Progress in treatment of massive ascites and hepatorenal syndrome

Intensive care management of children with acute liver failure

Acute liver failure is an uncommon condition associated with multi organ involvement, high morbidity and mortality. Etiology of acute liver failure varies with age and geographical location. Most cases of acute liver failure in India are due to infectious causes predominantly viral hepatitis. A significant group with indeterminate causation remains, despite careful investigation. The etiology of acute liver failure in infants is largely metabolic. The mainstay of management is supportive care in an intensive care unit. Monitoring of clinical and biochemical parameters is done frequently until the patient becomes stable. Mortality is predominantly due to raised intracranial pressure, infections and multi-organ failure. Liver transplant is an important life saving procedure for children with acute liver failure.

Ascites: pathogenesis and therapeutic principles

Ascites is a classic complication of advanced cirrhosis and it often marks the first sign of hepatic decompensation. Ascites occurs in more than 50% of patients with cirrhosis, worsens the course of the disease, and reduces survival substantially. Portal hypertension, splanchnic vasodilatation, liver insufficiency, and cardiovascular dysfunction are major pathophysiological hallmarks. Modern treatment of ascites is based on this recognition and includes modest salt restriction and stepwise diuretic therapy with spironolactone and loop-diuretics. Tense and refractory ascites should be treated with large volume paracentesis followed by plasma volume expansion or transjugular intrahepatic portosystemic shunt. Ascites complicated by spontaneous bacterial peritonitis requires adequate treatment with antibiotics. New potential treatment strategies include the use of vasopressin V(2)-receptor antagonists and vasoconstrictors. Since formation of ascites is associated with a poor prognosis, and treatment of fluid retention does not substantially improve survival, such patients should always be considered for liver transplantation.

Value of serum plasma pro-brain natriuretic peptide in the diagnosis of refractory ascites due to cirrhosis

AIM: To evaluate the relationship between the plasma levels of pro-brain natriuretic peptide (proBNP) with cirrhosis severity, and to determine whether the plasma proBNP is valuable for diagnosis of refractory ascites (RA).

METHODS: The plasma levels of proBNP in 38 patients with cirrhosis were analyzed by ELISA, and the effect of proBNP on diagnosis of RA was by ROC.

RESULTS: Plasma proBNP was significantly increased in cirrhotic patients compared with healthy subjects (228.0 ± 83.4 pmol/L vs 127.4 ± 21.1 pmol/L), and was significantly correlated with CTP score (r = 0.774, P < 0.01). Levels of proBNP of patients with pre-ascites, uncomplicated ascites and refractory ascites were 169.8 ± 51.3, 238.8 ± 55.2 and 320.3 ± 63.4 pmol/L, respectively. The area values under the ROC curve generated by the proBNP were 0.857 in the diagnosis of RA, and the optimal threshold values of the proBNP was 264 pmol/L.

CONCLUSION: The plasma level of proBNP is correlated with cirrhosis severity and is valuable for diagnosis of refractory ascites.

Natural history of hepatitis B virus-related cirrhotic patients hospitalized to control ascites

BACKGROUND AND AIM

Few studies have assessed the natural history of hepatitis B virus (HBV)-related cirrhotic ascites. We investigated the natural history of patients with HBV-related cirrhotic ascites hospitalized to control ascites and determined their prognosis, including survival rates and prognostic factors affecting survival.

METHODS

Between January 1996 and December 2005, 203 consecutive patients with HBV-related cirrhotic ascites were followed for a median of 80.7 months (range, 15-149) after their first significant ascitic decompensation that required hospitalization.

RESULTS

The mean age of all patients was 52.6 years. Male gender predominated (male/female, 138/65). A subgroup analysis of 165 patients who had ascitic decompensation as their first episode of hepatic decompensation revealed that gastrointestinal variceal bleeding developed after a median interval of 8 months following ascitic decompensation in 31 (18.8%) patients, hepatic encephalopathy occurred at 9 months in 53 (32.1%), spontaneous bacterial peritonitis appeared at 12.7 months in 24 (14.5%), hepatorenal syndrome occurred at 8.1 months in five (3%), and hepatocellular carcinoma was observed at 21.2 months in 10 (6.1%). The overall median survival was 12.4 months. The 1- and 3-year survival rates were 50.7 and 18.7%. The prognostic factors that independently correlated with survival at the time of ascitic decompensation were Child-Pugh classification B/C (P = 0.030), serum white blood cell (WBC; P = 0.035), serum creatinine (Cr; P = 0.039), serum sodium (Na; P = 0.010), and antiviral therapy (P = 0.040).

CONCLUSIONS

The prognosis of HBV-related cirrhotic patients with ascitic decompensation is poor. Child-Pugh class, serum WBC/Cr/Na, and antiviral therapy primarily influenced survival.

Pathogenetic background for treatment of ascites and hepatorenal syndrome

Ascites and hepatorenal syndrome (HRS) are the major and challenging complications of cirrhosis and portal hypertension that significantly affect the course of the disease. Liver insufficiency, portal hypertension, arterial vasodilatation, and systemic cardiovascular dysfunction are major pathophysiological hallmarks. Modern treatment of ascites is based on this recognition and includes modest salt restriction and stepwise diuretic therapy with spironolactone and loop diuretics. Tense and refractory ascites should be treated with a large volume paracentesis, followed by volume expansion or transjugular intrahepatic portosystemic shunt. New treatment strategies include the use of vasopressin V(2)-receptor antagonists and vasoconstrictors. The HRS denotes a functional and reversible impairment of renal function in patients with severe cirrhosis with a poor prognosis. Attempts of treatment should seek to improve liver function, ameliorate arterial hypotension and central hypovolemia, and reduce renal vasoconstriction. Ample treatment of ascites and HRS is important to improve the quality of life and prevent further complications, but since treatment of fluid retention does not significantly improve survival, these patients should always be considered for liver transplantation.

Suprahepatic venacavaplasty in liver transplantation: an analysis of 103 cases

AIM: To explore the values of suprahepatic venacavaplasty (cavaplasty) in liver transplan-tation.

METHODS: The new orthotopic liver transplantation procedure combined with cavaplasty was conducted in 103 patients.

RESULTS: There were no perioperative deaths in this study. The median operative and anhepatic-phase time in cavaplasty group (6.8 ± 0.8 h and 52.6 ± 14.5 min, respectively) were significantly shorter than those in classic and modified piggyback groups (7.4 ± 0.6 h, 86.5 ± 7.1 min; 7.9 ± 0.6 h, 78.4 ± 7.94 min) reported recently by other data, and blood loss was also less in cavaplasty group (2960 ± 1120 mL) than those in latter two groups (4662 ± 913 mL; 4441 ± 1072 mL). Post-operative acute renal failure occurred in 30 cases (29.1%), similar to that in classic group but higher than that in modified piggyback group. All the patients with acute renal failure recovered within 3 to 4 weeks.

CONCLUSION: Cavaplasty can simplify the resection procedure of the diseased liver and implantation of new liver, and reduce the operative time and blood loss during transplantation process, indicating that cavaplasty is safe, and should be clinically recommended.

Treatment of refractory ascites

In 1996, the International Ascites Club defined "refractory ascites" as ascites that cannot be mobilized by medical therapy or that recurs early after initial mobilization despite continued treatment. Of all patients with ascites, 5% to 10% will become refractory to medical therapy. Management of refractory ascites should attempt to control fluid accumulation, reduce the likelihood of developing complications such as spontaneous bacterial peritonitis (SBP) and the hepatorenal syndrome, and improve the patient's nutritional status and overall well-being. Measures to control ascites accumulation include documenting medication and dietary compliance and eliminating potentially nephrotoxic agents that promote sodium retention. Large volume paracentesis is an effective first step in managing these patients and can be performed routinely in an outpatient setting. When more than 5 L of fluid are removed during a paracentesis, intravenous albumin should be infused to reduce the likelihood of the patient developing postparacentesis circulatory dysfunction. Transjugular intrahepatic portosystemic shunt (TIPS) placement effectively eliminates ascites; however, there is no convincing evidence that the shunt improves mortality. Furthermore, it is associated with frequent complications of encephalopathy and shunt malfunction. We feel TIPS should be reserved for patients requiring extremely frequent paracentesis, those who develop significant postparacentesis circulatory dysfunction, or those with hepatic hydrothorax. Patients who have evidence of SBP should be treated with antibiotics and intravenous albumin infusion. Patients who have had a previous episode of SBP or an ascitic fluid protein level of less than 1.0 should receive prophylactic antibiotics. Overall, the prognosis for patients with refractory ascites remains grim, and liver transplantation is the only definitive therapy. Appropriate candidates should be identified promptly and referred for transplant evaluation.