elucidate its mechanisms are needed. Thus, we investigated whether an existing mouse model of CLD induced by 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) shows renal impairment in the early phase. Renal injury markers, renal histology (including immunohistochemistry for tubular injury markers and transmission electron microscopy), autophagy, and oxidative stress were studied longitudinally in DDC- and standard diet-fed BALB/c mice. Slight but significant renal dysfunction was evident in DDC-fed mice from the early phase. Meanwhile, histological examinations of the kidneys with routine light microscopy did not show definitive morphological findings, and electron microscopic analyses were required to detect limited injuries such as loss of brush border microvilli and mitochondrial deformities. Limited injuries have been recently designated as sublethal tubular cell injury. As humans with renal impairment, either with or without CLD, often show almost normal tubules, sublethal injury has been of particular interest. In this study, the injuries were associated with mitochondrial aberrations and oxidative stress, a possible mechanism for sublethal injury. Intriguingly, two defense mechanisms were associated with this injury that prevent it from progressing to apparent cell death: autophagy and single-cell extrusion with regeneration. Furthermore, the renal impairment of this model progressed to chronic kidney disease with interstitial fibrosis after long-term DDC feeding. These findings indicated that DDC induces renal impairment with sublethal tubular cell injury from the early phase, leading to chronic kidney disease. Importantly, this CLD mouse model could be useful for studying the pathophysiological mechanisms of sublethal tubular cell injury.
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Affiliation(s)
- Tokiko Ishida
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirokazu Kotani
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masashi Miyao
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Chihiro Kawai
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Leila Jemail
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hitoshi Abiru
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Keiji Tamaki
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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