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Rad NK, Heydari Z, Tamimi AH, Zahmatkesh E, Shpichka A, Barekat M, Timashev P, Hossein-Khannazer N, Hassan M, Vosough M. Review on Kidney-Liver Crosstalk: Pathophysiology of Their Disorders. CELL JOURNAL 2024; 26:98-111. [PMID: 38459727 PMCID: PMC10924833 DOI: 10.22074/cellj.2023.2007757.1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/25/2023] [Accepted: 12/30/2023] [Indexed: 03/10/2024]
Abstract
Kidney-liver crosstalk plays a crucial role in normal and certain pathological conditions. In pathologic states, both renal-induced liver damage and liver-induced kidney diseases may happen through these kidney-liver interactions. This bidirectional crosstalk takes place through the systemic conditions that mutually influence both the liver and kidneys. Ischemia and reperfusion, cytokine release and pro-inflammatory signaling pathways, metabolic acidosis, oxidative stress, and altered enzyme activity and metabolic pathways establish the base of this interaction between the kidneys and liver. In these concomitant kidney-liver diseases, the survival rates strongly correlate with early intervention and treatment of organ dysfunction. Proper care of a nephrologist and hepatologist and the identification of pathological conditions using biomarkers at early stages are necessary to prevent the complications induced by this complex and potentially vicious cycle. Therefore, understanding the characteristics of this crosstalk is essential for better management. In this review, we discussed the available literature concerning the detrimental effects of kidney failure on liver functions and liver-induced kidney diseases.
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Affiliation(s)
- Niloofar Khoshdel Rad
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
- Department of Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Heydari
- World-Class Research Center "Digital Biodesign and Personalized Healthcare", Sechenov University, Moscow, Russia
| | - Amir Hossein Tamimi
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
| | - Ensieh Zahmatkesh
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
| | - Anastasia Shpichka
- World-Class Research Center "Digital Biodesign and Personalized Healthcare", Sechenov University, Moscow, Russia
- Institute for Regenerative Medicine, Sechenov University, Moscow, Russia
- Chemistry Department, Lomonosov Moscow State University, Moscow, Russia
| | - Maryam Barekat
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
| | - Peter Timashev
- World-Class Research Center "Digital Biodesign and Personalized Healthcare", Sechenov University, Moscow, Russia
- Institute for Regenerative Medicine, Sechenov University, Moscow, Russia.
- Chemistry Department, Lomonosov Moscow State University, Moscow, Russia
| | - Nikoo Hossein-Khannazer
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Moustapha Hassan
- Experimental Cancer Medicine, Institution for Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | - Massoud Vosough
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran. ,
- Experimental Cancer Medicine, Institution for Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
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Huang X, Bindra J, Chopra I, Niewoehner J, Wan GJ. Treatment-Related Cost Analysis of Terlipressin for Adults with Hepatorenal Syndrome with Rapid Reduction in Kidney Function. Adv Ther 2023; 40:5432-5446. [PMID: 37812332 PMCID: PMC10611877 DOI: 10.1007/s12325-023-02674-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: 07/02/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Hepatorenal syndrome (HRS), a special form of acute kidney failure, is a rare, acute, life-threatening complication of cirrhosis and has a very poor prognosis. Terlipressin (TERLIVAZ®) is the first and only pharmacological treatment approved by Food and Drug Administration (September 2022) to improve kidney function for adults with HRS with rapid reduction in kidney function. We constructed a decision analytic economic model to estimate the cost per complete response/HRS reversal of terlipressin + albumin from a United States hospital perspective. METHODS A decision analytic model was developed to estimate the HRS treatment-related cost per response over an HRS hospitalization (assuming 14 days). Patients can experience either HRS reversal (complete response) or no HRS reversal (partial/no response) upon receipt of treatment. The efficacy, safety, and treatment duration data were from published head-to-head randomized international trials. Total treatment cost comprised drug acquisition and treatment-related costs (intensive care unit [ICU], dialysis [intermittent or continuous], pulse oximetry monitoring for terlipressin, and adverse events) sourced from the published literature. Cost per response, defined as the total treatment cost per HRS reversal was estimated for each treatment. The number needed to treat (NNT), defined as the number of patients treated to achieve HRS reversal in 1 additional patient, was estimated. RESULTS Cost per response of terlipressin + albumin was lower than midodrine and octreotide + albumin (M&O) (US$85,315 vs. $467,794) and norepinephrine + albumin ($81,614 vs. $139,324). NNT for HRS reversal was 2 patients with terlipressin + albumin vs. M&O + albumin and 4 patients with terlipressin + albumin vs. norepinephrine + albumin, respectively. CONCLUSIONS The analysis shows that terlipressin is a cost-effective treatment due to its higher efficacy and administration in the non-ICU setting. Terlipressin is a value-based treatment option for appropriate adults with HRS with rapid reduction in kidney function.
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Affiliation(s)
- Xingyue Huang
- Mallinckrodt Pharmaceuticals, 440 Route 22 East, Bridgewater, NJ, USA.
| | - Jas Bindra
- Falcon Research Group, North Potomac, MD, USA
| | | | - John Niewoehner
- Mallinckrodt Pharmaceuticals, 440 Route 22 East, Bridgewater, NJ, USA
| | - George J Wan
- Mallinckrodt Pharmaceuticals, 440 Route 22 East, Bridgewater, NJ, USA
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Dardari L, Taha M, Dahat P, Toriola S, Satnarine T, Zohara Z, Adelekun A, Seffah KD, Salib K, Arcia Franchini AP. The Efficacy of Carvedilol in Comparison to Propranolol in Reducing the Hepatic Venous Pressure Gradient and Decreasing the Risk of Variceal Bleeding in Adult Cirrhotic Patients: A Systematic Review. Cureus 2023; 15:e43253. [PMID: 37577269 PMCID: PMC10416553 DOI: 10.7759/cureus.43253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/09/2023] [Indexed: 08/15/2023] Open
Abstract
The most common cause of portal hypertension is liver cirrhosis. Portal hypertension causes many complications in cirrhotic patients; a significant complication is the formation of varices and the subsequent life-threatening variceal bleeding due to elevated portal venous pressures. Hepatic venous pressure gradient (HVPG) is the gold standard for measuring portal hypertension and guides management. Pharmacological treatments lower the HVPG, preventing the progression of varices and subsequent variceal bleeding. The pharmacological treatments frequently used in primary and secondary prophylaxis of a variceal bleed are nonselective beta (β)-adrenergic blockers. Propranolol was the first nonselective β-adrenergic blocker used for lowering HVPG and has been well studied. However, in the past decade, clinical trials have shown that carvedilol has been more effective. This study aims to establish whether carvedilol is more effective than propranolol in reducing the hepatic venous pressure gradient and decreasing the risk of variceal bleeding in adult cirrhotic patients. A systematic review has been conducted to gather relevant clinical trials comparing drugs and their effects on HVPG. Four databases: PubMed (Medical Literature Analysis and Retrieval System Online (MEDLINE)), Google Scholar, the Cochrane Library, and ScienceDirect, were analyzed, and records from January 1, 1999, to January 1, 2023, were chosen. There were a total of 1,235 potentially eligible records across the four databases. Using the eligibility criteria for this systematic review, seven studies of 533 patients were included. Across all seven clinical trials, it was found that carvedilol reduced HVPG more than propranolol and decreased the risk of variceal bleeding in adult cirrhotic patients.
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Affiliation(s)
- Lana Dardari
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maher Taha
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Purva Dahat
- Medical School, St. Martinus University, Willemstad, CUW
| | - Stacy Toriola
- Pathology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Travis Satnarine
- Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Zareen Zohara
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ademiniyi Adelekun
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Kofi D Seffah
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Piedmont Athens Regional Medical, Athens, USA
| | - Korlos Salib
- General Practice, El Demerdash Hospital, Cairo, EGY
| | - Ana P Arcia Franchini
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Thangaraj SR, Srinivasan M, Arzoun H, Thomas SS. A Systematic Review of the Emerging Treatment for Hepatorenal Syndrome With a Principal Focus on Terlipressin: A Recent FDA-Approved Drug. Cureus 2023; 15:e42367. [PMID: 37621788 PMCID: PMC10445509 DOI: 10.7759/cureus.42367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Hepatorenal syndrome (HRS), a consequence of liver cirrhosis, is the development of renal failure, which carries a grave prognosis. Reversing acute renal failure with various vasoconstrictor therapies at an appropriate time favors a good prognosis, especially when a liver transplant is not feasible. OBJECTIVE This study aims to compare various treatment modalities to deduce an effective way to manage HRS. METHODS The authors conducted a literature search in PubMed, Google Scholar, the Cochrane Library, and Science Direct in October 2022, using regular and MeSH keywords. A total of 1072 articles were identified. The PRISMA guidelines were used, the PICO framework was addressed, and the inclusion criteria were set based on studies from the past 10 years. After quality assessment, 14 studies were included for in-depth analysis in this review. Results: A total of 14 studies were included after quality assessment, including randomized controlled trials, systematic reviews, meta-analyses, and observational cohort studies. Nine hundred and forty-one patients represented this review's experimental and observational studies, apart from the other systematic reviews analyzed. Nine studies discovered that Terlipressin, especially when administered with albumin, was more effective than other conventional treatment modalities, including norepinephrine and midodrine, in terms of improving mortality and reversing the HRS. Four studies suggested that terlipressin exhibited similar effectiveness but found no significant difference. In contrast, one study found that norepinephrine was superior to terlipressin when particularly considering the adverse effects. CONCLUSION Terlipressin, one of the most widely used vasoconstrictor agents across the world, seems to be effective in reversing renal failure in HRS. Although adverse effects are seen with this agent, it is still beneficial when compared to other medications. Further studies with larger sample sizes may be warranted.
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Affiliation(s)
| | - Mirra Srinivasan
- Internal Medicine, St. Bernards Medical Center, Jonesboro, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hadia Arzoun
- Internal Medicine, St. Bernards Medical Center, Jonesboro, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Siji S Thomas
- Internal Medicine, St. Bernards Medical Center, Jonesboro, USA
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Vandenberk B, Altieri MH, Liu H, Raj SR, Lee SS. Review article: diagnosis, pathophysiology and management of atrial fibrillation in cirrhosis and portal hypertension. Aliment Pharmacol Ther 2023; 57:290-303. [PMID: 36571829 DOI: 10.1111/apt.17368] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/16/2022] [Accepted: 12/08/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia and its management in cirrhosis can be challenging due to the altered hepatic metabolism of medications and increased risk of bleeding. AIMS To provide a comprehensive overview of the diagnosis, pathophysiology and management of AF in patients with cirrhosis from both a cardiology and a hepatology perspective. METHODS An extensive literature search was performed using the terms 'atrial fibrillation' and 'cirrhosis'. Guideline documents and consensus statements were explored. RESULTS The prevalence of AF in patients with cirrhosis ranges between 6.6% and 14.2%, while the incidence of new-onset AF in the post-operative period after liver transplant ranged between 6.8% and 10.2%. AF in patients with cirrhosis is associated with adverse outcomes in both pre-transplant and post-transplant settings, including an increased risk of stroke when compared to the general population. We review the pathogenesis of AF in general and in cirrhosis. This review also provides guidance on the management of AF, including the use of anticoagulation and rate versus rhythm control. In the absence of strict contraindications, all patients with cirrhosis and AF should be anticoagulated. The use of DOACs is preferred over vitamin K antagonists. In patients with a high bleeding risk, a DOAC with an approved antidote may be preferred. CONCLUSIONS Atrial fibrillation is increased in patients with cirrhosis. AF management requires careful consideration of treatment options. Since patients with cirrhosis were excluded from all major randomised clinical trials, dedicated research on the pathophysiology and management of AF in cirrhosis is needed.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Mario H Altieri
- Division of Gastroenterology, Hepatology and Nutrition, CHU Caen, Caen, France
| | - Hongqun Liu
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Samuel S Lee
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Carter JA, Huang X, Jamil K, Corman S, Ektare V, Niewoehner J. Cost-effectiveness of terlipressin for hepatorenal syndrome: the United States hospital perspective. J Med Econ 2023; 26:1342-1348. [PMID: 37729445 DOI: 10.1080/13696998.2023.2260693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) is characterized by severely reduced renal perfusion that precipitates rapid morbidity and mortality. Terlipressin is the only US Food and Drug Administration-approved treatment to improve kidney function for adults with HRS with a rapid reduction in kidney function. Prior to the approval of terlipressin, unapproved vasoconstrictive agents used in HRS treatment were octreotide/midodrine and norepinephrine with albumin. METHODS A cohort decision-tree model representing a US hospital perspective assessed the clinical outcomes and direct medical costs (based primarily on hospital charges) of treating HRS with terlipressin + albumin (ALB) versus midodrine/octreotide (MID/OCT)+ALB, or norepinephrine (NorEp)+ALB. Treatment efficacy was defined by clinical response (complete/HRS reversal, partial, or no response) based on change of serum creatinine derived from published clinical trial reports. The proportions of patients with complete response were: terlipressin + ALB (36.2%), NorEp + ALB (19.1%), and MID/OCT + ALB (3.1%). Model outcomes included utilization of HRS-related healthcare resources (hospital and intensive care, outpatient and emergency department, dialysis, and transplantations), adverse events, and HRS-related mortality. Outcomes were assessed for the initial hospitalization in the base case and at 30, 60, and 90 days post-discharge. RESULTS Total costs incurred over the initial hospitalization with terlipressin + ALB were lower vs NorEp + ALB, primarily due to higher ICU costs with NorEp + ALB ($7,433 vs $61,897). TER + ALB was associated with higher total costs vs MID/OCT + ALB due to higher pharmacy costs with terlipressin + ALB. The cost per complete response achieved of terlipressin + ALB ($451,605) was half that of NorEp + ALB ($930,571) and one-tenth that of MID/OCT + ALB ($4,942,123). CONCLUSIONS HRS patients treated with terlipressin experienced better clinical outcomes and a lower cost per treatment response vs other unapproved treatments. ICU days and pharmacy costs were key cost drivers distinguishing the treatment groups. These outcomes suggest that terlipressin is cost-effective on the basis of total cost per response achieved.
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Wu HHL, Athwal VS, Kalra PA, Chinnadurai R. COVID-19 and hepatorenal syndrome. World J Gastroenterol 2022; 28:5666-5678. [PMID: 36338894 PMCID: PMC9627428 DOI: 10.3748/wjg.v28.i39.5666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/21/2022] [Accepted: 10/02/2022] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a highly infectious disease which emerged into a global pandemic. Although it primarily causes respiratory symptoms for affected patients, COVID-19 was shown to have multi-organ manifestations. Elevated liver enzymes appear to be commonly observed during the course of COVID-19, and there have been numerous reports of liver injury secondary to COVID-19 infection. It has been established that patients with pre-existing chronic liver disease (CLD) are more likely to have poorer outcomes following COVID-19 infection compared to those without CLD. Co-morbidities such as diabetes, hypertension, obesity, cardiovascular and chronic kidney disease frequently co-exist in individuals living with CLD, and a substantial population may also live with some degree of frailty. The mechanisms of how COVID-19 induces liver injury have been postulated. Hepatorenal syndrome (HRS) is the occurrence of kidney dysfunction in patients with severe CLD/fulminant liver failure in the absence of another identifiable cause, and is usually a marker of severe decompensated liver disease. Select reports of HRS following acute COVID-19 infection have been presented, although the risk factors and pathophysiological mechanisms leading to HRS in COVID-19 infection or following COVID-19 treatment remain largely unestablished due to the relative lack and novelty of published data. Evidence discussing the management of HRS in high-dependency care and intensive care contexts is only emerging. In this article, we provide an overview on the speculative pathophysiological mechanisms of COVID-19 induced HRS and propose strategies for clinical diagnosis and management to optimize outcomes in this scenario.
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Affiliation(s)
- Henry H L Wu
- Renal Research, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney 2065, New South Wales, Australia
| | - Varinder S Athwal
- Faculty of Biology, Medicine & Health (Division of Diabetes, Metabolism & Gastroenterology), The University of Manchester, Manchester M13 9PL, United Kingdom
| | - Philip A Kalra
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, United Kingdom
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, United Kingdom
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Téllez L, Guerrero A. Management of Liver Decompensation in Advanced Liver Disease (Renal Impairment, Liver Failure, Adrenal Insufficiency, Cardiopulmonary Complications). Clin Drug Investig 2022; 42:15-23. [PMID: 35522396 PMCID: PMC9205830 DOI: 10.1007/s40261-022-01149-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 12/17/2022]
Abstract
Systemic complications often occur in patients with advanced liver disease. In particular, the development of renal complications (acute kidney injury, hepatorenal syndrome), acute-on-chronic liver failure, cardiopulmonary diseases, or relative adrenal insufficiency can be serious in patients with advanced liver disease and may determine the patient’s quality of life and prognosis. Therefore, the early diagnosis of possible complications is the key to the prompt initiation of specific treatments that can improve quality of life and survival. For this purpose, networking with reference centers where multidisciplinary units are available is essential so that every patient is evaluated in clinical discussions involving specialists from different fields.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBERehd), Universidad de Alcalá, Ctra. Colmenar Viejo, km 9,100, 28034, Madrid, Spain.
| | - Antonio Guerrero
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBERehd), Universidad de Alcalá, Ctra. Colmenar Viejo, km 9,100, 28034, Madrid, Spain
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Miño Bernal JF, López Morales E, Sandino NJ, Molano Franco D. Cirrosis hepática o falla hepática crónica agudizada: definición y clasificación. REPERTORIO DE MEDICINA Y CIRUGÍA 2022. [DOI: 10.31260/repertmedcir.01217372.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La cirrosis se considera el estadio crónico e irreversible de la lesión hepática. Su etiología es diversa y abarca causas como las infecciones víricas, tóxicos como el alcohol, medicamentos, patologías autoinmunes y otras. La descompensación de la cirrosis hepática es consecuencia de cambios fisiopatológicos que se dan con el tiempo como ascitis, peritonitis bacteriana espontánea, hemorragia del tubo digestivo, síndrome hepatorrenal, encefalopatía hepática o hipertensión portopulmonar, mientras que la falla hepática crónica agudizada debe considerarse como una entidad que debe diferenciarse de la anterior, ya que es una falla multiorgánica de curso rápido, por lo regular en pacientes hospitalizados en unidad de cuidado intensivo, a menudo secundaria a desencadenantes como estados de choque. El clínico debe identificarlas para su abordaje y evaluación. El método actual adecuado para estadificar esta entidad es el puntaje CLIFF SOFA, que evalúa la mortalidad a 28 y 90 días, permitiendo intervenciones adecuadas en cada caso.
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Singh J, Dahiya DS, Kichloo A, Singh G, Khoshbin K, Shaka H. Hepatorenal syndrome: a Nationwide Trend Analysis from 2008 to 2018. Ann Med 2021; 53:2018-2024. [PMID: 34985399 PMCID: PMC8604523 DOI: 10.1080/07853890.2021.1998595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE This study was designed to assess the epidemiological trends and outcomes associated with Hepatorenal Syndrome (HRS). METHODS This retrospective interrupted trend study used the Nationwide Inpatient Sample (NIS) database for the years 2008, 2012, 2014, 20z16 and 2018 to identify adult (≥18 years) hospitalizations with a primary diagnosis of HRS. We determined epidemiological characteristics and trends for HRS hospitalizations. Additionally, we also calculated the inpatient mortality, mean length of stay (LOS) and mean total hospital charge (THC) using a multivariate regression trend analysis. RESULTS There was an increase in the total number of HRS hospitalizations from 22,864 in 2008 to 42,985 in 2018 with a trend towards increasing hospitalizations (p-trend <.001). The mean age for these hospitalizations ranged from 57.4-59.0 years with a significantly rising trend (p-trend <.001). Although the majority of HRS hospitalizations were men, we observed a trend towards increasing hospitalizations for women with an increase from 35.7% in 2008 to 39% in 2018 (p-trend <.001). Additionally, Whites made up a majority of the sample size (Table 1). After a multivariate regression trend analysis, we found a statistically significant trend towards declining inpatient mortality from 36.2% in 2008 to 25.7% in 2018 (p-trend <.001) for HRS hospitalizations (Table 2). We did not find a statistically significant trend for LOS and THC.[Table: see text][Table: see text]. CONCLUSION Total hospitalizations, hospitalizations for women and the mean age for HRS hospitalizations were on the rise between 2008 and 2018. However, the inpatient mortality declined.KEY MESSAGESIn the United States, there was a trend towards increasing hospitalizations and mean age for HRS.Although a male predominance was noted, HRS hospitalizations for women were on the rise.The inpatient mortality for HRS hospitalizations was on a decline and may indicate significant improvements in management.
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Affiliation(s)
- Jagmeet Singh
- Department of Nephrology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Gurdeep Singh
- Department of Medicine and Endocrinology, Lady of Lourdes Memorial Hospital, Binghamton, NY, USA
| | - Katayoun Khoshbin
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, USA
| | - Hafeez Shaka
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, USA
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Urinary neutrophil gelatinase-associated lipocalin: Acute kidney injury in liver cirrhosis. Clin Chim Acta 2021; 523:339-347. [PMID: 34666028 DOI: 10.1016/j.cca.2021.10.015] [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: 07/29/2021] [Revised: 10/01/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022]
Abstract
Acute kidney injury (AKI) in liver cirrhosis is associated with poor clinical outcomes including an increased long and short-term mortality. The common type of AKI observed in patients with cirrhosis are prerenal AKI (PRA), hepatorenal syndrome (HRS) and acute tubular necrosis (ATN). Despite the growing knowledge and uniform definition for the diagnosis of AKI, there are several challenges including, early diagnosis and management. Precisely differentiating the type of AKI is critical, as therapies differ significantly. In this review, we summarize AKI in liver cirrhosis, their definition, pathophysiology and deficiencies of using the existing biomarker, serum creatinine. We outline the current clinical evidence on the novel biomarker urinary neutrophil gelatinase-associated lipocalin (uNGAL) and its potential role as a biomarker in the early detection, differentiation and prognostication of AKI. This review also briefly talks about other forthcoming biomarkers which hold promise in the management of AKI in liver cirrhosis.
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Nassar M, Nso N, Medina L, Ghernautan V, Novikov A, El-Ijla A, Soliman KM, Kim Y, Alfishawy M, Rizzo V, Daoud A. Liver kidney crosstalk: Hepatorenal syndrome. World J Hepatol 2021; 13:1058-1068. [PMID: 34630874 PMCID: PMC8473490 DOI: 10.4254/wjh.v13.i9.1058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/12/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
The dying liver causes the suffocation of the kidneys, which is a simplified way of describing the pathophysiology of hepatorenal syndrome (HRS). HRS is characterized by reversible functional renal impairment due to reduced blood supply and glomerular filtration rate, secondary to increased vasodilators. Over the years, HRS has gained much attention and focus among hepatologists and nephrologists. HRS is a diagnosis of exclusion, and in some cases, it carries a poor prognosis. Different classifications have emerged to better understand, diagnose, and promptly treat this condition. This targeted review aims to provide substantial insight into the epidemiology, pathophysiology, diagnosis, and management of HRS, shed light on the various milestones of this condition, and add to our current understanding.
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Affiliation(s)
- Mahmoud Nassar
- Department of Medicine, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, NY 11432, United States
| | - Nso Nso
- Department of Medicine, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, NY 11432, United States
| | - Luis Medina
- Department of Medicine, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, NY 11432, United States
| | - Victoria Ghernautan
- Department of Medicine, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, NY 11432, United States
| | - Anastasia Novikov
- Department of Medicine, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, NY 11432, United States
| | - Alli El-Ijla
- Department of Medicine, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, NY 11432, United States
| | - Karim M Soliman
- Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Yungmin Kim
- Department of Medicine, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, NY 11432, United States
| | - Mostafa Alfishawy
- Department of Infectious Diseases, Infectious Diseases Consultants and Academic Researchers of Egypt IDCARE, Cairo 11562, Egypt
| | - Vincent Rizzo
- Department of Medicine, Icahn School of Medicine at Mount Sinai / NYC Health + Hospitals / Queens, New York, NY 11432, United States
| | - Ahmed Daoud
- Department of Medicine, Kasr Alainy Medical School, Cairo University, Cairo 11211, Egypt
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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.
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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
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14
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Flamm SL, Brown K, Wadei HM, Brown RS, Kugelmas M, Samaniego‐Picota M, Burra P, Poordad F, Saab S. The Current Management of Hepatorenal Syndrome-Acute Kidney Injury in the United States and the Potential of Terlipressin. Liver Transpl 2021; 27:1191-1202. [PMID: 33848394 PMCID: PMC8457138 DOI: 10.1002/lt.26072] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/16/2022]
Abstract
Acute kidney injury (AKI) in the setting of cirrhosis (hepatorenal syndrome [HRS]-AKI) is a severe and often fatal complication of end-stage liver disease. The goals of treatment are to reverse renal failure and prolong survival in patients who are critically ill. However, interventions have limited efficacy, and mortality rates remain high. In the United States, the mainstay of pharmacologic therapy consists of the off-label use of vasoconstrictive agents in combination with plasma expanders, a strategy that produces modest effects. Liver transplantation is the ultimate solution but is only an option in a minority of patients because contraindications to transplantation are common and organ availability is limited. Renal replacement therapy is a temporary option but is known to confer an extremely poor short-term prognosis in patients with HRS-AKI and at best serves as a bridge to liver transplantation for the minority of patients who are transplantation candidates. The high mortality rate associated with HRS-AKI in the United States is a reflection of the suboptimal standard of care. Improved therapeutic options to treat HRS-AKI are sought. Terlipressin is a drug approved in Europe for treatment of HRS-AKI and supported by recommendations for first-line therapy by some liver societies and experts around the world. This review article will discuss the substantial unmet medical need associated with HRS-AKI and the potential benefits if terlipressin was approved in the United States.
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Affiliation(s)
- Steven L. Flamm
- Division of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL
| | - Kimberly Brown
- Division of Gastroenterology and HepatologyTransplant InstituteHenry Ford HospitalDetroitMI
| | - Hani M. Wadei
- Department of TransplantationMayo ClinicJacksonvilleFL
| | - Robert S. Brown
- Department of Medicine, Division of Gastroenterology and HepatologyWeill Cornell MedicineNew YorkNY
| | | | | | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and GastroenterologyPadua University HospitalPaduaItaly
| | - Fred Poordad
- University of Texas Health San Antonio, Texas Liver InstituteSan AntonioTX
| | - Sammy Saab
- Department of Internal Medicine and SurgeryDavid Geffen School of Medicine at University of California Los AngelesLos AngelesCA
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15
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Yeh H, Chiang CC, Yen TH. Hepatocellular carcinoma in patients with renal dysfunction: Pathophysiology, prognosis, and treatment challenges. World J Gastroenterol 2021; 27:4104-4142. [PMID: 34326614 PMCID: PMC8311541 DOI: 10.3748/wjg.v27.i26.4104] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/17/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
The population of patients with hepatocellular carcinoma (HCC) overlaps to a high degree with those for chronic kidney disease (CKD) and end-stage renal disease (ESRD). The degrees of renal dysfunction vary, from the various stages of CKD to dialysis-dependent ESRD, which often affects the prognosis and treatment choice of patients with HCC. In addition, renal dysfunction makes treatment more difficult and may negatively affect treatment outcomes. This study summarized the possible causes of the high comorbidity of HCC and renal dysfunction. The possible mechanisms of CKD causing HCC involve uremia itself, long-term dialysis status, immunosuppressive agents for postrenal transplant status, and miscellaneous factors such as hormone alterations and dysbiosis. The possible mechanisms of HCC affecting renal function include direct tumor invasion and hepatorenal syndrome. Finally, we categorized the risk factors that could lead to both HCC and CKD into four categories: Environmental toxins, viral hepatitis, metabolic syndrome, and vasoactive factors. Both CKD and ESRD have been reported to negatively affect HCC prognosis, but more research is warranted to confirm this. Furthermore, ESRD status itself ought not to prevent patients receiving aggressive treatments. This study then adopted the well-known Barcelona Clinic Liver Cancer guidelines as a framework to discuss the indicators for each stage of HCC treatment, treatment-related adverse renal effects, and concerns that are specific to patients with pre-existing renal dysfunction when undergoing aggressive treatments against CKD and ESRD. Such aggressive treatments include liver resection, simultaneous liver kidney transplantation, radiofrequency ablation, and transarterial chemoembolization. Finally, focusing on patients unable to receive active treatment, this study compiled information on the latest systemic pharmacological therapies, including targeted and immunotherapeutic drugs. Based on available clinical studies and Food and Drug Administration labels, this study details the drug indications, side effects, and dose adjustments for patients with renal dysfunction. It also provides a comprehensive review of information on HCC patients with renal dysfunction from disease onset to treatment.
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Affiliation(s)
- Hsuan Yeh
- Department of Nephrology, Chang Gung Memorial Hospital and Chang Gung University, Taipei 105, Taiwan
| | - Chun-Cheng Chiang
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Chang Gung Memorial Hospital and Chang Gung University, Taipei 105, Taiwan
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Does Anemia Have a Potential Effect on Type 2 Hepatorenal Syndrome? Can J Gastroenterol Hepatol 2020; 2020:1134744. [PMID: 33381474 PMCID: PMC7762663 DOI: 10.1155/2020/1134744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 11/19/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background/Aims. Hepatorenal syndrome (HRS) is a form of functional renal failure arising in advanced cirrhosis and is characterized by a poor survival rate. Anemia is frequently observed during the clinical course of cirrhosis. Our study aimed to investigate the hematologic findings in patients with cirrhosis to determine the effects of anemia on renal functions in type 2 HRS and if it was a potential aggravating factor. Materials and Methods. This prospective study, in which all consecutive patients with cirrhosis were enrolled, was performed at a tertiary-level hospital (Military Hospital of Tunis) from January 2019 to June 2019. A total of 9 patients with HRS fulfilled the type 2 HRS diagnostic criteria, and 41 patients with cirrhosis without HRS were included. All data regarding patients were obtained from the medical record. Demographic data, routine hemograms, biochemical, and urinary test results were collected. Models of end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores were calculated. Results. The most common etiology of cirrhosis was viral hepatitis (66%). According to the CTP score, 23 patients were in the CTP-A stage, 13 in the CTP-B stage, and 14 patients were in the CTP-C stage. Patients with type 2 HRS had significantly lower hemoglobin levels compared with non-HRS stable cirrhosis patients. As hemoglobin levels decreased, renal function worsened on patients with type 2 HRS. Patients with lower hemoglobin levels had poor prognosis and survival compared with patients with higher hemoglobin levels. Logistic regression analysis showed that lower hemoglobin levels and higher MELD and CTP scores were statistically significant for an onset of type 2 HRS. Conclusion. Renal dysfunction is a frequent complication in patients with end-stage chronic liver disease. The role of anemia in aggravating HRS in patients with cirrhosis is explained by hypoxia that can lead to microcirculatory renal ischemia. Other studies are required to determine if anemia is a precipitant factor for HRS or not.
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Jamil M, Kichloo A, Soni RG, Jamal S, Khan MZ, Patel M, Albosta MS, Aljadah M, Bailey B, Singh J, Kanjwal K. Coexisting Cirrhosis Worsens Inpatient Outcomes in Patients With Infective Endocarditis: A Cross-Sectional Analysis of the National Inpatient Sample 2013-2014. Cureus 2020; 12:e11826. [PMID: 33409068 PMCID: PMC7781493 DOI: 10.7759/cureus.11826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Cirrhosis is known to be an important prognostic factor in determining morbidity and mortality in preoperative cardiac risk assessment for cardiac surgery. Data is limited on outcomes in patients with infective endocarditis (IE) and comorbid liver cirrhosis. The objective of our study is to evaluate the clinical outcomes in patients suffering from IE both with and without underlying liver cirrhosis as well as to determine rates of in-hospital mortality and factors that contribute to this outcome. Hypothesis Liver cirrhosis worsens clinical outcomes in patients with IE. Materials and methods Patients with a principal diagnosis of IE with and without liver cirrhosis were identified by querying the Healthcare Cost and Utilization (HCUP) database, specifically the National Inpatient Sample for the years 2013 and 2014 using International Classification of Diseases, Ninth Revision (ICD-9) codes. Results During 2013 and 2014, a total of 17,952 patients were admitted with a diagnosis of IE, out of whom 780 had concurrent liver cirrhosis. There was increased in-hospital mortality [15.6% vs 10.2%, aOR = 1.57 (1.27-1.93)], acute kidney injury [41.4% vs 32.6%, aOR = 1.45 (1.24-1.69)], and hematologic complications [32.1 vs 14.7%, aOR = 2.87 (2.44-3.37)] in patients with IE with liver cirrhosis when compared to patients with IE without liver cirrhosis. Patients having IE without liver cirrhosis underwent an increased number of interventions, i.e. aortic (7.2 vs 3.7%, aOR = 0.51 (0.34-0.76)) and mitral (4.9% vs 3.4%, aOR = 0.39 (0.23-0.69)) valvular replacements as compared to those with liver cirrhosis, which may explain the increased mortality seen in patients with liver cirrhosis. Conclusion Liver cirrhosis is an important prognostic risk factor for in-hospital mortality in patients with IE. The coagulopathic state in addition to increased rates of bleeding complications and renal dysfunction make these patients poor surgical candidates thus contributing to higher mortality. Further research into the individual risk factors contributing to the increased mortality rates in patients with IE and cirrhosis is required.
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Affiliation(s)
- Mohammad Jamil
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Asim Kichloo
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Ronak G Soni
- Internal Medicine, University of Toledo College of Medicine, Toledo, USA
| | - Shakeel Jamal
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Muhammad Zatmar Khan
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Mitra Patel
- Internal Medicine, University of Toledo College of Medicine, Toledo, USA
| | - Michael S Albosta
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Michael Aljadah
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Beth Bailey
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Jagmeet Singh
- Nephrology, Geisinger Commonwealth School of Medicine, Scranton, USA
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Cervantes Pérez E, Cervantes Guevara G, Cervantes Pérez G, Cervantes Cardona GA, Fuentes Orozco C, Pintor Belmontes KJ, Guzmán Ramírez BG, Reyes Aguirre LL, Barbosa Camacho FJ, Bernal Hernández A, González Ojeda A. Diagnostic utility of the serum-ascites albumin gradient in Mexican patients with ascites related to portal hypertension. JGH OPEN 2020; 4:838-842. [PMID: 33102752 PMCID: PMC7578298 DOI: 10.1002/jgh3.12404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/16/2020] [Accepted: 07/23/2020] [Indexed: 12/27/2022]
Abstract
Background and Aim Analysis of ascitic fluid is necessary to determine the etiology and to distinguish portal hypertension (PH)‐related and unrelated ascites. Numerous diagnostic parameters have been studied, but no single parameter has completely distinguished these. We aimed to validate the serum albumin–ascites gradient (SAAG) for the diagnosis of ascites secondary to PH and to establish cutoff points to predict PH using its sensitivity and specificity. Methods This was a cross‐sectional study conducted on patients diagnosed with ascites of any etiology. The SAAG and albumin concentration in ascitic fluid (AFA) were measured to establish their sensitivity and specificity for determining the presence or absence of PH. Cutoff points and levels of statistical significance were established based on the area under the curve. Results Eighty‐seven patients were evaluated, of whom 74 (84%) were men, with an average age of 54.0 ± 13.6 years. Seventy‐two (83%) were diagnosed at admission with PH‐related ascites and 15 (17%) with non‐PH‐related ascites. SAAG correctly classified 48 (67%) patients, but 24 (33%) were classified incorrectly, while AFA classified 59 (82%) correctly and only 13 (17%) incorrectly. The diagnostic accuracy of SAAG was 57 versus 73% for AFA. AFA had a sensitivity of 82% and specificity of 66% (95% confidence interval [CI]: 0.63–0.93), while SAAG had a sensitivity of 66% but a specificity of 86% (95% CI: 0.72–0.95). Conclusions The SAAG showed poor diagnostic performance with low sensitivity but high specificity. The diagnostic accuracy of AFA is superior to that of SAAG in discriminating between PH and non‐PH ascites.
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Affiliation(s)
- Enrique Cervantes Pérez
- Department of Clinical Nutrition, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Universidad Nacional Autónoma de México Mexico City Mexico
| | - Gabino Cervantes Guevara
- Department of Welfare and Sustainable Development University Center of the North, University of Guadalajara Colotlan Mexico
| | - Gabino Cervantes Pérez
- Gastroenterology Departament Hospital Civil de Guadalajara "Fray Antonio Alcalde" University of Guadalajara Guadalajara Mexico
| | - Guillermo Alonso Cervantes Cardona
- Department of Philosophical, Methodological and Instrumental Disciplines Health Sciences University Center, University of Guadalajara Guadalajara Mexico
| | - Clotilde Fuentes Orozco
- Biomedical Research Unit 02 Western National Medical Center, Mexican Institute of Social Security Guadalajara Mexico
| | - Kevin Josué Pintor Belmontes
- Biomedical Research Unit 02 Western National Medical Center, Mexican Institute of Social Security Guadalajara Mexico
| | | | - Laura Lizeth Reyes Aguirre
- Biomedical Research Unit 02 Western National Medical Center, Mexican Institute of Social Security Guadalajara Mexico
| | | | - Aldo Bernal Hernández
- Biomedical Research Unit 02 Western National Medical Center, Mexican Institute of Social Security Guadalajara Mexico
| | - Alejandro González Ojeda
- Biomedical Research Unit 02 Western National Medical Center, Mexican Institute of Social Security Guadalajara Mexico
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Sharkey J, Ressel L, Brillant N, Scarfe L, Wilm B, Park BK, Murray P. A Noninvasive Imaging Toolbox Indicates Limited Therapeutic Potential of Conditionally Activated Macrophages in a Mouse Model of Multiple Organ Dysfunction. Stem Cells Int 2019; 2019:7386954. [PMID: 31065278 PMCID: PMC6466849 DOI: 10.1155/2019/7386954] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/12/2019] [Indexed: 01/16/2023] Open
Abstract
Cell-based regenerative medicine therapies require robust preclinical safety, efficacy, biodistribution, and engraftment data prior to clinical testing. To address these challenges, we have developed an imaging toolbox comprising multispectral optoacoustic tomography and ultrasonography, which allows the degree of kidney, liver, and cardiac injury and the extent of functional recovery to be assessed noninvasively in a mouse model of multiorgan dysfunction. This toolbox allowed us to determine the therapeutic effects of adoptively transferred macrophages. Using bioluminescence imaging, we could then investigate the association between amelioration and biodistribution. Macrophage therapy provided limited improvement of kidney and liver function, although not significantly so, without amelioration of histological damage. No improvement in cardiac function was observed. Biodistribution analysis showed that macrophages homed and persisted in the injured kidneys and liver but did not populate the heart. Our data suggest that the limited improvement observed in kidney and liver function could be mediated by M2 macrophages. More importantly, we demonstrate here the utility of the imaging toolbox for assessing the efficacy of potential regenerative medicine therapies in multiple organs.
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Affiliation(s)
- Jack Sharkey
- Department of Cellular and Molecular Physiology, University of Liverpool, UK
- Centre for Preclinical Imaging, University of Liverpool, UK
| | - Lorenzo Ressel
- Department of Veterinary Pathology and Public Health, Institute of Veterinary Science, University of Liverpool, Liverpool, UK
| | - Nathalie Brillant
- Department of Molecular and Clinical Pharmacology, University of Edinburgh, UK
| | - Lauren Scarfe
- Department of Cellular and Molecular Physiology, University of Liverpool, UK
- Centre for Preclinical Imaging, University of Liverpool, UK
| | - Bettina Wilm
- Department of Cellular and Molecular Physiology, University of Liverpool, UK
- Centre for Preclinical Imaging, University of Liverpool, UK
| | - B. Kevin Park
- Department of Molecular and Clinical Pharmacology, University of Liverpool, UK
| | - Patricia Murray
- Department of Cellular and Molecular Physiology, University of Liverpool, UK
- Centre for Preclinical Imaging, University of Liverpool, UK
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A novel scoring model for predicting mortality risk in patients with cirrhosis and hepatorenal syndrome. Eur J Gastroenterol Hepatol 2018; 30:938-943. [PMID: 29634664 DOI: 10.1097/meg.0000000000001127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS This study aimed to create a risk scoring model for death from cirrhosis and hepatorenal syndrome, improve the detection rate of high-risk groups, and provide clinical evidence for early intervention treatment. PATIENTS AND METHODS We retrospectively recruited 196 patients with cirrhosis and hepatorenal syndrome between 1 January 2013 and 31 July 2014 at Beijing Ditan Hospital, Capital Medical University, China. The clinical information, biochemical values, age, and sex of the patients were included in the multivariate logistic regression model for screening independent risk factors. The model was validated in 56 patients with cirrhosis and hepatorenal syndrome between 1 August 2014 and 31 December 2014 at Beijing Ditan Hospital, Capital Medical University, China. RESULTS The death risk prediction scoring model included the following four independent risk factors: liver cancer, neutrophil above 70%, alanine aminotransferase higher than 40 U/l, and creatinine higher than 127 mmol/l. The sum death risk score ranged from 0 to 5: 0-2 identified patients with a lower risk of death (mortality rates: 12-41.4%), whereas 3-5 identified patients with a higher risk of death (mortality rates: 48.8-80%). Receiver-operating characteristic curves were constructed for the scoring model and the areas under the curves (AUC) were compared using the z-test. The AUC of the scoring model was 0.843. In addition, the AUC of validated model in 56 patients was 0.742. CONCLUSION The scoring model can accurately predict mortality risk in patients with hepatorenal syndrome.
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Vasoactive Agents for Hepatorenal Syndrome: A Mixed Treatment Comparison Network Meta-Analysis and Trial Sequential Analysis of Randomized Clinical Trials. J Gen Intern Med 2018; 33:97-102. [PMID: 28924736 PMCID: PMC5756164 DOI: 10.1007/s11606-017-4178-8] [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: 07/03/2017] [Revised: 07/19/2017] [Accepted: 08/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) is a common complication among patients with cirrhosis, primarily attributable to vasodilation of renal vessels. Vasoactive agents are commonly used to treat HRS. The present network meta-analysis compares the vasoactive agents used in HRS. METHODS We searched electronic databases for appropriate randomized controlled clinical trials in patients with HRS, comparing active interventions with either placebo or standard of care. The primary outcome was complete HRS reversal; secondary outcomes included partial HRS reversal, mortality, adverse events, and cardiovascular adverse events. The data were pooled using a random effects model. We also carried out direct comparisons for the primary outcome with trial sequential analysis. RESULTS A total of 16 studies were included in the systematic review. Rates of complete HRS reversal were significantly higher with terlipressin and noradrenaline combined with albumin than with placebo (OR 6.65, 95% CI: 2.08-21.31 and 6.81, 95% CI: 1.87-24.83, respectively). No significant differences were observed in terms of mortality, partial HRS reversal, or adverse events for any of the interventions. However, cardiovascular adverse events were significantly higher with continuous-infusion terlipressin/albumin (OR 7.07, 95% CI: 1.23-40.62), bolus terlipressin/albumin (OR 7.39, 95% CI: 1.89, 28.94), octreotide/midodrine/albumin (OR 9.85, 95% CI: 1.1, 88.1), and noradrenaline/albumin (OR 15.24, 95% CI: 2.1, 112.6) than with albumin alone. Trial sequential analyses revealed adequate evidence to conclude that terlipressin combined with albumin was effective in achieving complete HRS reversal. DISCUSSION Terlipressin combined with albumin shows strong evidence of improving short-term survival in patients with type 1 but not type 2 HRS. Through indirect comparison, noradrenaline with albumin was also associated with significant benefits in terms of HRS reversal.
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