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Jothimani D, Rela M, Kamath PS. Management of Portal Hypertension in the Older Patient. Curr Gastroenterol Rep 2024:10.1007/s11894-024-00930-y. [PMID: 38780678 DOI: 10.1007/s11894-024-00930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF THIS REVIEW Aging is a process of physiological slowing, reduced regenerative capacity and inability to maintain cellular homeostasis. World Health Organisation declared the commencement of population aging globally, largely attributed to improvement in the healthcare system with early diagnosis and effective clinical management. Liver ages similar to other organs, with reduction in size and blood flow. In this review we aim to evaluate the effect of aging in liver disease. RECENT FINDINGS Aging causes dysregulation of major carbohydrate, fat and protein metabolism in the liver. Age is a major risk factor for liver fibrosis accelerated by sinusoidal endothelial dysfunction and immunological disharmony. Age plays a major role in patients with liver cirrhosis and influence outcomes in patients with portal hypertension. Transient elastography may be an useful tool in the assessment of portal hypertension. Hepatic structural distortion, increased vascular resistance, state of chronic inflammation, associated comorbidities, lack of physiological reserve in the older population may aggravate portal hypertension in patients with liver cirrhosis and may result in pronounced variceal bleed. Cut-offs for other non-invasive markers of fibrosis may differ in the elderly population. Non-selective beta blockers initiated at lower dose followed by escalation are the first line of therapy in elderly patients with cirrhosis and portal hypertension, unless contraindicated. Acute variceal bleed in the elderly cirrhotic patients can be life threatening and may cause rapid exsanguination due to poor reserve and associated comorbidities. Vasoactive drugs may be associated with more adverse reactions. Early endoscopy may be warranted in the elderly patients with acute variceal bleed. Role of TIPS in the elderly cirrhotics discussed. Management of portal hypertension in the older population may pose significant challenges to the treating clinician.
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Affiliation(s)
- Dinesh Jothimani
- Institute of Liver disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India.
| | - Mohamed Rela
- Institute of Liver disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, 55906, USA
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Narayanan V, Devadas K, Sreesh S, Varghese J, Solanki R, Mohapatra SD, Pal R, Madhu D, Chakravorty A. Novel predictors of response to therapy with terlipressin and albumin in hepatorenal syndrome-acute kidney injury. Ann Gastroenterol 2024; 37:81-88. [PMID: 38223250 PMCID: PMC10785019 DOI: 10.20524/aog.2023.0853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/27/2023] [Indexed: 01/16/2024] Open
Abstract
Background A combination of terlipressin and albumin is the first-line pharmacologic treatment for hepatorenal syndrome-acute kidney injury (HRS-AKI). We assessed the response rates to terlipressin-albumin therapy in patients with HRS-AKI and determined early predictors of treatment response and survival. Methods A total of 84 patients with HRS-AKI (International Club of Ascites definition 2015) treated with terlipressin-albumin were included. Predictors of HRS reversal were identified by logistic regression analysis. Survival analysis was performed using the Kaplan-Meier method, and Cox regression models were used to determine independent predictors of mortality. Results Complete response to therapy was observed in 54.8%, partial response in 14.3%, and no response in 31% of patients. The factors associated with complete treatment response were the presence of systemic inflammatory response syndrome (SIRS), baseline serum creatinine, a rise in mean arterial pressure by day 3, and a reduction in the renal resistive index (ΔRRI) by day 3 of treatment. Independent predictors of HRS reversal were the presence of SIRS at baseline (P=0.022; odds ratio [OR] 15.74, 95% confidence interval [CI] 1.47-167.82) and ΔRRI ≥5% by day 3 of treatment (P=0.048; OR 6.67, 95%CI 1.021-43.62). Mean transplant-free survival at 6 months was significantly better in treatment responders (148 vs. 90 days, P<0.001). Independent predictors of 6-month mortality were response to treatment (P=0.004) and model for end-stage liver disease-sodium >23 (P=0.018). Conclusions SIRS and ΔRRI are simple parameters to predict treatment response in HRS-AKI. Non-responders have higher mortality and should be identified early to expedite liver transplantation.
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Affiliation(s)
- Vijay Narayanan
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
| | - Krishnadas Devadas
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
| | - Srijaya Sreesh
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
| | - Jijo Varghese
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
| | - Rushil Solanki
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
| | - Shivabrata Dhal Mohapatra
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
| | - Ravindra Pal
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
| | - Devika Madhu
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
| | - Avisek Chakravorty
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India (Vijay Narayanan, Krishnadas Devadas, Srijaya Sreesh, Jijo Varghese, Rushil Solanki, Shivabrata Dhal Mohapatra, Ravindra Pal, Devika Madhu, Avisek Chakravorty)
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Ozturk NB, Dinc EJ, Swami A, Gurakar A. Acute Kidney Injury and Hepatorenal Syndrome in Patients with Cirrhosis. J Clin Med 2023; 13:199. [PMID: 38202206 PMCID: PMC10779857 DOI: 10.3390/jcm13010199] [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: 11/22/2023] [Revised: 12/25/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
Acute kidney injury (AKI) is common in hospitalized patients with cirrhosis. Hepatorenal syndrome (HRS) is a type of AKI known as HRS-AKI. It is a severe complication of cirrhosis with high morbidity and mortality. While certain vasoconstrictor medications have been shown to improve HRS-AKI, no clear transplant-free survival benefit has been reported with medical therapies. Patients with HRS-AKI should be considered for urgent liver transplantation evaluation. In this review, we discuss the most recent updates on the definition, diagnosis, and management of AKI in cirrhosis, with special a emphasis on HRS.
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Affiliation(s)
- Nazli Begum Ozturk
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI 48073, USA
| | - Ece Janet Dinc
- School of Medicine, Baskent University, 06790 Ankara, Turkey
| | - Abhishek Swami
- Division of Nephrology, Beaumont Hospital, Royal Oak, MI 48073, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Johns Hopkins University Hospital, Baltimore, MD 21287, USA
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Pyrsopoulos NT, Bernstein D, Kugelmas M, Owen EJ, Reddy KR, Reau N, Saab S, Wadei HM. Improving Outcomes in Hepatorenal Syndrome-Acute Kidney Injury With Early Diagnoses and Implementation of Approved Treatment Regimens. Gastroenterol Hepatol (N Y) 2023; 19:3-13. [PMID: 38444690 PMCID: PMC10910386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Decompensated cirrhosis, defined by the overt manifestations of liver failure and portal hypertension (eg, ascites, hepatic encephalopathy, variceal bleeding), is the inflection point associated with increased morbidity and mortality in chronic liver disease. Acute kidney injury in the setting of cirrhosis (hepatorenal syndrome-acute kidney injury [HRS-AKI]) is a severe and often fatal complication. The goals of treatment of HRS-AKI are to reverse renal failure and prolong survival in these critically ill patients or perhaps to allow the transplant team to complete the pretransplant evaluation and bridge the patient to transplant. Historically, in the United States, standard-of-care treatments for HRS-AKI were chosen by default despite lack of data, off-label use, and suboptimal results. Terlipressin represents the first drug in the United States indicated for the treatment of HRS-AKI. This review provides an up-to-date overview of HRS-AKI, discusses terlipressin and how to incorporate this new treatment into patient care and streamline society guidelines on HRS diagnosis and treatment in a practical way for clinical use, and concludes with a sample order set that highlights the recommendations discussed throughout the supplement.
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Affiliation(s)
- Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Liver Transplantation, Rutgers New Jersey Medical School University Hospital, Newark, New Jersey
| | - David Bernstein
- NYU Grossman School of Medicine, Gastroenterology and Hepatology Ambulatory Network-Long Island, NYU Langone Health, New York, New York
| | | | - Emily J Owen
- Critical Care, Surgical Burn Trauma Intensive Care Unit, Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri
| | - K Rajender Reddy
- Division of Gastroenterology, University of Pennsylvania Health Services, Philadelphia, Pennsylvania
| | - Nancy Reau
- Rush University Medical Center, Chicago, Illinois
| | - Sammy Saab
- Department of Internal Medicine and Surgery, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Hani M Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida
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Loftus M, Brown RS, El-Farra NS, Owen EJ, Reau N, Wadei HM, Bernstein D. Improving the Management of Hepatorenal Syndrome-Acute Kidney Injury Using an Updated Guidance and a New Treatment Paradigm. Gastroenterol Hepatol (N Y) 2023; 19:527-536. [PMID: 37771795 PMCID: PMC10524408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Cirrhosis, or advanced scarring of the liver, represents the end stage of chronic liver disease and is associated with high morbidity and mortality. Hepatorenal syndrome-acute kidney injury (HRS -AKI), a condition causing functional and progressive kidney failure, is a complication of cirrhosis that contributes to its high mortality rate. In the United States, the standard-of-care treatments for HRS -AKI have historically been suboptimal. Recently, terlipressin became the first drug approved for HRS -AKI in the United States, and the American Association for the Study of Liver Diseases updated its guidance document on HRS diagnosis and management. Clinical practice guidelines and guidance documents have a variable effect on physician behavior owing to a lack of awareness, familiarity, and education. The imple mentation of standardized order sets can improve guidance adherence and the quality of care delivered by encouraging data-driven treatment administration, especially for new therapies. This review seeks to facilitate improvements in the management of HRS -AKI by discussing early HRS -AKI interventions, which will streamline diagnosis and treatment in a practical way for clinical use, and how to incorporate new treatments into patient care to improve survival in this subset of patients. Finally, these recommendations are integrated into a sample order set developed by members of the Chronic Liver Disease Foundation and experts in the management of HRS-AKI.
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Affiliation(s)
- Michelle Loftus
- North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Robert S. Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Neveen S. El-Farra
- UCLA Health, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Emily J. Owen
- Critical Care, Surgical Burn Trauma Intensive Care Unit, Department of Pharmacy, Barnes–Jewish Hospital, St. Louis, Missouri
| | - Nancy Reau
- Rush University Medical Center, Chicago, Illinois
| | - Hani M. Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida
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Mujtaba MA, Gamilla-Crudo AK, Merwat SN, Hussain SA, Kueht M, Karim A, Khattak MW, Rooney PJ, Jamil K. Terlipressin in combination with albumin as a therapy for hepatorenal syndrome in patients aged 65 years or older. Ann Hepatol 2023; 28:101126. [PMID: 37302573 DOI: 10.1016/j.aohep.2023.101126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION AND OBJECTIVES Clinical data for older patients with advanced liver disease are limited. This post hoc analysis evaluated the efficacy and safety of terlipressin in patients aged ≥65 years with hepatorenal syndrome using data from 3 Phase III, randomized, placebo-controlled studies (OT-0401, REVERSE, CONFIRM). PATIENTS AND METHODS The pooled population of patients aged ≥65 years (terlipressin, n = 54; placebo, n = 36) was evaluated for hepatorenal syndrome reversal-defined as a serum creatinine level ≤1.5 mg/dL (≤132.6 μmol/L) while receiving terlipressin or placebo, without renal replacement therapy, liver transplantation, or death-and the incidence of renal replacement therapy (RRT). Safety analyses included an assessment of adverse events. RESULTS Hepatorenal syndrome reversal was almost 2-times higher in terlipressin-treated patients compared with patients who received placebo (31.5% vs 16.7%; P = 0.143). Among surviving patients, the need for RRT was significantly reduced in the terlipressin group, with an almost 3-times lower incidence of RRT versus the placebo group (Day 90: 25.0% vs 70.6%; P = 0.005). Among 23 liver-transplant-listed patients, significantly fewer patients in the terlipressin versus placebo group needed RRT by Days 30 and 60 (P = 0.027 each). Fewer patients in the terlipressin group needed RRT post-transplant (P = 0.011). More terlipressin-treated patients who were listed for and received a liver transplant were alive and RRT-free by Day 90. No new safety signals were revealed in the older subpopulation compared with previously published data. CONCLUSIONS Terlipressin therapy may lead to clinical improvements in highly vulnerable patients aged ≥65 years with hepatorenal syndrome. CLINICAL TRIAL NUMBERS OT-0401, NCT00089570; REVERSE, NCT01143246; CONFIRM, NCT02770716.
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Affiliation(s)
- Muhammad A Mujtaba
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA.
| | | | - Shehzad N Merwat
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA
| | - Syed A Hussain
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA
| | - Michael Kueht
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA
| | - Aftab Karim
- Texas Health Presbyterian Hospital, 8200 Walnut Hill Ln, Dallas, TX, USA
| | - Muhammad W Khattak
- University of Illinois College of Medicine, 1 Illini Dr, Peoria, IL, USA
| | - Peggy J Rooney
- Mallinckrodt Pharmaceuticals, 53 I-78 Frontage Rd, Hampton, NJ, USA
| | - Khurram Jamil
- Mallinckrodt Pharmaceuticals, 53 I-78 Frontage Rd, Hampton, NJ, USA
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Jamil K, Huang X, Hayashida D, Lodaya K. The Hepatorenal Syndrome (HRS) Patient Pathway: Retrospective Analysis of Electronic Health Records. Curr Ther Res Clin Exp 2022; 96:100663. [PMID: 35399809 PMCID: PMC8987804 DOI: 10.1016/j.curtheres.2022.100663] [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: 06/01/2021] [Accepted: 02/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Hepatorenal syndrome (HRS) is among the leading causes of hospitalization and mortality in patients with chronic liver disease. Objective To assess the HRS patient journey from preadmission to postdischarge to understand patient characteristics, disease progression, treatment patterns, and outcomes. Methods We conducted a retrospective study using real-world data from a nationwide electronic health record database (Cerner Health Facts, Kansas City, Missouri). We used ICD-9/10 diagnosis codes to identify patients hospitalized with HRS between January 1, 2009, and January 31, 2018. We assessed patient characteristics and history, clinical presentation, treatment, and outcomes. Regression analysis was conducted to assess the association between patient characteristics and survival while adjusting for demographic and clinical covariates. Results The study included 3563 patients (62% men). Precipitants of HRS included gastrointestinal bleeding (18%), diuretics and infections (30%), and paracentesis (26%). Although 21% of patients had liver injury exclusively associated with alcohol use, 20% had hepatitis C, 8% had nonalcoholic steatohepatitis, and the etiology of the remainder (51%) was either some combination of conditions or unknown. A total of 42% of patients received vasopressors, including octreotide and midodrine (10%), other combinations of vasopressors (11%), or another single vasopressor (21%). In-hospital mortality was 34%, and 14% of patients were discharged to hospice. Regression analysis showed patients with acute-on-chronic liver failure had higher mortality in acute-on-chronic liver failure grades 1 (odds ratio = 1.59), 2 (odds ratio = 2.49), and 3 (odds ratio = 4.53) versus no acute-on-chronic liver failure. Among survivor patients, 38% were readmitted within 90 days of discharge; 23% of readmissions were HRS-related. Conclusions The HRS patient journey presented in this study highlights inconsistencies in, and provides insight into, associated hospital-based treatment strategies. A mortality rate of 34% along with a readmission rate of 23% associated with HRS-related complications warrant more disease awareness and effective treatment. Further research is needed to examine the interactions between the etiology of cirrhosis, precipitants, treatment, and outcomes. (Curr Ther Res Clin Exp. 2022; 82:XXX–XXX)
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Affiliation(s)
| | | | | | - Kunal Lodaya
- Boston Strategic Partners Inc, Boston, Massachusetts
- Address correspondence to: Kunal Lodaya, MD, Boston Strategic Partners, Inc, 4 Wellington St, Suite 3, Boston, MA 02118.
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Hepatorenal syndrome: pathophysiology and evidence-based management update. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2021; 59:227-261. [DOI: 10.2478/rjim-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Indexed: 11/20/2022] Open
Abstract
Abstract
Hepatorenal syndrome (HRS) is a functional renal failure that develops in patients with advanced hepatic cirrhosis with ascites and in those with fulminant hepatic failure. The prevalence of HRS varies among studies but in general it is the third most common cause of acute kidney injury (AKI) in cirrhotic patients after pre-renal azotemia and acute tubular necrosis. HRS carries a grim prognosis with a mortality rate approaching 90% three months after disease diagnosis. Fortunately, different strategies have been proven to be successful in preventing HRS. Although treatment options are available, they are not universally effective in restoring renal function but they might prolong survival long enough for liver transplantation, which is the ultimate treatment. Much has been learned in the last two decades regarding the pathophysiology and management of this disease which lead to notable evolution in the HRS definition and better understanding on how best to manage HRS patients. In the current review, we will summarize the recent advancement in epidemiology, pathophysiology, and management of HRS.
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Flamm SL, Brown K, Wadei HM, Brown RS, Kugelmas M, Samaniego‐Picota M, Burra P, Poordad F, Saab S. The Current Management of Hepatorenal Syndrome-Acute Kidney Injury in the United States and the Potential of Terlipressin. Liver Transpl 2021; 27:1191-1202. [PMID: 33848394 PMCID: PMC8457138 DOI: 10.1002/lt.26072] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/16/2022]
Abstract
Acute kidney injury (AKI) in the setting of cirrhosis (hepatorenal syndrome [HRS]-AKI) is a severe and often fatal complication of end-stage liver disease. The goals of treatment are to reverse renal failure and prolong survival in patients who are critically ill. However, interventions have limited efficacy, and mortality rates remain high. In the United States, the mainstay of pharmacologic therapy consists of the off-label use of vasoconstrictive agents in combination with plasma expanders, a strategy that produces modest effects. Liver transplantation is the ultimate solution but is only an option in a minority of patients because contraindications to transplantation are common and organ availability is limited. Renal replacement therapy is a temporary option but is known to confer an extremely poor short-term prognosis in patients with HRS-AKI and at best serves as a bridge to liver transplantation for the minority of patients who are transplantation candidates. The high mortality rate associated with HRS-AKI in the United States is a reflection of the suboptimal standard of care. Improved therapeutic options to treat HRS-AKI are sought. Terlipressin is a drug approved in Europe for treatment of HRS-AKI and supported by recommendations for first-line therapy by some liver societies and experts around the world. This review article will discuss the substantial unmet medical need associated with HRS-AKI and the potential benefits if terlipressin was approved in the United States.
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Affiliation(s)
- Steven L. Flamm
- Division of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL
| | - Kimberly Brown
- Division of Gastroenterology and HepatologyTransplant InstituteHenry Ford HospitalDetroitMI
| | - Hani M. Wadei
- Department of TransplantationMayo ClinicJacksonvilleFL
| | - Robert S. Brown
- Department of Medicine, Division of Gastroenterology and HepatologyWeill Cornell MedicineNew YorkNY
| | | | | | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and GastroenterologyPadua University HospitalPaduaItaly
| | - Fred Poordad
- University of Texas Health San Antonio, Texas Liver InstituteSan AntonioTX
| | - Sammy Saab
- Department of Internal Medicine and SurgeryDavid Geffen School of Medicine at University of California Los AngelesLos AngelesCA
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Interplay of cardiovascular mediators, oxidative stress and inflammation in liver disease and its complications. Nat Rev Cardiol 2020; 18:117-135. [PMID: 32999450 DOI: 10.1038/s41569-020-0433-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The liver is a crucial metabolic organ that has a key role in maintaining immune and endocrine homeostasis. Accumulating evidence suggests that chronic liver disease might promote the development of various cardiac disorders (such as arrhythmias and cardiomyopathy) and circulatory complications (including systemic, splanchnic and pulmonary complications), which can eventually culminate in clinical conditions ranging from portal and pulmonary hypertension to pulmonary, cardiac and renal failure, ascites and encephalopathy. Liver diseases can affect cardiovascular function during the early stages of disease progression. The development of cardiovascular diseases in patients with chronic liver failure is associated with increased morbidity and mortality, and cardiovascular complications can in turn affect liver function and liver disease progression. Furthermore, numerous infectious, inflammatory, metabolic and genetic diseases, as well as alcohol abuse can also influence both hepatic and cardiovascular outcomes. In this Review, we highlight how chronic liver diseases and associated cardiovascular effects can influence different organ pathologies. Furthermore, we explore the potential roles of inflammation, oxidative stress, vasoactive mediator imbalance, dysregulated endocannabinoid and autonomic nervous systems and endothelial dysfunction in mediating the complex interplay between the liver and the systemic vasculature that results in the development of the extrahepatic complications of chronic liver disease. The roles of ageing, sex, the gut microbiome and organ transplantation in this complex interplay are also discussed.
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Management and outcomes of hepatorenal syndrome at an urban academic medical center: a retrospective study. Eur J Gastroenterol Hepatol 2019; 31:1545-1549. [PMID: 31169567 DOI: 10.1097/meg.0000000000001462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study is aimed to evaluate the management of acute kidney injury (AKI) in our inner city, American hospital. We intended to ascertain whether or not there is prompt recognition of AKI in cirrhosis according to International Club of Ascites and acute kidney injury network criteria as well how effective we are at distinguishing among different causes of AKI. We aimed to calculated the mortality of hepatorenal syndrome (HRS) in our hospital, and to evaluate the adequacy of the established treatment of AKI at each stage of its algorithm. PATIENTS AND METHODS ICD diagnostic codes were used to identify patients with liver cirrhosis and acute renal failure. A total of 725 patients met the search criteria. We excluded the patients without clinical or imaging evidence of ascites, heart failure, on hemodialysis, baseline creatinine more than 1.5 mg/dl and patients who died within 48 h of developing acute renal failure. 291 patients met the inclusion criteria. All statistical analyses were performed using SPSS version 23.0 software with a two-sided significance level set at P value less than 0.05. RESULTS Mean age was 55.7 ± 0.61 and baseline serum creatinine was 0.94 ± 0.14. 66.5% of patients were African American, 27.3%, Hispanic, and 4.3% White. The average rise in creatinine from baseline was 1.36 ± 0.08 mg/dl. 27.2% of patients met the diagnostic criteria of HRS. 92.3% of patients with HRS received intravenous fluids and 75.4% received intravenous albumin within 48 h of acute creatinine rise. The in-hospital mortality rate was 14.1, 23.3, and 41.5% for patients with pre-renal azotemia, ARF, and HRS, respectively (P < 0.01). CONCLUSION This study demonstrates that with present tools, there is significantly higher mortality in HRS despite guideline-based treatment. Biomarkers for early diagnosis of HRS are necessary to avoid delays in initiation of HRS treatment while establishing the diagnosis. As well, worldwide standardization of the treatment of HRS will be important if the outcome is to be improved.
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Velez JCQ, Therapondos G, Juncos LA. Reappraising the spectrum of AKI and hepatorenal syndrome in patients with cirrhosis. Nat Rev Nephrol 2019; 16:137-155. [PMID: 31723234 DOI: 10.1038/s41581-019-0218-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 12/12/2022]
Abstract
The occurrence of acute kidney injury (AKI) in patients with end-stage liver disease constitutes one of the most challenging clinical scenarios in in-hospital and critical care medicine. Hepatorenal syndrome type 1 (HRS-1), which is a specific type of AKI that occurs in the context of advanced cirrhosis and portal hypertension, is associated with particularly high mortality. The pathogenesis of HRS-1 is largely viewed as a functional derangement that ultimately affects renal vasculature tone. However, new insights suggest that non-haemodynamic tubulo-toxic factors, such as endotoxins and bile acids, might mediate parenchymal renal injury in patients with cirrhosis, suggesting that concurrent mechanisms, including those traditionally associated with HRS-1 and non-traditional factors, might contribute to the development of AKI in patients with cirrhosis. Moreover, histological evidence of morphological abnormalities in the kidneys of patients with cirrhosis and renal dysfunction has prompted the functional nature of HRS-1 to be re-examined. From a clinical perspective, a diagnosis of HRS-1 guides utilization of vasoconstrictive therapy and decisions regarding renal replacement therapy. Patients with cirrhosis are at risk of AKI owing to a wide range of factors. However, the tools currently available to ascertain the diagnosis of HRS-1 and guide therapy are suboptimal. Short of liver transplantation, goal-directed haemodynamically targeted pharmacotherapy remains the cornerstone of treatment for this condition; improved understanding of the underlying pathogenic mechanisms might lead to better clinical outcomes. Here, we examine our current understanding of the pathophysiology of HRS-1 and existing challenges in its diagnosis and treatment.
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Affiliation(s)
- Juan Carlos Q Velez
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA, USA. .,Ochsner Clinical School, The University of Queensland, Brisbane, Australia.
| | - George Therapondos
- Department of Gastroenterology and Hepatology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Luis A Juncos
- Division of Nephrology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Renal Section, Department of Medicine, Central Arkansas Veterans Affairs Medical Center, Little Rock, AR, USA
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Carrier P, Debette-Gratien M, Jacques J, Loustaud-Ratti V. Cirrhotic patients and older people. World J Hepatol 2019; 11:663-677. [PMID: 31598192 PMCID: PMC6783402 DOI: 10.4254/wjh.v11.i9.663] [Citation(s) in RCA: 5] [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: 04/17/2019] [Revised: 06/18/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
The global population is aging, and so the number of older cirrhotic patients is increasing. Older patients are characterised by a risk of frailty and comorbidities, and age is a risk factor for mortality in cirrhotic patients. The incidence of non-alcoholic fatty liver disease as an aetiology of cirrhosis is increasing, while that of chronic viral hepatitis is decreasing. Also, cirrhosis is frequently idiopathic. The management of portal hypertension in older cirrhotic patients is similar to that in younger patients, despite the greater risk of treatment-related adverse events of the former. The prevalence of hepatocellular carcinoma increases with age, but its treatment is unaffected. Liver transplantation is generally recommended for patients < 70 years of age. Despite the increasing prevalence of cirrhosis in older people, little data are available and few recommendations have been proposed. This review suggests that comorbidities have a considerable impact on older cirrhotic patients.
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Affiliation(s)
- Paul Carrier
- Fédération d’Hépatologie, Centre Hospitalier Universitaire Dupuytren de Limoges, Limoges 87042, France
- Faculté de Médecine et de Pharmacie de Limoges, Rue Docteur Marcland, Limoges 87042, France
| | - Marilyne Debette-Gratien
- Fédération d’Hépatologie, Centre Hospitalier Universitaire Dupuytren de Limoges, Limoges 87042, France
- Faculté de Médecine et de Pharmacie de Limoges, Rue Docteur Marcland, Limoges 87042, France
| | - Jérémie Jacques
- Service de Gastroentérologie, Centre Hospitalier Universitaire Dupuytren de Limoges, Limoges 87042, France
| | - Véronique Loustaud-Ratti
- Fédération d’Hépatologie, Centre Hospitalier Universitaire Dupuytren de Limoges, Limoges 87042, France
- Faculté de Médecine et de Pharmacie de Limoges, Rue Docteur Marcland, Limoges 87042, France.
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Jamil K, Huang X, Lovelace B, Pham AT, Lodaya K, Wan G. The burden of illness of hepatorenal syndrome (HRS) in the United States: a retrospective analysis of electronic health records. J Med Econ 2019; 22:421-429. [PMID: 30724682 DOI: 10.1080/13696998.2019.1580201] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Hepatorenal Syndrome (HRS) is characterized by renal failure in patients with advanced chronic liver disease (CLD) and is the leading cause of hospitalizations in CLD. This study examines the clinical and economic burden, outcomes, and unmet need of HRS treatment in US hospitals. METHOD A retrospective cohort study was conducted based on a large electronic health records database (Cerner HealthFacts) with records for hospitalized HRS patients from January 2009-June 2015. Demographics, clinical characteristics, treatment patterns, and economic outcomes were analyzed. Prognostic indicators of cirrhosis, kidney injury, end-stage liver disease, and acute-on-chronic liver failure were used to determine mortality risk. RESULTS A total of 2,542 patients hospitalized with HRS were identified (average age = 57.9 years, 61.8% males, 74.2% Caucasian), with an average total hospital charge of $91,504 per patient and a mean length of stay (LOS) of 30.5 days. The mortality rate was 36.9% with 8.9% of patients discharged to hospice. Of all patients, 1,660 patients had acute kidney injury, 859 with Stage 3 disease, and 26.7% had dialysis. The 30-day readmission rate was 33.1%, 41% of which were unplanned. Nearly one-third of study patients had commercial insurance (30.2%), followed by Medicare (29.9%); hospital charges varied by LOS, receipt of dialysis, and discharge status. Regression analysis demonstrated that HRS costs are associated with LOS, dialysis, and hospital mortality. CONCLUSION HRS is associated with poor outcomes and high hospital costs. Analysis of HRS cost drivers demonstrated an unmet need for additional treatment options to improve outcomes in this patient population.
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Affiliation(s)
- Khurram Jamil
- a Mallinckrodt Pharmaceuticals, Inc , Bedminster , NJ , USA
| | - Xingyue Huang
- a Mallinckrodt Pharmaceuticals, Inc , Bedminster , NJ , USA
| | - Belinda Lovelace
- b Formerly of Mallinckrodt Pharmaceuticals, Inc , Bedminster , NJ , USA
| | - An T Pham
- b Formerly of Mallinckrodt Pharmaceuticals, Inc , Bedminster , NJ , USA
- c University of Washington School of Pharmacy , Seattle , WA , USA
| | - Kunal Lodaya
- d Boston Strategic Partners, Inc Health Economics and Outcomes Research , Boston , MA , USA
| | - George Wan
- a Mallinckrodt Pharmaceuticals, Inc , Bedminster , NJ , USA
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A novel scoring model for predicting mortality risk in patients with cirrhosis and hepatorenal syndrome. Eur J Gastroenterol Hepatol 2018; 30:938-943. [PMID: 29634664 DOI: 10.1097/meg.0000000000001127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS This study aimed to create a risk scoring model for death from cirrhosis and hepatorenal syndrome, improve the detection rate of high-risk groups, and provide clinical evidence for early intervention treatment. PATIENTS AND METHODS We retrospectively recruited 196 patients with cirrhosis and hepatorenal syndrome between 1 January 2013 and 31 July 2014 at Beijing Ditan Hospital, Capital Medical University, China. The clinical information, biochemical values, age, and sex of the patients were included in the multivariate logistic regression model for screening independent risk factors. The model was validated in 56 patients with cirrhosis and hepatorenal syndrome between 1 August 2014 and 31 December 2014 at Beijing Ditan Hospital, Capital Medical University, China. RESULTS The death risk prediction scoring model included the following four independent risk factors: liver cancer, neutrophil above 70%, alanine aminotransferase higher than 40 U/l, and creatinine higher than 127 mmol/l. The sum death risk score ranged from 0 to 5: 0-2 identified patients with a lower risk of death (mortality rates: 12-41.4%), whereas 3-5 identified patients with a higher risk of death (mortality rates: 48.8-80%). Receiver-operating characteristic curves were constructed for the scoring model and the areas under the curves (AUC) were compared using the z-test. The AUC of the scoring model was 0.843. In addition, the AUC of validated model in 56 patients was 0.742. CONCLUSION The scoring model can accurately predict mortality risk in patients with hepatorenal syndrome.
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Vasoactive Agents for Hepatorenal Syndrome: A Mixed Treatment Comparison Network Meta-Analysis and Trial Sequential Analysis of Randomized Clinical Trials. J Gen Intern Med 2018; 33:97-102. [PMID: 28924736 PMCID: PMC5756164 DOI: 10.1007/s11606-017-4178-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 07/19/2017] [Accepted: 08/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) is a common complication among patients with cirrhosis, primarily attributable to vasodilation of renal vessels. Vasoactive agents are commonly used to treat HRS. The present network meta-analysis compares the vasoactive agents used in HRS. METHODS We searched electronic databases for appropriate randomized controlled clinical trials in patients with HRS, comparing active interventions with either placebo or standard of care. The primary outcome was complete HRS reversal; secondary outcomes included partial HRS reversal, mortality, adverse events, and cardiovascular adverse events. The data were pooled using a random effects model. We also carried out direct comparisons for the primary outcome with trial sequential analysis. RESULTS A total of 16 studies were included in the systematic review. Rates of complete HRS reversal were significantly higher with terlipressin and noradrenaline combined with albumin than with placebo (OR 6.65, 95% CI: 2.08-21.31 and 6.81, 95% CI: 1.87-24.83, respectively). No significant differences were observed in terms of mortality, partial HRS reversal, or adverse events for any of the interventions. However, cardiovascular adverse events were significantly higher with continuous-infusion terlipressin/albumin (OR 7.07, 95% CI: 1.23-40.62), bolus terlipressin/albumin (OR 7.39, 95% CI: 1.89, 28.94), octreotide/midodrine/albumin (OR 9.85, 95% CI: 1.1, 88.1), and noradrenaline/albumin (OR 15.24, 95% CI: 2.1, 112.6) than with albumin alone. Trial sequential analyses revealed adequate evidence to conclude that terlipressin combined with albumin was effective in achieving complete HRS reversal. DISCUSSION Terlipressin combined with albumin shows strong evidence of improving short-term survival in patients with type 1 but not type 2 HRS. Through indirect comparison, noradrenaline with albumin was also associated with significant benefits in terms of HRS reversal.
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Modi RM, Patel N, Metwally SN, Mumtaz K. Outcomes of liver transplantation in patients with hepatorenal syndrome. World J Hepatol 2016; 8:999-1011. [PMID: 27648152 PMCID: PMC5002501 DOI: 10.4254/wjh.v8.i24.999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/20/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatorenal syndrome (HRS) plays an important role in patients with liver cirrhosis on the wait list for liver transplantation (LT). The 1 and 5-year probability of developing HRS in cirrhotic with ascites is 20% and 40%, respectively. In this article, we reviewed current concepts in HRS pathophysiology, guidelines for HRS diagnosis, effective treatment options presently available, and controversies surrounding liver alone vs simultaneous liver kidney transplant (SLKT) in transplant candidates. Many treatment options including albumin, vasoconstrictors, renal replacement therapy, and eventual LT have remained a mainstay in the treatment of HRS. Unfortunately, even after aggressive measures such as terlipressin use, the rate of recovery is less than 50% of patients. Moreover, current SLKT guidelines include: (1) estimation of glomerular filtration rate of 30 mL/min or less for 4-8 wk; (2) proteinuria > 2 g/d; or (3) biopsy proven interstitial fibrosis or glomerulosclerosis. Even with these updated criteria there is a lack of consistency regarding long-term benefits for SLKT vs LT alone. Finally, in regards to kidney dysfunction in the post-transplant setting, an estimation of glomerular filtration rate < 60 mL/min per 1.73 m2 may be associated with an increased risk of patients having long-term end stage renal disease. HRS is common in patients with cirrhosis and those on liver transplant waitlist. Prompt identification and therapy initiation in transplant candidates with HRS may improve post-transplantation outcomes. Future studies identifying optimal vasoconstrictor regimens, alternative therapies, and factors predictive of response to therapy are needed. The appropriate use of SLKT in patients with HRS remains controversial and requires further evidence by the transplant community.
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Sarwar S, Khan AA. Hepatorenal syndrome:Response to terlipressin and albumin and its determinants. Pak J Med Sci 2016; 32:274-8. [PMID: 27182222 PMCID: PMC4859005 DOI: 10.12669/pjms.322.9315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/07/2015] [Accepted: 01/18/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To determine the efficacy of terlipressin and albumin in improving renal functions in patient with hepatorenal syndrome (HRS) and to identify factors determinant of better response. METHODS In this quasi experimental interventional study patients of liver cirrhosis and ascites with HRS type I were treated with intravenous albumin and incremental dosage of terlipressin based on response with maximum dose of 12mg/day. Decline of creatinine below 1.5mg/dl was defined as complete response. Factors predictive of response to therapy were determined via linear regression analysis. RESULTS Twenty four patients were included with male to female ratio 3.8/1(19/5) and mean age 53.3 (±10.06). Complete response to terlipressin/albumin was seen in 14 (58.3%)patients, seven (29.2%) achieved partial response with > 25% creatinine decline while three (12.5%) had no response. Lower serum creatinine at diagnosis (P value 0.003), absence of hyperkalemia (p value 0.005) and absence of portal vein thrombosis (p value 0.05) are associated with response to treatment in HRS. Baseline serum creatinine (p value 0.003) was independent predictor of response to therapy in multivariate analysis. CONCLUSION Terlipressin and albumin is an effective treatment for HRS type I. Patients with lower baseline serum creatinine are more likely to respond to this therapy.
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Affiliation(s)
- Shahid Sarwar
- Dr. Shahid Sarwar, FCPS (Medicine) FCPS (Gastroenterology). Associate Professor Gujranwala Medical College, Consultant Gastroenterologist, Doctors Hospital & Medical Center, Lahore, Pakistan
| | - Anwaar A. Khan
- Anwaar A. Khan, MACP, FACG, FRCP, AGAF, FCPSEx- Dean and Professor of Gastroenterology, ShaikhZayed Post Graduate Medical Institute, Consultant Gastroenterologist, Doctors Hospital & Medical Center, Lahore, Pakistan
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