The association between the serum sodium level and the severity of complications in liver cirrhosis

Association of serum sodium and 24-hour urinary sodium level with the severity and complications of ascites in cirrhotic patients

Hyponatremia is an independent predictor of mortality in cirrhotic patients but little is known regarding the relationship between the level of serum sodium and 24-hour urinary sodium with the development of severity and complications of cirrhotic ascites. To observe the association of serum sodium and 24-hour urinary sodium levels with different grades of ascites and its complications in cirrhotic patients. In the department of Gastroenterology in a tertiary care hospital, this cross-sectional study was conducted from April 2019 to September 2020. A total of 96 admitted cirrhotic patients with ascites were enrolled in this study by consecutive sampling. Out of 96 patients with cirrhotic ascites, 48 patients had mild, moderate, and severe ascites and 48 patients had complications of ascites like refractory ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome. The mean serum sodium level was 131.69 ± 4.90 and 124.88 ± 5.67 mmol/L and the 24-hour urinary sodium level was 76.82 ± 45.64 and 35.26 ± 22.57 mmol/L in uncomplicated and complicated ascites groups respectively with P value < .001. In grade 1, grade 2, and grade 3 ascites, there was a significant (P = .001), association between mean serum sodium (mmol/L) level (R -0.777) and 24-hour urine sodium (mmol/L) level (R -0.704) but no significant difference was seen when refractory ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome were considered. In our finding, low serum sodium and low 24-hour urinary sodium levels were associated with the development of severe complications of cirrhotic ascites. Hence, Serum sodium and 24-hour urinary sodium levels can be good predictors of grading and complications of cirrhotic ascites.

Effects of bile duct ligation on the inhibitory control of supraoptic vasopressin neurons

Dilutional hyponatremia due to increased plasma arginine vasopressin (AVP) is associated with liver cirrhosis. However, plasma AVP remains elevated despite progressive hypoosmolality. This study investigated changes to inhibitory control of supraoptic nucleus (SON) AVP neurons during liver cirrhosis. Experiments were conducted with adult male Sprague-Dawley rats. Bile duct ligation was used as a model of chronic liver cirrhosis. An adeno-associated virus containing a construct with an AVP promoter and either green fluorescent protein (GFP) or a ratiometric chloride indicator, ClopHensorN, was bilaterally injected into the SON of rats. After 2 weeks, rats received either BDL or sham surgery, and liver cirrhosis was allowed to develop for 4 weeks. In vitro, loose patch recordings of action potentials were obtained from GFP-labeled and unlabeled SON neurons in response to a brief focal application of the GABAA agonist muscimol (100 μM). Changes to intracellular chloride ([Cl]i) following muscimol application were determined by changes to the fluorescence ratio of ClopHensorN. The contribution of cation chloride cotransporters NKCC1 and KCC2 to changes in intracellular chloride was investigated using their respective antagonists, bumetanide (BU, 10 μM) and VU0240551 (10 μM). Plasma osmolality and hematocrit were measured as a marker of dilutional hyponatremia. The results showed reduced or absent GABAA -mediated inhibition in a greater proportion of AVP neurons from BDL rats as compared to sham rats (100% inhibition in sham vs. 47% in BDL, p = .001). Muscimol application was associated with increased [Cl]i in most cells from BDL as compared to cells from sham rats (χ2  = 30.24, p < .001). NKCC1 contributed to the impaired inhibition observed in BDL rats (p < .001 BDL - BU vs. BDL + BU). The results show that impaired inhibition of SON AVP neurons and increased intracellular chloride contribute to the sustained dilutional hyponatremia in liver cirrhosis.

Effects of Short-Term Human Albumin Infusion for the Prevention and Treatment of Hyponatremia in Patients with Liver Cirrhosis

Background: Human albumin (HA) infusion is potentially effective for the management of hyponatremia in liver cirrhosis, but the current evidence is very limited. Methods: In this retrospective study, 2414 cirrhotic patients who were consecutively admitted to our hospital between January 2010 and June 2014 were included in the Hospitalization outcome cohort, and 339 cirrhotic patients without malignancy who were consecutively admitted to our department between December 2014 and April 2021 were included in the Long-term outcome cohort. The development and improvement of hyponatremia were compared between patients who received HA infusion during hospitalizations and did not. Logistic and Cox regression analyses were performed to evaluate the association of development and improvement of hyponatremia during hospitalizations with the outcomes. Odds ratios (ORs) and hazard ratios (HRs) were calculated. Results: In the two cohorts, HA infusion significantly decreased the incidence of hyponatremia and increased the rate of improvement of hyponatremia in cirrhotic patients during hospitalizations. In the Hospitalization outcome cohort, the development of hyponatremia during hospitalizations was significantly associated with increased in-hospital mortality (OR = 2.493, p < 0.001), and the improvement of hyponatremia during hospitalizations was significantly associated with decreased in-hospital mortality (OR = 0.599, p = 0.014). In the Long-term outcome cohort, the development of hyponatremia during hospitalizations was significantly associated with decreased long-term survival (HR = 0.400, p < 0.001), and the improvement of hyponatremia during hospitalizations was not significantly associated with long-term survival (HR = 1.085, p = 0.813). Conclusions: HA infusion can effectively prevent the development of hyponatremia and improve hyponatremia in cirrhotic patients during hospitalizations, which may influence the patients’ outcomes.

Salt consumption and mortality risk in cirrhotic patients: results from a cohort study

Since conducting a long-term randomised clinical trial is not logical and feasible to find the optimum dosage of salt intake in patients with cirrhosis, cohort studies are the best design to assess the long-term effects of dietary salt on the survival of cirrhotic patients. This cohort study aimed to evaluate the association between dietary intake of salt and mortality risk in cirrhotic patients. The present study was designed as a cohort in three referral hospitals in Iran in 2018. One hundred and twenty-one patients aged between 20 and 70 years with established cirrhosis were recruited. Dietary intakes, demographic data and disease severity were evaluated at the baseline. Participants were followed up annually. Crude survival was greater in patients with low-to-moderate salt consumption rather than in those with high consumption, and in non-consumers [34⋅26 (95 % CI 33⋅04, 35⋅49) v. 30⋅41 (95 % CI 27⋅13, 33⋅69) v. 32⋅72 (95 % CI 30⋅63, 34⋅80), P = 0⋅028; log-rank test]. Using the Cox proportional hazard model, it was shown that the risk of mortality in the high-salt consumption category was approximately 126 % higher than that of the reference category (non-consumers) [HR value 2⋅26, (95 % CI 0⋅91, 5⋅63)], while this risk for the low-to-moderate consumption group was about 28 % lower than the reference category [HR value 0⋅72, (95 % CI 0⋅26, 1⋅99), P-trend = 0⋅04]. In conclusion, a high daily dietary intake of salt might increase the rate of mortality and moderate salt restriction (instead of elimination of salt) decreases the risk of death.

Norepinephrine innervation of the supraoptic nucleus contributes to increased copeptin and dilutional hyponatremia in male rats

Dilutional hyponatremia associated with liver cirrhosis is due to inappropriate release of arginine vasopressin (AVP). Elevated plasma AVP causes water retention resulting in a decrease in plasma osmolality. Cirrhosis, in this study caused by ligation of the common bile duct (BDL), leads to a decrease in central vascular blood volume and hypotension, stimuli for nonosmotic AVP release. The A1/A2 neurons stimulate the release of AVP from the supraoptic nucleus (SON) in response to nonosmotic stimuli. We hypothesize that the A1/A2 noradrenergic neurons support chronic release of AVP in cirrhosis leading to dilutional hyponatremia. Adult, male rats were anesthetized with 2-3% isoflurane (mixed with 95% O2/5% CO2) and injected in the SON with anti-dopamine β-hydroxylase (DBH) saporin (DSAP) or vehicle followed by either BDL or sham surgery. Plasma copeptin, osmolality, and hematocrit were measured. Brains were processed for ΔFosB, dopamine β-hydroxylase (DBH), and AVP immunohistochemistry. DSAP injection: 1) significantly reduced the number of DBH immunoreactive A1/A2 neurons (A1, P < 0.0001; A2, P = 0.0014), 2) significantly reduced the number of A1/A2 neurons immunoreactive to both DBH and ΔFosB positive neurons (A1, P = 0.0015; A2, P < 0.0001), 3) reduced the number of SON neurons immunoreactive to both AVP and ΔFosB (P < 0.0001), 4) prevented the increase in plasma copeptin observed in vehicle-injected BDL rats (P = 0.0011), and 5) normalized plasma osmolality and hematocrit (plasma osmolality, P = 0.0475; hematocrit, P = 0.0051) as compared with vehicle injection. Our data suggest that A1/A2 neurons contribute to increased plasma copeptin and hypoosmolality in male BDL rats.

Hyponatremia in Cirrhosis

Hyponatremia is the most common electrolyte disorder encountered in clinical practice, and it is a common complication of cirrhosis reflecting an increase in nonosmotic secretion of arginine vasopressin as a result of of the circulatory dysfunction that is characteristic of advanced liver disease. Hyponatremia in cirrhosis has been associated with poor clinical outcomes including increased risk of morbidity and mortality, poor quality of life, and heightened health care utilization. Despite this, the treatment of hyponatremia in cirrhosis remains challenging as conventional therapies such as fluid restriction are frequently ineffective. In this review, we discuss the epidemiology, clinical outcomes, pathogenesis, etiology, evaluation, and management of hyponatremia in cirrhosis.

Clinical Practice Guidelines for Liver Transplantation in Saudi Arabia

The demand for liver transplantation in the Kingdom of Saudi Arabia (KSA) is associated with the country's high burden of liver disease. Trends in the epidemiology of liver transplantation indications among recipients in KSA have changed over 20 years. Non-alcoholic steatohepatitis has eclipsed the hepatitis C virus in the country due to the effective treatment strategies for HCV. Risk factors for NASH, like type 2 diabetes mellitus, obesity, and hyperlipidemia, are becoming a major concern and a leading indication for liver transplantation in the KSA. There is also a significantly increased prevalence and incidence of genetic adult familial liver diseases in KSA. New immunosuppressive agents and preservation solutions, improved surgical capabilities, and early disease recognition and management have increased the success rate of liver transplant outcome but concerns about the side effects of immunosuppressive therapy can jeopardise long-term survival outcomes. Despite this, indications for liver transplantation continue to increase, resulting in ongoing challenges to maximize the number of potential donors and reduce patient mortality rate while expecting to get transplanted. The Saudi Center of Organ Transplant is the recognized National Organ Donation Agency for transplantation, which renders important support for procurement and allocation of organs. This guidance document aims to help healthcare providers in managing patients in the liver transplant setting.

Perioperative Evolution of Sodium Levels in Cirrhotic Patients Undergoing Liver Transplantation: An Observational Cohort and Literature Review

Background & Aims

Hyponatremia is an important predictor of early death among cirrhotic patients in the orthotopic liver transplantation (OLT) waiting list. Evidence exists that prioritizing OLT waiting list according to the MELD score combined with plasma sodium concentration might prevent pre transplantation death. However, the evolution of plasma sodium concentrations during the perioperative period of OLT is not well known. We aimed to describe the evolution of perioperative sodium concentration during OLT and its relation to perioperative neurohormonal responses.

Methods

Twenty-seven consecutive cirrhotic patients who underwent OLT were prospectively included in the study over a period of 27 months. We studied the evolution of plasma sodium levels, the hemodynamics, the neurohormonal response and other biological markers during the perioperative period of OLT.

Results

Among study's population, four patients had hyponatremia before OLT, all with Child cirrhosis. In patients with hyponatremia, plasmatic sodium reached normal levels during surgery, and sodium levels remained within normal ranges 1 day, 7 days, as well as 6 months after surgery for all patients. Creatinine clearance was decreased significantly during the perioperative period, while creatinine and cystatin C levels increased significantly. Neutrophil gelatinase-associated lipocalin (NGAL) and vasopressin levels did not change significantly in this period. Plasma renin activity, concentrations of norepinephrine and brain natriuretic peptide varied significantly during the perioperative period.

Conclusion

In our study, plasmatic sodium concentrations among hyponatremic cirrhotic patients undergoing OLT seem to reach normal levels after OLT and remain stable six months after surgery providing more evidence for the importance of sodium levels in prioritization of liver transplant candidates. Further investigation of rapid correction and stabilization of sodium levels after OLT, as observed in our study, would be of interest in order to fully understand the mechanisms involved in cirrhosis-related hyponatremia, its prognostic value and clinical implications.

Hyponatremia Is Protective Against the Development of Portal Vein Thrombosis in Patients Undergoing Liver Transplant

BACKGROUND

Both hyponatremia and portal vein thrombosis (PVT) reflect the severity of liver dysfunction and are independently associated with increased morbidity in cirrhotic patients. In this study, we analyzed effects of hyponatremia on PVT development.

METHODS

Data on adult liver transplants (LTs) in the Model for End-Stage Liver Disease era through September 2016 were obtained. Receiver operating curves and multivariable logistic regression models were constructed to evaluate the association between serum sodium level and PVT. Based on the receiver operating curves, hyponatremia was defined as a sodium level below 125 mEq/L.

RESULTS

Of the 49,155 recipients included, 16% had hyponatremia (n = 7828) and 9% had PVT (n = 4414) at transplant. Subjects with hyponatremia had lower rates of PVT at the time of LT (4.4% vs 10.1%, P < .001), incidence of nonalcoholic steatohepatitis (10.8% vs 16.5%, P < .001), diabetes (19.7% vs 24.3%, P < .001), and need for dialysis (8.8% vs 16.0%, P < .001) as well as higher rates of chronic hepatitis C and B (37.6% vs 29.1%, P < .001 and 2.9% vs 1.7%, P < .001). Multivariable regression analysis confirmed that hyponatremia was independently associated with a decreased likelihood of PVT (odds ratio [OR], 0.44, P < .001). African American patients had a lower incidence of PVT (OR, 0.70; P < .001). Variables associated with a higher incidence of PVT were: nonalcoholic steatohepatitis (OR, 1.15; P = .005), moderate-to-severe ascites (OR, 1.10; P = .008), and Hispanic ethnicity (OR, 1.2; P < .001).

CONCLUSION

Hyponatremia is associated with a lower rate of PVT independent of severity of liver disease and other thrombotic risk factors. This protective effect should be taken into consideration during the perioperative management of hyponatremia in patients undergoing LT.

The Outcome of Cirrhotic Patients with Ascites Is Improved by the Normalization of the Serum Sodium Level by Tolvaptan

Objective Hyponatremia is frequently observed in patients with decompensated liver cirrhosis and it is also related to a poor prognosis. The vasopressin V2-receptor antagonist tolvaptan is used to treat cirrhotic patients with ascites and increases the serum sodium (Na) level. In this study, we investigated (i) whether or not correction of the Na level improves the prognosis of cirrhotic patients with ascites and (ii) predictors of normalization of the serum Na level after tolvaptan therapy. Methods This was a single-center retrospective study. A total of 95 Japanese cirrhotic patients (60 men, median age 63 years) were enrolled and received tolvaptan orally after hospitalization for ascites treatment. The serum Na level was monitored during the period of tolvaptan treatment. The laboratory data and survival rates of patients who achieved serum Na levels of <135 and ≥135 mEq/L after 1 week were compared. Results Patients showed serum Na levels of 136 (121-145) mEq/L, and 42.1% had a serum Na level of <135 mEq/L. Among patients with an initial serum Na level <135 mEq/L, 60.0% achieved a normal level after 1 week, and the survival rate was significantly higher in patients with a normalized serum Na level (p<0.01). The pretreatment brain natriuretic peptide (BNP) level was predictive of achieving a serum Na level of ≥135 mEq/L (odds ratio: 0.87, 95% confidence interval: 0.316-0.987, p<0.05). Conclusion Normalization of the Na level after one week was associated with a favorable outcome of tolvaptan therapy, and Na correction improved the prognosis.

Impact of hyponatremia on frequency of complications in patients with decompensated liver cirrhosis

Introduction

Hyponatremia is common in cirrhosis. The relationship between hyponatremia and severity of cirrhosis is evidenced by its close association with the occurrence of complications, the prevalence of hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis, refectory ascites, and hepatic hydrothorax. The aim of this study was assess the impact of hyponatremia on the occurrence of both liver-related complications and the hemodynamic cardiovascular dysfunction.

Methods

This prospective study was conducted in 2015 on 74 patients with liver cirrhosis. The patients were from the Gastroenterology and Hepatology Department of Theodor Bilharz Research Institute in Giza, Egypt. The patients were divided into three groups according to their serum level of sodium. Group 1 included 30 patients with serum sodium >135 meq/L, group 2 included 24 patients with serum sodium between135 and 125 meq/L, and group 3 included 20 patients with serum sodium <125 meq/L. For each of the patients, we conducted aclinical examination, laboratory investigations, chest X-ray, ECG, abdominal sonar, and echocardiography.

Results

Hyponatremia was found in 59.46% of our cirrhotic patients, and they showed significantly increased Model for End-Stage Liver Disease (MELD) score, MELD-Na score, QTc interval, Pulmonary vascular resistance (PVR) and inferior vena cava (IVC) collapsibility, and decreased SVR and IVC diameter. Also hepatic encephalopathy, ascites, renal failure, infectious complications, and pleural effusion were significantly more common in hyponatremic cirrhotic patients.

Conclusion

In cirrhosis, hyponatremia is more common in severe cardiovascular dysfunction and associated with increased risk of hepatic encephalopathy, ascites, illness severity scores, renal failure, infectious complications, and pleural effusion. We recommend selective oral administration of vasopressin V2-receptor antagonist, tolvaptan, which acts to increase the excretion of free water, thereby resolving hypervolemic hyponatremia and may have the potential to improve outcomes in these patients.

Risk factors for development of spontaneous bacterial peritonitis and subsequent mortality in cirrhotic patients with ascites

BACKGROUND

Patients with ascites are at risk for developing spontaneous bacterial peritonitis (SBP) - a severe complication associated with high mortality. We aimed to identify risk factors for SBP development and mortality to optimize stratification for primary prophylaxis and therapeutic strategies to improve survival.

METHODS

575 patients with cirrhosis and ascites undergoing paracentesis at a tertiary care hospital were included in this retrospective cohort study. Demographical, clinical and laboratory parameters were recorded at first paracentesis and during follow-up. Multivariate logistic regression analysis was used to identify independent predictors of SBP development and mortality.

RESULTS

Child-Pugh stage C (OR: 3.323; P = 0.009), ascitic fluid polymorph-nuclear cell (PMN) count (OR: 1.544; P = 0.028) and low serum sodium (OR: 0.917; P = 0.029) emerged as independent risk factors for SBP development. SBP-naïve patients undergoing paracentesis and presenting with PMN-counts ≥100 cells/μl, or hyponatraemia <125 mM were at highest risk for developing SBP. Increases in MELD and CRP levels indicated SBP development, while no changes where observed in a matched control group with sterile ascites at multiple paracenteses. MELD score (OR: 1.565; P = 0.001) and CRP (OR: 1.067; P = 0.037) were identified as independent risk factors for 30-day mortality after SBP diagnosis. In particular SBP patients with MELD≥22, CRP ≥3.5 mg/dl and development of grade III/IV hepatic encephalopathy showed highest mortality.

CONCLUSIONS

Low serum sodium levels, Child-Pugh stage C and elevated ascites PMN counts (≥100 cells/μl) indicate a significant risk for SBP development. SBP-related mortality is highest in patients with MELD≥22 and elevated CRP levels.

Resistive index and MELD-Na: nephrologic monitoring in cirrhotic patients awaiting liver transplantation

Renal dysfunction in cirrhotic patients is primarily related to disturbances in circulatory function. In decompensated cirrhosis, ascites and water retention are associated with development of dilutional hyponatremia. The arterial resistive index (RI) is a measure of resistance to arterial flow within the renal vascular bed. Hyponatremia is an independent predictor of mortality in patients with ascites. The aim of this study was to evaluate intrarenal RI in end-stage liver disease (ESLD) patients awaiting liver transplantation (LT) and its association with renal and hepatic function as assessed by Model for End-Stage Liver Disease (MELD) and MELD-Na scores. We evaluated 40 cirrhotic patients (23 males, 17 females) awaiting LT from January 2009 to January 2012. Twenty-six of the 40 patients (65%) showed a renal RI ≥ 0.70, the normal value according to standard reported evaluations. Patients with RI ≥ 0.70 showed significantly higher MELD and MELD-Na scores as well as greater higher serum creatinine and lower serum sodium concentrations compared with subject displaying RI <0.70. The most relevant result of our study was the strong association between elevated renal RI in ESLD patients and advanced liver dysfunction, as demonstrated by MELD and MELD-Na scores, hyponatremia, ascites, and acute renal failure episodes. In conclusion, this study suggested that intrarenal RI assessment should be considered in the clinical and nephrologic monitoring of cirrhotic patients awaiting LT.

[Impact of training about cervical cancer screening on health professionals working in basic health care units]

PURPOSE

To evaluate the impact of training professionals involved in the screening for cervical cancer in Basic Health Units in the city of Goiânia (GO).

METHODS

This was and intervention study in which the following data contained in the cervical cytopathology test form were examined: the woman's personal data, anamnesis, clinical examination and identification of the professional responsible for the collection. Professional training was evaluated by comparing the forms referring to the period from January 2007 to April 2009, before training, with the forms referring to the period from July 2010 to December 2012, after training. The Pearson χ2 test was used to analyze the results of training, with the 5% level of significance.

RESULTS

After training, there was a significantly increased frequency of recording patient schooling (from 67.2 to 92.6%, p<0.001), telephone number (from 78.9 to 98.7%, p<0.001), cervical inspection (from 86.8 to 96.6%, p<0.001), and signs suggestive of sexually transmitted diseases (from 80.8 to 93.5%, p<0.001). There was a reduction in the frequency of performing the exam within an interval of less than one year (p<0.001) and of one year (p<0.001). There was a reduction in the frequency of Pap smear testing in women under 25 years of age, from 22.0 to 17.9% (p<0.001). There was a significant increase in the proportion of satisfactory samples from 70.4 to 80.2% (p<0.001). A reduction of confounding factors was observed. The desiccation frequency was 2.9% before training and 2.0% after training (p<0.001). There was an increase in the frequency of representation of endocervical cells from 79.5 to 88.5% (p<0.001).

CONCLUSION

After training, there was a significant improvement in completing the application form, the performance of such tests regarding frequency and the age range recommended by the Ministry of Health, and the adequacy of the sample.

Hyponatraemia is an independent predictor of in-hospital mortality

BACKGROUND

Hyponatraemia increases morbidity and mortality, but the extent to which this condition influences mortality independently of other contributing factors is unclear.

MATERIALS AND METHODS

All hyponatremic patients admitted to the internal medicine department during a six month period were included. Medical records were reviewed and patients' demographics, underlying disease, cause of hyponatremia and in-hospital deaths were noted. Control group consisted of patients with normonatremia admitted to the same department during the same period matched 1:1 by sex, age and underlying disease. Difference in in-hospital mortality rate between the study and control groups was tested by chi-square test. Baseline demographics, underlying diseases, cause of hyponatremia and state of hyponatremia correction as possible risk factors for mortality were tested in a multivariate analysis.

RESULTS

The baseline cohort of all admitted patients consisted of 2,171 patients. Hyponatraemia was found in 278 (13%) patients (160 females and 118 males). The three most common causes of hyponatremia included gastrointestinal loss (52 patients), decreased oral intake (47 patients), and dilution hyponatremia (45 patients). The in-hospital mortality rate in the hyponatremic group was significantly higher compared with the control group (22% vs 7%, respectively; OR 3.75, 95% CI 2.17-6.48, p<0.0001). In a multivariate analysis age above 65 years, dilution hyponatremia, decreased oral intake as etiologic factors of hyponatremia, and unsuccessful hyponatremia correction were independent factors associated with increased mortality.

CONCLUSION

Hyponatraemia represents independent factor associated with in-hospital mortality. Age above 65 years, failure to correct hyponatremia and some specific etiologic factors of hyponatremia are related to increased mortality.

Elevated C-reactive protein and spontaneous bacterial peritonitis in children with chronic liver disease and ascites

OBJECTIVES

The aims of this study were to compare laboratory indices of spontaneous bacterial peritonitis (SBP) and noninfected ascites in children with chronic liver disease and to determine the infectious agents involved in SBP.

METHODS

The medical records of 90 children with chronic liver disease and ascites studied between January 2005 and August 2011 were reviewed for laboratory data of diagnostic significance in SBP. Standard laboratory tests included blood cell count, coagulation indices, liver and renal function tests, C-reactive protein (CRP), serum sodium concentration, serum albumin, and serum cultures. Ascitic fluid obtained from 152 paracentesis procedures was assayed for cytology, Gram stains, neutrophil counts, and bacteriological cultures.

RESULTS

The SBP group manifested significantly lower albumin levels and elevated CRP levels, prothrombin times, international normalized ratios, and leukocyte number (P<0.05 in each case). CRP was shown to be an independent variable in the prediction of SBP. Values of serum creatinine, sodium concentration, urea, total bilirubin and differential leukocyte shift were comparable in SBP and noninfected ascites. Streptococcus pneumoniae was the most prevalent infectious agent in the ascitic fluid (44%).

CONCLUSIONS

CRP may be useful in early detection and monitoring of SBP in children with liver disease.

Clinical and laboratorial features of spontaneous bacterial peritonitis in southern Brazil

CONTEXT AND OBJECTIVE

Spontaneous bacterial peritonitis (SBP) is a severe complication that occurs in 8-27% of hospitalized patients with liver cirrhosis and ascites, with high mortality rates. This study aimed to identify the clinical characteristics associated with SBP.

DESIGN AND SETTING

Cross-sectional study, conducted in a public university.

METHODS

The study consecutively included individuals with liver cirrhosis and ascites between September 2009 and March 2012. Forty-five patients were included: mean age 53.2 ± 12.3 years, 82.2% male, 73.8% Caucasian, mean Model of End-stage Liver Disease (MELD) score of 19.5 ± 7.2, and 33.3% with SBP. The subjects were divided into two groups: SBP and controls.

RESULTS

Comparison between individuals with SBP and controls showed that those with SBP had lower mean prothrombin activity time (36.1 ± 16.0% versus 47.1 ± 17.2%; P = 0.044) and lower median serum-ascites albumin gradient (SAAG) (1.2 versus 1.7, P = 0.045). There was a tendency towards higher mean MELD in the SBP group, not significant (22.2 ± 7.6 versus 17.9 ± 6.7; P = 0.067). There was a strong positive correlation between the neutrophil count in ascitic fluid and serum leukocyte count (r = 0.501; P = 0.001) and a negative correlation between the neutrophil count in ascitic fluid with prothrombin activity time (r = -0.385; P = 0.011).

CONCLUSION

A few characteristics are associated with the presence of SBP, especially liver dysfunction, SAAG and peripheral leukocytosis.

Hyponatremia-associated healthcare burden among US patients hospitalized for cirrhosis

INTRODUCTION

Hyponatremia is a frequent comorbid condition of patients hospitalized for cirrhosis and a predictor of disease severity and mortality. This study evaluated the healthcare burden of hyponatremia among patients hospitalized for cirrhosis in the real world.

METHODS

Hyponatremic (HN) patients (>-18 years of age) with cirrhosis were identified using the Premier Hospital Database (January 1, 2007 to March 31, 2010) and matched to non-HN patients with cirrhosis using a combination of exact patient characteristics and propensity score matching. Univariate and multivariate statistics were utilized to compare hospital resource utilization, cost, and 30-day hospital re-admission among patient cohorts.

RESULTS

The study population included 21,864 subjects (HN 10,932; non-HN 10,932). The hospital length of stay (LOS) (7.63 ± 7.4 vs. 5.89 ± 6.2 days; P < 0.001), hospital cost ($13,842 ± $20,702 vs. $11,140 ± $20,562; P < 0.001), intensive care unit (ICU) LOS (4.58 ± 4.7 vs. 3.59 ± 4.4 days; P < 0.001), and ICU cost ($7,038 ± $7,781 vs. $5,360 ± $7,557; P < 0.001) were greater for the HN cohort, as was the 30-day re-admission rate (all cause: 31.1% vs. 24.8%; P < 0.001; hyponatremia related: 25.1% vs. 11.0%; P < 0.001). Multivariate analysis showed that hyponatremia was associated with a 29.5% increase in hospital LOS, a 26.6% increase in overall hospital cost, a 23.2% increase in S. ICU LOS, and a 28.6% increase in ICU cost. Additionally, hyponatremia was associated with an increased risk of 30-day hospital re-admission (all cause: odds ratio [OR] 1.37; confidence interval [CI] 1.28-1.46; P < 0.001; hyponatremia related: OR 2.68; CI 2.48-2.90; P < 0.001).

CONCLUSION

Hyponatremia in patients with cirrhosis is a predictor of increased hospital resource use and 30-day hospital re-admission, and represents a potential target for intervention to reduce healthcare expenditures for patients hospitalized for cirrhosis.

Hyponatraemia: more than just a marker of disease severity?

Hyponatraemia--the most common serum electrolyte disorder--has also emerged as an important marker of the severity and prognosis of important diseases such as heart failure and cirrhosis. Acute hyponatraemia can cause severe encephalopathy, but the rapid correction of chronic hyponatraemia can also profoundly impair brain function and even cause death. With the expanding elderly population and the increased prevalence of hyponatraemia in this segment of society, prospective studies are needed to examine whether correcting hyponatraemia in the elderly will diminish cognitive impairment, improve balance and reduce the incidence of falls and fractures. Given that polypharmacy is also common in the elderly population, the various medications that may stimulate arginine vasopressin release and/or enhance the hormone's action to increase water absorption must also be taken into consideration. Whether hyponatraemia in a patient with cancer is merely a marker of poor prognosis or whether its presence may alter the patient's quality of life remains to be examined. In any case, hyponatraemia can no longer be considered as just a biochemical bystander in the ill patient. A systematic diagnostic approach is necessary to determine the specific aetiology of a patient's hyponatraemia. Therapy must then be dictated not only by recognized reversible causes such as advanced hypothyroidism, adrenal insufficiency, diuretics or other medicines, but also by whether the hyponatraemia occurred acutely or chronically. Information is emerging that the vast majority of cases of hyponatraemia are caused by the nonosmotic release of arginine vasopressin. Now that vasopressin V2-receptor blockers are available, a new era of clinical investigation is necessary to examine whether hyponatraemia is just a marker of severe disease or whether correction of hyponatraemia could improve a patient's quality of life. Such an approach must involve prospective randomized studies in different groups of patients with hyponatraemia, including those with advanced heart failure, those with cirrhosis, patients with cancer, and the elderly.

Retrospective analysis of factors influencing the development and progression of hepatic encephalopathy in patients with hepatitis B virus-related cirrhosis

AIM: To investigate the factors influencing the development and progression of hepatic encephalopathy (HE) in patients with hepatitis B virus (HBV)-related cirrhosis (HBCE).

METHODS: The clinical data for 78 patients with HBCE and 52 patients with HBV-related cirrhosis without HE (HBCNE) treated at the First Affiliated Hospital of Dalian Medical University from March 2002 to May 2011 were retrospectively analyzed. Factors analyzed include gender, age, precipitating factors, ascites, esophageal-gastric varices (EGV), splenomegaly, grade of HE, Child-Pugh grade, blood ammonia (NH4), serum sodium (Na), serum cholinesterase (CHE), serum total bilirubin (TBil), serum albumin (ALB), blood urea nitrogen (BUN), serum creatinine (Cr), and prothrombin time (PT).

RESULTS: Infection was the most common precipitating factor to induce HE in patients with HBV-related cirrhosis (35.6%). Grade Ⅱ HE was most common (36.8%), followed by grade Ⅳ HE (25.3%). Child-Pugh grade, ascites, NH4, Na, CHE, TBil, ALB, BUN, and PT were significantly different between the HBCE and HBCNE groups (0:8:79 vs 0:21:31, 19:68 vs 36:16, 20.74 ± 70.44 vs 46.53 ± 10.67, 136.01 ± 6.65 vs 141.48 ± 3.34, 1927.34 ± 70.52 vs 3342.01 ± 38.03, 91.75 ± 84.56 vs 58.98 ± 14.46, 25.53 ± 3.84 vs 29.48 ± 2.58, 13.57 ± 14.76 vs 6.41 ± 1.57, 21.34 ± 7.12 vs 18.59 ± 1.66; all P < 0.05). The level of NH4 in patients with grade Ⅳ HE was significantly higher than those in patients with gradeⅠ, Ⅱ or Ⅲ HE (156.91 ± 62.94 vs 104.13 ± 73.07, 112.69 ± 60.87, 104.67 ± 82.00; all P < 0.05). Compared to patients with gradeⅠHE, the levels of Na in patients with grade Ⅱ, Ⅲ or Ⅳ HE significantly decreased (135.22 ± 6.05, 134.91 ± 7.79, 134.55 ± 6.25 vs 139.73 ± 5.15; all P < 0.05), and CHE declined in patients with grade Ⅳ HE (1605.19 ± 76.01 vs 2325.46 ± 71.31, P < 0.05). The level of BUN in patients with grade Ⅳ HE was higher than those in patients with gradeⅠor Ⅱ HE (21.65 ± 23.69 vs 6.53 ± 3.41, 10.62 ± 7.37; both P < 0.05).

CONCLUSION: Preventing and controlling infection could decrease the incidence of HE in patients with HBV-related cirrhosis. High levels of NH4, TBil and BUN, low levels of Na, CHE and ALB, Child-Pugh grade C, ascites, and prolonged PT could increase the incidence of HBCE. High levels of NH4 and BUN, and low levels of Na and CHE are associated with more severe HE.

Hyponatremia in cirrhosis and end-stage liver disease: treatment with the vasopressin V₂-receptor antagonist tolvaptan

Hyponatremia is common in patients with cirrhosis and portal hypertension, and is characterized by excessive renal retention of water relative to sodium due to reduced solute-free water clearance. The primary cause is increased release of arginine vasopressin. Hyponatremia is associated with increased mortality in cirrhotic patients, those with end-stage liver disease (ESLD) on transplant waiting lists, and, in some studies, posttransplantation patients. Clinical evidence suggests that adding serum sodium to model for ESLD (MELD) scoring identifies patients in greatest need of liver transplantation by improving waiting list mortality prediction. Hyponatremia is also associated with numerous complications in liver disease patients, including severe ascites, hepatic encephalopathy, infectious complications, renal impairment, increased severity of liver disease in cirrhosis, and increased hospital stay and neurologic/infectious complications posttransplant. Vasopressin receptor antagonists, which act to increase free water excretion (aquaresis) and thereby increase serum sodium concentration, have been evaluated in patients with hypervolemic hyponatremia (including cirrhosis and heart failure) and euvolemic hyponatremia (SIADH). Tolvaptan, a selective vasopressin V(2)-receptor antagonist, is the only oral agent in this class approved for raising sodium levels in hypervolemic and euvolemic hyponatremia. The SALT trials showed that tolvaptan treatment rapidly and effectively resolved hyponatremia in these settings, including cirrhosis, and it has been shown that this agent can be safely and effectively used in long-term treatment. Fluid restriction should be avoided during the first 24 h of treatment to prevent overly rapid correction of hyponatremia, and tolvaptan should not be used in patients who cannot sense/respond to thirst, anuric patients, hypovolemic patients, and/or those requiring urgent intervention to raise serum sodium acutely.

Cystatin C: a predictor of hepatorenal syndrome in patients with liver cirrhosis

BACKGROUND

Recent studies suggest that serum cystatin C (CysC) is a more sensitive marker of renal functions than serum creatinine (Cr).

AIM

Evaluation of the clinical significance of cystatin C as a predictor of hepatorenal syndrome (HRS) in patients with liver cirrhosis, ascites, and normal serum Cr level.

METHODS

Eighty patients with cirrhotic ascites were enrolled in this study (53 men and 27 women; age: 59.5 ± 7.5 years). All patients were subjected to full clinical assessment and laboratory investigations focussing on renal functions, glomerular filtration rate, and measurement of serum cystatin level.

RESULTS

The Serum Cr and CysC levels were 1.04 ± 0.1 and 1.8 ± 0.8 mg/L, respectively. HRS developed in 18 patients during the follow-up period (6 months). Type 1 HRS was found in 5 patients and type 2 HRS was found in 13 patients with no significant difference between both types regarding baseline characteristics. Age (p < 0.001), albumin (p < 0.001), sodium (p < 0.005), cystatin C (p < 0.001), and e-GFRMDRD (estimated glomerular filtration rate-modification of the diet in renal disease) (p < 0.007) were significant dependent predictive factors for the development of HRS. The CysC level was the most independent predictive factor for HRS (OR, 2.1; 95% CI, 0.75-0.97; p < 0.002). Eighteen patients died during the follow-up period. Age (p < 0.001), INR (p < 0.001), e-GFRMDRD (p < 0.03), sodium (p < 0.01), MELD score (p < 0.05), albumin (p < 0.001), and CysC (p < 0.001) levels were significant dependent factors for predicting mortality. CysC (OR, 5.3; p < 0.006) level and INR (OR, 1.01; p < 0.006) were the most independent factors for predicting mortality.

CONCLUSION

Serum CysC level may be considered a predictor of HRS and mortality in patients with liver cirrhosis and ascites.

Managing hyponatremia in cirrhosis

The development of hyponatremia represents an ominous event in the progression of cirrhosis to end-stage liver disease. It usually develops in those with refractory ascites and is a manifestation of the non-osmotic release of arginine vasopressin (AVP). In the hospitalized cirrhotic patient, hyponatremia is associated with increased disease severity and mortality. In this article, we review the pathophysiology of hyponatremia, its clinical implications, evaluation, and treatment.

Spontaneous bacterial peritonitis before liver transplantation does not affect patient survival

BACKGROUND & AIMS

Spontaneous bacterial peritonitis (SBP) is a devastating complication of cirrhosis with high mortality. The impact of a prior episode of SBP on the outcome of liver transplantation (LT) is not well known. We aimed to determine the short- and long-term morbidity and mortality of patients who received LT, with and without a history of SBP.

METHODS

We reviewed the records of all adult patients who underwent LT at a single center between June 1999 and June 2009. Patients with SBP were compared with all other patients who underwent LT during the same time period, without prior episodes of SBP.

RESULTS

A total of 1491 adult patients underwent LT in the study period; 80 (5.4%) had at least 1 episode of SBP before LT. The mean follow-up time for all patients in the study was just over 4 years. Patients in the SBP cohort were more likely to be male (74%) and to have alcoholic liver disease. Patients with SBP had higher Child-Pugh and model for end-stage liver disease scores at the time of transplantation compared with controls, but there was no difference in long-term mortality between the 2 groups. Patients with SBP, however, were more likely to require surgery for complications related to LT within 1 year and were more likely to die of sepsis.

CONCLUSIONS

Despite higher Child-Pugh and model for end-stage liver disease score at the time of LT, survival times of patients with SBP before LT are similar to those patients without SBP.