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Jindal A, Singh H, Kumar G, Arora V, Sharma MK, Maiwall R, Rajan V, Tewathia HV, Vasishtha C, Sarin SK. Early Versus Standard Initiation of Terlipressin for Acute Kidney Injury in ACLF: A Randomized Controlled Trial (eTerli Study). Dig Dis Sci 2024; 69:2204-2214. [PMID: 38637454 DOI: 10.1007/s10620-024-08423-8] [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: 02/15/2024] [Accepted: 03/29/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND AND AIMS Terlipressin infusion is effective in hepatorenal syndrome (HRS-AKI). However, its efficacy for HRS-AKI resolution in acute-on-chronic liver failure (ACLF) patients has been suboptimal. Progression of AKI is rapid in ACLF. We investigated whether early initiation of terlipressin(eTerli) can improve response rates. METHODS Consecutive ACLF patients with stage II/III AKI despite albumin resuscitation (40 g) were randomized to receive terlipressin at 2 mg/24 h plus albumin at 12 h (ET, n = 35) or at 48 h as standard therapy (ST, n = 35). (June 22, 2020 to June 10, 2022). The primary end-point was AKI reversal by day7. RESULTS Baseline parameters including AKI stage and ACLF-AARC scores in two arms were comparable. Full AKI response at day 7 was higher in ET [24/35 (68.6%)] than ST arm [11/35 (31.4%; P 0.03]. Day3 AKI response was also higher in ET arm [11/35 (31.4%) vs. 4/35 (11.4%), P 0.04]. Using ST compared to ET [HR 4.3; P 0.026] and day 3 serum creatinine > 1.6 mg/dl [HR 9.1; AUROC-0.866; P < 0.001] predicted HRS-AKI non-response at day 7. ET patients showed greater improvement in ACLF grade, mean arterial pressure, and urine output at day 3, and required lower albumin within 7 days than ET arm (149.1 ± 41.8 g vs. 177.5 ± 40.3 g, P 0.006) and had lower 28-day mortality: 40% vs. 65.7%, P 0.031]. Early use of terlipressin than ST [HR 2.079; P 0.038], baseline HE [HR 2.929; P 0.018], and AKI persistence at day 3 [HR 1.369; P 0.011] predicted 28-day mortality. Fifteen (21.4%) patients had treatment related adverse effects, none was life threatening. CONCLUSION In ACLF patients, early initiation of terlipressin for AKI persisting after 12 h of volume expansion with albumin helps in reduced short-term mortality and early AKI reversal with regression of ACLF stage. These results indicate need for change in current practice for terlipressin usage in HRS-AKI.
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Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Hitesh Singh
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Guresh Kumar
- Department of Clinical Research and Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - V Rajan
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Harsh Vardhan Tewathia
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Chitranshu Vasishtha
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India.
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Wan YP, Wang AJ, Zhang W, Zhang H, Peng GH, Zhu X. Development and validation of a nomogram for predicting overall survival in cirrhotic patients with acute kidney injury. World J Gastroenterol 2022; 28:4133-4151. [PMID: 36157113 PMCID: PMC9403434 DOI: 10.3748/wjg.v28.i30.4133] [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: 02/07/2022] [Revised: 04/29/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and severe complication in patients with cirrhosis, and is associated with poor prognosis. Therefore, identifying cirrhotic patients with AKI who are at high risk of mortality is very important and may be helpful for providing timely medical interventions to improve the prognosis of these patients. However, studies focused on investigating the risk factors for the mortality of cirrhotic patients with AKI were scarce.
AIM To identify risk factors for mortality and establish a nomogram for predicting the prognosis of these patients.
METHODS Two hundred fifty consecutive patients with cirrhosis and AKI were recruited and randomly divided into training cohort (n = 173) and validation cohort (n = 77). In the training cohort, potential risk factors for death were identified by performing a Cox regression analysis, and a nomogram was established. The predictive performance of the nomogram was internally and externally validated by calculating the area under the receiver operating characteristic curve (AUROC), constructing a calibration curve and performing decision curve analysis.
RESULTS The serum sodium level, international normalized ratio, peak serum creatinine level > 1.5 mg/dL, the presence of hepatic encephalopathy and diabetes were potential risk factors for mortality of cirrhotic patients with AKI in the training dataset. A prognostic nomogram incorporating these variables was established for predicting the overall survival of these patients. Compared with Child-Turcotte-Pugh, the model for end-stage liver disease (MELD) and the MELD-Na scores, the nomogram in predicting 90- and 180-d mortality exhibited better discriminatory power with AUROCs of 0.792 and 0.801 for the training dataset and 0.817 and 0.862 for the validation dataset, respectively. With a nomogram score of 98, patients were divided into low- and high-risk groups, and high-risk patients had a higher mortality rate.
CONCLUSION A prognostic nomogram displayed good performance for predicting the overall survival of cirrhotic patients with AKI, and will assist clinicians in evaluating the prognosis of these patients.
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Affiliation(s)
- Yi-Peng Wan
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang 331706, Jiangxi Province, China
| | - An-Jiang Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang 331706, Jiangxi Province, China
| | - Wang Zhang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang 331706, Jiangxi Province, China
| | - Hang Zhang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang 331706, Jiangxi Province, China
| | - Gen-Hua Peng
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang 331706, Jiangxi Province, China
| | - Xuan Zhu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang 331706, Jiangxi Province, China
- Biomolecular Research Laboratory, Jiangxi Clinical Research Center for Gastroenterology, Nanchang 331706, Jiangxi Province, China
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Møller S, Kimer N, Barløse M, Bendtsen F. Pathophysiological-based treatments of complications of cirrhosis. Scand J Gastroenterol 2020; 55:383-394. [PMID: 32233873 DOI: 10.1080/00365521.2020.1744709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Detailed knowledge and understanding of the pathophysiological mechanisms and changes in hepatic and splanchnic function leading to the development of haemodynamic changes and portal hypertension in patients with cirrhosis are essential since it guides the search for targets to ameliorate liver-related abnormalities. Recent research has focused on the gut-liver axis, changes in intestinal permeability, translocation of bacterial products, and inflammation as important drivers of haemodynamic alterations and thereby targets for treatment. Additionally, treatment strategies should focus on microbiotic modulation, antiangiogenics, anti-inflammatory strategies, and modulation of bile acid metabolism. This paper aims to review contemporary pathophysiological-based treatment principles of the major complications of cirrhosis and portal hypertension and future targets for treatment.
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Affiliation(s)
- Søren Møller
- Department Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Bridge Translational Excellence Programme, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Mads Barløse
- Department Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) in cirrhosis consists of varying phenotypes, with hepatorenal syndrome (HRS) representing a single entity. Prompt recognition and diagnosis of AKI cause identifies appropriate therapeutic measures. This review provides an overview of AKI definitions, highlights challenges in quantifying renal impairment in cirrhosis, lists novel diagnostic AKI biomarkers, and summarizes transplantation implications. RECENT FINDINGS Biomarkers (neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, interleukin-18, and liver-type fatty acid-binding protein) may assist in the identification of underlying acute tubular necrosis. Of these, neutrophil gelatinase-associated lipocalin is the most promising; however, significant overlap occurs among AKI phenotypes, with diagnostic values yet to be defined. Mainstay treatment of HRS consists of albumin and vasopressors. Acute-on-chronic liver failure grade independently predicts response to terlipressin treatment. Many end-stage liver disease patients with AKI have underlying chronic kidney disease with important implications on pre and postliver transplantation mortality. Simultaneous liver-kidney transplant candidacy is based on low likelihood of renal recovery. SUMMARY Novel biomarkers may assist in identification of acute tubular necrosis and persistent/severe AKI. Norepinephrine has been suggested to be inferior to terlipressin, with additional research required. Increasing acute-on-chronic liver failure grade correlates with lower likelihood of vasopressor response in HRS. Severe preliver transplantation AKI confers significantly worse postliver transplantation renal outcomes.
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Wyawahare M, Krishna Reddy SS, Priyamvada PS, Rajendiran S. Utility of Urinary Neutrophil gelatinase associated lipocalin (NGAL) in decompensated cirrhosis. Indian J Nephrol 2020; 30:391-397. [PMID: 33840958 PMCID: PMC8023034 DOI: 10.4103/ijn.ijn_254_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/29/2019] [Accepted: 11/10/2019] [Indexed: 01/23/2023] Open
Abstract
Background and Aims: Renal failure occurring in the setting of cirrhosis increases mortality by more than threefold. Serum creatinine, the conventional marker for renal dysfunction has inherent limitations in identifying and categorizing renal dysfunction in patients with chronic liver disease (CLD). Neutrophil gelatinase associated lipocalin (NGAL) is a novel biomarker which gets upregulated as early as 2-6 hours following the insult to renal tubules. In this study, we aim to check the utility of uNGAL to identify the different phenotypes of renal dysfunction in patients with CLD. We also intend to assess the utility of NGAL to predict 90-day transplant-free survival in patients with CLD. Methods: A total number of 120 adult patients, with cirrhosis of liver were recruited. Those with pre-existing renal parenchymal disease, receiving nephrotoxic medications, spontaneous bacterial peritonitis, septic shock, proteinuria, hematuria, urinary tract infection and anuria were excluded. Urine samples for NGAL was measured at admission and at 48 hours thereafter. Patients were followed up for 90 days post admission. Results: Among the study population, 16 patients (13.3%) had normal kidney function, 43 (35.8%) had prerenal azotemia and 54 (45%) had Hepatorenal Syndrome (HRS - AKI) and 7 (5.8%) had acute tubular necrosis (ATN). Urinary NGAL (uNGAL) levels were considerably lower in patients with normal kidney function and prerenal azotemia. An uNGAL level of 124 ng/ml on admission could distinguish severe forms of renal injury, with a sensitivity of 86% and specificity of 84%. The non survivors had higher uNGAL levels at admission [209.6 ng/ml (118.7-376.8) vs. 123 (33.6-344.3); P = 0.013].The receiver operated curves for uNGAL and serum creatinine at admission did not show any significant difference for predicting 90 day mortality (AUC for uNGAL: 0.632 vs 0.580 for serum creatinine; difference in AUC 0.053, P value 0.17). Conclusion: uNGAL levels are elevated in patients with HRS-AKI and ATN. A higher uNGAL level at admission was suggestive of severe renal dysfunction. An elevated uNGAL on admission is associated with inferior survival. However, uNGAL is not superior to serum creatinine in predicting 90-day mortality.
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MacDonald AJ, Karvellas CJ. Acute kidney injury: A critical care perspective for orthotopic liver transplantation. Best Pract Res Clin Anaesthesiol 2019; 34:69-78. [PMID: 32334788 DOI: 10.1016/j.bpa.2019.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is associated with high perioperative mortality in patients undergoing liver transplantation (LT). In the era of Model of End-stage Liver Disease score-based allocation, more patients with impaired renal function are receiving LT. The majority of preoperative AKI is secondary to azotemia, including hepatorenal syndrome - a progressive form of renal impairment unique to liver failure. Prompt recognition and initiation of cause-directed therapies are central to improving post-transplant survival. Given that, the healthcare providers must develop an expertise in liver failure-related renal complications, specifically their management and perioperative implications. Notably, AKI may complicate intraoperative course, exacerbating hemodynamic instability, metabolic acidosis, and electrolyte and coagulation abnormalities. Adjunctive intraoperative continuous renal replacement therapy has been employed; however, prospective studies remain necessary to validate potential benefits.
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Affiliation(s)
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada; Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
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Renal Effects of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients with Liver Cirrhosis: A Nationwide Cohort Study. Gastroenterol Res Pract 2019; 2019:1743290. [PMID: 31687012 PMCID: PMC6811787 DOI: 10.1155/2019/1743290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/29/2019] [Indexed: 12/18/2022] Open
Abstract
Background The use of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) carries a risk of renal function deterioration in cirrhotic patients with ascites. However, whether the long-term use of ACEis/ARBs is safe in cirrhotic patients without ascites remains unknown. Methods In this nationwide cohort study, we identified 311,361 newly diagnosed cirrhotic patients between January 1997 and December 2013. To avoid indication and immortal time biases, patients receiving regular ACEi/ARB therapy, defined as the ACEi/ARB cohort, were matched to patients receiving regular calcium channel blockers (CCBs), defined as the CCB cohort, at a ratio of 1 : 1 by age, sex, and propensity scores for comorbidities and medications (2,188 patients in each cohort). Cumulative incidence rates and multivariate analyses of end-stage renal disease (ESRD) risk were adjusted for competing mortality. Results The 10-year cumulative incidence rates of ESRD were 2.32% (95% confidence interval [CI]: 1.45–3.20) in the ACEi/ARB cohort and 1.70% (95% CI: 1.03–2.36) in the CCB cohort (P = 0.610). In multivariate analyses, ACEi/ARB use was not associated with a higher risk of ESRD in cirrhotic patients (hazard ratio [HR] = 1.15; 95% CI: 0.69–1.94, P = 0.591). In the sensitivity test, the 10-year cumulative incidence rates of ESRD in cirrhotic patients with ascites were 6.50% (95% CI: 0.54–12.46) and 1.24% (95% CI: 0.00–2.71) in ACEi/ARB and CCB cohorts, respectively (P = 0.090). Conclusions Long-term ACEi/ARB use was not associated with a higher risk of ESRD in cirrhotic patients. However, the risk of ESRD tended to increase in cirrhotic patients with ascites.
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Nguyen-Tat M, Jäger J, Rey JW, Nagel M, Labenz C, Wörns MA, Galle PR, Marquardt JU. Terlipressin and albumin combination treatment in patients with hepatorenal syndrome type 2. United European Gastroenterol J 2019; 7:529-537. [PMID: 31065370 PMCID: PMC6488797 DOI: 10.1177/2050640619825719] [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] [Received: 08/01/2018] [Accepted: 12/04/2018] [Indexed: 12/12/2022] Open
Abstract
Background Hepatorenal syndrome (HRS) is associated with a poor prognosis. In HRS type 1, loss of renal function is rapidly progressive, while HRS type 2 is characterised by chronic ascites and more moderately elevated renal parameters. While treatment with terlipressin/albumin is well established in type 1, its effectiveness in chronic HRS is less clear. Objective The aim of this study was to evaluate the effectiveness of terlipressin/albumin treatment in patients with HRS type 2. Methods All patients with a first episode of HRS between April 2013 and February 2016 were included in this observational study. Relevant clinical and laboratory parameters were recorded and patients were followed. Results A total of 106 patients with HRS were included. With terlipressin therapy reversal of HRS types 1 and 2 was achieved in 48% and 46% of patients (p = 0.84) with relapse rates of 8% vs 50% (p = 0.001). Overall survival (OS) and survival free of liver transplantation (LTx) were similar in HRS types 1 and 2 (p = 0.69; p = 0.64). In multivariate analysis response to treatment was independently associated with better OS in HRS type 2, in addition to established risk factors such as lower Model for End-Stage Liver Disease score, absence of hepatic encephalopathy and eligibility for LTx. Conclusion A terlipressin treatment course seems to be justified in selected patients with HRS type 2, especially in countries and settings with long transplant waiting lists. In addition treatment response might also help to identify HRS type 2 patients with a more favourable outcome.
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Affiliation(s)
- Marc Nguyen-Tat
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
- Department of Medicine II, Klinikum
Osnabrück, Osnabrück, Germany
| | - Julia Jäger
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | | | - Michael Nagel
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | - Christian Labenz
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | - Marcus-Alexander Wörns
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | - Peter Robert Galle
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
| | - Jens Uwe Marquardt
- First Department of Medicine, Cirrhosis
Center Mainz (CCM), University Hospital Mainz, Mainz, Germany
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Premkumar M, Rangegowda D, Kajal K, Khumuckham JS. Noninvasive estimation of intravascular volume status in cirrhosis by dynamic size and collapsibility indices of the inferior vena cava using bedside echocardiography. JGH OPEN 2019; 3:322-328. [PMID: 31406926 PMCID: PMC6684769 DOI: 10.1002/jgh3.12166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/26/2019] [Accepted: 01/31/2019] [Indexed: 12/20/2022]
Abstract
Background and Aim Echocardiographic assessment of the inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) is a noninvasive estimate of intravascular volume status (IVS) but requires validation for cirrhosis. We evaluated IVC dynamics in cirrhosis and correlated it with conventional tools such as central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and right atrial pressure (RAP). Methods A total of 673 consecutive cirrhotic patients were screened by echocardiography, and 125 patients underwent right heart catheterization with recording of hepatic venous pressure gradient (HVPG), RAP, pulmonary artery (PA) pressure, and PCWP. CVP data were available for 80 (64%) patients, and finally, 76 patients (84% male, 50% ethanol related, mean age 52.1 years, 57.8% with ascites) with complete data were enrolled. Results The mean CVP measured was 12.8 ± 4.8 mmHg, and IVCCI was 29.5 ± 10.9%. The IVCD ranged from 0.97 to 2.26 cm and from 0.76 to 1.84 cm during expiration and inspiration, respectively, with a mean of 1.8 ± 0.9 cm. The mean IVCD correlated with RAP (r = 0.633, P = 0.043) but not with HVPG (r = 0.344, P = 0.755), PCWP (r = 0.562, P = 0.072), or PA pressure (r = 0.563, P = 0.588). A negative linear correlation was observed between the CVP and the IVCCI (r = −0.827, P = 0.023) in all patients and substratified for those with (r = −0.748, P = 0.039) and without ascites (r = −0.761, P = 0.047). A positive correlation was observed between CVP and IVCDmax (r = 0.671, P = 0.037) and IVCDmin (r = 0.612, P = 0.040). Conclusions IVCD and collapsibility index provides noninvasive IVS assessment, independent of HVPG or ascites, with the potential for calculating fluid requirements in cirrhosis.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India
| | - Devaraja Rangegowda
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India
| | - Kamal Kajal
- Department of Anesthesia and Critical Care Medicine Institute of Liver and Biliary Sciences New Delhi India
| | - Jelen S Khumuckham
- Department of Cardiology Institute of Liver and Biliary Sciences New Delhi India
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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.
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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
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11
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Piano S, Schmidt HH, Ariza X, Amoros A, Romano A, Hüsing-Kabar A, Solà E, Gerbes A, Bernardi M, Alessandria C, Scheiner B, Tonon M, Maschmeier M, Solè C, Trebicka J, Gustot T, Nevens F, Arroyo V, Gines P, Angeli P. Association Between Grade of Acute on Chronic Liver Failure and Response to Terlipressin and Albumin in Patients With Hepatorenal Syndrome. Clin Gastroenterol Hepatol 2018; 16:1792-1800.e3. [PMID: 29391267 DOI: 10.1016/j.cgh.2018.01.035] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/12/2018] [Accepted: 01/21/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Type 1 hepatorenal syndrome (HRS) is the most high-risk type of renal failure in patients with cirrhosis. Terlipressin and albumin are effective treatments for type 1 HRS. However, the effects of acute on chronic liver failure (ACLF) grade on response to treatment are not clear. We aimed to identify factors associated with response to treatment with terlipressin and albumin in patients with type 1 HRS (reduction in serum level of creatinine to below 1.5 mg/dL at the end of treatment) and factors associated with death within 90 days of HRS diagnosis (90-day mortality). METHODS We performed a retrospective analysis of 4 different cohorts of consecutive patients with HRS treated with terlipressin and albumin from February 2007 through January 2016 at medical centers in Europe (total, 298 patients). We analyzed demographic, clinical, and laboratory data collected before and during treatment; patients were followed until death, liver transplantation, or 90 days after HRS diagnosis. RESULTS Response to treatment was observed in 53% of patients. Of patients with grade 1 ACLF, 60% responded to treatment; among those with grade 2 ACLF, 48% responded, and among those with grade 3 ACLF, 29% responded (P < .001 for comparison between grades). In multivariate analysis, baseline serum level of creatinine (odds ratio, 0.23; P = .001) and ACLF grade (odds ratio, 0.63; P = .01) were independently associated with response to treatment. Patient age (hazard ratio [HR], 1.05; P < .001), white blood cell count (HR, 1.51; P = .006), ACLF grade (HR, 2.06; P < .001), and no response to treatment (HR, 0.41; P < .001) associated with 90-day mortality. CONCLUSION In a retrospective analysis of data from 4 cohorts of patients treated for type 1 HRS, we found ACLF grade to be the largest determinant of response to terlipressin and albumin. ACLF grade affects survival independently of response to treatment. New therapeutic strategies should be developed for patients with type 1 HRS and extrarenal organ failure.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED University of Padova, Padova, Italy
| | - Hartmut H Schmidt
- Klinik für Transplantationsmedizin, Universitätsklinikum Münster, Münster, Germany
| | - Xavier Ariza
- Liver Unit, Hospital Clìnic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; 5 - Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Alex Amoros
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Antonietta Romano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED University of Padova, Padova, Italy
| | - Anna Hüsing-Kabar
- Klinik für Transplantationsmedizin, Universitätsklinikum Münster, Münster, Germany
| | - Elsa Solà
- Liver Unit, Hospital Clìnic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; 5 - Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Alexander Gerbes
- Department of Medicine II, University Hospital LMU Munich, Liver Center Munich, Munich, Germany
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | - Bernhard Scheiner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED University of Padova, Padova, Italy
| | - Miriam Maschmeier
- Klinik für Transplantationsmedizin, Universitätsklinikum Münster, Münster, Germany
| | - Cristina Solè
- Liver Unit, Hospital Clìnic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; 5 - Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Jonel Trebicka
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain; Department of Internal Medicine I, University of Bonn, Bonn, Germany; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Institute for Bioengineering of Catalonia, Barcelona, Spain
| | - Thierry Gustot
- Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Frederik Nevens
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Vicente Arroyo
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Pere Gines
- Liver Unit, Hospital Clìnic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; 5 - Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED University of Padova, Padova, Italy.
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12
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Charatcharoenwitthaya P, Soonthornworasiri N, Karaketklang K, Poovorawan K, Pan-ngum W, Chotiyaputta W, Tanwandee T, Phaosawasdi K. Factors affecting mortality and resource use for hospitalized patients with cirrhosis: A population-based study. Medicine (Baltimore) 2017; 96:e7782. [PMID: 28796076 PMCID: PMC5556242 DOI: 10.1097/md.0000000000007782] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hospitalizations for advanced liver disease are costly and associated with significant mortality. This population-based study aimed to evaluate factors associated with in-hospital mortality and resource use for the management of hospitalized patients with cirrhosis.Mortality records and resource utilization for 52,027 patients hospitalized with cirrhosis and/or complications of portal hypertension (ascites, hepatic encephalopathy, variceal bleeding, spontaneous bacterial peritonitis, or hepatorenal syndrome) were extracted from a nationally representative sample of Thai inpatients covered by Universal Coverage Scheme during 2009 to 2013.The rate of dying in the hospital increased steadily by 12% from 9.6% in 2009 to 10.8% in 2013 (P < .001). Complications of portal hypertension were independently associated with increased in-hospital mortality except for ascites. The highest independent risk for hospital death was seen with hepatorenal syndrome (odds ratio [OR], 5.04; 95% confidence interval [CI], 4.38-5.79). Mortality rate remained high in patients with infection, particularly septicemia (OR, 4.26; 95% CI, 4.0-4.54) and pneumonia (OR, 2.44; 95% CI, 2.18-2.73). Receiving upper endoscopy (OR, 0.29; 95% CI, 0.27-0.32) and paracentesis (OR, 0.93; 95% CI, 0.87-1.00) were associated with improved patient survival. The inflation-adjusted national annual costs (P = .06) and total hospital days (P = .07) for cirrhosis showed a trend toward increasing during the 5-year period. Renal dysfunction, infection, and sequelae of portal hypertension except for ascites were independently associated with increased resource utilization.Renal dysfunction, infection, and portal hypertension-related complications are the main factors affecting in-hospital mortality and resource utilization for hospitalized patients with cirrhosis. The early intervention for modifiable factors is an important step toward improving hospital outcomes.
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Affiliation(s)
| | | | | | - Kittiyod Poovorawan
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University
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13
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Singh N, Ahmadzadeh S, Shokouh-Amiri H, Qazi YA, Sequeira A, Samant H, McMillan R, Zibari GB. Kidney outcomes in patients with liver cirrhosis and chronic kidney disease receiving an orthotopic liver transplant alone. Clin Transplant 2017; 31. [PMID: 28504869 DOI: 10.1111/ctr.13008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2017] [Indexed: 12/29/2022]
Abstract
Kidney transplant in patients with liver cirrhosis and nondialysis chronic kidney disease (CKD) is controversial. We report 14 liver cirrhotic patients who had persistently low MDRD-6 estimated glomerular filtration rate (e-GFR) <40 mL/min/1.73 m2 for ≥3 months and underwent either liver transplant alone (LTA; n=9) or simultaneous liver-kidney transplant (SLKT; n=5). Pretransplant, patients with LTA compared with SLKT had lower serum creatinine (2.5±0.73 vs 4.6±0.52 mg/dL, P=.001), higher MDRD-6 e-GFR (21.0±7.2 vs 10.3±2.0 mL/min/1.73 m2 , P=.002), higher 24-hour urine creatinine clearance (34.2±8.8 vs 18.0±2.2 mL/min, P=.002), lower proteinuria (133.2±117.7 vs 663±268.2 mg/24 h, P=.0002), and relatively normal kidney biopsy and ultrasound findings. Post-LTA, the e-GFR (mL/min/1.73 m2 ) increased in all nine patients, with mean e-GFR at 1 month (49.8±8.4), 3 months (49.6±8.7), 6 months (49.8±8.1), 12 months (47.6±9.2), 24 months (47.9±9.1), and 36 months (45.1±7.3) significantly higher compared to pre-LTA e-GFR (P≤.005 at all time points). One patient developed end-stage renal disease 9 years post-LTA and another patient expired 7 years post-LTA. The low e-GFR alone in the absence of other markers or risk factors of CKD should not be an absolute criterion for SLKT in patients with liver cirrhosis.
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Affiliation(s)
- Neeraj Singh
- John C. McDonald Regional Transplant Center, Willis Knighton Medical Center, Shreveport, LA, USA.,Division of Nephrology, Department of Medicine, LSUHSC-S, Shreveport, LA, USA
| | - Shahab Ahmadzadeh
- John C. McDonald Regional Transplant Center, Willis Knighton Medical Center, Shreveport, LA, USA
| | - Hosein Shokouh-Amiri
- John C. McDonald Regional Transplant Center, Willis Knighton Medical Center, Shreveport, LA, USA
| | - Yasir A Qazi
- Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Adrian Sequeira
- John C. McDonald Regional Transplant Center, Willis Knighton Medical Center, Shreveport, LA, USA.,Division of Nephrology, Department of Medicine, LSUHSC-S, Shreveport, LA, USA
| | - Hrishikesh Samant
- John C. McDonald Regional Transplant Center, Willis Knighton Medical Center, Shreveport, LA, USA.,Division of Gastroenterology, Department of Medicine, LSUHSC-S, Shreveport, LA, USA
| | - Robert McMillan
- John C. McDonald Regional Transplant Center, Willis Knighton Medical Center, Shreveport, LA, USA
| | - Gazi B Zibari
- John C. McDonald Regional Transplant Center, Willis Knighton Medical Center, Shreveport, LA, USA
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14
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Advances in the Diagnosis and Treatment of Acute Kidney Injury in Cirrhosis Patients. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8523649. [PMID: 28573142 PMCID: PMC5442329 DOI: 10.1155/2017/8523649] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/22/2017] [Indexed: 02/05/2023]
Abstract
Liver cirrhosis is a common progressive and chronic clinical liver disease. Due to the strong compensation ability of the liver, no obvious symptoms develop in the early stage. However, multiple systems are involved in decompensation of the liver. Acute kidney injury (AKI) is one of the most serious complications, characterized by a sharp drop in the glomerular filtration rate (GFR); a rapid increase in Scr and BUN, as well as sodium and water storage; and a disturbance of acid-base balance. The mortality rate is high, and the prognosis is very poor. Thus, it is important to make a definite diagnosis and initiate treatment in the early stage to decrease mortality and improve the prognosis. Although diagnosing liver cirrhosis with serum creatinine has many shortcomings, a dynamic change in this marker is still the main diagnostic criterion for AKI. Identifying new markers of kidney injury with clinical value has also become an increasing focus of research. In this text, we review recent changes regarding categorization of AKI diagnostic criteria as well as new markers of AKI and treatments for cirrhosis-related AKI.
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15
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Bosch J. Editorial: improving in-hospital management of decompensated cirrhosis by a 'care bundle' - hope, frustration, and lessons to learn. Aliment Pharmacol Ther 2017; 45:754-755. [PMID: 28150456 DOI: 10.1111/apt.13924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- J Bosch
- Hospital Clínic-IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain.,Inselspital, Bern University, Bern, Switzerland
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16
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Hurry PK, Poulsen JH, Bendtsen F, Møller S. Neutrophil gelatinase-associated lipocalin and cystatin C in cirrhosis and portal hypertension: Relations to organ extraction and dysfunction. J Gastroenterol Hepatol 2017; 32:473-481. [PMID: 27435243 DOI: 10.1111/jgh.13492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Early detection of renal dysfunction in cirrhosis is important, and several renal biomarkers have been put forward. Neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C are markers of renal dysfunction, but relations to splanchnic and systemic hemodynamics and kinetics are sparsely studied in cirrhosis. In patients with cirrhosis and portal hypertension, we studied plasma levels and renal, hepatic, and peripheral extraction of NGAL and cystatin C and relations to patients characteristics, liver dysfunction, and hemodynamics. METHODS Forty-five cirrhotic patients (Child class A/B/C:15/15/15) and 15 controls were evaluated with a full clinical, biochemical, and hemodynamic assessment. Urine and regional plasma concentrations of NGAL and cystatin C were measured. RESULTS There was no significant difference in circulating or hepatic NGAL or cystatin C between all patients and controls but a trend towards increased levels with increasing Child class. In addition, there was a significant renal but no hepatic or systemic extraction of both NGAL and cystatin C (P < 0.001). Plasma NGAL correlated with glomerular filtration rate (r = -0.56, P < 0.0001), and hepatic venous pressure gradient (r = 0.34,P = 0.02) and urinary NGAL correlated with heart rate (r = 0.58, P= 0.007), blood pressure (r = -0.46, P < 0.05), cardiac output (r = 0.45, P < 0.05), and systemic vascular resistance (SVR) (r = -0.48, p < 0.05). Plasma cystatin C correlated with hepatic venous pressure gradient (r = 0.45, P < 0.005), blood pressure (-0.40, P < 0.01), and glomerular filtration rate (r = 0.98, P < 0.000). CONCLUSIONS Extractions of NGAL and cystatin C levels seem largely unaffected by the severity of liver disease in cirrhosis with a renal extraction. These biomarkers therefore have the potential of being both valuable in diagnosing renal failure and reflecting the degree of portal hypertension and systemic haemodynamic changes.
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Affiliation(s)
- Preete Kapisha Hurry
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre, Denmark
| | | | - Flemming Bendtsen
- Gastro Unit, Medical Division, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Hvidovre, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre, Denmark
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17
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He XX, Wu XL, Chen RP, Chen C, Liu XG, Wu BJ, Huang ZM. Effectiveness of Omega-3 Polyunsaturated Fatty Acids in Non-Alcoholic Fatty Liver Disease: A Meta-Analysis of Randomized Controlled Trials. PLoS One 2016; 11:e0162368. [PMID: 27711128 PMCID: PMC5053538 DOI: 10.1371/journal.pone.0162368] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/22/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is a clinical syndrome with the main characteristic of diffuse liver cells with fatty changes. The clinical evolution of NAFLD includes simple non-alcoholic fatty liver, non-alcoholic steatohepatitis (NASH), liver fibrosis and cirrhosis, and even hepatocellular carcinoma. METHODS AND FINDINGS We conducted this review to identify the effectiveness of omega-3 polyunsaturated fatty acids (ω-3 PUFA) in NAFLD. We searched PubMed, Cochrane Library and Embase. All randomized controlled trials (RCTs) of ω-3 PUFA treatment for NAFLD were considered. Two reviewers assessed the quality of each study and collected data independently. Disagreements were resolved by discussion among the reviewers and any of the other authors of the paper. We performed a meta-analysis and reported summary estimates of outcomes as inverse variance (IV), fixed or random, with 95% confidence intervals (CIs). We included seven RCTs involving 442 patients (227 for the experimental group and 215 for the control group). All the patients were divided into two groups: one treated with ω-3 PUFA and the other was the control group (generally placebo). The demographics of the ω-3 PUFA and control groups were comparable. Beneficial changes in alanine aminotransferase (ALT) (IV 95% CI: -7.61 [-12.83 to -2.39], p = 0.004), total cholesterol (TC) (IV 95% CI: -13.41 [-21.44 to -5.38], p = 0.001), triglyceride (TG) (IV 95% CI: -43.96 [-51.21 to -36.71], p<0.00001) and high-density lipoprotein cholesterol (HDL-C) (IV 95% CI: 6.97 [2.05 to 11.90], p = 0.006) favored ω-3 PUFA treatment. Omega-3 PUFA tended towards a beneficial effect on aspartate aminotransferase (AST) (IV 95% CI: -6.89 [-17.71 to 3.92], p = 0.21), γ-glutamyl transferase (GGT) (IV 95% CI: -8.28 [-18.38 to 1.83], p = 0.11) and low-density lipoprotein cholesterol (LDL-C) (IV 95% CI: -7.13 [-14.26 to 0.0], p = 0.05). CONCLUSIONS Supplementation with ω-3 PUFA is a practical and effective treatment for NAFLD to decrease ALT, TC and increase HDL-C, especially to decrease TG. Omega-3 PUFA also has a tendency toward a beneficial effect on AST, GGT and LDL-C. More high-quality, large RCTs are needed to validate our findings.
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Affiliation(s)
- Xi-Xi He
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Xiao-Li Wu
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Ren-Pin Chen
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Chao Chen
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Xiao-Gang Liu
- Department of Gastroenterology, Ningxia People’s Hospital, Yinchuan, Ningxia, China
| | - Bin-Jiao Wu
- Department of Acupuncture and Moxibustion, The People’s Hospital of Yueqing, Wenzhou, Zhejiang Province, China
| | - Zhi-Ming Huang
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- * E-mail:
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18
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Busk TM, Bendtsen F, Møller S. Hepatorenal syndrome in cirrhosis: diagnostic, pathophysiological, and therapeutic aspects. Expert Rev Gastroenterol Hepatol 2016; 10:1153-1161. [PMID: 27248461 DOI: 10.1080/17474124.2016.1196132] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Renal failure is a common and serious complication in cirrhosis and represents a wide spectrum of etiologies. The hepatorenal syndrome (HRS) represents a distinct type of renal failure, only seen in cirrhotic patients with ascites. The diagnostic criteria, knowledge in the pathophysiology of renal failure and HRS, and treatment hereof, have evolved tremendously during the last decades, and it is the aim of this review to summarize these discoveries. Areas covered: The focus will primarily be on treatment and prevention of renal failure and HRS, but areas concerning definition, diagnosis, including biomarkers, and pathophysiology, will also be covered through a comprehensive, critical reading of the latest literature, encompassing the most recent, updated, international guidelines, reviews and high-impact original literature. Expert commentary: The advances made in the understanding of the pathophysiology of HRS and other complications of cirrhosis within the recent decades, have provided the basis for improved diagnostic criteria and the development of treatments that have substantially increased survival rates in cirrhotic patients suffering from these conditions. Focus should, in the nearest future, be on continuing this positive development, thus further improving prognosis for cirrhotic patients with HRS.
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Affiliation(s)
- Troels M Busk
- a Department of Clinical Physiology and Nuclear Medicine , Centre of Functional Imaging and Research, Copenhagen University Hospital Hvidovre , Hvidovre , Denmark.,b Gastro Unit, Medical Division , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Flemming Bendtsen
- b Gastro Unit, Medical Division , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Søren Møller
- a Department of Clinical Physiology and Nuclear Medicine , Centre of Functional Imaging and Research, Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
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19
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Shan R, Yin H, Yang W, Li J, Zhang M, Zhao M, Shao J, Wang A. Influencing factors of transient elastography in detecting liver stiffness. Exp Ther Med 2016; 12:2302-2306. [PMID: 27698728 DOI: 10.3892/etm.2016.3617] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 05/20/2015] [Indexed: 12/20/2022] Open
Abstract
Liver stiffness, which correlates well with liver fibrosis stage, can be measured noninvasively by transient elastography, also known as Fibroscan. The present study aimed to determine the independent factors influencing Fibroscan detection by multiple regression analysis. A total of 181 patients who required liver biopsy were enrolled. Liver stiffness measurement (LSM) was detected by Fibroscan on the day of liver biopsy, while clinical information and routine biochemical examination results were also collected. Correlation was analyzed by Spearman's correlation, and multiple regression analysis was performed to analyze the independent influencing factors. The results demonstrated that platelet (PLT) levels, serum albumin (ALB), prothrombin activity (PTA) and body mass index (BMI) were independent predictors of liver stiffness. The contribution of these four predictors to the regression equation was in the following descending order: PLT (negative correlation) > ALB (negative correlation) > PTA (negative correlation) > BMI (positive correlation). In conclusion, the parameters of PLT, ALB, PTA and BMI are independent predicting factors affecting Fibroscan detection. Therefore, the diagnosis and evaluation of liver fibrosis should comprehensively consider the results of Fibroscan, and clinical and laboratory examinations.
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Affiliation(s)
- Rong Shan
- Department of Ultrasound, Jinan Infectious Disease Hospital, Jinan, Shandong 250021, P.R. China; Department of Ultrasound, Shandong University, Jinan, Shandong 250014, P.R. China
| | - Hong Yin
- Department of Ultrasound, Jinan Maternity and Child Care Hospital, Jinan, Shandong 250000, P.R. China
| | - Wenjuan Yang
- Department of Emergency, Jinan Center Hospital, Jinan, Shandong 250001, P.R. China
| | - Jianzhi Li
- Department of Ultrasound, Jinan Infectious Disease Hospital, Jinan, Shandong 250021, P.R. China
| | - Meifang Zhang
- Department of Ultrasound, Jinan Infectious Disease Hospital, Jinan, Shandong 250021, P.R. China
| | - Min Zhao
- Department of Ultrasound, Jinan Infectious Disease Hospital, Jinan, Shandong 250021, P.R. China
| | - Jiang Shao
- Department of Ultrasound, Jinan Infectious Disease Hospital, Jinan, Shandong 250021, P.R. China
| | - Aiguang Wang
- Department of Oncology, Qianfoshan Hospital Affiliated to Shandong University, Jinan, Shandong 250014, P.R. China
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20
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Huggins JT, Doelken P, Walters C, Rockey DC. Point-of-Care Echocardiography Improves Assessment of Volume Status in Cirrhosis and Hepatorenal Syndrome. Am J Med Sci 2016; 351:550-3. [PMID: 27140719 DOI: 10.1016/j.amjms.2016.02.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 01/28/2015] [Indexed: 01/04/2023]
Abstract
The management of patients with cirrhosis along with acute kidney injury is complex and depends in large part on accurate assessment of intravascular volume status. Assessment of intravascular volume status by point-of-care echocardiography often relies solely on inferior vena cava size and variability evaluation; however, this parameter should be interpretated with an understanding of right ventricular function integrated with stroke volume and flow. Attempts to optimize intra-abdominal hemodynamics favorably are clearly problematic when physical examination findings or rudimentary assessments of central venous pressure or change in central venous pressure are used. Here, we have demonstrated the potential utility of point-of-care echocardiography to optimize the hemodynamic state in patients with decompensated cirrhosis along with acute kidney injury. This case is very unique and describes how this technique may have great promise in optimizing the intra-abdominal hemodynamics and predict the timing of large-volume paracentesis in patients with decompensated cirrhosis, which in turn can aid in promoting favorable renal recovery.
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Affiliation(s)
- John Terrill Huggins
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Peter Doelken
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, New York
| | - Chet Walters
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Don C Rockey
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
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21
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McPherson S, Dyson J, Austin A, Hudson M. Response to the NCEPOD report: development of a care bundle for patients admitted with decompensated cirrhosis-the first 24 h. Frontline Gastroenterol 2016; 7:16-23. [PMID: 26834955 PMCID: PMC4717433 DOI: 10.1136/flgastro-2014-100491] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 09/22/2014] [Accepted: 09/28/2014] [Indexed: 02/04/2023] Open
Abstract
Recently, there has been a significant increase in the prevalence of chronic liver disease in the UK, and as a result, hospital admissions and deaths due to liver disease have also increased. The 2013 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) of patients with alcohol-related liver disease (ARLD) found that less than half the number of patients who died from ARLD received 'good care', and avoidable deaths were identified. In order to improve the care of patients admitted with ARLD, the NCEPOD report recommended that a 'toolkit' for the acute management of patients admitted with decompensated ARLD be developed and made widely available. As a result, we have developed a 'care bundle' for patients admitted with decompensated cirrhosis (of all aetiologies) to ensure that effective evidence-based treatments are delivered within the first 24 h. This care bundle provides a checklist to ensure that all appropriate investigations are undertaken when a patient with decompensated cirrhosis presents and provides clinicians with clear guidance on the initial management of alcohol withdrawal, infection, acute kidney injury, gastrointestinal bleeding and encephalopathy. The first 24 h are particularly important, as early intervention can reduce mortality and shorten hospital stay, and specialist gastroenterology/liver advice is not always available during this period. This review will discuss the care bundle and the evidence base behind the treatment recommendations made.
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Affiliation(s)
- Stuart McPherson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Jessica Dyson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Austin
- Department of Gastroenterology, Derby Hospitals NHS Foundation Trust, Derby, UK
- British Society of Gastroenterology, Liver Section, London, UK
| | - Mark Hudson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- British Association for the Study of the Liver, London, UK
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22
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Bucsics T, Mandorfer M, Schwabl P, Bota S, Sieghart W, Ferlitsch A, Trauner M, Peck-Radosavljevic M, Reiberger T. Impact of acute kidney injury on prognosis of patients with liver cirrhosis and ascites: A retrospective cohort study. J Gastroenterol Hepatol 2015; 30:1657-65. [PMID: 25967931 DOI: 10.1111/jgh.13002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Acute kidney injury (AKI) is a common complication in patients with liver cirrhosis, and its impact on the clinical course is increasingly recognized. Diagnostic classification systems for AKI in cirrhosis have been suggested. The prognostic significance of the respective AKI stages remains to be evaluated in decompensated cirrhosis with ascites. METHODS Data of consecutive patients with cirrhosis and ascites undergoing paracentesis at a tertiary care center were analyzed. AKI was defined as an increase in serum creatinine of ≥ 0.3 mg/dL or by ≥ 50% within 7 days after paracentesis, and classified according to (i) revised Acute Kidney Injury Network (AKIN) criteria and (ii) modified AKI criteria for cirrhosis (C-AKI). In contrast to AKIN, C-AKI stage A discriminates prognosis based on an absolute creatinine cut-off at < 1.5 mg/dL versus C-AKI stage B at ≥ 1.5 mg/dL. RESULTS The final study cohort included 239 patients. Median transplant-free survival was 768 days (95% confidence interval [CI]: 331-1205 days) without AKI, 198 (0-446) in AKI-1, 91 (0-225) in AKI-2, 19 (0-40) and in AKI-3, whereas it was 89 (20-158) days in C-AKI-A, 384 (0-1063) in C-AKI-B, and 22 (7-776) in C-AKI-C. Mild AKI was already associated with significantly increased 30-day mortality (AKI-1:26.4%, C-AKI-A:33.3%) as compared with patients without AKI (14.3%), even when serum creatinine remained within normal range (< 1.2 mg/dL) we observed a significant 30-day mortality. CONCLUSION AKIN criteria-considering small increases in serum creatinine rather than absolute thresholds-seem to be more accurate for estimating prognosis of AKI after paracentesis than C-AKI criteria. Even patients developing AKI-1 with "normal" serum creatinine are at increased risk for mortality.
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Affiliation(s)
- Theresa Bucsics
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Simona Bota
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Sieghart
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Arnulf Ferlitsch
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
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23
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Abstract
Patients with cirrhosis and portal hypertension are at an increased risk of the development of circulatory dysfunction that may potentially result in multiple organ failure. Apart from the liver, this may involve the heart, lungs, kidneys, the immune system, the adrenal glands, and other organ systems. As the disease progresses, the circulation becomes hyperdynamic, and signs of cardiac, pulmonary, and renal dysfunction are observed, in addition to reduced survival. Infections and an altered cardiac function known as cirrhotic cardiomyopathy may be precipitators for the development of other complications such as hepatorenal syndrome. In patients with chronic organ dysfunction, various precipitating events may induce an acute-on-chronic renal failure and acute-on-chronic liver failure that negatively affect the prognosis. Future research on the pathophysiologic mechanisms of the complications and the precipitating factors is essential to understand the basics of the treatment of these challenging conditions. The aim of the present review is to focus on the development and precipitating factors of various organ failures in patients with decompensated cirrhosis.
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Abstract
Acute-on-chronic liver failure combines an acute deterioration in liver function in an individual with pre-existing chronic liver disease and hepatic and extrahepatic organ failures, and is associated with substantial short-term mortality. Common precipitants include bacterial and viral infections, alcoholic hepatitis, and surgery, but in more than 40% of patients, no precipitating event is identified. Systemic inflammation and susceptibility to infection are characteristic pathophysiological features. A new diagnostic score, the Chronic Liver Failure Consortium (CLIF-C) organ failure score, has been developed for classification and prognostic assessment of patients with acute-on-chronic liver failure. Disease can be reversed in many patients, and thus clinical management focuses upon the identification and treatment of the precipitant while providing multiorgan-supportive care that addresses the complex pattern of physiological disturbance in critically ill patients with liver disease. Liver transplantation is a highly effective intervention in some specific cases, but recipient identification, organ availability, timing of transplantation, and high resource use are barriers to more widespread application. Recognition of acute-on-chronic liver failure as a clinically and pathophysiologically distinct syndrome with defined diagnostic and prognostic criteria will help to encourage the development of new management pathways and interventions to address the unacceptably high mortality.
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, King's College Hospital, London, UK.
| | - Rajiv Jalan
- Liver Failure Group, Division of Medicine, University College London, London, UK; Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Alberto Quaglia
- Histopathology Section, Institute of Liver Studies, King's College Hospital, London, UK
| | - Kenneth Simpson
- Department of Hepatology, University of Edinburgh, Edinburgh, UK
| | - Julia Wendon
- Liver Intensive Therapy Unit, King's College Hospital, London, UK
| | - Andrew Burroughs
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
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25
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Spadaro L, Privitera G, Fede G, Magliocco O, Russello M, Piro S, Rabuazzo AM, Purrello F. Diabetes increases renovascular impedance in patients with liver cirrhosis. Intern Emerg Med 2015; 10:703-9. [PMID: 25863499 DOI: 10.1007/s11739-015-1235-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 03/17/2015] [Indexed: 12/11/2022]
Abstract
Renal failure is a common complication of cirrhosis and is associated with poor prognosis. Several reports have demonstrated the clinical utility of renal resistive indices in the assessment of renal function in cirrhosis patients. It is unknown whether the occurrence of diabetes affects renal haemodynamic indices in patients with cirrhosis. Therefore, the aim of our study was to compare renal Doppler indices in cirrhotic patients with and without type 2 diabetes mellitus (T2DM) and in diabetics without cirrhosis, and to relate the Doppler parameters to albuminuria. We evaluated 89 consecutive patients with normal renal functioning, including 37 with cirrhosis and T2DM (CD-Group), 41 with cirrhosis without diabetes (C-Group) and 11 with diabetes without cirrhosis (D-Group). The kidney pulsatility index (PI) and resistance index (RI) were measured by Doppler ultrasound. Renal function was expressed as the estimated glomerular filtration rate (eGFR) using the modification of diet in renal disease (MDRD) formula. Microalbuminuria (µAlb) was also evaluated. No significant differences were observed with respect to age, the Child-Pugh class or the serum creatinine level. The eGFR was mildly reduced in the CD-Group compared with the C-Group and D-Group, and µAlb was present in 24.4 % of the patients in the CD-Group and in 9 % of those in the D-Group. The PI and RI were significantly increased in the CD-Group and D-Group compared with the C-Group. Both the PI and RI were significantly associated with µAlb independent of age and Child-Pugh class. The novel finding of this study was that T2DM potentially impairs renal haemodynamics in patients with cirrhosis.
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Affiliation(s)
- Luisa Spadaro
- Department of Experimental and Clinical Medicine, Garibaldi Hospital Catania, University of Catania, Via Palermo, 636, 95122, Catania, Italy
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Sobhonslidsuk A. Current position of vasoconstrictor and albumin infusion for type 1 hepatorenal syndrome. World J Gastrointest Pharmacol Ther 2015; 6:28-31. [PMID: 26261732 PMCID: PMC4526839 DOI: 10.4292/wjgpt.v6.i3.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/11/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP), refractory ascites, hepatorenal syndrome (HRS), hyponatremia and hepatic encephalopathy are complications which frequently happen during a clinical course of decompensated cirrhosis. Splanchnic and peripheral vasodilatation, increased intrarenal vasoconstriction and impaired cardiac responsive function are pathological changes causing systemic and hemodynamic derangement. Extreme renal vasoconstriction leads to severe reduction of renal blood flow and glomerular filtration rate, which finally evolves into the clinical feature of HRS. Clinical manifestations of type 1 and type 2 HRS come to medical attention differently. Patients with type 1 HRS present as acute kidney injury whereas those with type 2 HRS will have refractory ascites as the leading problem. Prompt diagnosis of type 1 HRS can halt the progression of HRS to acute tubular necrosis if the combined treatment of albumin infusion and vasoconstrictors is started timely. HRS reversal was seen in 34%-60% of patients, followed with decreasing mortality. Baseline serum levels of creatinine less than 5 mg/dL, bilirubin less than 10 mg/dL, and increased mean arterial pressure of over 5 mmHg by day 3 of the combined treatment of vasoconstrictor and albumin are the predictors of good response. Type 1 HRS can be prevented in some conditions such as albumin infusion in SBP, prophylactic antibiotics for upper gastrointestinal hemorrhage, albumin replacement after large volume paracentesis in cirrhotic patients with massive ascites. The benefit of albumin infusion in infection with primary source other than SBP requires more studies.
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27
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Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of advanced cirrhosis. Type 1 hepatorenal syndrome is the best-known and most severe form of AKI, and it has a precise definition and a set of specific diagnostic criteria. More recently, it has become recognized that milder degrees of renal dysfunction also have a negative impact on patient outcome in various patient populations. Key Messages: Several definitions and criteria for staging the severity of AKI have been proposed, including the RIFLE (Risk, Injury, Failure, Loss of Function and End-Stage Renal Disease) group, the Acute Kidney Injury Network (AKIN), and the Kidney Disease: Improving Global Outcome (KDIGO) group. All of them incorporate some changes of serum creatinine and urine output in the definition and staging of AKI. The hepatology community has mostly embraced the AKIN diagnostic and staging criteria and has applied them in the prognostication of patients with advanced cirrhosis. However, the AKIN criteria have not been strictly applied in all studies on cirrhosis. This is partly related to the fact that changes in urine output are difficult to assess in advanced cirrhosis, and partly related to the difficulty in defining the baseline serum creatinine from which the change in serum creatinine is calculated. This has led to some confusion in the interpretation of results of the various studies on AKI in cirrhosis. More recently, some investigators have suggested incorporating the AKIN criteria with setting a lower limit of serum creatinine of 1.5 mg/dl in determining the diagnosis and prognosis of AKI in cirrhosis. CONCLUSIONS This is an ongoing debate as to how best to define AKI in cirrhosis. In the near future there should be prospective clinical trials that will clarify which diagnostic and staging criteria of AKI will best serve the cirrhotic population.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ont., Canada
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28
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Wong F. Treatment to improve acute kidney injury in cirrhosis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2015; 13:235-48. [PMID: 25773606 DOI: 10.1007/s11938-015-0050-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OPINION STATEMENT Acute kidney injury (AKI) is an ominous complication of decompensated cirrhosis, which can be fatal if not treated promptly. It is important that clinicians recognize that AKI has occurred and institute timely treatment. Recent establishment of diagnostic criteria and treatment guidelines are most useful, and these will be further refined as treatments are being modified to improve patient outcome. To manage such a patient, firstly, the cause of the AKI needs to be identified and any precipitating factors corrected. Bacterial infections are a common cause of AKI in cirrhosis, and it is recommended to offer empirical antibiotics in cases of suspicious bacterial infection until all the cultures are negative. Patients should be given albumin infusion in doses of 1 g/kg of body weight for at least 2 days. This can improve the filling of the central circulation, and also absorb many of the bacterial products or inflammatory cytokines that play a role in mediating the renal dysfunction. Often, albumin infusion alone may be sufficient to reverse the AKI. For patients who have acute or type 1 hepatorenal syndrome (HRS1), which is a special form of AKI, pharmacotherapy in the form of vasoconstrictor will be needed. The vasoconstrictor can be terlipressin, norepinephrine, or midodrine, depending on the local availability of drugs or facilities. Currently, approximately 40 % of patients will respond to a combination of vasoconstrictor and albumin. All patients with HRS1 should be assessed for liver transplant. If accepted for liver transplantation, those patients who do not respond to vasocontrictors and albumin need to be started on renal replacement therapy, which otherwise has no place in the treatment of HRS1. Once listed, liver transplantation should occur promptly, preferable under 2 weeks. Otherwise, the chances for renal recovery after liver transplant are significantly reduced, necessitating a renal transplant at the future date.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada,
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29
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Londoño MC, Abraldes JG, Altamirano J, Decaens T, Forns X. Clinical trial watch: reports from the AASLD Liver Meeting®, Boston, November 2014. J Hepatol 2015; 62:1196-203. [PMID: 25646885 DOI: 10.1016/j.jhep.2015.01.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 12/26/2022]
Abstract
The late and fast developments in the field of viral hepatitis were highly expected in the 2014 AASLD Liver Meeting®. Several combinations using direct acting antivirals (DAAs) showed high rates of sustained virological response (∼95%). Importantly, high cure rates were also demonstrated in patients with previous treatment failures, decompensated cirrhosis and hepatitis C recurrence after transplantation, making it clear that the interferon era is over (not so clear for ribavirin, which might still have a role in difficult-to-treat populations). Importantly, sustained virological response was associated with an improvement in liver function (MELD and Child-Pugh scores) in patients with advanced liver disease. In the field of liver cirrhosis, there were relevant data assessing the optimal empirical antibiotic therapy in patients with spontaneous bacterial peritonitis and high risk of resistant bacteria, as well as studies evaluating the role of terlipressin in type I hepatorenal syndrome and in septic shock. Regarding hepatic encephalopathy, two randomized trials suggest that the manipulation of the microbioma in patients with cirrhosis may have a role in the management of this complication. Some novel data on NASH support the beneficial effect of bariatric surgery (after failure of lifestyle intervention) in morbid obese patients with such diagnosis: clinical and histological improvements after surgery were evident in most patients with sufficient follow-up. A few controlled studies focused on the treatment of severe acute alcoholic hepatitis. Finally, several studies on hepatocellular carcinoma (HCC) were presented, covering topics such as ultrasound screening in cirrhosis, cryoablation treatment of early HCC and the relevance of downstaging in patients with HCC awaiting liver transplantation.
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Affiliation(s)
- María-Carlota Londoño
- Liver Unit, Hospital Clínic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Juan G Abraldes
- Cirrhosis Care Clinic (CCC), Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - José Altamirano
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain
| | - Thomas Decaens
- Universités de Grenoble, CHU de Grenoble, Pôle DIGI-DUNE, Service d'Hépatologie et de Gastroentérologie, INSERM U823, Institut Albert Bonniot, Grenoble, France
| | - Xavier Forns
- Liver Unit, Hospital Clínic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain.
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30
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Angeli P, Gines P, Wong F, Bernardi M, Boyer TD, Gerbes A, Moreau R, Jalan R, Sarin SK, Piano S, Moore K, Lee SS, Durand F, Salerno F, Caraceni P, Kim WR, Arroyo V, Garcia-Tsao G. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut 2015; 64:531-7. [PMID: 25631669 DOI: 10.1136/gutjnl-2014-308874] [Citation(s) in RCA: 344] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Pere Gines
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain Instituto Reina Sofia d'Investigación en Nefrologia (IRSIN), Barcelona, Spain
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mauro Bernardi
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Thomas D Boyer
- Department of Medicine, Liver Research Institute, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Alexander Gerbes
- Liver Unit, Klinikum Munich, Ludwig Maximilian University of Munich, Munich, Germany
| | - Richard Moreau
- Inserm U1149, Centre de recherche sur l'Inflammation (CRI), Paris, France UMR S_1149, Université Paris Diderot, Paris, France DHU UNITY, Service d'hépatologie, Hôpital Beaujon, APHP, Clichy, France
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Salvatore Piano
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Kevin Moore
- UCL Institute of Liver and Digestive Health, Royal Free Campus, University College London, London, UK
| | - Samuel S Lee
- Liver Unit, University of Calgary, Calgary, Canada
| | - Francois Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France INSERM U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3, Clichy, France
| | - Francesco Salerno
- Policlinico IRCCS San Donato, Medicina Interna ed Epatologia, Università di Milano, Milan, Italy
| | - Paolo Caraceni
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University Medical School, Palo Alto, California, USA
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
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31
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Angeli P, Ginès P, Wong F, Bernardi M, Boyer TD, Gerbes A, Moreau R, Jalan R, Sarin SK, Piano S, Moore K, Lee SS, Durand F, Salerno F, Caraceni P, Kim WR, Arroyo V, Garcia-Tsao G. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. J Hepatol 2015; 62:968-74. [PMID: 25638527 DOI: 10.1016/j.jhep.2014.12.029] [Citation(s) in RCA: 473] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 12/17/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine-DIMED, University of Padova, Padova, Italy.
| | - Pere Ginès
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain; Instituto Reina Sofia d'Investigación en Nefrologia (IRSIN), Barcelona, Spain
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mauro Bernardi
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Thomas D Boyer
- Department of Medicine, Liver Research Institute, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Alexander Gerbes
- Liver Unit, Klinikum Munich, Ludwig Maximilian University of Munich, Munich, Germany
| | - Richard Moreau
- Inserm U1149, Centre de recherche sur l'Inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; DHU UNITY, Service d'hépatologie, Hôpital Beaujon, APHP, Clichy, France
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Salvatore Piano
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Kevin Moore
- UCL Institute of Liver and Digestive Health, Royal Free Campus, University College London, London, UK
| | - Samuel S Lee
- Liver Unit, University of Calgary, Calgary, Canada
| | - Francois Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France; INSERM U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3, Clichy, France
| | - Francesco Salerno
- Policlinico IRCCS San Donato, Medicina Interna ed Epatologia, Università di Milano, Milan, Italy
| | - Paolo Caraceni
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University Medical School, Palo Alto, California, USA
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
Hepatorenal syndrome (HRS) is one of the most detrimental conditions in patients with end stage liver cirrhosis and acute liver failure, with high morbidity and mortality. The pathophysiology of HRS is complex and has not been fully elucidated. The therapeutic approaches for HRS are limited, among them, terlipressin in combination with albumin infusion is the first line choice. Liver transplantation remains the most effective treatment method. Patients with HRS often experience poor prognosis and have low survival, and early diagnosis of HRS may play a critical role in making treatment plans and improving the prognosis. Currently, it is needed to enhance the reliability of diagnostic methods and the feasibility of therapeutic regimens, which can improve the quality of life and reduce the family and social financial burden. The aim of this review is to summarize the recent advances in understanding the pathophysiology, diagnosis and management of HRS.
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33
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Reply to: "A cut-off serum creatinine value of 1.5 mg/dl for AKI--to be or not to be". J Hepatol 2015; 62:744-6. [PMID: 25485796 DOI: 10.1016/j.jhep.2014.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 11/27/2014] [Accepted: 12/01/2014] [Indexed: 12/30/2022]
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Møller S, Henriksen JH, Bendtsen F. Extrahepatic complications to cirrhosis and portal hypertension: Haemodynamic and homeostatic aspects. World J Gastroenterol 2014; 20:15499-15517. [PMID: 25400435 PMCID: PMC4229516 DOI: 10.3748/wjg.v20.i42.15499] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/06/2014] [Accepted: 06/23/2014] [Indexed: 02/07/2023] Open
Abstract
In addition to complications relating to the liver, patients with cirrhosis and portal hypertension develop extrahepatic functional disturbances of multiple organ systems. This can be considered a multiple organ failure that involves the heart, lungs, kidneys, the immune systems, and other organ systems. Progressive fibrosis of the liver and subsequent metabolic impairment leads to a systemic and splanchnic arteriolar vasodilatation. This affects both the haemodynamic and functional homeostasis of many organs and largely determines the course of the disease. With the progression of the disease, the circulation becomes hyperdynamic with cardiac, pulmonary as well as renal consequences for dysfunction and reduced survival. Infections and a changed cardiac function known as cirrhotic cardiomyopathy may be involved in further aggravation of other complications such as renal failure precipitating the hepatorenal syndrome. Patients with end-stage liver disease and related complications as for example the hepatopulmonary syndrome can only radically be treated by liver transplantation. As a bridge to this treatment, knowledge on the mechanisms of the pathophysiology of complications is essential for the choice of vasoactive drugs, antibiotics, drugs with specific effects on fibrogenesis and inflammation, and drugs that target specific receptors.
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35
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Frequency, pattern and short-term outcome of chronic renal dysfunction in patients with cirrhosis: a prospective study using HRS and ADQI-IAC criteria. Eur J Gastroenterol Hepatol 2014; 26:1296-9. [PMID: 25171022 DOI: 10.1097/meg.0000000000000173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diagnostic criteria of hepatorenal syndrome type 2 (HRS2) fail to detect milder degrees of chronic renal dysfunction (CRD) in cirrhosis and exclude patients with pre-existing kidney disease. Definitions addressing this have been proposed by Working Party of the Acute Dialysis Quality Initiative and International Ascites Club (ADQI-IAC). AIMS We studied the frequency, pattern and short-term outcome of CRD in patients with cirrhosis, using both HRS2 and ADQI-IAC criteria. PATIENTS AND METHODS Consecutive patients with cirrhosis and stable serum creatinine for 3 months or more attending outpatient clinics in Colombo North Teaching Hospital (Ragama, Sri Lanka) were prospectively recruited and followed up. RESULTS Of 277 patients with cirrhosis and stable serum creatinine, 23 (8.3%) fulfilled criteria for HRS2, and 65/277 (23.5%) had estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m [ADQI-IAC definition of chronic kidney disease (CKD)]. This included the 23 patients with HRS2 and an additional 42/65 (64.6%) who did not fulfil diagnostic criteria for HRS2 (non-HRS2 CKD). In all, 58/277 (20.9%) died during follow-up [mean 9.8 months (SD 4.5)]. This included 12/23 (52.2%) with HRS2 and 14/42 (33.3%) with non-HRS2 CKD. On the basis of multiple regression model, Child-Turcotte-Pugh class and CRD were significantly associated with death. After correcting for Child-Turcotte-Pugh class, both HRS2 (odds ratio 4.56, 95% confidence interval 1.79-11.53) and non-HRS2 CKD (odds ratio 2.19, 95% confidence interval 1.02-4.68) were independently associated with death. CONCLUSION Compared with HRS2 criteria, eGFR less than 60 ml/min/1.73 m detected almost twice the number of cirrhotics with CRD. Patients with eGFR less than 60 ml/min/1.73 m who did not fulfil criteria for HRS2 also had significant short-term mortality. ADQI-IAC criteria thus appear to be a more useful definition of CRD in cirrhotics.
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Ishii M, Mizuguchi T, Harada K, Ota S, Meguro M, Ueki T, Nishidate T, Okita K, Hirata K. Comprehensive review of post-liver resection surgical complications and a new universal classification and grading system. World J Hepatol 2014; 6:745-751. [PMID: 25349645 PMCID: PMC4209419 DOI: 10.4254/wjh.v6.i10.745] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/01/2014] [Accepted: 09/17/2014] [Indexed: 02/06/2023] Open
Abstract
Liver resection is the gold standard treatment for certain liver tumors such as hepatocellular carcinoma and metastatic liver tumors. Some patients with such tumors already have reduced liver function due to chronic hepatitis, liver cirrhosis, or chemotherapy-associated steatohepatitis before surgery. Therefore, complications due to poor liver function are inevitable after liver resection. Although the mortality rate of liver resection has been reduced to a few percent in recent case series, its overall morbidity rate is reported to range from 4.1% to 47.7%. The large degree of variation in the post-liver resection morbidity rates reported in previous studies might be due to the lack of consensus regarding the definitions and classification of post-liver resection complications. The Clavien-Dindo (CD) classification of post-operative complications is widely accepted internationally. However, it is hard to apply to some major post-liver resection complications because the consensus definitions and grading systems for post-hepatectomy liver failure and bile leakage established by the International Study Group of Liver Surgery are incompatible with the CD classification. Therefore, a unified classification of post-liver resection complications has to be established to allow comparisons between academic reports.
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Adebayo D, Morabito V, Davenport A, Jalan R. Renal dysfunction in cirrhosis is not just a vasomotor nephropathy. Kidney Int 2014; 87:509-15. [PMID: 25296092 PMCID: PMC4346614 DOI: 10.1038/ki.2014.338] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 04/17/2014] [Accepted: 04/17/2014] [Indexed: 12/13/2022]
Abstract
The short-term mortality of cirrhotic patients who develop renal dysfunction remains unacceptably high, and as such the treatment of this condition is an unmet need. Although features of kidney injury are well recognized in these patients, the pathophysiology is complex and not completely understood. Improved understanding of the pathophysiological mechanisms involved in renal dysfunction occurring on a background of cirrhosis is key to developing effective treatment strategies to improve survival. Renal dysfunction due to hepatorenal syndrome (HRS) is characteristic of cirrhosis. Our current understanding is that HRS is functional in nature and occurs as a consequence of hemodynamic changes associated with portal hypertension. However, there is evidence in the literature suggesting that, histologically, the kidneys are not always normal in the vast majority of patients who present with renal dysfunction on the background of cirrhosis. Furthermore, there is emerging data implicating nonvasomotor mechanisms in the pathophysiology of renal dysfunction in cirrhosis. This mini-review aims to present the evidence suggesting that factors other than hemodynamic dysregulation have an important role in the development of this major complication for patients with progressive cirrhosis.
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Affiliation(s)
- Danielle Adebayo
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Vincenzo Morabito
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
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Immunologic, hemodynamic, and adrenal incompetence in cirrhosis: impact on renal dysfunction. Hepatol Int 2014; 9:17-27. [DOI: 10.1007/s12072-014-9581-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 08/28/2014] [Indexed: 12/20/2022]
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Møller S, Krag A, Bendtsen F. Kidney injury in cirrhosis: pathophysiological and therapeutic aspects of hepatorenal syndromes. Liver Int 2014; 34:1153-63. [PMID: 24673771 DOI: 10.1111/liv.12549] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 03/19/2014] [Indexed: 02/13/2023]
Abstract
Acute kidney injury (AKI) is frequent in patients with cirrhosis. AKI and hyponatraemia are major determinants of the poor prognosis in advanced cirrhosis. The hepatorenal syndrome (HRS) denotes a functional and potential reversible impairment of renal function. Type 1 HRS, a special type of AKI, is a rapidly progressive AKI, whereas the renal function in type 2 HRS decreases more slowly. HRS is precipitated by factors such as sepsis that aggravate the effective hypovolaemia in decompensated cirrhosis, by lowering arterial pressure and cardiac output and enhanced sympathetic nervous activity. Therefore, attempts to prevent and treat HRS should seek to improve liver function and to ameliorate arterial hypotension, central hypovolaemia and cardiac output, and to reduce renal vasoconstriction. Ample treatment of HRS is important to prevent further progression and death, but as medical treatment only modestly improves long-term survival, these patients should always be considered for liver transplantation. Hyponatraemia, defined as serum sodium <130 mmol/L, is common in patients with decompensated cirrhosis. From a pathophysiological point of view, hyponatraemia is related to an impairment of renal solute-free water excretion most likely caused by an increased vasopressin secretion. Patients with cirrhosis mainly develop hypervolaemic hyponatraemia. Current evidence does not support routine use of vaptans in the management of hyponatraemia in cirrhosis.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology 239, Center of Functional and Diagnostic Imaging and Research, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
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Sanyal AJ, Abdelmalek MF, Suzuki A, Cummings OW, Chojkier M. No significant effects of ethyl-eicosapentanoic acid on histologic features of nonalcoholic steatohepatitis in a phase 2 trial. Gastroenterology 2014; 147:377-84.e1. [PMID: 24818764 DOI: 10.1053/j.gastro.2014.04.046] [Citation(s) in RCA: 221] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 04/04/2014] [Accepted: 04/25/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS n-3 polyunsaturated fatty acids reduce insulin resistance, lipogenesis, and inflammation, which are features of nonalcoholic steatohepatitis (NASH). Ethyl-eicosapentanoic acid (EPA-E) is a synthetic polyunsaturated fatty acid that reduces hypertriglyceridemia. We report the final results of a phase 2b multicenter, prospective, double-blind, randomized, placebo-controlled trial of EPA-E for NASH. METHODS Our study, performed at 37 sites in North America, included subjects with NASH and nonalcoholic fatty liver disease (NAFLD) activity scores ≥ 4, with minimum scores of 1 for steatosis and inflammation, along with either ballooning or at least stage 1a fibrosis. A total of 243 subjects were randomly assigned to groups given placebo (n = 75), low-dosage EPA-E (1800 mg/d; n = 82), or high-dosage EPA-E (2700 mg/d; n = 86) for 12 months. Subjects were examined at 4-week intervals for 3 months, 6-week intervals for the next 3 months, and every 3 months thereafter, until 1 month after the last dose was taken. Liver biopsies were collected 2 weeks after the last dose of EPA-E or placebo. The primary efficacy end point was NAFLD activity score ≤ 3, without worsening of fibrosis; or a decrease in NAFLD activity score by ≥ 2 with contribution from >1 parameter, without worsening of fibrosis, 1 year after the last dose of EPA-E or placebo was given. RESULTS Similar proportions of subjects in each group met the primary end point (40%, 37%, and 35.9% for placebo, low-dosage, and high-dosage EPA-E, respectively). EPA-E had no significant effects on steatosis, inflammation, ballooning, or fibrosis scores. There were no significant effects on levels of liver enzymes, insulin resistance, adiponectin, keratin 18, high-sensitivity C-reactive protein, or hyaluronic acid. High-dosage EPA-E reduced levels of triglyceride (-6.5 mg/dL vs an increase of 12 mg/dL in the placebo group; P = .03). There were no treatment-related serious adverse events. CONCLUSIONS In a phase 2 trial, EPA-E had no significant effect on the histologic features of NASH. EPA-E reduced subjects' levels of triglyceride compared with placebo, without any increase in serious adverse events. Clinicaltrials.gov Number: 01154985.
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Affiliation(s)
- Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia.
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina
| | - Ayako Suzuki
- Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Division of Gastroenterology, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
| | - Oscar W Cummings
- Department of Pathology, Indiana University, Bloomington, Indiana
| | - Mario Chojkier
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California, San Diego, San Diego, California
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Abstract
Cirrhosis patients’ comorbidities are their other diseases than cirrhosis. Comorbidities are neither causes nor consequences of cirrhosis, but they can increase mortality and are therefore clinically important. They are also an important source of confounding in epidemiologic studies. Comorbidity scoring systems have been developed as tools to measure the cirrhosis patient’s total burden of comorbidity, and they are useful in the clinic and for epidemiologic studies. The recently developed CirCom score is the only comorbidity scoring system developed specifically for cirrhosis patients, and it may be preferred over the older, generic, and more complex Charlson comorbidity index. Studies of individual comorbid diseases can provide insight into the interactions between cirrhosis and other diseases and thus into the pathophysiology of cirrhosis. This article reviews the literature on comorbidity in cirrhosis.
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Leithead JA, Hayes PC, Ferguson JW. Review article: advances in the management of patients with cirrhosis and portal hypertension-related renal dysfunction. Aliment Pharmacol Ther 2014; 39:699-711. [PMID: 24528130 DOI: 10.1111/apt.12653] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 10/12/2013] [Accepted: 01/19/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND In cirrhosis, portal hypertension is associated with a spectrum of renal dysfunction that has significant implications for morbidity and mortality. AIM To discuss recent progress in the patho-physiological mechanisms and therapeutic options for portal hypertension-related renal dysfunction. METHODS A literature search using Pubmed was performed. RESULTS Portal hypertension-related renal dysfunction occurs in the setting of marked neuro-humoral and circulatory derangement. A systemic inflammatory response is a pathogenetic factor in advanced disease. Such physiological changes render the individual vulnerable to further deterioration of renal function. Patients are primed to develop acute kidney injury when exposed to additional 'hits', such as sepsis. Recent progress has been made regarding our understanding of the aetiopathogenesis. However, treatment options once hepatorenal syndrome develops are limited, and prognosis remains poor. Various strategies to prevent acute kidney injury are suggested. CONCLUSION Prevention of acute kidney injury in high risk patients with cirrhosis and portal hypertension-related renal dysfunction should be a clinical priority.
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Affiliation(s)
- J A Leithead
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK; NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
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Darstein F, König C, Hoppe-Lotichius M, Grimm D, Knapstein J, Mittler J, Lang H, Galle PR, Zimmermann T. Impact of pancreatic comorbidities in patients with end-stage liver disease on outcome after liver transplantation. Eur J Intern Med 2014; 25:281-5. [PMID: 24468121 DOI: 10.1016/j.ejim.2014.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 12/13/2013] [Accepted: 01/03/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Diseases leading to end-stage liver disease (ESLD), especially alcoholic liver cirrhosis cause comorbidities of the pancreas, too. The aim of this retrospective study was to determine the impact of pancreatic alterations diagnosed pretransplant on the outcome after liver transplantation (LT). METHODS In total, data from 372 LT patients were analyzed. Patients were followed up for a mean of 4.2 years. Incidence of chronic pancreatitis (CP), pancreatic cysts (PC) and intraductal papillary mucinous neoplasm (IPMN) was acquired retrospectively from patient's charts. RESULTS CP, IPMN and PC were rarely diagnosed in LT-recipients [CP (3.8%), PC (1.6%) and IPMN (1.6%)]. There was no significant correlation of IPMN, CP, PC and other patient characteristics. The prevalence of CP (log rank: p=0.315), PC (log rank: p=0.242) and IPMN (log rank: p=0.491) did not influence patient survival. CONCLUSION Frequency of radiological alterations of the pancreas in LT recipients (such as CP, PC, IPMN) diagnosed by sonography, CT scan or MRI is comparable to the non-transplant population. Short term survival of LT-recipients after transplantation is not reduced for patients with CP, PC and patients with branch-duct IPMN (with a low-risk for malignancy according to international consensus guidelines).
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Affiliation(s)
- Felix Darstein
- I. Medizinische Klinik der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Christina König
- I. Medizinische Klinik der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Maria Hoppe-Lotichius
- Viszeral- und Transplantationschirurgie der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Daniel Grimm
- I. Medizinische Klinik der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Johanna Knapstein
- I. Medizinische Klinik der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Jens Mittler
- Viszeral- und Transplantationschirurgie der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Hauke Lang
- Viszeral- und Transplantationschirurgie der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Peter Robert Galle
- I. Medizinische Klinik der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Tim Zimmermann
- I. Medizinische Klinik der Universitätsmedizin Mainz, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Germany.
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Piano S, Rosi S, Maresio G, Fasolato S, Cavallin M, Romano A, Morando F, Gola E, Frigo AC, Gatta A, Angeli P. Evaluation of the Acute Kidney Injury Network criteria in hospitalized patients with cirrhosis and ascites. J Hepatol 2013; 59:482-9. [PMID: 23665185 DOI: 10.1016/j.jhep.2013.03.039] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 03/07/2013] [Accepted: 03/10/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS For several years hepatologists have defined acute renal failure in patients with cirrhosis as an increase in serum creatinine (sCr) ≥ 50% to a final value of sCr>1.5mg/dl (conventional criterion). Recently, the Acute Kidney Injury Network (AKIN) defined acute renal failure as acute kidney injury (AKI) on the basis of an absolute increase in sCr of 0.3mg/dl or a percentage increase in sCr ≥ 50% providing also a staging from 1 to 3. AKIN stage 1 was defined as an increase in sCr ≥ 0.3mg/dl or increase in sCr ≥ 1.5-fold to 2-fold from baseline. AKI diagnosed with the two different criteria was evaluated for the prediction of in-hospital mortality. METHODS Consecutive hospitalized patients with cirrhosis and ascites were included in the study and evaluated for the development of AKI. RESULTS Conventional criterion was found to be more accurate than AKIN criteria in improving the prediction of in-hospital mortality in a model including age and Child-Turcotte-Pugh score. The addition of either progression of AKIN stage or a threshold value for sCr of 1.5mg/dl further improves the value of AKIN criteria in this model. More in detail, patients with AKIN stage 1 and sCr<1.5mg/dl had a lower mortality rate (p=0.03), a lower progression rate (p=0.01), and a higher improvement rate (p=0.025) than patients with AKIN stage 1 and sCr ≥ 1.5mg/dl. CONCLUSIONS Conventional criterion is more accurate than AKIN criteria in the prediction of in-hospital mortality in patients with cirrhosis and ascites. The addition of either the progression of AKIN stage or the cut-off of sCr ≥ 1.5mg/dl to the AKIN criteria improves their prognostic accuracy.
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Affiliation(s)
- Salvatore Piano
- Department of Medicine (DIMED), University of Padova, Padova, Italy
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Chen YW, Tsai CF, Wang TE, Chang CW, Pan CF, Wu CJ, Chen HH. Cautious application of the hepatorenal syndrome criteria to critically ill patients with cirrhosis. Liver Int 2013; 33:959-60. [PMID: 23560886 DOI: 10.1111/liv.12167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Yu-Wei Chen
- Division of Nephrology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Chia-Fu Tsai
- Division of Chest Medicine; Department of Internal Medicine; Changhua Christian Hospital; Changhua Taiwan
| | - Tsang-En Wang
- Division of Gastroenterology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Ching-Wei Chang
- Division of Gastroenterology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Chi-Feng Pan
- Division of Nephrology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Chih-Jen Wu
- Division of Nephrology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Han-Hsiang Chen
- Division of Nephrology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
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