1
|
Mohan PB, Nagaraju SP, Musunuri B, Rajpurohit S, Bhat G, Shetty S. Study of prevalence, risk factors for acute kidney injury, and mortality in liver cirrhosis patients. Ir J Med Sci 2024; 193:1817-1825. [PMID: 38517600 PMCID: PMC11294372 DOI: 10.1007/s11845-024-03663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/29/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION Acute kidney injury (AKI) occurs frequently in patients with end-stage liver disease and cirrhosis and is associated with increased short-term mortality. This study aims to study the prevalence and risk factors associated with AKI development and mortality in cirrhosis of liver patients. METHODOLOGY In the current prospective study, hospitalized patients with liver cirrhosis from October 2021 to March 2023 were recruited. Demographic, clinical, and laboratory data were collected, which included, the etiology of cirrhosis, comorbidities, severity of liver disease, and relevant biochemical parameters. The patient was followed up for 90 days to record the clinical outcome. The statistical software SPSS was utilized to conduct the analysis. RESULTS Of 364 liver cirrhosis patients, 25.2% (n, 92) had AKI and belonged to an average age of 51.54 ± 11.82 years. The majority of individuals in the study were males (90.4%), and alcohol (63.4%) was the most common etiology of liver cirrhosis. The present study showed that higher level of direct bilirubin (p = 0.011) and MELD score (p = 0.0001) were identified as significant risk factors for AKI development in patients with liver cirrhosis. Regarding mortality, the significant risk factors were the presence of AKI (p = 0.045) and MELD score (p = 0.025). Among AKI patients, 90-day mortality rates were higher in patients with acute tubular necrosis (p value = 0.010) and stage 3 AKI (p value = 0.001). CONCLUSION AKI is common in cirrhosis of liver patients. Elevated levels of direct bilirubin and MELD score emerged as significant factors associated with AKI development. Furthermore, AKI and MELD scores were identified as independent risk factors for mortality at both 30 and 90 days. Survival rates were influenced by both the type and stage of AKI; AKI stage 3 and ATN patients had significantly higher mortality rate. Early AKI detection and management are crucial for reducing mortality risk in liver cirrhosis patients.
Collapse
Affiliation(s)
- Pooja Basthi Mohan
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Shankar Prasad Nagaraju
- Department of Nephrology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Balaji Musunuri
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Siddheesh Rajpurohit
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Ganesh Bhat
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Shiran Shetty
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India.
| |
Collapse
|
2
|
Idalsoaga F, Díaz LA, Fuentes-López E, Ayares G, Valenzuela F, Meza V, Manzur F, Sotomayor J, Rodriguez H, Chianale F, Villagrán S, Schalper M, Villafranca P, Veliz MJ, Uribe P, Puebla M, Bustamante P, Aguirre H, Busquets J, Roblero JP, Mezzano G, Hernandez-Tejero M, Arrese M, Arab JP. Active alcohol consumption is associated with acute-on-chronic liver failure in Hispanic patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:562-573. [PMID: 37778718 DOI: 10.1016/j.gastrohep.2023.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe clinical entity associated with elevated short-term mortality. We aimed to characterize patients with decompensated cirrhosis according to presence of ACLF, their association with active alcohol intake, and long-term survival in Latin America. METHODS Retrospective cohort study of decompensated cirrhotic in three Chilean university centers (2017-2019). ACLF was diagnosed according EASL-CLIF criteria. We assessed survival using competing-risk and time-to-event analyses. We evaluated the time to death using accelerated failure time (AFT) models. RESULTS We included 320 patients, median age of 65.3±11.7 years old, and 48.4% were women. 92 (28.7%) patients met ACLF criteria (ACLF-1: 29.3%, ACLF-2: 27.1%, and ACLF-3: 43.4%). The most common precipitants were infections (39.1%), and the leading organ failure was kidney (59.8%). Active alcohol consumption was frequent (27.7%), even in patients with a prior diagnosis of non-alcoholic fatty liver disease (NAFLD) (16.2%). Ninety-two (28.7%) patients had ACLF (ACLF-1: 8.4%, ACLF-2: 7.8%, and ACLF-3: 12.5%). ACLF patients had a higher MELD-Na score at admission (27 [22-31] versus 16 [12-21], p<0.0001), a higher frequency of alcohol-associated liver disease (36.7% versus 24.9%, p=0.039), and a more frequent active alcohol intake (37.2% versus 23.8%, p=0.019). In a multivariate model, ACLF was associated with higher mortality (subdistribution hazard ratio 1.735, 95%CI: 1.153-2.609; p<0.008). In the AFT models, the presence of ACLF during hospitalization correlated with a shorter time to death: ACLF-1 shortens the time to death by 4.7 times (time ratio [TR] 0.214, 95%CI: 0.075-0.615; p<0.004), ACLF-2 by 4.4 times (TR 0.224, 95%CI: 0.070-0.713; p<0.011), and ACLF-3 by 37 times (TR 0.027, 95%CI: 0.006-0.129; p<0.001). CONCLUSIONS Patients with decompensated cirrhosis and ACLF exhibited a high frequency ofactive alcohol consumption. Patients with ACLF showed higher mortality and shorter time todeath than those without ACLF.
Collapse
Affiliation(s)
- Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ayares
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Valenzuela
- Departamento de Medicina Interna, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Victor Meza
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Franco Manzur
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joaquín Sotomayor
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hernán Rodriguez
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Franco Chianale
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sofía Villagrán
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | | | - Paz Uribe
- Escuela de Medicina, Universidad de Chile, Santiago, Chile
| | | | - Pablo Bustamante
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Herman Aguirre
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Javiera Busquets
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Juan Pablo Roblero
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Gabriel Mezzano
- Sección de Gastroenterología, Hospital del Salvador, Santiago, Chile; Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile
| | - Maria Hernandez-Tejero
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA; Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada.
| |
Collapse
|
3
|
Abstract
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.
Collapse
Affiliation(s)
- Mahathi Avadhanam
- Department of Emergency Medicine, Queen Elizabeth hospital, London, UK
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Gachibowli, Hyderabad, India-500032.
| |
Collapse
|
4
|
Hong C, Zhu Q, Li Y, Tang S, Lin S, Yang Y, Yuan S, Shao L, Wu Y, Liu B, Li B, Meng F, Chen Y, Hong M, Qi X. Acute kidney injury defined by cystatin C may be superior for predicting the outcomes of liver cirrhosis with acute gastrointestinal bleeding. Ren Fail 2022; 44:398-406. [PMID: 35225149 PMCID: PMC8890530 DOI: 10.1080/0886022x.2022.2039193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND & AIMS Acute kidney injury (AKI) is conventionally evaluated by a dynamic change of serum creatinine (Scr). Cystatin C (CysC) seems to be a more accurate biomarker for assessing kidney function. This retrospective multicenter study aims to evaluate whether AKI re-defined by CysC can predict the in-hospital outcomes of patients with liver cirrhosis and acute gastrointestinal bleeding. METHODS Overall, 677 cirrhotic patients with acute gastrointestinal bleeding, in whom both Scr and CysC levels were detected at admissions, were screened. eGFRScr, eGFRCysC, and eGFRScr-CysC were calculated. MELD-Na score and AKI were re-evaluated by CysC instead of Scr. Odds ratios (ORs) were calculated in the logistic regression analyses. The receiver operating characteristic (ROC) curve analyses were performed. RESULTS Univariate logistic regression analyses demonstrated that baseline Scr and CysC levels, eGFRScr, eGFRCysC, eGFRScr-CysC, original MELD-Na score defined by Scr, MELD-Na score re-defined by CysC, and AKI re-defined by CysC, but not conventional AKI defined by Scr, were significantly associated with in-hospital death. ROC analyses showed that baseline CysC level, eGFRScr, eGFRCysC, eGFRScr-CysC, original MELD-Na score defined by Scr, and MELD-Na score re-defined by CysC, but not baseline Scr level, could significantly predict the risk of in-hospital death. CONCLUSIONS AKI re-defined by CysC may be superior for predicting the in-hospital mortality of cirrhotic patients with acute gastrointestinal bleeding.
Collapse
Affiliation(s)
- Cen Hong
- Department of Gastroenterology, General Hospital of Northern Theater Command (formally called General Hospital of Shenyang Military Area), Shenyang, China
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong Frist Medical University, Jinan, China
| | - Yiling Li
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Shanhong Tang
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu, China
| | - Su Lin
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yida Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force Hospital of Northern Theater Command, Shenyang, China
| | - Yunhai Wu
- Department of Critical Care Medicine, The Sixth People's Hospital of Shenyang, Shenyang, China
| | - Bang Liu
- Department of Hepatobiliary Disease, Fuzong Clinical Medical College of Fujian Medical University & 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Bimin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fanping Meng
- Department of Biological Therapy, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yu Chen
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You’an Hospital, Affiliated to Capital Medical University, Beijing, China
| | - Min Hong
- Department of Nephrology, General Hospital of Northern Theater Command (formally called General Hospital of Shenyang Military Area), Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formally called General Hospital of Shenyang Military Area), Shenyang, China
- CONTACT Xingshun Qi Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, China
| |
Collapse
|
5
|
Balcar L, Tonon M, Semmler G, Calvino V, Hartl L, Incicco S, Jachs M, Bauer D, Hofer BS, Gambino CG, Accetta A, Brocca A, Trauner M, Mandorfer M, Piano S, Reiberger T. Risk of further decompensation/mortality in patients with cirrhosis and ascites as the first single decompensation event. JHEP Rep 2022; 4:100513. [PMID: 35845294 PMCID: PMC9284386 DOI: 10.1016/j.jhepr.2022.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 05/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background & Aims Although ascites is the most frequent first decompensating event in cirrhosis, the clinical course after ascites as the single index decompensation is not well defined. The aim of this multicentre study was thus to systematically investigate the incidence and type of further decompensation after ascites as the first decompensating event and to assess risk factors for mortality. Methods A total of 622 patients with cirrhosis presenting with grade 2/3 ascites as the single index decompensating event at 2 university hospitals (Padova and Vienna) between 2003 and 2021 were included. Events of further decompensation, liver transplantation, and death were recorded. Results The mean age was 57 ± 11 years, and most patients were male (n = 423, 68%) with alcohol-related (n = 366, 59%) and viral (n = 200,32%) liver disease as the main aetiologies. In total, 323 (52%) patients presented with grade 2 and 299 (48%) with grade 3 ascites. The median Child-Pugh score at presentation was 8 (IQR 7-9), and the mean model for end-stage liver disease (MELD) was 15 ± 6. During a median follow-up period of 49 months, 350 (56%) patients experienced further decompensation: refractory ascites (n = 130, 21%), hepatic encephalopathy (n = 112, 18%), spontaneous bacterial peritonitis (n = 32, 5%), hepatorenal syndrome-acute kidney injury (n = 29, 5%). Variceal bleeding as an isolated further decompensation event was rare (n = 18, 3%), whereas non-bleeding further decompensation (n = 161, 26%) and ≥2 concomitant further decompensation events (n = 171, 27%) were frequent. Transjugular intrahepatic portosystemic shunt was used in only 81 (13%) patients. In patients presenting with grade 2 ascites, MELD ≥15 indicated a considerable risk for further decompensation (subdistribution hazard ratio [SHR] 2.18; p <0.001; 1-year incidences: <10: 10% vs. 10-14: 13% vs. ≥15: 28%) and of mortality (SHR 1.89; p = 0.004; 1-year incidences: <10: 3% vs. 10-14: 6% vs. ≥15: 14%). Importantly, mortality was similarly high throughout MELD strata in grade 3 ascites (p = n.s. for different MELD strata; 1-year incidences: <10: 14% vs. 10-14: 15% vs. ≥15: 20%). Conclusions Further decompensation is frequent in patients with ascites as a single index decompensation event and only rarely owing to bleeding. Although patients with grade 2 ascites and MELD <15 seem to have a favourable prognosis, those with grade 3 ascites are at a high risk of mortality across all MELD strata. Lay summary Decompensation (the development of symptoms as a result of worsening liver function) marks a turning point in the disease course for patients with cirrhosis. Ascites (i.e. , the accumulation of fluid in the abdomen) is the most common first decompensating event, yet little is known about the clinical course of patients who develop ascites as a single first decompensating event. Herein, we show that the severity of ascites is associated with mortality and that in patients with moderate ascites, the widely used prognostic MELD score can predict patient outcomes.
Collapse
Key Words
- ACLF, acute-on-chronic liver failure
- Acute kidney injury
- Baveno
- CI, confidence interval
- CPS, Child–Pugh score
- HCC, hepatocellular carcinoma
- HE, hepatic encephalopathy
- HRS-AKI, hepatorenal syndrome–acute kidney injury
- Hepatic decompensation
- ICA, International Club of Ascites
- INR, international normalised ratio
- IQR, interquartile range
- LT, liver transplantation
- MELD, model for end-stage liver disease
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- PVT, portal vein thrombosis
- Portal hypertension
- RA, refractory ascites
- SBP, spontaneous bacterial peritonitis
- SHR, subdistribution hazard ratio
- Spontaneous bacterial peritonitis
- TFS, transplant-free survival
- TIPS, transjugular intrahepatic portosystemic shunt
- UNOS MELD (2016), United Network for Organ Sharing model for end-stage liver disease (2016)
- VB, variceal bleeding
- aSHR, adjusted subdistribution hazard ratio
Collapse
Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padua, Italy
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padua, Italy
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Simone Incicco
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padua, Italy
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Carmine Gabriele Gambino
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padua, Italy
| | - Antonio Accetta
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padua, Italy
| | - Alessandra Brocca
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padua, Italy
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padua, Italy
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Baveno Cooperation: an EASL consortium
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padua, Italy
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
6
|
Qi X, Bai Z, Zhu Q, Cheng G, Chen Y, Dang X, Ding H, Han J, Han L, He Y, Ji F, Jin H, Li B, Li H, Li Y, Li Z, Liu B, Liu F, Liu L, Lin S, Ma D, Meng F, Qi R, Ren T, Shao L, Tang S, Tang Y, Teng Y, Wang C, Wang R, Wu Y, Xu X, Yang L, Yuan J, Yuan S, Yang Y, Zhao Q, Zhang W, Yang Y, Guo X, Xie W. Practice guidance for the use of terlipressin for liver cirrhosis-related complications. Therap Adv Gastroenterol 2022; 15:17562848221098253. [PMID: 35601800 PMCID: PMC9121451 DOI: 10.1177/17562848221098253] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Liver cirrhosis is a major global health burden worldwide due to its high risk of morbidity and mortality. Role of terlipressin for the management of liver cirrhosis-related complications has been recognized during recent years. This article aims to develop evidence-based clinical practice guidance on the use of terlipressin for liver cirrhosis-related complications. METHODS Hepatobiliary Study Group of the Chinese Society of Gastroenterology of the Chinese Medical Association and Hepatology Committee of the Chinese Research Hospital Association have invited gastroenterologists, hepatologists, infectious disease specialists, surgeons, and clinical pharmacists to formulate the clinical practice guidance based on comprehensive literature review and experts' clinical experiences. RESULTS Overall, 10 major guidance statements regarding efficacy and safety of terlipressin in liver cirrhosis were proposed. Terlipressin can be beneficial for the management of cirrhotic patients with acute variceal bleeding and hepatorenal syndrome (HRS). However, the evidence regarding the use of terlipressin in cirrhotic patients with ascites, post-paracentesis circulatory dysfunction, and bacterial infections and in those undergoing hepatic resection and liver transplantation remains insufficient. Terlipressin-related adverse events, mainly including gastrointestinal symptoms, electrolyte disturbance, and cardiovascular and respiratory adverse events, should be closely monitored. CONCLUSION The current clinical practice guidance supports the use of terlipressin for gastroesophageal variceal bleeding and HRS in liver cirrhosis. High-quality studies are needed to further clarify its potential effects in other liver cirrhosis-related complications.
Collapse
Affiliation(s)
| | | | | | - Gang Cheng
- Department of Life Sciences and
Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Yu Chen
- Difficult and Complicated Liver Diseases and
Artificial Liver Center, Beijing You’an Hospital, Capital Medical
University, Beijing, China
| | - Xiaowei Dang
- Department of Hepatobiliary and Pancreatic
Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou,
China
| | - Huiguo Ding
- Department of Gastrointestinal and Hepatology,
Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Juqiang Han
- Institute of Liver Disease, The 7th Medical
Centre of Chinese People Liberation Army General Hospital, Beijing,
China
| | - Lei Han
- Department of Hepatobiliary Surgery, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yingli He
- Department of Infectious Diseases, First
Affiliated Teaching Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Fanpu Ji
- Department of Infectious Diseases, The Second
Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hongxu Jin
- Department of Emergency Medicine, General
Hospital of Northern Theater Command, Shenyang, China
| | - Bimin Li
- Department of Gastroenterology, The First
Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hongyu Li
- Department of Gastroenterology, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yiling Li
- Department of Gastroenterology, First
Affiliated Hospital of China Medical University, Shenyang, China
| | - Zhiwei Li
- Department of Hepato-Biliary Surgery, Shenzhen
Third People’s Hospital, Shenzhen, China
| | - Bang Liu
- Department of Hepatobiliary Disease, 900
Hospital of the Joint Logistics Team, Fuzhou, China
| | - Fuquan Liu
- Department of Interventional Radiology,
Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lei Liu
- Department of Gastroenterology, Tangdu
Hospital of the Fourth Military Medical University, Xi’an, China
| | - Su Lin
- Liver Research Center, The First Affiliated
Hospital of Fujian Medical University, Fuzhou, China
| | - Dapeng Ma
- Department of Critical Care Medicine, The
Sixth People’s Hospital of Dalian, Dalian, China
| | - Fanping Meng
- Department of Infectious Diseases, The Fifth
Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ruizhao Qi
- Department of General Surgery, The Fifth
Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Tianshu Ren
- Department of Pharmacy, General Hospital of
Northern Theater Command, Shenyang, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force
Hospital of Northern Theater Command, Shenyang, China
| | - Shanhong Tang
- Department of Gastroenterology, General
Hospital of Western Theater Command, Chengdu, China
| | - Yufu Tang
- Department of Hepatobiliary Surgery, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yue Teng
- Department of Emergency Medicine, General
Hospital of Northern Theater Command, Shenyang, China
| | - Chunhui Wang
- Department of Hepatobiliary Surgery, General
Hospital of Northern Theater Command, Shenyang, China
| | - Ran Wang
- Department of Gastroenterology, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yunhai Wu
- Department of Critical Care Medicine, Sixth
People’s Hospital of Shenyang, Shenyang, China
| | - Xiangbo Xu
- Department of Gastroenterology, General
Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and
Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Ling Yang
- Department of Gastroenterology, Union
Hospital, Tongji Medical College, Huazhong University of Science and
Technology, Wuhan, China
| | - Jinqiu Yuan
- Clinical Research Center, The Seventh
Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi’an Central
Hospital, Xi’an, China
| | - Yida Yang
- Collaborative Innovation Center for Diagnosis
and Treatment of Infectious Diseases, The First Affiliated Hospital,
Zhejiang University School of Medicine, Hangzhou, China
| | - Qingchun Zhao
- Department of Pharmacy, General Hospital of
Northern Theater Command, Shenyang, China
| | - Wei Zhang
- Department of Hepatobiliary Surgery, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yongping Yang
- Department of Liver Disease, The Fifth Medical
Center of Chinese PLA General Hospital, 100 West Fourth Ring Middle Road,
Beijing 100039, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General
Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang 110015,
Liaoning, China
| | - Weifen Xie
- Department of Gastroenterology, Changzheng
Hospital, Naval Medical University, Shanghai 200003, China
| |
Collapse
|
7
|
Ji K, Li X, Zhu H, Zhao S, Zhan P, Shi Y, Ye S, Xie B, Zhang Y, Yu P, Ren Z, Ding J, Han X, Li Z. A creatinine-based model for predicting recurrent bleeding after modified percutaneous transhepatic variceal embolization in patients with cirrhosis. J Interv Med 2022; 5:95-102. [PMID: 35936666 PMCID: PMC9348999 DOI: 10.1016/j.jimed.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kun Ji
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xin Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Hanlong Zhu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Si Zhao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu Province, China
| | - Pengchao Zhan
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yang Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shuwen Ye
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Bingcan Xie
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yuyuan Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Peng Yu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhigang Ren
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Juan Ding
- Department of Quality Control, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhen Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- Corresponding author. Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, No.1 East Jian She Road, Zhengzhou 450052, Henan Province, China.
| |
Collapse
|
8
|
Acute Kidney Injury in Patients with Liver Cirrhosis: Prevalence, Predictors, and In-Hospital Mortality at a District Hospital in Ghana. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4589767. [PMID: 35237687 PMCID: PMC8885249 DOI: 10.1155/2022/4589767] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 11/30/2021] [Accepted: 02/11/2022] [Indexed: 12/16/2022]
Abstract
Background Acute kidney injury (AKI) is one of the most severe complications of cirrhosis and portends an ominous prognosis with an estimated mortality of about 50% in a month and 65% within a year. Infection and hypovolemia have been found to be the main precipitating factors of AKI in liver cirrhosis. Early detection and treatment of AKI may improve outcomes. AKI in patients with liver cirrhosis in Ghana and their impact on inpatient mortality are largely unknown. This study was aimed at determining the prevalence, precipitating factors, predictors, and in-hospital mortality of AKI in patients with liver cirrhosis admitted to a district hospital in Ghana. Methods Consecutive hospitalized patients with liver cirrhosis from 1 January 2018 to 30 April 2020 were recruited. Patient's demographic data and clinical features were collected using a standardized questionnaire. Biochemical and haematological tests as well as abdominal ultrasound scans were done for all patients. All patients were then followed up until discharge or death. Results There were 117 (65.4%) males out of the 179 patients with a mean age of 49.94 and 45.84 years for those with and without AKI, respectively. The prevalence of AKI was 27.9% (50/179). Out of 50 participants with AKI, 64.0% (32/50) died, contributing 41.0% of all in-patient mortality amongst participants. There was a significant association between AKI and death (p ≤ 0.001). The major precipitating factors of AKI were infections (60.0%), hypovolemia (20.0%) due to gastrointestinal bleeding and gastroenteritis, and refractory ascites (16.0%). Alkaline phosphatase, INR, model for end-stage liver disease sodium, sodium, and blood urea nitrogen were independent predictors of AKI. Conclusion AKI was common among patients with liver cirrhosis with high in-patient mortality. Identification of these precipitants and independent predictors of AKI may lead to prompt and targeted treatment with reduction in patient mortality.
Collapse
|
9
|
Fox R, Stenning K, Slee A, Macnaughtan J, Davies N. Sarcopenia in liver cirrhosis: Prevalence, pathophysiology and therapeutic strategies. Anal Biochem 2022; 647:114581. [DOI: 10.1016/j.ab.2022.114581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/31/2022] [Indexed: 11/01/2022]
|
10
|
Wang PL, Silver SA, Djerboua M, Thanabalasingam S, Zarnke S, Flemming JA. Recovery From Acute Kidney Injury Requiring Dialysis in Patients With Cirrhosis: A Population-Based Study. Am J Kidney Dis 2021; 80:55-64.e1. [PMID: 34808296 DOI: 10.1053/j.ajkd.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/21/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The decision to initiate kidney replacement therapy (KRT) for acute kidney injury (AKI) in cirrhosis remains controversial as it is unclear which patients will benefit. We sought to characterize factors associated with recovery from AKI requiring KRT in patients with cirrhosis to inform shared clinical decision-making. STUDY DESIGN Population-based retrospective cohort study. SETTING & PARTICIPANTS Adult patients from Ontario, Canada identified, using administrative data, to have cirrhosis at the time of admission to hospital with AKI (based on serum creatinine) requiring KRT (01/01/2009-12/31/2016) and followed until 12/31/2017. EXPOSURES Demographics and comorbidities prior to admission. OUTCOMES Kidney recovery defined as the absence of KRT for at least 30 days. ANALYTICAL APPROACH The cumulative incidences of kidney recovery, death, and liver transplantation were calculated at 1, 3, 6, and 12 months and independent predictors of kidney recovery were evaluated using Fine and Gray competing risk regression models that generated subdistribution hazards ratios (sHR). RESULTS Overall, 722 patients were included (median age 61 years [IQR 54-68]; MELD-Na 26 [IQR 22-34]; 66% male; 52% had viral hepatitis, 25% non-alcoholic fatty liver disease, 18% alcohol-associated liver disease). The cumulative incidences of kidney recovery at 1, 3, 6, and 12 months were 3%, 22%, 25%, and 26%, respectively. Higher MELD-Na score (sHR 0.72 per 5 units, 95%CI 0.65-0.80), acute-on-chronic liver failure (sHR 0.61, 95%CI 0.43-0.86), and sepsis (sHR 0.57, 95%CI 0.41-0.81) were associated with a lower hazard of kidney recovery while those on a liver transplant waitlist (sHR 3.10, 95% CI 1.96-4.88) and who were admitted to a teaching hospital (sHR 1.48, 95%CI 1.05-2.08) were more likely to experience kidney recovery. LIMITATIONS Observational design, AKI etiology not identified. CONCLUSIONS Kidney recovery from KRT occurred in only one-quarter of patients and was very unlikely after 3-months. These findings provide information regarding prognosis that may guide decisions regarding KRT initiation and continuation.
Collapse
Affiliation(s)
| | | | | | | | | | - Jennifer A Flemming
- Department of Medicine; ICES, Queen's University; Department of Public Health Sciences, Queen's University.
| |
Collapse
|
11
|
Piano S, Cardenas A. Metabolomics to Predict Acute Kidney Injury in Cirrhosis. Hepatology 2021; 74:2339-2341. [PMID: 34268779 DOI: 10.1002/hep.32060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/06/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Andres Cardenas
- GI/Liver Transplant Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona Spain and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| |
Collapse
|
12
|
Islek A, Tumgor G. Acute-on-chronic liver failure in children. World J Hepatol 2021; 13:1289-1298. [PMID: 34786166 PMCID: PMC8568578 DOI: 10.4254/wjh.v13.i10.1289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/16/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
Although various complex definitions of acute-on-chronic liver failure (ACLF) have been suggested in relation to adult patients, there is currently no universal definition of the syndrome in pediatric patients. In simplified terms, ACLF is characterized by the acute deterioration of the liver functions due to the effects of a precipitating factor on the basis of a chronic liver disease. Acute events and underlying liver diseases are very different in children from those seen in adults. Moreover, acute events and underlying chronic liver diseases vary among geographical regions, although it seems that the most common such diseases and acute events are autoimmune hepatitis, Wilson’s disease, and their flares. ACLF is associated with a poor prognosis. While no scoring systems have been developed to predict the prognosis for children with ACLF, modified versions of the Asian Pacific Association for the Study of the liver’s acute-on-chronic liver failure scoring system and the Chronic Liver Failure-Sequential Organ Failure Assessment criteria can be used in children until specific and validated scoring systems are available. Aside from liver transplantation, there is no proven treatment for ACLF. Thus, the early recognition of ACLF prior to the development of extrahepatic organ failure is important.
Collapse
Affiliation(s)
- Ali Islek
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01330, Turkey
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01330, Turkey
| |
Collapse
|
13
|
Singh SP, Wadhawan M, Acharya SK, Bopanna S, Madan K, Sahoo MK, Bhat N, Misra SP, Duseja A, Mukund A, Anand AC, Goel A, Satyaprakash BS, Varghese J, Panigrahi MK, Tandan M, Mohapatra MK, Puri P, Rathi PM, Wadhwa RP, Taneja S, Thomas V, Bhatia V. Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding. Indian J Gastroenterol 2021; 40:519-540. [PMID: 34890020 DOI: 10.1007/s12664-021-01169-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 02/04/2023]
Abstract
Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.
Collapse
Affiliation(s)
- Shivaram P Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, 753 001, India.
| | - Manav Wadhawan
- Department of Hepatology and Liver Transplant, Institute of Liver and Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
| | - Subrat K Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, 751 024, India
| | - Sawan Bopanna
- Department of Gastroenterology and Hepatology, Fortis Flt. Lt. Rajan Dhall Hospital, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi, 110 070, India
| | - Kaushal Madan
- Department of Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, 110 017, India
| | - Manoj K Sahoo
- Department of Medical Gastroenterology, IMS and SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, 751 003, India
| | - Naresh Bhat
- Department of Gastroenterology and Hepatology, Aster CMI Hospital, Bangalore, 560 092, India
| | - Sri P Misra
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, 211 001, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Anil C Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, 751 024, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | | | - Joy Varghese
- Department of Hepatology and Transplant Hepatology, Institute of Liver Disease and Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Chennai, 600 100, India
| | - Manas K Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751 019, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, 500 082, India
| | - Mihir K Mohapatra
- Department of Surgical Gastroenterology, Srirama Chandra Bhanja Medical College, Cuttack, 753 007, India
| | - Pankaj Puri
- Department of Gastroenterology and Hepatology, Fortis Escorts Liver and Digestive Diseases Institute, Okhla Road, New Delhi, 110 025, India
| | - Pravin M Rathi
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, 400 008, India
| | - Rajkumar P Wadhwa
- Department of Gastroenterology, Apollo BGS Hospital, Adichuchanagiri Road, Kuvempunagar, Mysore, 570 023, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Varghese Thomas
- Department of Gastroenterology, Malabar Medical College Hospital, Modakkallur, Calicut, 673 321, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | | |
Collapse
|
14
|
Acute-on-Chronic Liver Failure in Cirrhosis. J Clin Med 2021; 10:jcm10194406. [PMID: 34640424 PMCID: PMC8509281 DOI: 10.3390/jcm10194406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 12/12/2022] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a syndrome that develops in patients with acutely decompensated chronic liver disease. It is characterised by high 28-day mortality, the presence of one or more organ failures (OFs) and a variable but severe grade of systemic inflammation. Despite the peculiarity of each one, every definition proposed for ACLF recognizes it as a proper clinical entity. In this paper, we provide an overview of the diagnostic criteria proposed by the different scientific societies and the clinical characteristics of the syndrome. Established and experimental treatments are also described. Among the former, the most relevant are directed to support organ failures, treat precipitating factors and carry out early assessment for liver transplantation (LT). Further studies are needed to better clarify pathophysiology of the syndrome and discover new therapies.
Collapse
|
15
|
Hepatorenal syndrome: pathophysiology and evidence-based management update. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2021; 59:227-261. [DOI: 10.2478/rjim-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Indexed: 11/20/2022] Open
Abstract
Abstract
Hepatorenal syndrome (HRS) is a functional renal failure that develops in patients with advanced hepatic cirrhosis with ascites and in those with fulminant hepatic failure. The prevalence of HRS varies among studies but in general it is the third most common cause of acute kidney injury (AKI) in cirrhotic patients after pre-renal azotemia and acute tubular necrosis. HRS carries a grim prognosis with a mortality rate approaching 90% three months after disease diagnosis. Fortunately, different strategies have been proven to be successful in preventing HRS. Although treatment options are available, they are not universally effective in restoring renal function but they might prolong survival long enough for liver transplantation, which is the ultimate treatment. Much has been learned in the last two decades regarding the pathophysiology and management of this disease which lead to notable evolution in the HRS definition and better understanding on how best to manage HRS patients. In the current review, we will summarize the recent advancement in epidemiology, pathophysiology, and management of HRS.
Collapse
|
16
|
Zanetto A, Shalaby S, Feltracco P, Gambato M, Germani G, Russo FP, Burra P, Senzolo M. Recent Advances in the Management of Acute Variceal Hemorrhage. J Clin Med 2021; 10:jcm10173818. [PMID: 34501265 PMCID: PMC8432221 DOI: 10.3390/jcm10173818] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal bleeding is one of the most relevant causes of death in patients with cirrhosis and clinically significant portal hypertension, with gastroesophageal varices being the most frequent source of hemorrhage. Despite survival has improved thanks to the standardization on medical treatment aiming to decrease portal hypertension and prevent infections, mortality remains significant. In this review, our goal is to discuss the most recent advances in the management of esophageal variceal hemorrhage in cirrhosis with specific attention to the treatment algorithms involving the use of indirect measurement of portal pressure (HVPG) and transjugular intrahepatic portosystemic shunt (TIPS), which aim to further reduce mortality in high-risk patients after acute variceal hemorrhage and in the setting of secondary prophylaxis.
Collapse
Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; (A.Z.); (S.S.); (M.G.); (G.G.); (F.P.R.); (P.B.)
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; (A.Z.); (S.S.); (M.G.); (G.G.); (F.P.R.); (P.B.)
| | - Paolo Feltracco
- Anesthesiology and Intensive Care Unit, Department of Medicine, Padova University Hospital, 35128 Padova, Italy;
| | - Martina Gambato
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; (A.Z.); (S.S.); (M.G.); (G.G.); (F.P.R.); (P.B.)
| | - Giacomo Germani
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; (A.Z.); (S.S.); (M.G.); (G.G.); (F.P.R.); (P.B.)
| | - Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; (A.Z.); (S.S.); (M.G.); (G.G.); (F.P.R.); (P.B.)
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; (A.Z.); (S.S.); (M.G.); (G.G.); (F.P.R.); (P.B.)
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Via Giustiniani 2, 35128 Padova, Italy; (A.Z.); (S.S.); (M.G.); (G.G.); (F.P.R.); (P.B.)
- Correspondence:
| |
Collapse
|
17
|
Lang M, Lang AL, Tsui BQ, Wang W, Erly BK, Shen B, Kapoor B. Renal-function change after transjugular intra-hepatic portosystemic shunt placement and its relationship with survival: a single-center experience. Gastroenterol Rep (Oxf) 2021; 9:306-312. [PMID: 34567562 PMCID: PMC8460113 DOI: 10.1093/gastro/goaa081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/15/2020] [Accepted: 09/27/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The effect of transjugular intra-hepatic portosystemic shunt (TIPS) placement on renal function and the correlation of post-TIPS Cr with mortality remain unclear. This study aimed to assess the effect of TIPS placement on renal function and to examine the relationship between post-TIPS Cr and mortality risk. METHODS A total of 593 patients who underwent de novo TIPS placement between 2004 and 2017 at a single institution were included in the study. The pre-TIPS Cr level (T0; within 7 days before TIPS placement) and post-TIPS Cr levels, at 1-2 days (T1), 5-12 days (T2), and 15-40 days (T3), were collected. Predictors of Cr change after TIPS placement and the 1-year mortality rate were analysed using multivariable linear-regression and Cox proportional-hazards models, respectively. RESULTS Overall, 21.4% of patients (n = 127) had elevated baseline Cr (≥1.5 mg/dL; mean, 2.51 ± 1.49 mg/dL) and 78.6% (n = 466) had normal baseline Cr (<1.5 mg/dL; mean, 0.92 ± 0.26 mg/dL). Patients with elevated pre-TIPS Cr demonstrated a decrease in post-TIPS Cr (difference, -0.60 mg/dL), whereas patients with normal baseline Cr exhibited no change (difference, <0.01 mg/dL). The 30-day, 90-day, and 1-year mortality rates were 13%, 20%, and 32%, respectively. Variceal bleeding as a TIPS-placement indication (hazard ratio = 1.731; P = 0.036), higher T0 Cr (hazard ratio = 1.834; P = 0.012), and higher T3 Cr (hazard ratio = 3.524; P < 0.001) were associated with higher 1-year mortality risk. CONCLUSION TIPS placement improved renal function in patients with baseline renal dysfunction and the post-TIPS Cr level was a strong predictor of 1-year mortality risk.
Collapse
Affiliation(s)
- Min Lang
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Angela L. Lang
- Department of Anesthesia, Critical Care, and Pain Management, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Q. Tsui
- Department of Radiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Brian K. Erly
- Colorado School of Public Health, Aurora, Colorado, USA
| | - Bo Shen
- The Inflammatory Bowel Disease Center at Columbia, Columbia University Irving Medical Center, New York, NY, USA
| | - Baljendra Kapoor
- Division of Vascular and Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
18
|
Makar M, Reja D, Chouthai A, Kabaria S, Patel AV. The impact of acute kidney injury on mortality and clinical outcomes in patients with alcoholic cirrhosis in the USA. Eur J Gastroenterol Hepatol 2021; 33:905-910. [PMID: 32976187 DOI: 10.1097/meg.0000000000001947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Acute kidney injury (AKI) is associated with increased morbidity and mortality in patients with chronic liver disease. Although the impact of AKI on patients with liver disease has been established, its impact on alcoholic cirrhosis has not been studied. METHODS Our study utilized data from the National Inpatient Sample for the year 2016 for all patients with a diagnosis of alcoholic cirrhosis and AKI. Primary outcomes were mortality, length of stay (LOS) and hospitalization cost were compared. Secondary outcomes were complications of cirrhosis and its impact on mortality. Multivariate logistic regression analysis and propensity-score matching were used to compare the two groups. RESULTS A total of 29 906 patients were included and 6733 (22.5%) had AKI. Propensity-matched multivariate analysis demonstrates that AKI was associated with a significant increase risk of mortality [odds ratio (OR): 8.09; 95% confidence interval (CI), 6.68-9.79; P < 0.0001]. AKI prolonged the hospital stay by 3.68 days (95% CI, 3.42-3.93; P < 0.0001) and increased total hospital charges by $50 284 (95% CI, 45 829-54 739; P < 0.0001). AKI increased the risk of complications of cirrhosis, including hepatorenal syndrome (OR: 19.15; 95% CI, 16.1-22.76), ascites (OR: 2.27; 95% CI, 2.11-2.44), hepatic encephalopathy (OR: 2.54; 95% CI, 1.87-3.47) and portal hypertension (OR: 1.08; 95% CI, 1.01-1.16). CONCLUSION AKI in alcoholic cirrhosis significantly increases the risk of mortality, hospitalizations costs and LOS. Further studies are needed on addressing renal failure and treatment options for patients with alcoholic cirrhosis.
Collapse
Affiliation(s)
| | | | | | | | - Anish Vinit Patel
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| |
Collapse
|
19
|
Reja M, Patel R, Pioppo L, Tawadros A, Bhurwal A, Marino D, Rustgi V. Renal Failure is Associated With Increased Mortality and Hospital Utilization in Patients Admitted With Nonalcoholic Steatohepatitis. J Clin Gastroenterol 2021; 55:433-438. [PMID: 32740097 DOI: 10.1097/mcg.0000000000001389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/04/2020] [Indexed: 12/13/2022]
Abstract
GOALS We aimed to investigate the mortality and hospital utilization outcomes of hospitalized nonalcoholic steatohepatitis (NASH) patients with and without kidney failure in a nationwide cohort. BACKGROUND NASH is a common medical condition associated with significant morbidity and mortality. A paucity of data exists regarding the impact of kidney failure (defined as acute and chronic kidney failure) on outcomes of NASH hospitalizations. MATERIALS AND METHODS We conducted a retrospective cohort study using the 2016 Nationwide Inpatient Sample dataset of adult patients hospitalized for NASH, stratified for the presence of renal failure. The primary outcome was inpatient mortality, predictors were analyzed using multivariate logistic regression. Secondary outcomes were the length of stay and mean total hospitalization charges. RESULTS The overall sample included 7,135,090 patients. Among 6855 patients admitted for NASH, 598 or 8.7% had comorbid kidney failure. After multivariate regression analysis, NASH patients with renal failure had increased in-hospital mortality [odds ratio=28.72, 95% confidence interval (CI): 8.99-91.73], length of stay (β=3.02, 95% CI: 2.54-3.5), total hospital charges (β=$37,045, 95% CI: $31,756.18-$42,335.62). Positive predictors of mortality in the renal failure group were Charlson Comorbidity Index ≥3 [adjusted odds ratio (aOR)=3.46, 95% CI: 1.04-11.51], variceal bleeding (aOR=3.02, 95% CI: 1.06-8.61), and hepatic encephalopathy (aOR=26.38, 95% CI: 1.29-540.56). Predictors of decreased mortality were Medicaid (aOR=0.047, 95% CI: 0.28-0.79) and private insurance (aOR=0.56, 95% CI: 0.38-0.83). CONCLUSIONS The prevalence of renal failure in NASH hospitalizations is associated with markedly increased mortality, hospital costs, and length of stay. As a result, clinicians should be vigilant in treating kidney failure in this population.
Collapse
Affiliation(s)
| | | | | | | | | | - Daniel Marino
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Vinod Rustgi
- Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School
| |
Collapse
|
20
|
Jeon H, Kim JH, Lee SS, Kim HJ, Cha RR, Cho HC, Lee JM, Ha CY, Kim HJ, Kim TH, Jung WT, Lee OJ. Impact of acute kidney injury on survival in patients with chronic hepatitis C: a retrospective cohort study. BMC Infect Dis 2021; 21:301. [PMID: 33765952 PMCID: PMC7993493 DOI: 10.1186/s12879-021-05991-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 03/16/2021] [Indexed: 12/15/2022] Open
Abstract
Background Acute kidney injury (AKI) is expected to occur commonly in patients with chronic hepatitis C. In addition, AKI may affect the survival of patients with chronic hepatitis C. However, few studies are available on this topic. We aimed to evaluate the incidence of AKI in patients with chronic hepatitis C and investigate the factors related to overall mortality. Methods Between January 2005 and December 2018, 1252 patients with chronic hepatitis C virus (HCV) infection, defined as persistent HCV RNA for at least 6 months, were retrospectively enrolled at two centers. Of them, 1008, 123, and 121 patients had chronic hepatitis (CH), compensated cirrhosis (Com-LC), and decompensated cirrhosis (Decom-LC) or hepatocellular carcinoma (HCC) at entry, respectively. Factors associated with AKI and overall mortality were evaluated using the Cox proportional regression model. The Kaplan-Meier survival curves for the development of AKI and overall mortality were generated. Results Over a mean follow-up period of 5.2 years, 285 patients developed AKI, with an incidence rate of 4.35 per 100 person-years. The incidence of AKI increased gradually with progression of chronic hepatitis C: CH (3.32 per 100 person-years), Com-LC (5.86 per 100 person-years), and Decom-LC or HCC (17.28 per 100 person-years). The patients without AKI showed better survival rates at 14 years than the patients with AKI (94.2% vs. 26.3%, P < 0.001). In multivariate Cox regression analysis, AKI (hazard ratio, 6.66; 95% confidence interval, 4.26–10.41) remained an independent risk factor for overall mortality. Conclusion AKI is common in patients with chronic HCV infection and is associated with significant overall mortality. Therefore, clinicians should carefully monitor the occurrence of AKI, which is an important predictor of mortality in patients with chronic hepatitis C. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05991-2.
Collapse
Affiliation(s)
- Hankyu Jeon
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongnam, 51472, Republic of Korea
| | - Jae Heon Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongnam, 51472, Republic of Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea. .,Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongnam, 51472, Republic of Korea. .,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea.
| | - Hee Jin Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongnam, 51472, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Ra Ri Cha
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongnam, 51472, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Hyun Chin Cho
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Jae Min Lee
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongnam, 51472, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Chang Yoon Ha
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Hyun Jin Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongnam, 51472, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Tae Hyo Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Woon Tae Jung
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Ok-Jae Lee
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| |
Collapse
|
21
|
Terres AZ, Balbinot RS, Muscope ALF, Longen ML, Schena B, Cini BT, Luis Rost G, Balensiefer JIL, Eberhardt LZ, Balbinot RA, Balbinot SS, Soldera J. Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:25-39. [PMID: 33746028 DOI: 10.1016/j.gastrohep.2021.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/22/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients. METHODS An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis. RESULTS The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality. CONCLUSION The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.
Collapse
Affiliation(s)
- Alana Zulian Terres
- Internal Medicine, Hospital Pompeia, Caxias do Sul, RS, Brazil; Gastroenterology, Hospital Geral de Caxias do Sul (RS), Brazil
| | - Rafael Sartori Balbinot
- Residency in Internal Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil; Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | | | | | - Bruna Schena
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | - Bruna Teston Cini
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | - Gilberto Luis Rost
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | | | | | - Raul Angelo Balbinot
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Department of Gastroenterology, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Silvana Sartori Balbinot
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Department of Gastroenterology, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Jonathan Soldera
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
| |
Collapse
|
22
|
Carrion AF, Martin P. Keeping Patients with End-Stage Liver Disease Alive While Awaiting Transplant: Management of Complications of Portal Hypertension. Clin Liver Dis 2021; 25:103-120. [PMID: 33978573 DOI: 10.1016/j.cld.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Complications of portal hypertension such as gastroesophageal variceal hemorrhage, ascites, and spontaneous bacterial peritonitis, as well as pulmonary complications, are often responsible for diminished quality of life, excess morbidity and mortality, increased health care resource use and expenditure, and dropout from the liver transplant (LT) waiting list. Therefore, the care of LT candidates on the waiting list must be centered on anticipation and prompt intervention for these complications.
Collapse
Affiliation(s)
- Andres F Carrion
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, Office 1189, Miami, FL 33136, USA.
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th #1115, Miami, FL 33136, USA
| |
Collapse
|
23
|
Changing epidemiology and outcomes of acute kidney injury in hospitalized patients with cirrhosis - a US population-based study. J Hepatol 2020; 73:1092-1099. [PMID: 32387698 PMCID: PMC7994029 DOI: 10.1016/j.jhep.2020.04.043] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Acute kidney injury (AKI) is a significant clinical event in cirrhosis yet contemporary population-based studies on the impact of AKI on hospitalized cirrhotics are lacking. We aimed to characterize longitudinal trends in incidence, healthcare burden and outcomes of hospitalized cirrhotics with and without AKI using a nationally representative dataset. METHODS Using the 2004-2016 National Inpatient Sample (NIS), admissions for cirrhosis with and without AKI were identified using ICD-9 and ICD-10 codes. Regression analysis was used to analyze the trends in hospitalizations, costs, length of stay and inpatient mortality. Descriptive statistics, simple and multivariable logistic regression were used to assess associations between individual characteristics, comorbidities, and cirrhosis complications with AKI and death. RESULTS In over 3.6 million admissions for cirrhosis, 22% had AKI. AKI admissions were more costly (median $13,127 [IQR $7,367-$24,891] vs. $8,079 [IQR $4,956-$13,693]) and longer (median 6 [IQR 3-11] days vs. 4 [IQR 2-7] days). Over time, AKI prevalence doubled from 15% in 2004 to 30% in 2016. CKD was independently and strongly associated with AKI (adjusted odds ratio 3.75; 95% CI 3.72-3.77). Importantly, AKI admissions were 3.75 times more likely to result in death (adjusted odds ratio 3.75; 95% CI 3.71-3.79) and presence of AKI increased risk of mortality in key subgroups of cirrhosis, such as those with infections and portal hypertension-related complications. CONCLUSIONS The prevalence of AKI is significantly increased among hospitalized cirrhotics. AKI substantially increases the healthcare burden associated with cirrhosis. Despite advances in cirrhosis care, a significant gap remains in outcomes between cirrhotics with and without AKI, suggesting that AKI continues to represent a major clinical challenge. LAY SUMMARY Sudden damage to the kidneys is becoming more common in people who are hospitalized and have cirrhosis. Despite advances in cirrhosis care, those with damage to the kidneys remain at higher risk of dying.
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Xu X, Liu B, Lin S, Li B, Wu Y, Li Y, Zhu Q, Yang Y, Tang S, Meng F, Chen Y, Yuan S, Shao L, Bernardi M, Yoshida EM, Qi X. Terlipressin May Decrease In-Hospital Mortality of Cirrhotic Patients with Acute Gastrointestinal Bleeding and Renal Dysfunction: A Retrospective Multicenter Observational Study. Adv Ther 2020; 37:4396-4413. [PMID: 32860184 DOI: 10.1007/s12325-020-01466-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute gastrointestinal bleeding (GIB) rapidly reduces effective blood volume, thereby precipitating acute kidney injury (AKI). Terlipressin, which can induce splanchnic vasoconstriction and increase renal perfusion, has been recommended for acute GIB and hepatorenal syndrome in liver cirrhosis. Thus, we hypothesized that terlipressin might be beneficial for cirrhotic patients with acute GIB and renal impairment. METHODS In this Chinese multi-center study, 1644 cirrhotic patients with acute GIB were retrospectively enrolled. AKI was defined according to the International Club of Ascites (ICA) criteria. Renal dysfunction was defined as serum creatinine (sCr) > 133 μmol/L at admission and/or any time point during hospitalization. Incidence of renal impairment and in-hospital mortality were the primary end-points. RESULTS The incidence of any stage ICA-AKI, ICA-AKI stages 1B, 2, and 3, and renal dysfunction in cirrhotic patients with acute GIB was 7.1%, 1.8%, and 5.0%, respectively. The in-hospital mortality was significantly increased by renal dysfunction (14.5% vs. 2.2%, P < 0.001) and ICA-AKI stages 1B, 2, and 3 (11.1% vs. 2.8%, P = 0.011), but not any stage ICA-AKI (5.7% vs. 2.7%, P = 0.083). The in-hospital mortality was significantly decreased by terlipressin in patients with renal dysfunction (3.6% vs. 20.0%, P = 0.044), but not in those with any stage ICA-AKI (4.5% vs. 6.0%, P = 0.799) or ICA-AKI stages 1B, 2, and 3 (0.0% vs. 14.3%, P = 0.326). CONCLUSION Renal dysfunction increased the in-hospital mortality of cirrhotic patients with acute GIB. Terlipressin might decrease the in-hospital mortality of cirrhotic patients with acute GIB and renal dysfunction. TRIAL REGISTRATION NCT03846180 ( https://clinicaltrials.gov ).
Collapse
Affiliation(s)
- Xiangbo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
| | - Bang Liu
- Department of Hepatobiliary Disease, Fuzong Clinical Medical College of Fujian Medical University & 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Su Lin
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Bimin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yunhai Wu
- Department of Critical Care Medicine, The Sixth People's Hospital of Shenyang, Shenyang, China
| | - Yiling Li
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Yida Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Shanhong Tang
- Department of Digestive diseases, General Hospital of Western Theater Command, Chengdu, China
| | - Fanping Meng
- Department of Biological Therapy, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yu Chen
- Difficult and Complicated Liver Diseases and Artificial Liver Center, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force Hospital of Northern Theater Command, Shenyang, China
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Eric M Yoshida
- Division of Gastroenterology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China.
| |
Collapse
|
26
|
Abstract
Risk scoring for patients with cirrhosis has evolved greatly over the past several decades. However, patients with low Model for End-Stage Liver Disease-Sodium scores still suffer from liver-related morbidity and mortality. Unfortunately, it is not clear which of these low Model for End-Stage Liver Disease-Sodium score patients would benefit from earlier consideration of liver transplantation. This article reviews the literature of risk prediction in patients with cirrhosis, identifies which patients may benefit from earlier interventions, such as transplantation, and proposes directions for future research.
Collapse
|
27
|
Shin J, Yu JH, Jin YJ, Yim HJ, Jung YK, Yang JM, Song DS, Kim YS, Kim SG, Kim DJ, Suk KT, Yoon EL, Lee SS, Kim CW, Kim HY, Jang JY, Jeong SW. Acute-on-chronic liver failure as a major predictive factor for mortality in patients with variceal bleeding. Clin Mol Hepatol 2020; 26:540-553. [PMID: 32937688 PMCID: PMC7641565 DOI: 10.3350/cmh.2020.0034] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND/AIMS This study examined the risk factors associated with mortality in cirrhotic patients hospitalized with variceal bleeding, and evaluated the effects of acute-on-chronic liver failure (ACLF) on the prognosis of these patients. METHODS This study was retrospectively conducted on patients registered in the Korean acute-on-chronic liver failure study cohort, and on 474 consecutive cirrhotic patients hospitalized with variceal bleeding from January 2013 to December 2013 at 21 university hospitals. ACLF was defined as described by the European Association for the Study of Liver-Chronic Liver Failure Consortium. RESULTS Among a total of 474 patients, 61 patients were diagnosed with ACLF. The cumulative overall survival (OS) rate was lower in the patients with ACLF than in those without (P<0.001), and patients with higher ACLF grades had a lower OS rate (P<0.001). The chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score was identified as a significant prognostic factor in patients hospitalized with variceal bleeding (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.30-1.50; P<0.001), even in ACLF patients with variceal bleeding (HR, 1.32; 95% CI, 1.19-1.46, P<0.001). Concerning the prediction of the mortality risk at 28- and 90-day using CLIF-SOFA scores, c-statistics were 0.895 (95% CI, 0.829-0.962) and 0.897 (95% CI, 0.842-0.951), respectively, and the optimal cut-off values were 6.5 and 6.5, respectively. CONCLUSION In cirrhotic patients hospitalized with variceal bleeding, the prognosis was poor when accompanied by ACLF, especially depending upon CLIF-SOFA score. CLIF-SOFA model well predicted the 28-day or 90-day mortality for cirrhotic patients who experienced variceal bleeding.
Collapse
Affiliation(s)
- Jongbeom Shin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jung Hwan Yu
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Young-Joo Jin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Hyung Joon Yim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Young Kul Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jin Mo Yang
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Seon Song
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Bucheon, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Bucheon, Korea
| | - Dong Joon Kim
- Institute of Liver and Digestive Diseases, Hallym University, Chuncheon, Korea.,Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Ki Tae Suk
- Institute of Liver and Digestive Diseases, Hallym University, Chuncheon, Korea.,Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Eileen L Yoon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Chang Wook Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Young Jang
- Institute for Digestive Research and Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Soung Won Jeong
- Institute for Digestive Research and Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Seoul, Korea
| |
Collapse
|
28
|
The Prognosis Analysis of Liver Cirrhosis with Acute Variceal Bleeding and Validation of Current Prognostic Models: A Large Scale Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7372868. [PMID: 32879889 PMCID: PMC7448238 DOI: 10.1155/2020/7372868] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/07/2020] [Accepted: 08/04/2020] [Indexed: 12/21/2022]
Abstract
Background Acute variceal bleeding is a major cause of death in liver cirrhosis. This large scale retrospective cohort study aims to analyze the prognosis of patients with cirrhosis and acute variceal bleeding and to validate the current prognostic models. Methods Patients with cirrhosis and acute variceal bleeding were enrolled from Jan 2019 to March 2020. The independent prognostic factors for in-hospital death were identified by logistic regression analyses. Area under curves (AUCs) was compared among Child-Pugh, cirrhosis acute gastrointestinal bleeding (CAGIB) score, and model for end-stage liver disease (MELD) and neutrophil-lymphocyte ratio (NLR) scores. Results Overall, 379 patients with liver cirrhosis and acute variceal bleeding were consecutively evaluated. The majority of the patients were males (59.1%) and the mean age of all patients were 53.7 ± 1.3 years (range 14-89). Hepatitis B virus (HBV) was the most common underlying cause of liver cirrhosis (54.1%). 72 (19%) patients had hepatocellular carcinoma. Multivariate logistic regression analyses showed that age, HCC, WBC, total serum bilirubin, serum creatinine, and ALT were independently associated with in-hospital death. And the odds ratios (ORs) for in-hospital death were 1.066 (95% CI 1.017-1.118, P = 0.008), 7.19 (95% CI 2.077-24.893, P = 0.001), 1.123 (95% CI 1.051-1.201, P = 0.001), 1.014 (95% CI 1.005-1.023, P = 0.003), 1.012 (95% CI 1.004-1.021, P = 0.006), and 1.005 (95% CI 1.000-1.009, P = 0.036), respectively. In the whole cohort with HCC patients, the AUCs of Child-Pugh, CAGIB, MELD and NLR scores were 0.842 (95% CI 0.801-0.878), 0.840 (95% CI 0.799-0.876), 0.798 (95% CI 0.754-0.838), and 0.688 (95% CI 0.639-0.735), respectively. The differences were statistically significant between Child-Pugh and NLR scores (P = 0.0118), and between CAGIB and NLR scores (P = 0.0354). Conclusion Child-Pugh and CAGIB scores showed better predictive performance for prognosis of patients with cirrhosis and acute variceal bleeding than NLR scores.
Collapse
|
29
|
Francoz C. Acute kidney injury in cirrhosis: An immediate threat but also a ticking time bomb. J Hepatol 2020; 72:1043-1045. [PMID: 32197803 DOI: 10.1016/j.jhep.2020.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/16/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, France, INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France.
| |
Collapse
|
30
|
Affiliation(s)
- Vicente Arroyo
- From the European Foundation for the Study of Chronic Liver Failure (EF Clif) and the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) Consortium - both in Barcelona (V.A., R.M., R.J.); INSERM, Université de Paris, Centre de Recherche sur l'Inflammation, and Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy - both in France (R.M.); and the Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London (R.J.)
| | - Richard Moreau
- From the European Foundation for the Study of Chronic Liver Failure (EF Clif) and the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) Consortium - both in Barcelona (V.A., R.M., R.J.); INSERM, Université de Paris, Centre de Recherche sur l'Inflammation, and Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy - both in France (R.M.); and the Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London (R.J.)
| | - Rajiv Jalan
- From the European Foundation for the Study of Chronic Liver Failure (EF Clif) and the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) Consortium - both in Barcelona (V.A., R.M., R.J.); INSERM, Université de Paris, Centre de Recherche sur l'Inflammation, and Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy - both in France (R.M.); and the Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London (R.J.)
| |
Collapse
|
31
|
Zhang J, Liu J, Wu Y, Romeiro FG, Levi Sandri GB, Zhou X, Li M, Qi X. Effect of terlipressin on renal function in cirrhotic patients with acute upper gastrointestinal bleeding. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:340. [PMID: 32355784 PMCID: PMC7186671 DOI: 10.21037/atm.2020.02.135] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Renal dysfunction is a serious morbidity in cirrhotic patients with acute upper gastrointestinal bleeding (AUGIB). Terlipressin is the first-line treatment choice for acute variceal bleeding and hepatorenal syndrome (HRS). This study aimed to assess the effect of terlipressin on renal function in patients with liver cirrhosis and AUGIB. METHODS We retrospectively reviewed 40 cirrhotic patients with AUGIB treated with terlipressin by an attending physician between January 2016 and June 2018. We analyzed the change of renal function parameters, including cystatin C (CysC) and creatinine (Cr), during the use of terlipressin and after terlipressin was stopped. We also identified the factors associated with renal function improvement in patients without active bleeding during the use of terlipressin. RESULTS During the use of terlipressin, CysC value was significantly reduced (1.3±0.8 vs. 1.1±0.7, P=0.001); Cr value was reduced, but the reduction was not statistically significant (68.8±24 vs. 65.5±23, P=0.817); the rate of CysC reduction was significantly higher in patients treated with terlipressin than those treated with somatostatin/octreotide (73.1% vs. 0%, P=0.005); the rate of Cr reduction was not significantly different between patients treated with terlipressin and somatostatin/octreotide (61.5% vs. 20%, P=0.148); no factor associated with CysC reduction was identified; higher hemoglobin, red blood cell, and platelet and lower prothrombin time and international normalized ratio at baseline were significantly associated with Cr reduction. After terlipressin was stopped, neither CysC nor Cr value was significantly reduced (P=0.852 and P=0.296). CONCLUSIONS Terlipressin may be beneficial on preventing renal function impairment in cirrhotic patients with AUGIB.
Collapse
Affiliation(s)
- Jingqiao Zhang
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Jie Liu
- Department of Pharmaceutical Sciences, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Yunhai Wu
- ICU, The Sixth Hospital of Shenyang, Shenyang 110006, China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
| | | | - Xinmiao Zhou
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- Postgraduate College, Jinzhou Medical University, Jinzhou 121001, China
| | - Miaomiao Li
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- Postgraduate College, Dalian Medical University, Dalian 116044, China
| | - Xingshun Qi
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| |
Collapse
|
32
|
Carrion AF, Radhakrishnan R, Martin P. Diagnosis and management of renal dysfunction in patients with cirrhosis. Expert Rev Gastroenterol Hepatol 2020; 14:1-7. [PMID: 31868027 DOI: 10.1080/17474124.2020.1708190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Renal dysfunction commonly occurs in patients with cirrhosis and is typically associated with poor prognosis. Several pathophysiologic mechanisms are responsible for renal disease in these patients, prompt identification permits individualized management.Areas covered: Pathophysiology, evaluation and differential diagnosis, management and prognosis of renal disease in patients with cirrhosis. Special focus on management of hepatorenal syndrome and indications for simultaneous liver-kidney transplantation.Literature search methodology: a detailed literature search was performed using PubMed without date restrictions. Published guidelines and position papers were also used and cross-referenced to identify additional studies.Expert opinion: The prognostic significance of renal dysfunction in patients with cirrhosis is highlighted by the inclusion of serum creatinine in the model for end-stage liver disease (MELD). Both acute and chronic renal dysfunction result in increased mortality in patients with cirrhosis, although there are marked differences related to the etiology of renal disease. Early recognition and prompt intervention determined by the most likely etiology are key in the management of these patients. Simultaneous liver-kidney transplantation improves patient survival compared to isolated liver transplantation in patients with cirrhosis and persistent renal impairment; however, selection of candidates must be judicious and individualized due to the ongoing shortage of donor kidneys.
Collapse
Affiliation(s)
- Andres F Carrion
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Paul Martin
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
33
|
Bai Z, An Y, Guo X, Teschke R, Méndez-Sánchez N, Li H, Qi X. Role of Terlipressin in Cirrhotic Patients with Ascites and without Hepatorenal Syndrome: A Systematic Review of Current Evidence. Can J Gastroenterol Hepatol 2020; 2020:5106958. [PMID: 32676484 PMCID: PMC7333040 DOI: 10.1155/2020/5106958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/18/2020] [Indexed: 02/07/2023] Open
Abstract
Ascites, a common complication in cirrhosis, is prone to the development of acute kidney injury or hepatorenal syndrome and can be complicated by circulatory dysfunction after paracentesis. Terlipressin has not been considered as the mainstay treatment option for ascites in cirrhosis yet. The present work aimed to systematically review the current evidence regarding the use of terlipressin in cirrhosis with ascites and without hepatorenal syndrome. PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies. Twelve studies were eligible. In 3 studies (1 randomized controlled trial and 2 single-arm studies without controls) involving 32 patients who received terlipressin for nonrefractory ascites, terlipressin improved hemodynamics by decreasing the heart rate and cardiac output and increasing the mean arterial pressure and systemic vascular resistance. In 5 studies (1 randomized controlled trial, 2 single-arm studies without controls, and 2 comparative studies with controls) involving 67 patients who received terlipressin for refractory ascites, terlipressin improved renal function by increasing the glomerular filtration rate, renal blood flow, urinary sodium, and urine output and decreasing serum creatinine. In 4 studies (4 randomized controlled trials) involving 71 patients who received terlipressin for preventing from paracentesis-induced circulatory dysfunction, terlipressin prevented from paracentesis-induced circulatory dysfunction by increasing the mean arterial pressure and systemic vascular resistance and decreasing plasma renin. Terlipressin may improve hemodynamics, severity of ascites, and renal function and prevent from paracentesis-induced circulatory dysfunction in cirrhosis with ascites and without hepatorenal syndrome. However, no study has evaluated the effect of terlipressin for prevention of acute kidney injury.
Collapse
Affiliation(s)
- Zhaohui Bai
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- 2Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110840, China
| | - Yang An
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- 2Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110840, China
| | - Xiaozhong Guo
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Rolf Teschke
- 3Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, D-63450 Hanau, Germany
| | - Nahum Méndez-Sánchez
- 4Liver Research Unit, Medica Sur Clinic and Foundation and Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Hongyu Li
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Xingshun Qi
- 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| |
Collapse
|
34
|
Bai Z, Primignani M, Guo X, Zheng K, Li H, Qi X. Incidence and mortality of renal dysfunction in cirrhotic patients with acute gastrointestinal bleeding: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2019; 13:1181-1188. [PMID: 31736376 DOI: 10.1080/17474124.2019.1694904] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Gastrointestinal bleeding (GIB) is a common complication in cirrhosis. Renal dysfunction may be crucial for the outcomes of cirrhotic patients with acute GIB. This study aimed to explore the incidence and mortality of renal dysfunction in cirrhotic patients with acute GIB.Methods: The PubMed, EMBASE, and Cochrane Library databases were searched. We pooled the incidence and mortality of renal dysfunction in cirrhotic patients using a random-effect model. Odds ratio (OR) with 95% confidence interval (CI) were calculated.Results: Seventeen studies were included. The pooled incidence of renal dysfunction was 21% (95%CI = 16%-25%) in cirrhosis with acute GIB. In subgroup analyses, the pooled incidence of renal failure, acute kidney injury (AKI), and renal impairment were 21%, 25%, and 15%, respectively. The pooled mortality was 46% (95%CI = 37%-55%) in cirrhosis with acute GIB and renal dysfunction. In subgroup analyses, the pooled mortality in patients with renal failure, AKI, and renal impairment were 42%, 47%, and 49%, respectively. Renal dysfunction significantly increased the mortality of cirrhosis with acute GIB (OR = 4.92; 95%CI = 3.47-6.96; P < 0.001).Conclusion: Renal dysfunction is a common indicator for poor outcome of cirrhosis with acute GIB. Prevention of renal dysfunction in such patients should be further explored.
Collapse
Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, P.R. China
| | - Massimo Primignani
- CRC "A.M. e A. Migliavacca" Center for the Study of Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico Università degli Studi di Milano Via F., Milan, Italy
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Kexin Zheng
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
- Postgraduate College, Jinzhou Medical University, Jinzhou, P.R. China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| |
Collapse
|
35
|
Bai Z, Li B, Lin S, Liu B, Li Y, Zhu Q, Wu Y, Yang Y, Tang S, Meng F, Chen Y, Yuan S, Shao L, Qi X. Development and Validation of CAGIB Score for Evaluating the Prognosis of Cirrhosis with Acute Gastrointestinal Bleeding: A Retrospective Multicenter Study. Adv Ther 2019; 36:3211-3220. [PMID: 31512140 PMCID: PMC6822790 DOI: 10.1007/s12325-019-01083-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Acute gastrointestinal bleeding (GIB) is a major cause of death in liver cirrhosis. This multicenter study aims to develop and validate a novel and easy-to-access model for predicting the prognosis of patients with cirrhosis and acute GIB. METHODS Patients with cirrhosis and acute GIB were enrolled and randomly divided into the training (n = 865) and validation (n = 817) cohorts. In the training cohort, the independent predictors for in-hospital death were identified by logistic regression analyses, and then a new prognostic model (i.e., CAGIB score) was established. Area under curve (AUC) of CAGIB score was calculated by receiver operating characteristic curve analysis and compared with Child-Pugh, model for end-stage liver disease (MELD), MELD-Na, and neutrophil-lymphocyte ratio (NLR) scores. RESULTS In the training cohort, hepatocellular carcinoma (HCC), diabetes, total bilirubin (TBIL), albumin (ALB), alanine aminotransferase (ALT), and serum creatinine (Scr) were independent predictors of in-hospital death. CAGIB score = diabetes (yes = 1, no = 0) × 1.040 + HCC (yes = 1, no = 0) × 0.974 + TBIL (μmol/L) × 0.005 - ALB (g/L) × 0.091 + ALT (U/L) × 0.001 + Scr (μmol/L) × 0.012 - 3.964. In the training cohort, the AUC of CAGIB score for predicting in-hospital death was 0.829 (95% CI 0.801-0.854, P < 0.0001), which was higher than that of Child-Pugh (0.762, 95% CI 0.732-0.791), MELD (0.778, 95% CI 0.748-0.806), MELD-Na (0.765, 95% CI 0.735-0.793), and NLR (0.587, 95% CI 0.553-0.620) scores. In the validation cohort, the AUC of CAGIB score (0.714, 95% CI 0.682-0.746, P = 0.0006) remained higher than that of Child-Pugh (0.693, 95% CI 0.659-0.725), MELD (0.662, 95% CI 0.627-0.695), MELD-Na (0.660, 95% CI 0.626-0.694), and NLR (0.538, 95% CI 0.503-0.574) scores. CONCLUSION CAGIB score has a good predictive performance for prognosis of patients with cirrhosis and acute GIB.
Collapse
Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Bimin Li
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Su Lin
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Bang Liu
- Department of Hepatobiliary Disease, 900 Hospital of the Joint Logistics Team (formerly called Fuzhou General Hospital), Fuzhou, China
| | - Yiling Li
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Yunhai Wu
- Department of Critical Care Medicine, Sixth People's Hospital of Shenyang, Shenyang, China
| | - Yida Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shanhong Tang
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu, China
| | - Fanping Meng
- Department of Biological Therapy, Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yu Chen
- Difficult and Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force Hospital of Northern Theater Command, Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China.
| |
Collapse
|
36
|
Bhatti HW, Tahir U, Chaudhary NA, Bhatti S, Hafeez M, Rizvi ZA. Factors associated with renal dysfunction in hepatitis C-related cirrhosis and its correlation with Child-Pugh score. BMJ Open Gastroenterol 2019; 6:e000286. [PMID: 31275583 PMCID: PMC6577365 DOI: 10.1136/bmjgast-2019-000286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/05/2019] [Accepted: 04/19/2019] [Indexed: 01/15/2023] Open
Abstract
Objectives To assess factors associated with renal dysfunction (RD) in hepatitis C virus (HCV) cirrhosis, correlate renal parameters with Child-Pugh score (CPS) and find a cut-off value of CPS to determine RD. Materials and methods It was a cross-sectional study that included 70 cases of liver cirrhosis secondary to HCV from a period of 6 months at Combined Military Hospital, Multan. Diagnosis of HCV was confirmed by serological assay and liver cirrhosis by ultrasonography. CPS was determined and lab reports were taken. Patients were divided into two groups as not having RD (serum creatinine≤1.5 mg/dL) and having RD (serum creatinine≥1.5 mg/dL). Estimated glomerular filtration rate (eGFR) was calculated by chronic kidney disease epidemiology collaboration (CKD-EPI) formula. Data were analyzed using SPSS V.23.0. χ2, Kruskal-Wallis test and Pearson coefficient of correlation were applied. ROC curve was drawn to evaluate cut-off value of CPS for the presence of RD. Level of significance was set at p<0.05. Results Patients with CP grade B or C develop RD as compared to patients with CP grade A (p=0.000). Mean age, urea, creatinine and eGFR varies significantly among patients who develop RD and patients who do not (p=0.02, p=0.000, p=0.000 and p=0.000, respectively). eGFR negatively correlates with CPS (r=−0.359, p=0.002). Creatinine, urea and ALBI score positively correlates with CPS (r=+0.417, p=0.000; r=+0.757, p=0.000; r=+0.362, p=0.002, respectively). Conclusion Ascites and encephalopathy are associated with RD in HCV cirrhosis.
Collapse
Affiliation(s)
| | - Umama Tahir
- Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | | | - Sania Bhatti
- Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | | | | |
Collapse
|
37
|
Bansho ETO, Silva PES, Colombo BS, Wildner LM, Bazzo ML, Dantas-Corrêa EB, Schiavon LL, Narciso-Schiavon JL. Prognostic Significance of The New Criteria for Acute Kidney Injury in Cirrhosis. Ann Hepatol 2019; 17:461-469. [PMID: 29735786 DOI: 10.5604/01.3001.0011.7390] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND New criteria for acute kidney injury (AKI) in cirrhosis have been proposed, but its prognostic significance is unclear. This study aims to evaluate the prognostic significance of the AKI criteria in cirrhotic patients hospitalized for acute decompensation. MATERIAL AND METHODS This is a prospective cohort study. AKI was defined as an increase in creatinine (Cr) levels ≥ 0.3 mg/dL in 48 h or ≥ 50% of the basal value in the last 7d. AKI was divided into stages 1 (elevation: < 2x basal), 2 (2 or 3x), and 3 (> 3x). RESULTS In this study, 227 patients aged 53.9 ± 11.5 years were included, of whom 37% had AKI (28% AKI1, 5% AKI2, and 4% AKI3). Thirty percent of the patients died or were transplanted within 90 days from causes related to the presence of ascites at hospital admission and higher values of Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) scores, but not to the presence of AKI. In a regression analysis conducted to assess the effect of the final Cr level in patients with AKI, 90-day mortality was associated with ascites, higher CLIF-SOFA score, and AKI with final Cr level ≥ 1.5 mg/dL. The patients with AKI with Cr levels ≥ 1.5 mg/dL showed lower transplant-free survival rates than those without AKI, and those with AKI1 with final Cr level < 1.5 mg/dL. CONCLUSIONS Early AKI was frequent and associated with 90-day mortality or transplantation only when the final Cr level was ≥ 1.5 mg/dL. Distinct approaches are needed for patients with AKI1 according to final Cr.
Collapse
Affiliation(s)
- Emilia T O Bansho
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Pedro Eduardo S Silva
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Bruno S Colombo
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Letícia M Wildner
- Department of Clinical Analysis, University Hospital Polydoro Ernani de São Thiago-Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Maria Luiza Bazzo
- Department of Clinical Analysis, University Hospital Polydoro Ernani de São Thiago-Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Esther B Dantas-Corrêa
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Leonardo L Schiavon
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Janaína L Narciso-Schiavon
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| |
Collapse
|
38
|
Clinical Aspects and Prognosis Evaluation of Cirrhotic Patients Hospitalized with Acute Kidney Injury. Can J Gastroenterol Hepatol 2019; 2019:6567850. [PMID: 30941330 PMCID: PMC6421012 DOI: 10.1155/2019/6567850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/18/2018] [Accepted: 01/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Acute kidney injury occurs in approximately 20% of hospitalized cirrhotic patients. Mortality is estimated at 60% within a month and 65% within a year. AIMS To evaluate survival in 30 days and in 3 months of cirrhotic patients hospitalized with acute kidney injury, identifying factors associated with mortality. METHODS 52 patients with cirrhosis admitted to an academic tertiary center who presented acute kidney injury according to the International Club of Ascites criteria were evaluated. Clinical and laboratory data was collected at diagnosis between 2011 and 2015. RESULTS Average age was 54.6 (±10.7) years and 69.2% were male. The average MELD, MELD-Na, and Child-Pugh scores were 21.9 (±7.0), 24.5 (±6.7), and 10.1 (±2.2), respectively. Thirty patients (57.7%) were in acute kidney injury stage 1, 16 (30.8%) in stage 2, and six (11.6%) in stage 3. Mortality was 28.6% in 30 days and 44.9% in three months. In multivariate analysis, variables that were associated independently to mortality were lack of response to expansion treatment and Child-Pugh score. Mortality was 93.3% in three months among nonresponders compared to 28.6% among those who responded to volume expansion (p<0.0001). CONCLUSION Acute kidney injury in cirrhosis has dire prognosis, particularly in patients with advanced cirrhosis and in nonresponders to volume expansion.
Collapse
|
39
|
Umemura T, Joshita S, Shibata S, Sugiura A, Yamazaki T, Fujimori N, Matsumoto A, Tanaka E. Renal impairment is associated with increased risk of mortality in patients with cirrhosis: A retrospective cohort study. Medicine (Baltimore) 2019; 98:e14475. [PMID: 30732215 PMCID: PMC6380877 DOI: 10.1097/md.0000000000014475] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Although renal impairment is a frequent complication in cirrhosis that is associated with a poor prognosis, little has been reported on the clinical significance of renal impairment in cirrhosis in Japan. This retrospective study assessed the impact of renal impairment on mortality in Japanese cirrhosis patients taking conventional diuretics.A total of 157 patients with cirrhosis receiving diuretic treatment were evaluated for the presence and status of renal impairment, defined as an increase in serum creatinine of ≥ 0.3 mg/dL or by ≥ 50%, and then classified according to the International Club of Ascites (ICA)-Acute Kidney Injury (AKI) staging system.Eighty of 157 (51%) patients fulfilled the criteria for renal impairment. Thirty-four (43%) patients had ICA-AKI stage 1, 32 (40%) stage 2, and 14 (18%) stage 3. Multivariate analysis revealed female gender (hazard ratio [HR] = 0.407, 95% confidence interval = 0.193-0.857; P = .018), ALT ≥35 IU/L (HR = 3.841, 95% confidence interval = 1.785-8.065; P = .001), and the presence of renal impairment (HR = 4.275, 95% confidence interval = 1.962-9.312; P < .001) as independent factors significantly increasing the risk of mortality. Cumulative survival rates increased significantly with ICA-AKI stage (log-rank test, P = .009).Renal impairment was a predictive marker of mortality in Japanese patients with cirrhosis. Stratification according to ICA-AKI criteria of kidney function impairment may be a good prognostic indicator of cirrhosis outcome.
Collapse
Affiliation(s)
- Takeji Umemura
- Department of Medicine, Division of Hepatology and Gastroenterology, Shinshu University School of Medicine
- Research Center for Next Generation Medicine, Shinshu University, Matsumoto, Nagano, Japan
| | - Satoru Joshita
- Department of Medicine, Division of Hepatology and Gastroenterology, Shinshu University School of Medicine
- Research Center for Next Generation Medicine, Shinshu University, Matsumoto, Nagano, Japan
| | - Soichiro Shibata
- Department of Medicine, Division of Hepatology and Gastroenterology, Shinshu University School of Medicine
| | - Ayumi Sugiura
- Department of Medicine, Division of Hepatology and Gastroenterology, Shinshu University School of Medicine
| | - Tomoo Yamazaki
- Department of Medicine, Division of Hepatology and Gastroenterology, Shinshu University School of Medicine
| | - Naoyuki Fujimori
- Department of Medicine, Division of Hepatology and Gastroenterology, Shinshu University School of Medicine
| | - Akihiro Matsumoto
- Department of Medicine, Division of Hepatology and Gastroenterology, Shinshu University School of Medicine
| | - Eiji Tanaka
- Department of Medicine, Division of Hepatology and Gastroenterology, Shinshu University School of Medicine
| |
Collapse
|
40
|
Chiang JM, Chiang SF, Chen JS, Tang R, Yeh CY, Hsieh PS, Tsai WS, You JF, Hung HY, Lai CC, Lin JR. The impact of kidney function on colorectal cancer patients with localized and regional diseases: An observational study from Taiwan. Indian J Cancer 2019; 56:241-247. [DOI: 10.4103/ijc.ijc_294_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
41
|
Varga ZV, Erdelyi K, Paloczi J, Cinar R, Zsengeller ZK, Jourdan T, Matyas C, Nemeth BT, Guillot A, Xiang X, Mehal A, Hasko G, Stillman IE, Rosen S, Gao B, Kunos G, Pacher P. Disruption of Renal Arginine Metabolism Promotes Kidney Injury in Hepatorenal Syndrome in Mice. Hepatology 2018; 68:1519-1533. [PMID: 29631342 PMCID: PMC6173643 DOI: 10.1002/hep.29915] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/03/2018] [Indexed: 12/11/2022]
Abstract
UNLABELLED Tubular dysfunction is an important feature of renal injury in hepatorenal syndrome (HRS) in patients with end-stage liver disease. The pathogenesis of kidney injury in HRS is elusive, and there are no clinically relevant rodent models of HRS. We investigated the renal consequences of bile duct ligation (BDL)-induced hepatic and renal injury in mice in vivo by using biochemical assays, real-time polymerase chain reaction (PCR), Western blot, mass spectrometry, histology, and electron microscopy. BDL resulted in time-dependent hepatic injury and hyperammonemia which were paralleled by tubular dilation and tubulointerstitial nephritis with marked upregulation of lipocalin-2, kidney injury molecule 1 (KIM-1) and osteopontin. Renal injury was associated with dramatically impaired microvascular flow and decreased endothelial nitric oxide synthase (eNOS) activity. Gene expression analyses signified proximal tubular epithelial injury, tissue hypoxia, inflammation, and activation of the fibrotic gene program. Marked changes in renal arginine metabolism (upregulation of arginase-2 and downregulation of argininosuccinate synthase 1), resulted in decreased circulating arginine levels. Arginase-2 knockout mice were partially protected from BDL-induced renal injury and had less impairment in microvascular function. In human-cultured proximal tubular epithelial cells hyperammonemia per se induced upregulation of arginase-2 and markers of tubular cell injury. CONCLUSION We propose that hyperammonemia may contribute to impaired renal arginine metabolism, leading to decreased eNOS activity, impaired microcirculation, tubular cell death, tubulointerstitial nephritis and fibrosis. Genetic deletion of arginase-2 partially restores microcirculation and thereby alleviates tubular injury. We also demonstrate that BDL in mice is an excellent, clinically relevant model to study the renal consequences of HRS. (Hepatology 2018; 00:000-000).
Collapse
Affiliation(s)
- Zoltan V. Varga
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Katalin Erdelyi
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Janos Paloczi
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Resat Cinar
- Laboratory of Physiological Studies, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Zsuzsanna K. Zsengeller
- Department of Medicine, Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Tony Jourdan
- Laboratory of Physiological Studies, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Csaba Matyas
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Balazs Tamas Nemeth
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Adrien Guillot
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Xiaogang Xiang
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Adam Mehal
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - George Hasko
- Department of Anesthesiology, Columbia University, New York, NY, 10032, USA
| | - Isaac E. Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Seymour Rosen
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Bin Gao
- Laboratory of Liver Diseases, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - George Kunos
- Laboratory of Physiological Studies, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| | - Pal Pacher
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health/NIAAA, Bethesda, MD 20852, USA
| |
Collapse
|
42
|
Gupta K, Rani P, Rohatgi A, Verma M, Handa S, Dalal K, Jain A. Noradrenaline for reverting hepatorenal syndrome: a prospective, observational, single-center study. Clin Exp Gastroenterol 2018; 11:317-324. [PMID: 30271187 PMCID: PMC6151092 DOI: 10.2147/ceg.s153858] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate the effectiveness of noradrenaline for the treatment of hepatorenal syndrome (HRS). Background HRS represents the development of renal failure in cirrhotic patients. The standard treatment for HRS is terlipressin, which, as opposed to noradrenaline, is more expensive and less accessible in most tertiary care centers. Patients and methods Thirty consecutive patients with HRS type 1 received noradrenaline (1–4.0 mg/hour) and albumin for 14 days. The parameters recorded were: serum creatinine levels, creatinine clearance, mean arterial pressure (MAP), urine output, and serum sodium levels evaluated at baseline and on treatment days 1, 3, 7, and 14. Results Most patients achieved serum creatinine levels <1.5 mg/dL and were considered responders (22/30, 73%), whereas eight patients (27%) were nonresponders. At baseline, responders and nonresponders differed only regarding initial bilirubin levels and international normalized ratio values. Treatment duration was 7.5±3.2 days. Responders experienced a significant (p<0.05) decrease in serum creatinine levels (from 3.26±0.48 to 1.28±0.14 mg/dL), as well as a significant increase (p<0.05) in creatinine clearance (from 21±4.1 to 67.7±12.1 mL/min), urine output (from 583±41.1 to 1163±105 mL/day), MAP (from 79.2±2.94 to 93.9±2.34 mmHg), and serum sodium levels (from 125±2.01 to 132.3±1.39 mEq/L). In nonresponders, the MAP increased, but serum creatinine levels also increased, reflecting a decrease in creatinine clearance and urine output, with no significant change in serum sodium levels over the duration of the treatment. Conclusion In most patients, noradrenaline treatment induced systemic vasoconstriction resulting in HRS reversal, with acceptable safety, in agreement with previously reported outcomes of terlipressin treatment.
Collapse
Affiliation(s)
- Kamesh Gupta
- Department of Internal Medicine, Lady Hardinge Medical College, New Delhi, India,
| | - Pooja Rani
- Department of Internal Medicine, Lady Hardinge Medical College, New Delhi, India,
| | - Anurag Rohatgi
- Department of Internal Medicine, Lady Hardinge Medical College, New Delhi, India,
| | - Mukesh Verma
- Department of Internal Medicine, Lady Hardinge Medical College, New Delhi, India,
| | - Shivani Handa
- Department of Gastroenterology, Liver Associates of Texas, Houston, TX, USA
| | - Keemi Dalal
- Department of Internal Medicine, Lady Hardinge Medical College, New Delhi, India,
| | - Anand Jain
- Department of Internal Medicine, Lady Hardinge Medical College, New Delhi, India,
| |
Collapse
|
43
|
Abstract
Hepatorenal syndrome (HRS) is a form of kidney function impairment that characteristically occurs in cirrhosis. Recent changes in terminology have led to acute HRS being referred to as acute kidney injury (AKI)-HRS and chronic HRS as chronic kidney disease (CKD)-HRS. AKI-HRS is characterized by a severe impairment of kidney function owing to vasoconstriction of the renal arteries in the absence of substantial abnormalities in kidney histology. Pathogenetic mechanisms involve disturbances in circulatory function due to a marked splanchnic arterial vasodilation, which triggers the activation of vasoconstrictor factors. An intense systemic inflammatory reaction that is characteristic of advanced cirrhosis may also be involved. The main triggering factors of AKI-HRS are bacterial infections, particularly spontaneous bacterial peritonitis. The diagnosis of AKI-HRS is a challenge because of a lack of specific diagnostic tools and mainly involves the differential diagnosis from other forms of AKI, particularly acute tubular necrosis. The prognosis of patients with AKI-HRS is poor, with a median survival of ≤3 months. The ideal treatment for AKI-HRS is liver transplantation in patients without contraindications. Medical therapy consists of vasoconstrictor drugs to counteract splanchnic arterial vasodilation together with volume expansion with albumin. Effective measures to prevent AKI-HRS include early identification and treatment of bacterial infections and the administration of albumin in patients with spontaneous bacterial peritonitis.
Collapse
Affiliation(s)
- Pere Ginès
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain.
| | - Elsa Solà
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, CA, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
44
|
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
|
45
|
Carrier P, Debette-Gratien M, Essig M, Loustaud-Ratti V. Beyond serum creatinine: which tools to evaluate renal function in cirrhotic patients? Hepatol Res 2018; 48:771-779. [PMID: 29954046 DOI: 10.1111/hepr.13224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/06/2018] [Accepted: 06/23/2018] [Indexed: 02/08/2023]
Abstract
In cirrhotic patients, a high serum creatinine value is an independent mortality factor. Similarly, it is predictive of renal insufficiency after liver transplantation. In these cases, chronic kidney disease is also an independent mortality factor. A relevant evaluation of glomerular filtration rate is crucial, particularly in cases of end-stage liver disease or liver transplantation, and is key for the decision to undertake dual liver-kidney transplantation. Serum creatinine or creatinine-based equations are the most used tools in clinical practice but they significantly overestimate renal function. Equilibrium inulin renal clearance remains the gold standard but is time consuming and expensive. Cystatin C and cystatin C-based equations are less influenced by muscle mass or bilirubin value, but their dosage is not standardized and they are expensive. Pharmacological models using exogenous markers, new kidney biomarkers, Doppler coupled with ultrasounds, and kidney histology could be interesting tools but their indications need to be specified.
Collapse
Affiliation(s)
- Paul Carrier
- Hepatology Federation, Hepatology and Gastroenterology Unit, Teaching Hospital Limoges, Tours, Poitiers, Limoges, France.,INSERM U-1248, Medicine and Pharmacy Faculty, Limoges University, Tours, Poitiers, Limoges, France.,Nephrology Unit, Teaching Hospital Limoges, Tours, Poitiers, Limoges, France
| | - Marilyne Debette-Gratien
- Hepatology Federation, Hepatology and Gastroenterology Unit, Teaching Hospital Limoges, Tours, Poitiers, Limoges, France.,INSERM U-1248, Medicine and Pharmacy Faculty, Limoges University, Tours, Poitiers, Limoges, France.,Nephrology Unit, Teaching Hospital Limoges, Tours, Poitiers, Limoges, France
| | - Marie Essig
- INSERM U-1248, Medicine and Pharmacy Faculty, Limoges University, Tours, Poitiers, Limoges, France.,Nephrology Unit, Teaching Hospital Limoges, Tours, Poitiers, Limoges, France.,FHU SUPORT (SUrvival oPtimization in Organ Transplantation), Transplantation Federation, Tours, Poitiers, Limoges, France
| | - Véronique Loustaud-Ratti
- Hepatology Federation, Hepatology and Gastroenterology Unit, Teaching Hospital Limoges, Tours, Poitiers, Limoges, France.,INSERM U-1248, Medicine and Pharmacy Faculty, Limoges University, Tours, Poitiers, Limoges, France.,Nephrology Unit, Teaching Hospital Limoges, Tours, Poitiers, Limoges, France
| |
Collapse
|
46
|
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.
Collapse
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
| |
Collapse
|
47
|
EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1537] [Impact Index Per Article: 256.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
|
48
|
Patidar KR, Kang L, Bajaj JS, Carl D, Sanyal AJ. Fractional excretion of urea: A simple tool for the differential diagnosis of acute kidney injury in cirrhosis. Hepatology 2018; 68:224-233. [PMID: 29315697 PMCID: PMC6033653 DOI: 10.1002/hep.29772] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/04/2017] [Accepted: 12/29/2017] [Indexed: 12/15/2022]
Abstract
UNLABELLED Current approaches to determine the cause of acute kidney injury (AKI) in patients with cirrhosis are suboptimal. The aim of this study was to determine the utility of fractional excretion of urea (FEUrea) for the differential diagnosis of AKI in patients with cirrhosis. A retrospective analysis was performed in patients (n = 50) with cirrhosis and ascites admitted with AKI. Using adjudicated etiology assessment as the reference standard, receiver operating curves and optimal cutoff, sensitivity (Sn), and specificity (Sp) for the diagnosis of prerenal azotemia (PRA), type 1 hepatorenal syndrome (HRS), and acute tubular necrosis (ATN) were derived. Validation was performed in an independent cohort (n = 50) and by bootstrap analysis. The causes of AKI (derivation:validation cohorts) were: PRA 21:21, HRS 18:15, and ATN 11:14. Median FEUrea was statistically different across all etiologies of AKI in the derivation cohort (PRA 30.1 vs. HRS 20.2 vs. ATN 43.6; P < 0.001) and validation cohort (PRA 23.1 vs. HRS 13.3 vs. ATN 44.7; P < 0.001). The area underneath the curve (cutoff, Sn/Sp) for FEUrea was 0.96 (33.4, 85/100) for ATN versus non-ATN, 0.87 (28.7, 75/83) for HRS versus non-HRS, and 0.81 (21.6, 90/61) for PRA versus HRS. When applied to the validation cohort, Sn/Sp were maintained for ATN versus non-ATN (93/97), HRS versus non-HRS (100/63), and for PRA versus HRS (67/80). After bootstrapping, Sn/Sp for FEUrea in the ATN versus non-ATN, HRS versus non-HRS, and PRA versus HRS was 88/96, 63/97, and 55/87, respectively. CONCLUSION FEUrea is a promising tool for the differential diagnosis of AKI in patients with cirrhosis. (Hepatology 2018;68:224-233).
Collapse
Affiliation(s)
- Kavish R. Patidar
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond Virginia, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond Virginia, USA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond Virginia, USA
| | - Daniel Carl
- Division of Nephrology, Virginia Commonwealth University, Richmond Virginia, USA
| | - Arun J. Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond Virginia, USA
| |
Collapse
|
49
|
Sun DQ, Zheng CF, Liu WY, Van Poucke S, Mao Z, Shi KQ, Wang XD, Wang JD, Zheng MH. AKI-CLIF-SOFA: a novel prognostic score for critically ill cirrhotic patients with acute kidney injury. Aging (Albany NY) 2017; 9:286-296. [PMID: 28114104 PMCID: PMC5310668 DOI: 10.18632/aging.101161] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/15/2017] [Indexed: 12/22/2022]
Abstract
Critically ill cirrhotic patients with acute kidney injury (AKI) are associated with high mortality rates. The aims of this study were to develop a specific prognostic score for critically ill cirrhotic patients with AKI, the acute kidney injury - Chronic Liver Failure - Sequential Organ Failure- Assessment score (AKI-CLIF-SOFA) score. This study focused on 527 cirrhotic patients with AKI admitted to intensive care unit and constructed a new scoring system, the AKI-CLIF-SOFA, which can be used to prognostically assess mortality in these patient population. Parameters included in this model were analysed by cox regression. The area under the receiver operating characteristic curve (auROC) of AKI-CLIF-SOFA scoring system was 0.74 in 30 days, 0.74 in 90 days, 0.72 in 270 days and 0.72 in 365 days. Additionally, this study demonstrated that the new model had more discriminatory power than chronic liver failure- sequential organ failure assessment score (CLIF-SOFA), SOFA, model for end stage liver disease (MELD), kidney disease improving global outcomes (KDIGO) and simplified acute physiology score II (SAPS II) (auROC: 0.72, 0.66, 0.64, 0.62, 0.63 and 0.65 respectively, all P < 0.05) for the prediction of the 365-days mortality. Therefore, AKI-CLIF-SOFA demonstrated a valuable discriminative ability compared with KDIGO, CLIF-SOFA, MELD, SAPS II and SOFA in critically ill cirrhotic patients with AKI.
Collapse
Affiliation(s)
- Dan-Qin Sun
- Department of Nephrology, Affiliated Wuxi Second Hospital, Nanjing Medical University, Wuxi 214002, China
| | - Chen-Fei Zheng
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Wen-Yue Liu
- Department of Endocrinology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Sven Van Poucke
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Zhi Mao
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Ke-Qing Shi
- Department of Hepatology, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.,Institute of Hepatology, Wenzhou Medical University, Wenzhou 325000, China
| | - Xiao-Dong Wang
- Department of Hepatology, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.,Institute of Hepatology, Wenzhou Medical University, Wenzhou 325000, China
| | - Ji-Dong Wang
- Department of Nephrology, Affiliated Wuxi Second Hospital, Nanjing Medical University, Wuxi 214002, China
| | - Ming-Hua Zheng
- Department of Hepatology, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.,Institute of Hepatology, Wenzhou Medical University, Wenzhou 325000, China
| |
Collapse
|
50
|
|