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Hsieh MH, Kao TY, Hsieh TH, Kao CC, Peng CY, Lai HC, Cheng HH, Ho MW, Chi CY, Kao JT. Predictors of liver fibrosis changes assessed by paired liver biopsies in chronic hepatitis C patients treated with direct-acting antivirals. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024:S1684-1182(24)00149-X. [PMID: 39216998 DOI: 10.1016/j.jmii.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 07/15/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND/PURPOSE There are limited studies performing paired liver biopsies in chronic hepatitis C (CHC) patients treated with direct-acting antivirals (DAA). We aimed to investigate the predictors of liver fibrosis changes assessed by paired liver biopsies in these patients. METHODS From March 2017 to March 2020, 113 CHC patients were prospectively enrolled to receive DAA therapy at our hospital. Paired liver biopsies were performed at baseline and 12 weeks after the end of treatment. RESULTS Among the entire cohort, the rate of sustained virological response (SVR) was 100%. Four baseline variables independently predicted fibrosis regression, including age <65 years [odds ratio (OR) = 2.725, p = 0.036], fibrosis stages (METAVIR scores) < 3 (OR = 4.874, p = 0.040), hemoglobin levels ≥12.5 g/dL (OR = 3.538, p = 0.029), and platelet counts ≥160 103/μL (OR = 2.958, p = 0.023). Besides, five independent predictors of fibrosis progression included baseline age ≥66 years (OR = 16.351, p = 0.024), body mass index (BMI) ≥26.5 kg/m2 (OR = 21.666, p = 0.009), sofosbuvir/ribavirin use (OR = 29.465, p = 0.031), platelet counts <119 103/μL (OR = 33.739, p = 0.026), and the absence of alanine aminotransferase (ALT) levels declining from >35 U/L at baseline to ≤35 U/L at 4 weeks after baseline (OR = 284.534, p = 0.026). CONCLUSION For DAA-treated CHC patients, those with baseline age <65 years, fibrosis stages <3, hemoglobin levels ≥12.5 g/dL, or platelet counts ≥160 103/μL are more likely to attain fibrosis regression. There is a higher risk of fibrosis progression in those with baseline age ≥66 years, BMI ≥26.5 kg/m2, sofosbuvir/ribavirin use, platelet counts <119 103/μL, or the absence of early ALT normalization at 4 weeks after baseline.
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Affiliation(s)
- Ming-Han Hsieh
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Tzu-Yu Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ting-Hui Hsieh
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Chi Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Yuan Peng
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsueh-Chou Lai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsing-Hung Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Mao-Wang Ho
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Yu Chi
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Jung-Ta Kao
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.
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Martínez-Alarcón L, Martínez-Nicolás A, Jover-Aguilar M, López-López V, Alconchel-Gago F, Ríos A, Madrid JA, de los Ángeles Rol M, Ramírez P, Ramis G. Relationship between Circadian System Status, Child-Pugh Score, and Clinical Outcome in Cirrhotic Patients on Waiting Lists for Liver Transplantation. J Clin Med 2024; 13:4529. [PMID: 39124795 PMCID: PMC11313636 DOI: 10.3390/jcm13154529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: Many patients suffering from liver cirrhosis are eventually added to waiting lists for liver transplantation whose priority is established based on scales such as the Child-Pugh score. However, two marker rhythms of the circadian system, motor activity and distal temperature, are not evaluated. Methods: To determine the relationship between the functional status of the circadian system and the Child-Pugh scale in patients awaiting liver transplantation, distal temperature, motor activity, and light exposure rhythms were monitored for a full week using a wrist device (Kronowise 6.0) in 63 patients (17 women, 46 men) aged between 20 and 76 years. Results: Circadian parameters (amplitude, regularity, and fragmentation) of motor activity rhythms, distal temperature, and light exposure worsen in close association with liver disease severity as assessed by using the Child-Pugh score. Likewise, the worsening of rhythmic parameters and liver disease is associated with a deterioration in the markers of the red series: count, hemoglobin, and hematocrit. Conclusions: These results indicate the utility of ambulatory monitoring of marker rhythms to complement the clinical information provided by the Child-Pugh scale and to help establish nutrition, physical exercise, and sleep guidelines that promote better survival and quality of life in these patients.
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Affiliation(s)
- Laura Martínez-Alarcón
- Departamento de Producción Animal, Hospital Clínico Universitario Virgen de la Arrixaca (UDICA), 30120 Murcia, Spain;
- Instituto Murciano de Investigación Biosanitaria (IMIB), 30120 Murcia, Spain; (A.M.-N.); (M.J.-A.); (J.A.M.); (M.d.l.Á.R.)
| | - Antonio Martínez-Nicolás
- Instituto Murciano de Investigación Biosanitaria (IMIB), 30120 Murcia, Spain; (A.M.-N.); (M.J.-A.); (J.A.M.); (M.d.l.Á.R.)
- Chronobiology Laboratory, Department of Physiology, College of Biology, University of Murcia, Mare Nostrum Campus, 30100 Murcia, Spain
- Human Physiology Area, Faculty of Sport Sciences, University of Murcia, Santiago de la Ribera-San Javier, 30720 Murcia, Spain
- Ciber Fragilidad y Envejecimiento Saludable (CIBERFES), 28029 Madrid, Spain
| | - Marta Jover-Aguilar
- Instituto Murciano de Investigación Biosanitaria (IMIB), 30120 Murcia, Spain; (A.M.-N.); (M.J.-A.); (J.A.M.); (M.d.l.Á.R.)
| | - Víctor López-López
- Servicio de Cirugía, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain; (V.L.-L.); (F.A.-G.); (A.R.); (P.R.)
| | - Felipe Alconchel-Gago
- Servicio de Cirugía, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain; (V.L.-L.); (F.A.-G.); (A.R.); (P.R.)
| | - Antonio Ríos
- Servicio de Cirugía, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain; (V.L.-L.); (F.A.-G.); (A.R.); (P.R.)
| | - Juan Antonio Madrid
- Instituto Murciano de Investigación Biosanitaria (IMIB), 30120 Murcia, Spain; (A.M.-N.); (M.J.-A.); (J.A.M.); (M.d.l.Á.R.)
- Chronobiology Laboratory, Department of Physiology, College of Biology, University of Murcia, Mare Nostrum Campus, 30100 Murcia, Spain
- Ciber Fragilidad y Envejecimiento Saludable (CIBERFES), 28029 Madrid, Spain
| | - María de los Ángeles Rol
- Instituto Murciano de Investigación Biosanitaria (IMIB), 30120 Murcia, Spain; (A.M.-N.); (M.J.-A.); (J.A.M.); (M.d.l.Á.R.)
- Chronobiology Laboratory, Department of Physiology, College of Biology, University of Murcia, Mare Nostrum Campus, 30100 Murcia, Spain
- Ciber Fragilidad y Envejecimiento Saludable (CIBERFES), 28029 Madrid, Spain
| | - Pablo Ramírez
- Servicio de Cirugía, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain; (V.L.-L.); (F.A.-G.); (A.R.); (P.R.)
| | - Guillermo Ramis
- Instituto Murciano de Investigación Biosanitaria (IMIB), 30120 Murcia, Spain; (A.M.-N.); (M.J.-A.); (J.A.M.); (M.d.l.Á.R.)
- Departamento de Producción Animal, Facultad de Veterinaria, Campus de Espinardo, Universidad de Murcia, 30100 Murcia, Spain
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Tantia P, Aggarwal P, Acharya S, Kumar S, Kothari M, Kadam A, Patil R. Exploring Haematological Complications in Cirrhosis of the Liver: A Comprehensive Review. Cureus 2024; 16:e65319. [PMID: 39184703 PMCID: PMC11344626 DOI: 10.7759/cureus.65319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 07/24/2024] [Indexed: 08/27/2024] Open
Abstract
Various chronic liver diseases inevitably end up with cirrhosis of the liver, and this comes with a whole range of haematological complications. Therefore, this detailed review has discussed pathophysiology, clinical manifestations, diagnostic measures, and treatment plans for these anomalies. Closely related are conditions such as anaemia, thrombocytopenia, coagulopathy, leukopenia, and haemolytic disorders, which are known to contribute to morbidity and mortality in cirrhotic patients significantly. Therefore, we need to understand the causes of these problems to find ways of helping our patients better. For this reason, multidisciplinary management will be key in ensuring proper monitoring, timely intervention, and preventive measures for haematological abnormalities in cirrhosis. Additionally, there have been tremendous advancements in therapeutic options, like adjunctive therapies or haematopoietic growth factors, which hold much promise regarding patient outcomes. This article emphasizes the proactive management of haematological complications associated with cirrhosis while highlighting the need for further research coupled with collaboration aimed at strengthening prevention strategies, diagnostic methods, and curative interventions.
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Affiliation(s)
- Parav Tantia
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Parth Aggarwal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sunil Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Manjeet Kothari
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhinav Kadam
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Rajvardhan Patil
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Zhang T, Mao W. Elevated neutrophil-to-hemoglobin ratio as an indicator of poor survival in hepatitis B virus-related decompensated cirrhosis. Biomark Med 2024; 18:477-483. [PMID: 38884135 DOI: 10.1080/17520363.2024.2352420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/22/2024] [Indexed: 06/18/2024] Open
Abstract
Aim: Our goal was to explore the prognostic value of the neutrophil-to-hemoglobin ratio (NHR) in HBV-related decompensated cirrhosis (HBV-DC) patients. Methods: 172 HBV-DC patients were enrolled. Multivariate analyses were used to identify risk factors influencing 30-day mortality. Results: The 30-day mortality was 12.8% (22/172). nonsurvivors exhibited a higher NHR than survivors. On multivariate analysis, NHR and model for end-stage liver disease (MELD) score were the only independent predictors of mortality. Notably, the predictive capabilities of NHR were found to be comparable to those of the MELD score. Conclusion: High NHR was associated with poor prognosis in HBV-DC patients, and NHR can serve as an effective and readily available indicator for the prediction of mortality in these patients.
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Affiliation(s)
- Tan Zhang
- Department of Clinical Laboratory, Shengzhou People's Hospital, Shengzhou Branch of the First Affiliated Hospital of Zhejiang University, Shengzhou, 312400, China
| | - WeiLin Mao
- Department of Clinical Laboratory, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
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5
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Meischl T, Balcar L, Park YR, Bucher L, Meier P, Suhr Y, Pomej K, Mandorfer M, Reiberger T, Trauner M, Scheiner B, Pinter M. Anaemia is independently associated with mortality in patients with hepatocellular carcinoma. ESMO Open 2024; 9:103593. [PMID: 38848660 PMCID: PMC11214999 DOI: 10.1016/j.esmoop.2024.103593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Anaemia is frequent in patients with cancer and/or liver cirrhosis and is associated with impaired quality of life. Here, we investigated the impact of anaemia on overall survival (OS) and clinical characteristics in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS HCC patients treated between 1992 and 2018 at the Medical University of Vienna were retrospectively analysed. Anaemia was defined as haemoglobin level <13 g/dl in men and <12 g/dl in women. RESULTS Of 1262 assessable patients, 555 (44.0%) had anaemia. The main aetiologies of HCC were alcohol-related liver disease (n = 502; 39.8%) and chronic hepatitis C (n = 375; 29.7%). Anaemia was significantly associated with impaired liver function, portal hypertension, more advanced Barcelona Clinic Liver Cancer stage and elevated C-reactive protein (CRP). In univariable analysis, anaemia was significantly associated with shorter median OS [9.5 months, 95% confidence interval (95% CI) 7.3-11.6 months] versus patients without anaemia (21.5 months, 95% CI 18.3-24.7 months) (P < 0.001). In multivariable analysis adjusted for age, Model for End-stage Liver Disease, number of tumour nodules, size of the largest nodule, macrovascular invasion, extrahepatic spread, first treatment line, alpha-fetoprotein and CRP, anaemia remained an independent predictor of mortality (adjusted hazard ratio 1.23, 95% CI 1.06-1.43, P = 0.006). CONCLUSIONS Anaemia was significantly associated with mortality in HCC patients, independent of established liver- and tumour-related prognostic factors. Whether adequate management of anaemia can improve outcome of HCC patients needs further evaluation.
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Affiliation(s)
- T Meischl
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna; 3(rd) Medical Department (Haematology & Oncology), Hanusch-Krankenhaus, Vienna, Austria
| | - L Balcar
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna
| | - Y-R Park
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna; Department of Dermatology, University Hospital Regensburg, Regensburg, Germany
| | - L Bucher
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna
| | - P Meier
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna
| | - Y Suhr
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna
| | - K Pomej
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna
| | - M Mandorfer
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna
| | - T Reiberger
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - M Trauner
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna
| | - B Scheiner
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna
| | - M Pinter
- Division of Gastroenterology und Hepatology, Department of Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna.
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Tabish M, Agarwal S, Gopi S, Rana R, Ahmed S, Gunjan D, Sharma S, Saraya A. Randomized Controlled Trial of Intravenous Ferric Carboxymaltose vs Oral Iron to Treat Iron Deficiency Anemia After Variceal Bleed in Patients With Cirrhosis. Am J Gastroenterol 2024:00000434-990000000-01084. [PMID: 38517084 DOI: 10.14309/ajg.0000000000002775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Limited evidence exists on the optimal strategy to correct iron deficiency anemia after variceal bleeding (VB) in cirrhosis. This trial compared the efficacy and safety of intravenous ferric carboxymaltose (IV-FCM) with those of oral iron therapy in this cohort. METHODS In this open-label, single-center, randomized controlled trial, eligible patients with hemoglobin <10 g/dL and iron deficiency (ferritin <100 ng/mL) after VB received either IV-FCM (1,500-2,000 mg) divided into 2 doses (n = 48) or oral carbonyl iron (100 mg elemental iron/day) (n = 44) for 3 months. The primary outcome was change in hemoglobin at 3 months. Secondary outcomes included improvement in anemia (last hemoglobin >12 g/dL), normalization of iron stores (ferritin >100 ng/mL), liver-related adverse events, adverse drug reactions, and changes in quality of life (CLDQOL questionnaire). RESULTS Baseline characteristics, including median Child-Turcotte-Pugh score 7 (interquartile range [IQR] 6-9), Model for End-Stage Liver Disease score 12 (IQR 10-17), blood hemoglobin (8.25 ± 1.06 g/dL), and ferritin (30.00 ng/mL [15.00-66.50]), were comparable in both arms. The median increase in hemoglobin at 3 months in the IV and oral arms was 3.65 g/dL (IQR 2.55-5.25) and 1.10 g/dL (IQR 0.05-2.90 g/dL) ( P < 0.001), respectively. Iron stores normalized in 84.6% and 21% of the IV and oral arms, respectively ( P < 0.001). Anemia improved in 50% and 21.9% in the IV and oral arms, respectively ( P < 0.009). Patients in the IV arm showed a significant improvement in all domains of CLDQOL. Liver-related adverse events were comparable in both arms. Transient mild/moderate hypophosphatemia developed in 43% of patients receiving IV-FCM. DISCUSSION Intravenous iron replacement is efficacious and safe to treat iron deficiency anemia after VB in patients with cirrhosis.
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Affiliation(s)
- Mohammad Tabish
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
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Liu Y, Clarke R, Bennett DA, Zong G, Gan W. Iron Status and Risk of Heart Disease, Stroke, and Diabetes: A Mendelian Randomization Study in European Adults. J Am Heart Assoc 2024; 13:e031732. [PMID: 38497484 PMCID: PMC11010009 DOI: 10.1161/jaha.123.031732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 02/28/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND The relevance of iron status biomarkers for coronary artery disease (CAD), heart failure (HF), ischemic stroke (IS), and type 2 diabetes (T2D) is uncertain. We compared the observational and Mendelian randomization (MR) analyses of iron status biomarkers and hemoglobin with these diseases. METHODS AND RESULTS Observational analyses of hemoglobin were compared with genetically predicted hemoglobin with cardiovascular diseases and diabetes in the UK Biobank. Iron biomarkers included transferrin saturation, serum iron, ferritin, and total iron binding capacity. MR analyses assessed associations with CAD (CARDIOGRAMplusC4D [Coronary Artery Disease Genome Wide Replication and Meta-Analysis Plus The Coronary Artery Disease Genetics], n=181 522 cases), HF (HERMES [Heart Failure Molecular Epidemiology for Therapeutic Targets), n=115 150 cases), IS (GIGASTROKE, n=62 100 cases), and T2D (DIAMANTE [Diabetes Meta-Analysis of Trans-Ethnic Association Studies], n=80 154 cases) genome-wide consortia. Observational analyses demonstrated J-shaped associations of hemoglobin with CAD, HF, IS, and T2D. In contrast, MR analyses demonstrated linear positive associations of higher genetically predicted hemoglobin levels with 8% higher risk per 1 SD higher hemoglobin for CAD, 10% to 13% for diabetes, but not with IS or HF in UK Biobank. Bidirectional MR analyses confirmed the causal relevance of iron biomarkers for hemoglobin. Further MR analyses in global consortia demonstrated modest protective effects of iron biomarkers for CAD (7%-14% lower risk for 1 SD higher levels of iron biomarkers), adverse effects for T2D, but no associations with IS or HF. CONCLUSIONS Higher levels of iron biomarkers were protective for CAD, had adverse effects on T2D, but had no effects on IS or HF. Randomized trials are now required to assess effects of iron supplements on risk of CAD in high-risk older people.
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Affiliation(s)
- Yunan Liu
- CAS Key Laboratory of Nutrition, Metabolism and Food SafetyShanghai Institute of Nutrition and Health, University of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Robert Clarke
- Nuffield Department of Population HealthUniversity of OxfordOxfordUnited Kingdom
| | - Derrick A. Bennett
- Nuffield Department of Population HealthUniversity of OxfordOxfordUnited Kingdom
- Medical Research Council Population Health Research Unit at the University of OxfordOxfordUnited Kingdom
| | - Geng Zong
- CAS Key Laboratory of Nutrition, Metabolism and Food SafetyShanghai Institute of Nutrition and Health, University of Chinese Academy of Sciences, Chinese Academy of SciencesShanghaiChina
| | - Wei Gan
- Human Genetics Centre of Excellence, Novo Nordisk Research Centre Oxford, Innovation Building, Old Road CampusOxfordUnited Kingdom
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Hegland NØ, Rezahosseini O, Pedersen CR, Møller DL, Bugge TB, Wareham NE, Arentoft NS, Hillingsø J, Lund TK, Rasmussen A, Nielsen SD. Anemia in liver transplant recipients: prevalence, severity, risk factors, and survival. APMIS 2024; 132:152-160. [PMID: 38084017 DOI: 10.1111/apm.13364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/11/2023] [Indexed: 02/17/2024]
Abstract
Information about anemia in liver transplant (LTx) recipients is scarce. We investigated the prevalence and severity of anemia before and within the first-year post-LTx, risk factors for having anemia before LTx, and 1-year survival according to anemia status before LTx. This retrospective cohort study received data from The Knowledge Center for Transplantation database at Rigshospitalet, Copenhagen, Denmark. Uni- and multivariate logistic regression were used to investigate factors associated with anemia and a Kaplan-Meier plot to illustrate the probability of survival. We included 346 first-time adult LTx recipients. The median age was 50 years (IQR: 42-57), and 203 (59%) were male. The prevalence of anemia before and 1-year post-LTx were 69 and 45%, respectively. Male sex (aOR 4.0 [95% CI: 2.2-7.2]; p < 0.001) and each unit increase in MELD score (aOR 1.2 [95% CI: 1.1-1.2]; p < 0.001) were positively associated with anemia before LTx. Compared to autoimmune liver diseases, LTx recipients with fulminant hepatic failure (aOR 0.03 [0.00-0.17]; p = 0.001) had lower odds for anemia. The 1-year survival in LTx recipients who had and did not have anemia before transplantation were 93 and 91% (p = 0.47). Anemia was frequent among LTx recipients, and anemia before LTx did not affect 1-year survival.
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Affiliation(s)
- Nina Øksnes Hegland
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Omid Rezahosseini
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Christian Ross Pedersen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Dina Leth Møller
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Terese Brun Bugge
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Neval Ete Wareham
- Centre of Excellence for Health, Immunity, and Infections (CHIP), Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
| | - Nicoline Stender Arentoft
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Jens Hillingsø
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Kromann Lund
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Dam Nielsen
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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Abiru S, Kugiyama Y, Suehiro T, Motoyoshi Y, Saeki A, Nagaoka S, Yamasaki K, Komori A, Yatsuhashi H. Zinc supplementation with polaprezinc was associated with improvements in albumin, prothrombin time activity, and hemoglobin in chronic liver disease. J Clin Biochem Nutr 2024; 74:162-168. [PMID: 38510683 PMCID: PMC10948345 DOI: 10.3164/jcbn.23-89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/07/2023] [Indexed: 03/22/2024] Open
Abstract
Zinc deficiency occurs in a variety of diseases, including chronic liver disease (CLD). We investigated the correlation between zinc levels and biochemical and hematological tests in CLD and the effect of zinc supplementation with polaprezinc on these values. The first study (Study 1) was a retrospective observational study of 490 patients with CLD not receiving zinc supplementation, with data available from September 2009 to August 2021. Univariate and multiple regression analysis showed that serum zinc levels correlated most strongly with albumin (Alb) and also significantly with prothrombin time activity (PT%) and hemoglobin (Hb). A subsequent study (Study 2) focused on patients with advanced CLD who used polaprezinc for more than 90 days between January 2005 and August 2021. Using a self-controlled design with the 6-month period prior to polaprezinc as the control period, comparisons showed that Alb (p<0.0001), PT% (p<0.0005), and Hb (p<0.01) were significantly improved in the polaprezinc-treated patients compared to the control group. In conclusion, serum zinc levels were correlated with serum Alb, Hb, and PT% in patients with CLD, and zinc supplementation with polaprezinc was associated with improvements in Alb, Hb, and PT% within at least 6 months.
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Affiliation(s)
- Seigo Abiru
- The Department of Internal Medicine, NHO Saga Hospital, 1-20-1 Hinode, Saga 849-8577, Japan
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
| | - Yuki Kugiyama
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
| | - Tomoyuki Suehiro
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
| | - Yasuhide Motoyoshi
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
| | - Akira Saeki
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
| | - Shinya Nagaoka
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
| | - Kazumi Yamasaki
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
| | - Atsumasa Komori
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
| | - Hiroshi Yatsuhashi
- Clinical Research Center, NHO Nagasaki Medical Center, 2-1001-1 Kubara, Omura, Nagasaki 856-8562, Japan
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Tan S, Jiang J, Qiu L, Liang Y, Meng J, Tan N, Xiang B. Prevalence of Malnutrition in Patients with Hepatocellular Carcinoma: A Comparative Study of GLIM Criteria, NRS2002, and PG-SGA, and Identification of Independent Risk Factors. Nutr Cancer 2024; 76:335-344. [PMID: 38379140 DOI: 10.1080/01635581.2024.2314317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/30/2024] [Indexed: 02/22/2024]
Abstract
AIM Malnutrition is prevalent in hepatocellular carcinoma (HCC) patients, linked to poor outcomes, necessitating early intervention. This study aimed to investigate malnutrition in HCC patients, assess Nutrition Risk Screening 2002 (NRS-2002) and Patient-Generated Subjective Global Assessment (PG-SGA) vs. Global Leadership Initiative on Malnutrition (GLIM) criteria, and identify independent risk factors. METHOD A cross-sectional retrospective study was conducted on 207 patients with HCC. Nutritional screening/assessment results and blood samples were collected within 72 h of admission. This study assessed the prevalence of malnutrition using the NRS-2002 and PG-SGA and retrospectively using the GLIM criteria. The performance of the screening tools was evaluated using kappa (K) values. Logistic regression analyses were performed to determine whether laboratory parameters were associated with malnutrition as identified by the GLIM criteria. RESULTS Of the participants, 30.4% were at risk of malnutrition according to NRS-2002. The agreement between the NRS-2002 and GLIM criteria was substantial. The GLIM criteria and PG-SGA diagnosed malnutrition in 43 and 54.6% of the participants, respectively. Age, anemia, and ascites correlated with malnutrition in regression. CONCLUSION The GLIM criteria, along with NRS-2002 and PG-SGA, aid in diagnosing malnutrition in HCC patients. Recognizing risk factors improves accuracy, enabling timely interventions for better outcomes.
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Affiliation(s)
- Shengqiang Tan
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
- Department of Hepatobiliary Surgery, Liuzhou People's Hospital Affiliated to Guangxi Medical University, Liuzhou, China
| | - Jie Jiang
- Department of Clinical Nutrition, Liuzhou People's Hospital Affiliated to Guangxi Medical University, Liuzhou, China
| | - Liulin Qiu
- Department of Clinical Nutrition, Liuzhou People's Hospital Affiliated to Guangxi Medical University, Liuzhou, China
| | - Yaohao Liang
- Department of Hepatobiliary Surgery, Liuzhou People's Hospital Affiliated to Guangxi Medical University, Liuzhou, China
| | - Jianyi Meng
- Department of Hepatobiliary Surgery, Liuzhou People's Hospital Affiliated to Guangxi Medical University, Liuzhou, China
| | - Ning Tan
- College of Basic Medical Sciences, Guilin Medical University, Guilin, China
| | - Bangde Xiang
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
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11
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Zanetto A, Campello E, Bulato C, Willems R, Konings J, Roest M, Gavasso S, Nuozzi G, Toffanin S, Zanaga P, Burra P, Russo FP, Senzolo M, de Laat B, Simioni P. Whole blood thrombin generation shows a significant hypocoagulable state in patients with decompensated cirrhosis. J Thromb Haemost 2024; 22:480-492. [PMID: 37866518 DOI: 10.1016/j.jtha.2023.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/20/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Patients with cirrhosis have a normal to increased thrombin generation (TG) capacity in platelet-poor plasma (PPP). By reflecting the contribution of all circulating blood cells, whole blood (WB) TG may allow a more physiological assessment of coagulation. OBJECTIVES We compared WB-TG vs PPP-TG in patients with cirrhosis. METHODS Assessment of coagulation included routine tests, factor VIII, natural anticoagulants, PPP-TG, and WB-TG. TG assays were performed with and without thrombomodulin. Twenty-five healthy subjects were included as controls. RESULTS We included 108 patients (Child-Pugh A/B/C, 44/24/40). Compared with controls, patients had significantly lower platelet count, longer international normalized ratio, higher FVIII, and lower levels of protein C/S and antithrombin. Regarding thrombomodulin-modified TG assays, in compensated cirrhosis, both PPP-TG and WB-TG indicated an increased TG capacity, as reflected by an endogenous thrombin potential (ETP) significantly higher than controls. In contrast, in decompensated cirrhosis, PPP-TG indicated a hypercoagulable state with increased ETP, higher peak height, and shorter time-to-peak than controls, whereas WB-TG revealed a progressive impairment of TG kinetics and total capacity, ultimately resulting in a profound hypocoagulable state in patients with Child-Pugh C cirrhosis (ie, significant prolongation of lag time and time-to-peak with reduction of both ETP and peak height). In decompensated patients, bacterial infections and severity of anemia were associated with a further reduction of both ETP and peak height. CONCLUSION Compensated cirrhosis is associated with an increased TG capacity. In decompensated cirrhosis, contrary to PPP-TG, which indicates hypercoagulability, WB-TG shows a significant hypocoagulable state. The clinical value of these findings deserves further investigation.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy. https://twitter.com/azanetto
| | - Elena Campello
- General Internal Medicine Unit, Azienda Ospedale - Università Padova, Padova, Italy; Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Cristiana Bulato
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Ruth Willems
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Joke Konings
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Mark Roest
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Sabrina Gavasso
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Giorgia Nuozzi
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Serena Toffanin
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Paola Zanaga
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Paolo Simioni
- General Internal Medicine Unit, Azienda Ospedale - Università Padova, Padova, Italy; Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy.
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12
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Zanetto A, Campello E, Senzolo M, Simioni P. The evolving knowledge on primary hemostasis in patients with cirrhosis: A comprehensive review. Hepatology 2024; 79:460-481. [PMID: 36825598 DOI: 10.1097/hep.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 02/25/2023]
Abstract
Patients with cirrhosis develop complex alterations in primary hemostasis that include both hypocoagulable and hypercoagulable features. This includes thrombocytopenia, multiple alterations of platelet function, and increased plasma levels of von Willebrand factor. Contrary to the historical view that platelet dysfunction in cirrhosis might be responsible for an increased bleeding tendency, the current theory posits a rebalanced hemostasis in patients with cirrhosis. Severe thrombocytopenia is not indicative of the bleeding risk in patients undergoing invasive procedures and does not dictate per se the need for pre-procedural prophylaxis. A more comprehensive and individualized risk assessment should combine hemostatic impairment, the severity of decompensation and systemic inflammation, and the presence of additional factors that may impair platelet function, such as acute kidney injury and bacterial infections. Although there are multiple, complex alterations of platelet function in cirrhosis, their net effect is not yet fully understood. More investigations evaluating the association between alterations of platelet function and bleeding/thrombosis may improve risk stratification in patients with decompensated cirrhosis. Besides hemostasis, the assessment of von Willebrand factor Ag and ADP-induced, whole-blood platelet aggregation normalized by platelet count (VITRO score and PLT ratio) are promising biomarkers to predict the risk of hepatic decompensation and survival in both compensated and decompensated patients. Further investigations into the in vivo interplay between platelets, circulating blood elements, and endothelial cells may help advance our understanding of cirrhotic coagulopathy. Here, we review the complex changes in platelets and primary hemostasis in cirrhosis and their potential clinical implications.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Padova, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Elena Campello
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Padova, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Paolo Simioni
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
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Cizmic A, Rahmanian PB, Gassa A, Kuhn E, Mader N, Wahlers T. Prognostic value of ascites in patients with liver cirrhosis undergoing cardiac surgery. J Cardiothorac Surg 2023; 18:302. [PMID: 37898812 PMCID: PMC10613375 DOI: 10.1186/s13019-023-02393-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/30/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Mild or moderate liver cirrhosis increases the risk of complications after cardiac surgery. Ascites is the most common complication associated with liver cirrhosis. However, the prognostic value of ascites on postoperative morbidity and mortality after cardiac surgery remains uninvestigated. METHODS A retrospective study included 69 patients with preoperatively diagnosed liver cirrhosis who underwent cardiac surgery between January 2009 and January 2018 at the Department of Cardiothoracic Surgery, University Hospital of Cologne, Germany. The patients were divided into ascites and non-ascites groups based on preoperatively diagnosed ascites. Thirty-day mortality, postoperative complications, length of stay, and blood transfusions were analyzed postoperatively. RESULTS Out of the total of 69 patients, 14 (21%) had preoperatively diagnosed ascites. Ascites group had more postoperative complications such as blood transfusions (packed red blood cells: 78.6% vs. 40.0%, p = 0.010; fresh frozen plasma: 57.1% vs. 29.1%, p = 0.049), acute kidney injury (78.6% vs. 45.5%, p = 0.027), longer ICU stay (8 vs. 3 days, p = 0.044) with prolonged mechanical ventilation (57.1% vs. 23.6%, p = 0.015) and tracheotomy (28.6% vs. 3.6%, p = 0.003). The 30-day mortality rate was significantly higher in the ascites group than in the non-ascites group (35.7% vs. 5.5%, p = 0.002). CONCLUSION Ascites should be implemented in preoperative risk score assessments in cirrhotic patients undergoing cardiac surgery. Preoperative treatment of ascites could reduce the negative impact of ascites on postoperative complications after cardiac surgery. However, this needs to be thoroughly investigated in prospective randomized clinical trials.
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Affiliation(s)
- Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Asmae Gassa
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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14
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Ali N, Ferrao K, Mehta KJ. Liver Iron Loading in Alcohol-Associated Liver Disease. THE AMERICAN JOURNAL OF PATHOLOGY 2023; 193:1427-1439. [PMID: 36306827 DOI: 10.1016/j.ajpath.2022.08.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/15/2022] [Accepted: 08/31/2022] [Indexed: 02/04/2023]
Abstract
Alcohol-associated liver disease (ALD) is a common chronic liver disease with increasing incidence worldwide. Alcoholic liver steatosis/steatohepatitis can progress to liver fibrosis/cirrhosis, which can cause predisposition to hepatocellular carcinoma. ALD diagnosis and management are confounded by several challenges. Iron loading is a feature of ALD which can exacerbate alcohol-induced liver injury and promote ALD pathologic progression. Knowledge of the mechanisms that mediate liver iron loading can help identify cellular/molecular targets and thereby aid in designing adjunct diagnostic, prognostic, and therapeutic approaches for ALD. Herein, the cellular mechanisms underlying alcohol-induced liver iron loading are reviewed and how excess iron in patients with ALD can promote liver fibrosis and aggravate disease pathology is discussed. Alcohol-induced increase in hepatic transferrin receptor-1 expression and up-regulation of high iron protein in Kupffer cells (proposed) facilitate iron deposition and retention in the liver. Iron is loaded in both parenchymal and nonparenchymal liver cells. Iron-loaded liver can promote ferroptosis and thereby contribute to ALD pathology. Iron and alcohol can independently elevate oxidative stress. Therefore, a combination of excess iron and alcohol amplifies oxidative stress and accelerates liver injury. Excess iron-stimulated hepatocytes directly or indirectly (through Kupffer cell activation) activate the hepatic stellate cells via secretion of proinflammatory and profibrotic factors. Persistently activated hepatic stellate cells promote liver fibrosis, and thereby facilitate ALD progression.
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Affiliation(s)
- Najma Ali
- GKT School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Kevin Ferrao
- GKT School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Kosha J Mehta
- Centre for Education, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom.
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15
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Butt MF, Jalan R. Review article: Emerging and current management of acute-on-chronic liver failure. Aliment Pharmacol Ther 2023; 58:774-794. [PMID: 37589507 DOI: 10.1111/apt.17659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/02/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a clinically and pathophysiologically distinct condition from acutely decompensated cirrhosis and is characterised by systemic inflammation, extrahepatic organ failure, and high short-term mortality. AIMS To provide a narrative review of the diagnostic criteria, prognosis, epidemiology, and general management principles of ACLF. Four specific interventions that are explored in detail are intravenous albumin, extracorporeal liver assist devices, granulocyte-colony stimulating factor, and liver transplantation. METHODS We searched PubMed and Cochrane databases for articles published up to July 2023. RESULTS Approximately 35% of hospital inpatients with decompensated cirrhosis have ACLF. There is significant heterogeneity in the criteria used to diagnose ACLF; different definitions identify different phenotypes with varying mortality. Criteria established by the European Association for the Study of the Liver were developed in prospective patient cohorts and are, to-date, the most well validated internationally. Systemic haemodynamic instability, renal dysfunction, coagulopathy, neurological dysfunction, and respiratory failure are key considerations when managing ACLF in the intensive care unit. Apart from liver transplantation, there are no accepted evidence-based treatments for ACLF, but several different approaches are under investigation. CONCLUSION The recognition of ACLF as a distinct entity from acutely decompensated cirrhosis has allowed for better patient stratification in clinical settings, facilitating earlier engagement with the intensive care unit and liver transplantation teams. Research priorities over the next decade should focus on exploring novel treatment strategies with a particular focus on which, when, and how patients with ACLF should be treated.
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Affiliation(s)
- Mohsin F Butt
- Centre for Neuroscience, Trauma and Surgery, Wingate Institute of Neurogastroenterology, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Liver Failure Group, University College London Medical School, Royal Free Hospital Campus, London, UK
- National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottinghamshire, UK
| | - Rajiv Jalan
- Liver Failure Group, University College London Medical School, Royal Free Hospital Campus, London, UK
- European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) Consortium, Barcelona, Spain
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16
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Jensen ASH, Ytting H, Winther-Sørensen M, Burisch J, Bergquist A, Gluud LL, Wewer Albrechtsen NJ. Autoimmune liver diseases and diabetes. Eur J Gastroenterol Hepatol 2023; 35:938-947. [PMID: 37505973 DOI: 10.1097/meg.0000000000002594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Autoimmune liver diseases include autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. They are chronic, heterogenous diseases affecting the liver which is a key metabolic organ that ensures glucose homeostasis. It is well known that patients with other chronic liver diseases such as cirrhosis and nonalcoholic fatty liver disease (NAFLD) display glucose disturbances like insulin resistance and have an increased risk of diabetes. Previous evidence on glucose disturbances in patients with autoimmune liver disease is scarce but does point towards a potentially increased risk of type 1 diabetes and type 2 diabetes. The underlying mechanisms are unknown but may reflect genetic predisposition, concurrent NAFLD and or cirrhosis development, and treatment (steroid) related impairment of glucose homeostasis. Therefore, increased awareness and surveillance of diabetes development in patients with autoimmune liver disease may be important. Overall, detection and treatment of diabetes generally follow the usual diabetes guidelines; however, in patients with advanced liver cirrhosis, HbA1c may not be a reliable marker of average glucose levels, and treatment with insulin is generally recommended. In addition, it has recently been suggested that sodium-glucose cotransporter 2 inhibitors may be beneficial in treating refractory ascites. Further research on diabetes risk in autoimmune liver disease is warranted.
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Affiliation(s)
- Anne-Sofie H Jensen
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
| | - Henriette Ytting
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Rigshospitalet
- Institute for Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen
| | - Marie Winther-Sørensen
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Johan Burisch
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
| | - Annika Bergquist
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
- Department of Upper GI Diseases, Karolinska University Hospital, Department of Medicine, Karolinska Institutet, Stockholm
| | - Lise Lotte Gluud
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
- Institute for Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen
| | - Nicolai J Wewer Albrechtsen
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Department of Clinical Biochemistry, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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Bevilacqua M, De Marco L, Stupia R, Dima F, Cattazzo F, Paon V, Ieluzzi D, Dalbeni A, Sacerdoti D. Spur cells in liver cirrhosis are predictive of acute-on-chronic liver failure and liver-related mortality regardless of severe anaemia. Intern Emerg Med 2023; 18:1397-1404. [PMID: 37212944 PMCID: PMC10412654 DOI: 10.1007/s11739-023-03303-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023]
Abstract
Chronic anaemia in advanced liver disease is a frequent finding. The aim was to explore the clinical impact of spur cell anaemia, a rare entity typically associated with end-stage of the disease. One-hundred and nineteen patients (73.9% males) with liver cirrhosis of any etiology were included. Patients with bone marrow diseases, nutrients deficiencies and hepatocellular carcinoma were excluded. In all patients, a blood sample was collected to check for the presence of spur cells on blood smear. A complete blood biochemical panel was recorded together with Child-Pugh (CP) score and Model for End-Stage Liver Disease (MELD) score. For each patients, clinically relevant events, such as acute-on-chronic liver failure (ACLF) and 1 year liver-related mortality, were registered. Patients were then grouped according to the percentage of spur cells at smear (> 5%, 1-5%, < 1%). Severe anaemia was defined as haemoglobin levels lower than 8 g/dL. 9.2% of subjects had > 5% spur cells, only 2 had evidence of haemolysis. In patients with > 5% spur cells, haemoglobin and albumin were lower compared with the other sub-group, while MELD score, CP score, International Normalized Ratio, ferritin, creatinine and unconjugated bilirubin were higher. Patients with more spur cells were more decompensated and developed more frequently ACLF. ACLF and liver-related mortality were significantly and independently associated with the presence of > 5% spur cells but not with baseline severe anaemia. Cirrhotic patients have a fairly high prevalence of spur cells, not always associated with severe haemolytic anaemia. The presence of spur red cells is per se associated with a worse prognosis and, therefore, should be always evaluated to prioritize patients for intensive management and eventually liver transplantation.
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Affiliation(s)
- Michele Bevilacqua
- Department of Medicine, General Medicine C, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
| | - Leonardo De Marco
- Department of Medicine, General Medicine C, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Roberta Stupia
- Department of Medicine, General Medicine C, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Francesco Dima
- Clinical Biochemistry, University of Verona, Verona, Italy
| | - Filippo Cattazzo
- Department of Medicine, General Medicine C, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Veronica Paon
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Donatella Ieluzzi
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Andrea Dalbeni
- Department of Medicine, General Medicine C, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - David Sacerdoti
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
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Souki FG, Raveh Y, Sancassani R, Livingstone J, Shatz V, Ashrafi B, Shuman M, Nicolau-Raducu R. Characteristics, Risk Factors, and Outcome of New-onset Systolic Heart Failure After Liver Transplantation: A Single-center Cohort. Transplant Direct 2023; 9:e1499. [PMID: 37305649 PMCID: PMC10256427 DOI: 10.1097/txd.0000000000001499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 04/23/2023] [Accepted: 04/27/2023] [Indexed: 06/13/2023] Open
Abstract
New-onset systolic heart failure (HF) after liver transplantation (LT) is a significant cause of morbidity and mortality; however, its characteristics are still insufficiently delineated. HF may involve the left ventricle (LV), right ventricle (RV), or both ventricles. We explored the incidence, characteristics, etiologies, risks, involved cardiac chambers, and outcomes of HF after LT. Methods This study included 528 adult patients with preoperative LV ejection fraction ≥ 55% who underwent LT between 2016 and 2020. The primary outcome was new-onset systolic HF, defined by the presence of clinical signs, symptoms, and echocardiographic evidence of reduced LVejection fraction <50% and RV dysfunction within the first year after LT. Results Thirty-one patients (6%) developed systolic HF within a median of 9 d (1-364). Of those, 23% of patients had ischemic HF, whereas 77% had nonischemic HF. Nonischemic HF was caused by stress (11), sepsis (8), or other factors (5). Nonischemic HF was secondary to isolated LV failure in 58% of patients or RV ± LV failure in 42% of patients. Recursive partitioning identified subgroups with varying risks and uncovered interaction between variables. HF risk increased from 4.2% to 13% when epinephrine and/or norepinephrine drips were used intraoperatively (P < 0.01). When no epinephrine and/or norepinephrine were used, HF risk increased from 3.1% to 38.5% if baseline hemoglobin was <7.2 g/dL (P < 0.01). When baseline hemoglobin was ≥7.2 g/dL, HF risk increased from 0% to 5.2% when ≥3500 mL crystalloid was used intraoperatively (P < 0.01). Posttransplant first-year survival and reversibility of HF depended on the etiology (stress, sepsis, ischemia, etc) and cardiac chamber involvement (isolated LV or RV ± LV). RV dysfunction was associated with inferior recovery of cardiac function and poorer survival than nonischemic isolated LV dysfunction (50% versus 70%, respectively). Conclusions Posttransplant new-onset HF is mostly nonischemic in nature and is associated with increased morbidity and mortality.
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Affiliation(s)
- Fouad G. Souki
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Yehuda Raveh
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Rhea Sancassani
- Department of Cardiology, Jackson Memorial Hospital, Miami, FL
| | - Joshua Livingstone
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Vadim Shatz
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Behrouz Ashrafi
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Miryam Shuman
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Ramona Nicolau-Raducu
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL
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Koschade SE, Moser LM, Sokolovskiy A, Michael FA, Serve H, Brandts CH, Finkelmeier F, Zeuzem S, Trebicka J, Ferstl P, Ballo O. Bone Marrow Assessment in Liver Cirrhosis Patients with Otherwise Unexplained Peripheral Blood Cytopenia. J Clin Med 2023; 12:4373. [PMID: 37445409 DOI: 10.3390/jcm12134373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
We performed a retrospective single-center analysis to investigate the diagnostic yield of bone marrow puncture in patients with liver cirrhosis and cytopenia. Liver cirrhosis patients receiving bone marrow aspiration or biopsy for the diagnostic work-up of otherwise unexplained peripheral blood cytopenia at our institution between 2004 and 2020 were enrolled in this study. We evaluated findings from cytologic, histologic and immunologic assessment and final diagnostic outcomes. A total of 118 patients with a median age of 55 years and a median Child-Pugh score of B (8 points) were enrolled. The main etiologies of liver cirrhosis were viral hepatitis (B and C) or chronic alcohol consumption. The majority of patients (60%) exhibited concurrent anemia, leukocytopenia and thrombocytopenia. Bone marrow assessment revealed normal, unspecific or reactive alterations in 117 out of 118 patients (99%). One patient was diagnosed with myelodysplastic syndrome. Our findings suggest that peripheral blood cytopenia in patients with liver cirrhosis is rarely associated with a primary bone marrow pathology.
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Affiliation(s)
- Sebastian E Koschade
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Laura M Moser
- Department for Children and Adolescents, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Artur Sokolovskiy
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Florian A Michael
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Hubert Serve
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Christian H Brandts
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Jonel Trebicka
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
- Department of Internal Medicine B, University of Münster, 48149 Münster, Germany
| | - Philip Ferstl
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Olivier Ballo
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
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Cooper KM, Colletta A, Moulton K, Ralto KM, Devuni D. Kidney disease in patients with chronic liver disease: Does sex matter? World J Clin Cases 2023; 11:3980-3992. [PMID: 37388789 PMCID: PMC10303604 DOI: 10.12998/wjcc.v11.i17.3980] [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: 03/21/2023] [Revised: 04/30/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Kidney disease in patients with liver disease is serious and increases mortality. Up to 50% of patients hospitalized experience an episode of acute kidney injury. In general, men with liver disease are thought to be at increased risk of kidney disease. However, this association should be considered with caution because most studies use creatinine-based inclusion criteria, which is negatively biased against women. In this review, we synthesize data on sex differences in kidney disease in patients with chronic liver disease in the clinical setting and discuss potential physiologic underpinnings.
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Affiliation(s)
- Katherine M Cooper
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Alessandro Colletta
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kristen Moulton
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kenneth M Ralto
- Department of Medicine, Division of Renal Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Deepika Devuni
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
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Zhang Q, Mao W, He X, Yuan M. High red cell distribution width-to-platelet ratio indicates adverse outcomes for hepatitis B virus-associated decompensated cirrhosis. Biomark Med 2023; 17:189-196. [PMID: 37158064 DOI: 10.2217/bmm-2023-0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: This work was designed to determine the association between red cell distribution width-to-platelet ratio (RPR) and 30-day prognosis in hepatitis B virus-associated decompensated cirrhosis (HBV-DC) patients. Methods: A total of 168 HBV-DC patients were included. Independent risk factors for poor prognosis were determined by logistic regression analyses. Results: A total of 21 (12.5%) patients died within 30 days. RPR was higher in nonsurvivors than in survivors. Multivariate analysis identified RPR and Model for End-Stage Liver Disease (MELD) score as independent prognostic predictors, and the predictive value of RPR was similar to that of the MELD score. Moreover, combining RPR with the MELD score further improved the predictive value for mortality. Conclusion: RPR has potential as a reliable tool for the prediction of poor prognosis in HBV-DC patients.
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Affiliation(s)
- Qiu Zhang
- Department of Clinical Laboratory, Shengzhou People's Hospital, Shengzhou Branch of the First Affiliated Hospital of Zhejiang University, Shengzhou, 312400, China
| | - WeiLin Mao
- Department of Clinical Laboratory, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Xia He
- Department of Clinical Laboratory, Shengzhou People's Hospital, Shengzhou Branch of the First Affiliated Hospital of Zhejiang University, Shengzhou, 312400, China
| | - ManChun Yuan
- Department of Clinical Laboratory, Shengzhou People's Hospital, Shengzhou Branch of the First Affiliated Hospital of Zhejiang University, Shengzhou, 312400, China
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Roy A, Rodge G, Goenka MK. Spur Cell Anaemia in Cirrhosis: A Narrative Review. J Clin Exp Hepatol 2023; 13:500-508. [PMID: 37250881 PMCID: PMC10213867 DOI: 10.1016/j.jceh.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
The presence of anaemia has been linked to increased complications and a worse prognosis in cirrhosis. Spur cell anaemia (SCA) is a specific form of haemolytic anaemia reported in patients with advanced cirrhosis. The literature on the entity has not been systematically reviewed, despite the classical association and frequent association with worse outcomes. We undertook a narrative review of available literature on SCA which yielded only 4 were original studies, one case series and the rest of the literature as case reports and clinical images. SCA is usually defined by the presence of spur cell rate of ≥5%, although there remains a lack of consensus in the definition. SCA has been classically associated with alcohol-related cirrhosis but can be seen across the spectrum of cirrhosis and acute to chronic liver failure. Patients with SCA tend to have evidence of higher grades of liver dysfunction, abnormal lipid profiles, worse prognostic scores and a high mortality. Experimental therapies including corticosteroids, pentoxifylline, flunarizine and plasmapheresis has been tried with variable effect, but liver transplantation remains the management of choice. We propose a stepwise approach to diagnosis and re-enforce the need for further prospective research, especially in subgroups of advanced cirrhosis like acute to chronic liver failure.
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Affiliation(s)
- Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
| | - Gajanan Rodge
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
| | - Mahesh K. Goenka
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
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23
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Lingas EC. Hematological Abnormalities in Cirrhosis: A Narrative Review. Cureus 2023; 15:e39239. [PMID: 37337504 PMCID: PMC10277171 DOI: 10.7759/cureus.39239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/21/2023] Open
Abstract
Liver cirrhosis remains a major public health issue. Liver fibrosis leading to cirrhosis is the terminal stage of various chronic liver diseases. Inflammatory cytokines are involved in the pathogenesis. Patients with cirrhosis often have hematological abnormalities, such as anemia and thrombocytopenia, which have multifactorial etiologies. Anemia in cirrhosis could be related to bleeding leading to iron deficiency anemia or other nutritional anemia such as vitamin B12 and folate deficiency. The pathophysiology of thrombocytopenia in liver cirrhosis has been postulated to range from splenic sequestration to bone marrow suppression from toxic agents, such as alcohol. It often complicates management due to the risk of bleeding with severely low platelets. This review aimed to highlight pathogenesis of liver cirrhosis, hematological abnormalities in liver cirrhosis, and their clinical significance.
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Pompili E, Baldassarre M, Zaccherini G, Tufoni M, Iannone G, Pratelli D, Palmese F, Vizioli L, Faggiano C, Bedogni G, Domenicali M, Caraceni P. Low haemoglobin level predicts early hospital readmission in patients with cirrhosis and acute decompensation. JHEP Rep 2023; 5:100698. [PMID: 37025944 PMCID: PMC10070139 DOI: 10.1016/j.jhepr.2023.100698] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 04/08/2023] Open
Abstract
Background & Aims Patients with decompensated cirrhosis present frequent hospitalisations with a relevant clinical and socio-economic impact. This study aims to characterise unscheduled readmissions up to 1-year follow-up and identify predictors of 30-day readmission after an index hospitalisation for acute decompensation (AD). Methods We performed a secondary analysis of a prospectively collected cohort of patients admitted for AD. Laboratory and clinical data at admission and at discharge were collected. Timing and causes of unscheduled readmissions and mortality were recorded up to 1 year. Results A total of 329 patients with AD were included in the analysis. Acute-on-chronic liver failure was diagnosed in 19% of patients at admission or developed in an additional 9% of patients during the index hospitalisation. During the 1-year follow-up, 182 patients (55%) were rehospitalised and 98 (30%) more than once. The most frequent causes of readmission were hepatic encephalopathy (36%), ascites (22%), and infection (21%). Cumulative incidence of readmission was 20% at 30 days, 39% at 90 days, and 63% at 1 year. Fifty-four patients were readmitted for emergent liver-related causes within 30 days. Early readmission was associated with a higher 1-year mortality (47 vs. 32%, p = 0.037). Multivariable Cox regression analysis showed that haemoglobin (Hb) ≤8.7 g/dl (hazard ratio 2.63 [95% CI 1.38-5.02], p = 0.003) and model for end-stage liver disease-sodium score (MELD-Na) >16 at discharge (hazard ratio 2.23 [95% CI 1.27-3.93], p = 0.005), were independent predictors of early readmission. In patients with MELD-Na >16 at discharge, the presence of Hb ≤8.7 g/dl doubles the risk of early rehospitalisation (44% vs. 22%, p = 0.02). Conclusion Besides MELD-Na, a low Hb level (Hb ≤8.7 g/dl) at discharge emerged as a new risk factor for early readmission, contributing to identification of patients who require closer surveillance after discharge. Impact and Implications Patients with decompensated cirrhosis face frequent hospitalisations. In the present study, type and causes of readmissions were analysed during 1-year follow-up in patients discharged after the index hospitalisation for an acute decompensation of the disease. Early (30-day) liver-related readmission was associated with higher 1-year mortality. The model for end-stage liver disease-sodium score and low haemoglobin at discharge were identified as independent risk factors for early readmissions. Haemoglobin emerged as a new easy-to-use parameter associated with early readmission warranting further investigation.
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Affiliation(s)
- Enrico Pompili
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Centre for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Manuel Tufoni
- Unit of Semeiotics, Liver and Alcohol-related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Dario Pratelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Francesco Palmese
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Luca Vizioli
- Internal Medicine Unit for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Chiara Faggiano
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgio Bedogni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Marco Domenicali
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Department of Primary Health Care, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Corresponding authors. Addresses: Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy. Tel.: +39-051-214-2919; fax: +39-051-214-2930.
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25
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Rashidi-Alavijeh J, Nuruzade N, Frey A, Huessler EM, Hörster A, Zeller AC, Schütte A, Schmidt H, Willuweit K, Lange CM. Implications of anaemia and response to anaemia treatment on outcomes in patients with cirrhosis. JHEP Rep 2023; 5:100688. [PMID: 36926273 PMCID: PMC10011825 DOI: 10.1016/j.jhepr.2023.100688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/29/2022] [Accepted: 01/12/2023] [Indexed: 01/30/2023] Open
Abstract
Background & Aims Anaemia is frequently observed in patients with cirrhosis and was identified as a predictor of adverse outcomes, such as increased mortality and occurrence of acute-on-chronic liver failure. To date, the possible effects of iron supplementation on these adverse outcomes are not well described. We therefore aimed to assess the role of iron supplementation in patients with cirrhosis and its capability to improve prognosis. Methods Laboratory diagnostics were performed in consecutive outpatients with cirrhosis admitted between July 2018 and December 2019 to the University Hospital Essen. Associations with transplant-free survival were assessed in regression models. Results A total of 317 outpatients with cirrhosis were included, of whom 61 received a liver transplant (n = 19) or died (n = 42). In multivariate Cox regression analysis, male sex (hazard ratio [HR] = 3.33, 95% CI [1.59, 6.99], p = 0.001), model for end-stage liver disease score (HR = 1.19, 95% CI [1.11, 1.27], p <0.001) and the increase of haemoglobin levels within 6 months (ΔHb6) (HR = 0.72, 95% CI [0.63, 0.83], p <0.001) were associated with transplant-free survival. Regarding the prediction of haemoglobin increase, intake of rifaximin (beta = 0.50, SD beta = 0.19, p = 0.007) and iron supplementation (beta = 0.79, SD beta = 0.26, p = 0.003) were significant predictors in multivariate analysis. Conclusions An increase of haemoglobin levels is associated with improvement of transplant-free survival in patients with cirrhosis. Because the prediction of haemoglobin increase significantly depends on rifaximin and iron supplementation, application of these two medications can have an important impact on the outcome of these patients. Impact and implications Anaemia is very common in patients with cirrhosis and is known to be a predictor of negative outcomes, but little is known about the effect of iron substitution in these individuals. In our cohort, increase of haemoglobin levels improved transplant-free survival of patients with cirrhosis. The increase of haemoglobin levels was mainly induced by iron supplementation and was even stronger in the case of concomitant use of iron and rifaximin. Clinical trial registration UME-ID-10042.
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Key Words
- ACLF, acute-on-chronic liver failure
- AIH, autoimmune hepatitis
- ALT, alanine aminotransferase
- AP, alkaline phosphatase
- AST, aspartate aminotransferase
- CRP, C-reactive protein
- Haemoglobin
- INR, international normalised ratio
- Iron deficiency
- Iron supplementation
- LT, liver transplantation
- Liver transplantation
- MELD, model for end-stage liver disease
- NASH, non-alcoholic steatohepatitis
- NSBBs, non-selective beta blockers
- PBC, primary biliary cholangitis
- PSC, primary sclerosing cholangitis
- Rifaximin
- SSC, secondary sclerosing cholangitis
- TIPS, transjugular intrahepatic portosystemic shunt
- aPTT, activated partial thromboplastin time
- ΔHb3, difference of haemoglobin levels after 3 months
- ΔHb6, difference of haemoglobin levels after 6 months
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Affiliation(s)
- Jassin Rashidi-Alavijeh
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Nargiz Nuruzade
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Alexandra Frey
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Eva-Maria Huessler
- Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University of Duisburg-Essen, Duisburg, Germany
| | - Anne Hörster
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Amos Cornelius Zeller
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Andreas Schütte
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Hartmut Schmidt
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Katharina Willuweit
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Christian Markus Lange
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
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Clinicodemographic profile of chronic liver disease patients at a tertiary care hospital: a retrospective analysis. Ann Med Surg (Lond) 2023; 85:390-393. [PMID: 36923767 PMCID: PMC10010787 DOI: 10.1097/ms9.0000000000000248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/08/2023] [Indexed: 03/06/2023] Open
Abstract
With the global burden of chronic liver disease (CLD) on the rise, especially due to the rise in obesity and metabolic syndrome, a third-world country like Nepal faces a different problem. With alcohol intake being rooted in Nepalese culture, alcoholic liver disease (ALD) is the most common cause of CLD in our society. Methods This is a retrospective observational study conducted in the inpatient ward of the Department of Gastroenterology at the University in Nepal. Ethical approval was taken from the Institutional Review Committee, and a structured questionnaire format was used to record the data retrospectively using admission log books and admission sheets. Demographic data regarding age, sex, and address were collected, while the form of decompensation during presentation was used as a source of clinical data. For statistical analysis, see SPSS 21 (IBM Corp., Released 2012. IBM SPSS Statistics for Windows, Version 21.0; IBM Corp.) was used. Results A male-to-female ratio of 2:1 was found, with ALD the most common cause of CLD in admitted patients. Similarly, the majority of patients were admitted due to ascites, which was compounded by spontaneous bacterial peritonitis. 93.60% of patients admitted with CLD had a deranged prothrombin time, while only about a third of patients had elevated aspartate aminotransferase and/or alanine aminotransferase. Conclusion The large burden of ALD highlights the importance of awareness programs at the community level, which have been neglected till date.
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Ning X, Cao J, Wang W, Xu Z, Yang F, Li M, Wang H, Li N, Zhou G, Bai Y, Cai C, Li B, Han L, Qiao F, Lu F. Impact of transcatheter tricuspid valve replacement for tricuspid regurgitation on hepatic, cardiac, and venous structure. Int J Cardiol 2023; 372:33-39. [PMID: 36450337 DOI: 10.1016/j.ijcard.2022.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/09/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with long-term tricuspid regurgitation (TR) are mostly accompanied by hepatic, cardiac, and venous remodeling. Transcatheter tricuspid valve replacement (TTVR) device has emerged as a promising alternative to open-heart surgery for TR patients. No study has assessed the impact of TTVR on hepatic, cardiac, and venous remodeling. METHODS Twenty-two patients with TR enrolled in this study underwent TTVR between October 2020 and January 2021. Liver, heart, and veins were reconstructed by three-dimensional computed tomography reconstruction software at baseline and 6 months follow-up. RESULTS Twenty-two patients were enrolled in this study. The mean age was 64.8 ± 8.2 years, and all patients had severe or greater TR with multiple comorbidities. The left hepatic lobe volume decreased from 518.8 ± 171.9 ml to 470.4 ± 179.6 ml at 6 months during follow-up (p = 0.049). Evidence of a decrease in three hepatic veins parameters and splenic vein parameters was noted from baseline to 6 months. And a significant decrease in right atrial volume (317.5 ml [interquartile range: 216.1 to 497.3 ml] vs. 266.7 ml [interquartile range: 178.7 to 480.7 ml]; p = 0.003) were observed in the study. CONCLUSIONS Six-month outcomes show that TR elimination by LuX-Valve is associated with the reverse remodeling of liver, heart, and veins. Accordingly, LuX-Valve is a promising alternative for patients presenting with severe TR.
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Affiliation(s)
- Xiaoping Ning
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Jingyi Cao
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Wei Wang
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Zhiyun Xu
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Fan Yang
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Mengxing Li
- Department of Thoracic Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - He Wang
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Ning Li
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Guangwei Zhou
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Yifan Bai
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Chengliang Cai
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Bailing Li
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Lin Han
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China
| | - Fan Qiao
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China.
| | - Fanglin Lu
- Department of Cardiovascular Surgery, Changhai hospital affiliated to the Naval Medical University, Shanghai 200433, China.
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Park H, Lo-Ciganic WH, Huang J, Wu Y, Henry L, Peter J, Sulkowski M, Nelson DR. Machine learning algorithms for predicting direct-acting antiviral treatment failure in chronic hepatitis C: An HCV-TARGET analysis. Hepatology 2022; 76:483-491. [PMID: 35034373 PMCID: PMC9287493 DOI: 10.1002/hep.32347] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS We aimed to develop and validate machine learning algorithms to predict direct-acting antiviral (DAA) treatment failure among patients with HCV infection. APPROACH AND RESULTS We used HCV-TARGET registry data to identify HCV-infected adults receiving all-oral DAA treatment and having virologic outcome. Potential pretreatment predictors (n = 179) included sociodemographic, clinical characteristics, and virologic data. We applied multivariable logistic regression as well as elastic net, random forest, gradient boosting machine (GBM), and feedforward neural network machine learning algorithms to predict DAA treatment failure. Training (n = 4894) and validation (n = 1631) patient samples had similar sociodemographic and clinical characteristics (mean age, 57 years; 60% male; 66% White; 36% with cirrhosis). Of 6525 HCV-infected adults, 95.3% achieved sustained virologic response, whereas 4.7% experienced DAA treatment failure. In the validation sample, machine learning approaches performed similarly in predicting DAA treatment failure (C statistic [95% CI]: GBM, 0.69 [0.64-0.74]; random forest, 0.68 [0.63-0.73]; feedforward neural network, 0.66 [0.60-0.71]; elastic net, 0.64 [0.59-0.70]), and all four outperformed multivariable logistic regression (0.51 [0.46-0.57]). Using the Youden index to identify the balanced risk score threshold, GBM had 66.2% sensitivity and 65.1% specificity, and 12 individuals were needed to evaluate to identify 1 DAA treatment failure. Over 55% of patients with treatment failure were classified by the GBM in the top three risk decile subgroups (positive predictive value: 6%-14%). The top 10 GBM-identified predictors included albumin, liver enzymes (aspartate aminotransferase, alkaline phosphatase), total bilirubin levels, sex, HCV viral loads, sodium level, HCC, platelet levels, and tobacco use. CONCLUSIONS Machine learning algorithms performed effectively for risk prediction and stratification of DAA treatment failure.
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Affiliation(s)
- Haesuk Park
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Wei-Hsuan Lo-Ciganic
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - James Huang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Yonghui Wu
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Linda Henry
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Joy Peter
- Department of Medicine, University of Florida, Gainesville, Florida
| | | | - David R. Nelson
- Department of Medicine, University of Florida, Gainesville, Florida
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Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, and a significant proportion (20-40%) of patients with HCC develop paraneoplastic syndromes (PNS). Despite this, there is a paucity of clinical evidence regarding PNS in HCC. AREAS COVERED A systematic search was performed to identify relevant case studies regarding PNS in HCC. Another search was conducted to identify studies that evaluated the impact of PNS on survival outcomes in HCC. Since there are currently no international guidelines for PNS in HCC, this review aims to provide comprehensive summaries and recommendations of PNS in HCC, including the pathophysiology, clinical features, diagnostic approach, and management, so that clinicians remain guided in caring for HCC patients with PNS. In general, PNS are associated with poorer survival outcomes and negative prognostic markers of HCC. EXPERT OPINION The presence of PNS has a significant influence on survival rates and clinical outcomes of patients with HCC. They contribute to significant morbidity, influencing patients' quality of life and fitness for curative and palliative therapies. Therefore, it is paramount for PNS to be integrated into routine investigations after diagnosing HCC to guide further management and prognostication of the disease.
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Affiliation(s)
- Yuki Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheong Wei Terence Huey
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Hepato-Pancreatico-Biliary Surgery, Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishalkumar Girishchandra Shelat
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Hepato-Pancreatico-Biliary Surgery, Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 119] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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Schwabl P, Seeland BA, Riedl F, Schubert TL, Königshofer P, Brusilovskaya K, Petrenko O, Hofer B, Schiefer AI, Trauner M, Peck-Radosavljevic M, Reiberger T. Splenectomy ameliorates portal pressure and anemia in animal models of cirrhotic and non-cirrhotic portal hypertension. Adv Med Sci 2022; 67:154-162. [PMID: 35272246 DOI: 10.1016/j.advms.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/30/2021] [Accepted: 02/23/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE Portal hypertension (PH)-associated splenomegaly is caused by portal venous congestion and splanchnic hyperemia. This can trigger hypersplenism, which favors the development of cytopenia. We investigated the time-dependent impact of splenectomy on portal pressure and blood cell counts in animal models of non-cirrhotic and cirrhotic PH. MATERIALS AND METHODS Ninety-six rats underwent either partial portal vein ligation (PPVL), bile duct ligation (BDL), or sham operation (SO), with subgroups undergoing additional splenectomy. Portal pressure, mean arterial pressure, heart rate, blood cell counts and hemoglobin concentrations were evaluated throughout 5 weeks following surgery. RESULTS Following PPVL or BDL surgery, the animals presented a progressive rise in portal pressure, paralleled by decreased mean arterial pressure and accelerated heart rate. Splenectomy curbed the development of PH in both models (PPVL: 16.25 vs. 17.93 mmHg, p = 0.083; BDL: 13.55 vs. 15.23 mmHg, p = 0.028), increased mean arterial pressure (PPVL: +7%; BDL: +9%), and reduced heart rate (PPVL: -10%; BDL: -13%). Accordingly, splenectomized rats had lower von Willebrand factor plasma levels (PPVL: -22%; BDL: -25%). Splenectomy resulted in higher hemoglobin levels in PPVL (14.15 vs. 13.08 g/dL, p < 0.001) and BDL (13.20 vs. 12.39 g/dL, p = 0.097) animals, and significantly increased mean corpuscular hemoglobin concentrations (PPVL: +9%; BDL: +15%). Thrombocytopenia only developed in the PPVL model and was alleviated in the splenectomized subgroup. Conversely, BDL rats presented with thrombocytosis, which was not affected by splenectomy. CONCLUSIONS Splenectomy improves both cirrhotic and non-cirrhotic PH, and ameliorates the hyperdynamic circulation. Hypersplenism related anemia and thrombocytopenia were only significantly improved in the non-cirrhotic PH model.
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Affiliation(s)
- Philipp Schwabl
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Berit Anna Seeland
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria
| | - Florian Riedl
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria
| | - Tim Lukas Schubert
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria
| | - Philipp Königshofer
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Ksenia Brusilovskaya
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Oleksandr Petrenko
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Ludwig Boltzmann Institute, Vienna, Austria; CeMM Research Center for Molecular Medicine, Austrian Academy of Sciences, Vienna, Austria
| | - Benedikt Hofer
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Ana-Iris Schiefer
- Division of Pathology, Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria; Innere Medizin und Gastroenterologie (IMuG), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Thomas Reiberger
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Experimental (HEPEX) Laboratory, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Ludwig Boltzmann Institute, Vienna, Austria; CeMM Research Center for Molecular Medicine, Austrian Academy of Sciences, Vienna, Austria.
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Low Hemoglobin-to-Red Cell Distribution Width Ratio Is Associated with Mortality in Patients with HBV-Related Decompensated Cirrhosis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5754790. [PMID: 35198637 PMCID: PMC8860564 DOI: 10.1155/2022/5754790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 12/15/2022]
Abstract
Background The prognostic role of hemoglobin-to-red blood cell distribution width ratio (HRR) in HBV-related decompensated cirrhosis (HBV-DeCi) has not been established. The present study is aimed at determining the potential of HRR as a predictive factor for the prognosis of HBV-DeCi patients. Methods The study included 177 HBV-DeCi patients. The clinical outcome was death at 30 days. Multivariate regression analysis and receiver operating characteristic curve analysis were applied to assess the predictive value of HRR for poor outcomes. Results A total of 26 patients (14.7%) had died by 30 days. Patients with unfavorable outcomes had lower HRR than patients with favorable outcomes. Multivariate analysis revealed that HRR and Model for End-Stage Liver Disease (MELD) score were independently associated with poor outcomes. Combination of HRR and MELD score may improve prognostic accuracy in HBV-DeCi. Conclusions The present findings indicate that low HRR may be a promising predictor for mortality in HBV-DeCi patients.
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Manrai M, Dawra S, Kapoor R, Srivastava S, Singh A. Anemia in cirrhosis: An underestimated entity. World J Clin Cases 2022; 10:777-789. [PMID: 35127894 PMCID: PMC8790443 DOI: 10.12998/wjcc.v10.i3.777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/18/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
Anemia in a patient with cirrhosis is a clinically pertinent but often overlooked clinical entity. Relevant guidelines highlight the algorithmic approach of managing a patient of cirrhosis presenting with acute variceal hemorrhage but day-to-day management in hospital and out-patient raises multiple dilemmas: Whether anemia is a disease complication or a part of the disease spectrum? Should iron, folic acid, and vitamin B complex supplementation and nutritional advice, suffice in those who can perform tasks of daily living but have persistently low hemoglobin. How does one investigate and manage anemia due to multifactorial etiologies in the same patient: Acute or chronic blood loss because of portal hypertension and bone marrow aplasia secondary to hepatitis B or C viremia? To add to the clinician’s woes the prevalence of anemia increases with increasing disease severity. We thus aim to critically analyze the various pathophysiological mechanisms complicating anemia in a patient with cirrhosis with an emphasis on the diagnostic flowchart in such patients and proposed management protocols thereafter.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Rajan Kapoor
- Department of Medicine, Command Hospital, Kolkata 70027, India
| | - Sharad Srivastava
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Covered Transjugular Intrahepatic Portosystemic Shunt Improves Hypersplenism-Associated Cytopenia in Cirrhosis. Dig Dis Sci 2022; 67:5693-5703. [PMID: 35301618 PMCID: PMC9652242 DOI: 10.1007/s10620-022-07443-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 02/07/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Patients with cirrhosis often develop portal hypertension-associated splenomegaly and hypersplenism, potentially causing severe cytopenia. AIMS Systematic assessment on the impact of transjugular intrahepatic portosystemic shunt (TIPS) implantation on platelet count (PLT), hemoglobin (Hb), and white blood cell count (WBC). METHODS Patients with cirrhosis undergoing covered TIPS implantation were retrospectively included. Patients with malignancies or hematologic disorders were excluded. Hematology lab work was recorded at baseline (pre-TIPS) and at regular intervals after TIPS. RESULTS One hundred ninety-two patients (male: 72.4%, age: 56 ± 10 years; MELD: 12.1 ± 3.6) underwent TIPS implantation. Higher-grade (≥ G2) thrombocytopenia (PLT < 100 G/L) was present in 54 (28.7%), ≥ G2 anemia (Hb < 10 g/dL) in 57 (29.7%), and ≥ G2 leukopenia (WBC < 2 G/L) in 3 (1.6%) patients pre-TIPS, respectively. Resolution of ≥ G2 thrombocytopenia, anemia, and leukopenia occurred in 24/55 (43.6%), 23/57 (40.4%), and 2/3 (66.7%), respectively. Similar results were also observed in the subgroup of patients without 'bleeding' TIPS-indication, with improvements of G ≥ 2 thrombocytopenia and of G ≥ 2 anemia in 19.8% and 10.2% of patients after TIPS, respectively. CONCLUSIONS Thrombocytopenia, anemia, and leukopenia frequently improved after TIPS. Therefore, moderate- to higher-grade thrombocytopenia should not be regarded as a contraindication against TIPS, but rather be considered in case of severe thrombocytopenia-particularly prior to surgery or interventions.
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Ferrao K, Ali N, Mehta KJ. Iron and iron-related proteins in alcohol consumers: cellular and clinical aspects. J Mol Med (Berl) 2022; 100:1673-1689. [PMID: 36214835 PMCID: PMC9691479 DOI: 10.1007/s00109-022-02254-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 01/05/2023]
Abstract
Alcohol-associated liver disease (ALD) is one of the most common chronic liver diseases. Its pathological spectrum includes the overlapping stages of hepatic steatosis/steatohepatitis that can progress to liver fibrosis and cirrhosis; both are risk factors for hepatocellular carcinoma. Moreover, ALD diagnosis and management pose several challenges. The early pathological stages are reversible by alcohol abstinence, but these early stages are often asymptomatic, and currently, there is no specific laboratory biomarker or diagnostic test that can confirm ALD etiology. Alcohol consumers frequently show dysregulation of iron and iron-related proteins. Examination of iron-related parameters in this group may aid in early disease diagnosis and better prognosis and management. For this, a coherent overview of the status of iron and iron-related proteins in alcohol consumers is essential. Therefore, here, we collated and reviewed the alcohol-induced alterations in iron and iron-related proteins. Reported observations include unaltered, increased, or decreased levels of hemoglobin and serum iron, increments in intestinal iron absorption (facilitated via upregulations of duodenal divalent metal transporter-1 and ferroportin), serum ferritin and carbohydrate-deficient transferrin, decrements in serum hepcidin, decreased or unaltered levels of transferrin, increased or unaltered levels of transferrin saturation, and unaltered levels of soluble transferrin receptor. Laboratory values of iron and iron-related proteins in alcohol consumers are provided for reference. The causes and mechanisms underlying these alcohol-induced alterations in iron parameters and anemia in ALD are explained. Notably, alcohol consumption by hemochromatosis (iron overload) patients worsens disease severity due to the synergistic effects of excess iron and alcohol.
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Affiliation(s)
- Kevin Ferrao
- GKT School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Najma Ali
- GKT School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kosha J Mehta
- Centre for Education, Faculty of Life Sciences and Medicine, King's College London, London, UK.
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Zhao TY, Cong QW, Liu F, Yao LY, Zhu Y. Nonlinear Relationship Between Macrocytic Anemia and Decompensated Hepatitis B Virus Associated Cirrhosis: A Population-Based Cross-Sectional Study. Front Pharmacol 2021; 12:755625. [PMID: 34616304 PMCID: PMC8488205 DOI: 10.3389/fphar.2021.755625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/06/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Mean corpuscular volume (MCV) is major used as an indicator for the differential diagnosis of anemia. Macrocytic anemia in decompensated cirrhosis is common. However, the relationship between macrocytic anemia and decompensated hepatitis B virus (HBV) associated cirrhosis has not been fully addressed. Methods: In this cross-sectional study, a total of 457 patients diagnosed decompensated HBV associated cirrhosis who met all inclusion criteria from 2011 to 2018 were analyzed. Association between macrocytic anemia and the liver damaged (Model for End Stage Liver Disease (MELD) score) were examined using multiple logistic regression analyses and identified using smooth curve fitting. Results: Compared with normocytic anemia, MCV and MELD are significantly positively correlated in macrocytic anemia (p < 0.001). A non-linear relationship of MCV and MELD association was found though the piecewise linear spline models in patients with decompensated HBV associated cirrhosis. MCV positive correlated with MELD when the MCV was greater than 98.2 fl (regression coefficient = 0.008, 95% CI 0.1, 0.4). Conclusion: Macrocytic anemia may be a reliable predictor for mortality because it is closely related to the degree of liver damage in patients with decompensated HBV associated cirrhosis.
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Affiliation(s)
- Tian-Yu Zhao
- Liver Disease Center of Integrated Traditional Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Qing-Wei Cong
- Liver Disease Center of Integrated Traditional Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Fang Liu
- Liver Disease Center of Integrated Traditional Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Li-Ying Yao
- Liver Disease Center of Integrated Traditional Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Zhu
- Liver Disease Center of Integrated Traditional Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Diagnosis and Management of Autoimmune Hemolytic Anemia in Patients with Liver and Bowel Disorders. J Clin Med 2021; 10:jcm10030423. [PMID: 33499290 PMCID: PMC7865399 DOI: 10.3390/jcm10030423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/12/2022] Open
Abstract
Anemia is a common feature of liver and bowel diseases. Although the main causes of anemia in these conditions are represented by gastrointestinal bleeding and iron deficiency, autoimmune hemolytic anemia should be considered in the differential diagnosis. Due to the epidemiological association, autoimmune hemolytic anemia should particularly be suspected in patients affected by inflammatory and autoimmune diseases, such as autoimmune or acute viral hepatitis, primary biliary cholangitis, and inflammatory bowel disease. In the presence of biochemical indices of hemolysis, the direct antiglobulin test can detect the presence of warm or cold reacting antibodies, allowing for a prompt treatment. Drug-induced, immune-mediated hemolytic anemia should be ruled out. On the other hand, the choice of treatment should consider possible adverse events related to the underlying conditions. Given the adverse impact of anemia on clinical outcomes, maintaining a high clinical suspicion to reach a prompt diagnosis is the key to establishing an adequate treatment.
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Perceptions on the management of varices and on the use of albumin in patients with cirrhosis among GI specialists in Austria. Wien Klin Wochenschr 2020; 133:421-431. [PMID: 33270161 PMCID: PMC8116244 DOI: 10.1007/s00508-020-01769-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Portal hypertension (PH) causes severe complications in patients with liver cirrhosis, such as variceal bleeding and ascites; however, data on the knowledge and perceptions on guideline recommendations for the management of varices and the use of albumin is scarce. METHODS We designed two structured surveys on (i) the management of varices and (ii) the use of albumin for Austrian physicians of specialized Gastro-Intestinal (GI) centers. The interviewed physicians were confronted spontaneously and provided ad hoc responses to the questionnaire. RESULTS In total, 158 surveys were completed. Interestingly, many specialists (30%) would recommend a follow-up gastroscopy after 1 year in patients with compensated cirrhosis without varices (i.e., overtreatment). For small varices, 81.5% would use non-selective beta blockers (NSBB) for primary prophylaxis (PP). For PP in patients with large varices, endoscopic band ligation (EBL) plus NSBB was preferred by 51.4% (i.e., overtreatment). Knowledge on the indication criteria for early TIPS (transjugular intrahepatic portosystemic shunt) was reported by 54.3%, but only 20% could report these criteria correctly. The majority (87.1%) correctly indicated a preference to use NSBB and EBL for secondary prophylaxis (SP). The majority of participating gastroenterologists reported no restrictions on the use of albumin (89.8%) in their hospitals. Of the interviewed specialists, 63.6% would use albumin in patients with SBP; however, only 11.4% would use the doses recommended by guidelines. The majority of specialists indicated using albumin at the recommended doses for hepatorenal syndrome (HRS-AKI, 86.4%) and for large volume paracentesis (LVP, 73.3%). The individual responses regarding albumin use for infections/sepsis, hyponatremia, renal impairment, and encephalopathy were heterogeneous. CONCLUSION The reported management of PH and varices is mostly adherent to guidelines, but endoscopic surveillance in patients without varices is too intense and EBL is overused in the setting of PP. Knowledge on the correct use of early TIPS must be improved among Austrian specialists. Albumin use is widely unrestricted in Austria; however, albumin is often underdosed in established indications.
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The effect of anemia on the efficacy and safety of treating chronic hepatitis C infection with direct-acting antivirals in patients with chronic kidney disease. Int Urol Nephrol 2020; 53:749-761. [PMID: 33111161 DOI: 10.1007/s11255-020-02656-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/14/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIM Chronic hepatitis-C infection is a great health burden in Egypt. The effect of anemia on the efficacy and safety of direct-acting anti-viral (DAA) therapies for those with chronic-kidney disease (CKD) has not been evaluated. PATIENTS/METHODS This single-center retrospective study included 235 renal patients: i.e., 70-CKD patients not on hemodialysis (42 with anemia, 28 without); 40 hemodialysis patients (16 anemic; 24 non-anemic), and 125 kidney-transplant (KTx) recipients (40 anemic; 85 non-anemic). Anemia was defined by a hemoglobin level < 10.5 g/dL. Hemodialysis patients received ritonavir-boosted paritaprevir/ombitasvir. KTx patients received sofosbuvir/daclatasvir. CKD patients with eGFR > 30 mL/min/1.73 m2 received sofosbuvir/daclatasvir. Those with eGFR < 30 mL/min/1.73 m2 received ritonavir-boosted paritaprevir/ombitasvir; 64 non-anemic patients also received ribavirin therapy. RESULTS Mean age of CKDs was 49.1 years, 43.2 years for HDs, and 45.2 years for KTx patients. Most were male; body-mass index was ~ 23.8. Anemia did not affect the efficacy of DAAs in hemodialysis, CKD, or KTx patients. Most patients achieved a rapid virologic response (RVR), and a 12- and 24-week sustained viral response. Worsening of anemia among the non-anemic group was mostly related to ribavirin therapy in hemodialysis patients (11/16 patients). Acute kidney injury in CKDs occurred more frequently within the anemic group (59.5%) compared to the non-anemic group (32.1%). For KTx, graft impairment was more common among the anemic group (7/40) compared to the non-anemic group (2/85). CONCLUSION Hemoglobin levels of < 10.5 g/dL prior to DAA treatment did not affect the virological response in renal patients but was associated with increased serum creatinine among KTx and those with CKD.
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Fierro-Fine A, Guerin L, Hicsasmaz H, Brown KE. Clinical Factors Associated with Hepatocellular Iron Deposition in End-stage Liver Disease. J Clin Transl Hepatol 2020; 8:231-239. [PMID: 33083244 PMCID: PMC7562807 DOI: 10.14218/jcth.2020.00022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/18/2020] [Accepted: 06/19/2020] [Indexed: 02/06/2023] Open
Abstract
Background and Aims: Hepatocellular iron accumulation in patients with chronic liver disease has been linked to adverse outcomes. The objective of this study was to identify clinical factors associated with hemosiderosis. Methods: A total of 103 consecutive liver transplant recipients were identified, in whom liver biopsy had been performed prior to transplantation. Laboratory and clinical data at biopsy and transplant were abstracted from the medical records and hepatocyte iron was graded in the biopsy and explant. The association of change in iron score from biopsy to transplant, with the time interval between these two events, was examined using linear mixed model analysis for repeated measures. Results: Most subjects had advanced fibrosis (F3-F4) at liver biopsy, which was performed on average about 2.5 years before transplant. Over 80% of patients had no or 1+ hepatocyte iron at biopsy; iron increased between biopsy and transplant in about 40%. The only demographic or clinical feature that correlated with increased iron was the presence of a transjugular intrahepatic portosystemic shunt. Increased iron at transplant was associated with higher serum iron and transferrin saturation at biopsy, and with lower hemoglobin level, greater mean corpuscular volume, mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration, higher ferritin and model for end-stage liver disease score at transplant. Conclusions: The development of hemosiderosis in end-stage liver disease is associated with lower hemoglobin levels and alterations in red blood cell indices that are suggestive of hemolysis. These observations suggest that extravascular hemolysis may play a role in the development of secondary iron overload.
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Affiliation(s)
- Amelia Fierro-Fine
- Department of Pathology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Leana Guerin
- Department of Pathology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | | | - Kyle E. Brown
- Division of Gastroenterology-Hepatology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
- Program in Free Radical and Radiation Biology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
- Iowa City Veterans Administration Medical Center, Iowa City, IA, USA
- Correspondence to: Kyle E. Brown, Division of Gastroenterology-Hepatology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 4553 JCP, 200 Hawkins Drive, Iowa City, IA 52242, USA. Tel: +1-319-384-6579, Fax: +1-319-356-7918, E-mail:
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41
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Kedarisetty CK, Kumar R. Spur Cells Causing Severe and Transfusion-Refractory Anemia in Patients With Acute-on-Chronic Liver Failure. Cureus 2020; 12:e10568. [PMID: 33110713 PMCID: PMC7579423 DOI: 10.7759/cureus.10568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/09/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation of chronic liver disease associated with organ failures. Anemia of diverse etiology is common in patients with ACLF. Spur cell anemia (SCA) is a form of acquired hemolytic anemia that occurs rarely in such patients due to dysregulated lipids metabolism. Spur cells are large erythrocytes with spike-like projections, which predispose them for sequestration and destruction in splenic canaliculi. There is a paucity of data on SCA in patients with ACLF. Here we report a series of five ACLF patients who had severe (hemoglobin level < 8 g/dL) and transfusion-refractory SCA with aggressive clinical course and high mortality rate.
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Affiliation(s)
| | - Ramesh Kumar
- Gastroenterology, All India Institute of Medical Sciences, Patna, IND
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42
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Leo M, DI Giacinto F, Nardini M, Mazzini A, Rossi C, Porceddu E, Papi M, Grieco A, DE Spirito M, Ciasca G. Erythrocyte viscoelastic recovery after liver transplantation in a cirrhotic patient affected by spur cell anaemia. J Microsc 2020; 280:287-296. [PMID: 32885445 DOI: 10.1111/jmi.12958] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/31/2020] [Accepted: 08/26/2020] [Indexed: 01/13/2023]
Abstract
In physiological conditions, red blood cells (RBCs) are capable of dramatic deformations when passing through the microvasculature. This extreme deformability is closely related to the RBC biconcave shape, to the fluidic nature of the haemoglobin and the cell membrane structure, primarily consisting of a phospholipid bilayer with an underlying two-dimensional spectrin network. In many pathological and inflammatory conditions, the shape and the extreme deformability of erythrocytes appear to be significantly altered. These findings have stimulated intense research towards the search and validation of novel erythrocyte-based mechanical biomarkers, useful for disease diagnosis and therapy monitoring. In this study, we investigated with Atomic Force Microscopy (AFM) the mechanical properties of erythrocytes obtained from a 68 years old cirrhotic man diagnosed with spur cell anaemia and cold agglutinated disease, before and after liver transplantation. Mechanical changes are compared with ultrastructural alterations as studied by scanning electron microscopy and discussed according to confocal fluorescence microscopy results, showing possible alterations induced by the cirrhotic environment at the level of the RBCs cytoskeletal organisation and lipidic composition. Taken together, the results here presented show that liver transplantation not only contributes to restoring the proper RBC morphology, but it also induces recovery of the physiological viscous behaviour of cells, further stressing the relevance of viscous and dissipative forces in determining the RBC biomechanical response.
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Affiliation(s)
- M Leo
- Internal Medicine, Gastroenterology and Hepatology, Fondazione Policlinico Universitario, Agostino Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - F DI Giacinto
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - M Nardini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - A Mazzini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - C Rossi
- Area Diagnostica di Laboratorio UOC Chimica, Biochimica e Biologia Molecolare, Fondazione Policlinico A. Gemelli IRCCS, Roma, Italy
| | - E Porceddu
- Internal Medicine, Gastroenterology and Hepatology, Fondazione Policlinico Universitario, Agostino Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - M Papi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - A Grieco
- Liver Transplant Medicine Unit, Department of Gastroenterological, Endocrine and Metabolic Sciences, Fondazione Policlinico Universitario Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - M DE Spirito
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - G Ciasca
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento di Neuroscienze, Sezione di Fisica, Università Cattolica del Sacro Cuore, Roma, Italy
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43
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Scheiner B, Northup PG, Lisman T, Mandorfer M. Author response to Letter to the Editor: 'AB0, von Willebrand factor/Factor VIII and portal vein thrombosis in decompensated cirrhosis: Too late to unmask the culprit?'. Liver Int 2020; 40:1790-1791. [PMID: 32367685 DOI: 10.1111/liv.14499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Bernard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Patrick G Northup
- Center for the Study of Hemostasis in Liver Disease, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
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44
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Bitto N, Tosetti G, La Mura V, Primignani M. AB0, von Willebrand factor/factor VIII and portal vein thrombosis in decompensated cirrhosis: Too late to unmask the culprit? Liver Int 2020; 40:1788-1789. [PMID: 32343027 DOI: 10.1111/liv.14493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Niccolò Bitto
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C Medicina Generale Emostasie Trombosi, Milano, Italy
| | - Giulia Tosetti
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | - Vincenzo La Mura
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C Medicina Generale Emostasie Trombosi, Milano, Italy.,Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy.,Dipartimento di Scienze Biomediche per la Salute, Università degli studi di Milano, Milano, Italy
| | - Massimo Primignani
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
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45
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Singh S, Manrai M, V S P, Kumar D, Srivastava S, Pathak B. Association of liver cirrhosis severity with anemia: does it matter? Ann Gastroenterol 2020; 33:272-276. [PMID: 32382230 PMCID: PMC7196620 DOI: 10.20524/aog.2020.0478] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/09/2020] [Indexed: 12/13/2022] Open
Abstract
Background The etiology of anemia in liver disease is diverse and often multifactorial. Anemia is more severe in advanced stages of liver cirrhosis and can be a predictor of the severity of liver disease. Methods In this cross-sectional observational study, we included 181 cirrhotic patients with anemia owing to liver cirrhosis and its complications. The population was divided into 2 groups based on the model for end-stage liver disease (MELD) score and the severity of anemia was assessed in the 2 groups. Similarly, hemoglobin levels were assessed in 3 groups based on the Child-Turcotte-Pugh (CTP) classification. Results There was a statistically significant correlation between CTP class and hemoglobin (P<0.001), with the lowest hemoglobin levels in CTP C patients. The correlation coefficient between hemoglobin and MELD score was -0.671 and was statistically significant, establishing that hemoglobin levels decrease with increasing severity of liver cirrhosis. Of 58 patients with macrocytosis, 45 (77.6%) had a MELD score of >12, whereas only 13 patients (22.4%) had a MELD score of <12. This difference was statistically significant (P<0.0001). Conclusions This study shows that hemoglobin levels decrease with increasing severity of liver disease; thus, this measure can be used in the initial assessment of patients to give a picture of the severity of the disease. A larger prospective trial is needed to establish the use of hemoglobin levels for assessing severity and predicting mortality in patients with liver cirrhosis.
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Affiliation(s)
- Sonal Singh
- Department of Internal Medicine, Military Hospital Dehradun (Sonal Singh)
| | - Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune (Manish Manrai, Parvathi V.S., Basant Pathak)
| | - Parvathi V S
- Department of Internal Medicine, Armed Forces Medical College, Pune (Manish Manrai, Parvathi V.S., Basant Pathak)
| | - Dharmendra Kumar
- Department of Internal Medicine, Command Hospital, Pune (Dharmendra Kumar, Sharad Srivastava)
| | - Sharad Srivastava
- Department of Internal Medicine, Command Hospital, Pune (Dharmendra Kumar, Sharad Srivastava)
| | - Basant Pathak
- Department of Internal Medicine, Armed Forces Medical College, Pune (Manish Manrai, Parvathi V.S., Basant Pathak)
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46
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Simbrunner B, Beer A, Wöran K, Schmitz F, Primas C, Wewalka M, Pinter M, Dolak W, Scheiner B, Puespoek A, Trauner M, Oberhuber G, Mandorfer M, Reiberger T. Portal hypertensive gastropathy is associated with iron deficiency anemia. Wien Klin Wochenschr 2020; 132:1-11. [PMID: 31912289 PMCID: PMC6978296 DOI: 10.1007/s00508-019-01593-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 12/07/2019] [Indexed: 12/14/2022]
Abstract
Background and aims Portal hypertensive gastropathy (PHG) is common in patients with cirrhosis and may cause bleeding. This study systematically explored the independent impact of patient characteristics, portal hypertension and hepatic dysfunction on PHG severity and associated anemia. Methods Patients with cirrhosis undergoing endoscopy were included in this retrospective analysis and PHG was endoscopically graded as absent, mild or severe. Clinical and laboratory parameters and hepatic venous pressure gradient (HVPG) were assessed with respect to an association with severity of PHG. Results A total of 110 patients (mean age: 57 years, 69% male) with mostly alcoholic liver disease (49%) or viral hepatitis (30%) were included: 15 (13.6%) patients had no PHG, 59 (53.6%) had mild PHG, and 36 (32.7%) had severe PHG. Severe PHG was significantly associated with male sex (83.3% vs. 62.2% in no or mild PHG; p = 0.024) and higher Child-Turcotte-Pugh (CTP) stage (CTP-C: 38.9% vs. 27.0% in no or mild PHG; p = 0.030), while MELD was similar (p = 0.253). Patients with severe PHG had significantly lower hemoglobin values (11.2 ± 0.4 g/dL vs. 12.4 ± 0.2 g/dL; p = 0.008) and a higher prevalence of iron-deficiency anemia (IDA: 48.5% vs. 26.9%; p = 0.032). Interestingly, HVPG was not significantly higher in severe PHG (median 20 mm Hg) vs. mild PHG (19 mm Hg) and no PHG (18 mm Hg; p = 0.252). On multivariate analysis, CTP score (odds ratio, OR: 1.25, 95% confidence interval, CI 1.02–1.53; p = 0.033) was independently associated with severe PHG, while only a trend towards an independent association with IDA was observed (OR: 2.28, 95% CI 0.91–5.72; p = 0.078). Conclusion The CTP score but not HVPG or MELD were risk factors for severe PHG. Importantly, anemia and especially IDA are significantly more common in patients with severe PHG. Electronic supplementary material The online version of this article (10.1007/s00508-019-01593-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Andrea Beer
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Katharina Wöran
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Fabian Schmitz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Christian Primas
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Marlene Wewalka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Vienna, Austria
| | - Werner Dolak
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Andreas Puespoek
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | | | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria.
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