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Çekmen N, Uslu A. Anaesthesia management for liver transplantation: A narrative review. J Perioper Pract 2024; 34:226-240. [PMID: 37970678 DOI: 10.1177/17504589231193551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Orthotopic liver transplantation is the definitive standard treatment for end-stage liver disease. Orthotopic liver transplantation anaesthesia management is a complex procedure that requires a multidisciplinary team approach. Understanding the complex pathophysiology of end-stage liver disease and its complications in the affected systems is essential for proper anaesthesia management in orthotopic liver transplantation. Orthotopic liver transplantation is a dynamic process, and preoperative optimisation is essential in these patients. Therefore, anaesthesiologists should focus on rapidly fluctuating physiology, haemodynamics, metabolic, and coagulation status in the anaesthesia management of these patients. Perioperative care and anaesthesia for orthotopic liver transplantation can be divided into preoperative evaluation, anaesthesia induction and management, dissection, anhepatic, neo-hepatic, and postoperative care, with essential anaesthetic considerations at each point. Considering the clinical situation, haemodynamic changes, misapplications, knowledge, attitude, and multimodal and multidisciplinary approach are vital in anaesthesia and the perioperative period. In our review, in line with the literature, we aimed to present the perioperative and anaesthesia management in orthotopic liver transplantation patients.
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Affiliation(s)
- Nedim Çekmen
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Ahmed Uslu
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Baskent University, Ankara, Turkey
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2
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Meng J, Liu S, Wu X. Engineered probiotics as live biotherapeutics for diagnosis and treatment of human diseases. Crit Rev Microbiol 2024; 50:300-314. [PMID: 36946080 DOI: 10.1080/1040841x.2023.2190392] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 01/09/2023] [Indexed: 03/23/2023]
Abstract
The use of probiotics to regulate the intestinal microbiota to prevent and treat a large number of disorders and diseases has been an international research hotspot. Although conventional probiotics have a certain regulatory role in nutrient metabolism, inhibiting pathogens, inducing immune regulation, and maintaining intestinal epithelial barrier function, they are unable to treat certain diseases. In recent years, aided by the continuous development of synthetic biology, engineering probiotics with desired characteristics and functionalities to benefit human health has made significant progress. In this article, we summarise the mechanism of action of conventional probiotics and their limitations and highlight the latest developments in the design and construction of probiotics as living diagnostics and therapeutics for the detection and treatment of a series of diseases, including pathogen infections, cancer, intestinal inflammation, metabolic disorders, vaccine delivery, cognitive health, and fatty liver. Besides we discuss the concerns regarding engineered probiotics and corresponding countermeasures and outline the desired features in the future development of engineered live biotherapeutics.
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Affiliation(s)
- Jiao Meng
- Laboratory of Nutrient Resources and Synthetic Biology, Tianjin Institute of Industrial Biotechnology, Chinese Academy of Science, Tianjin, China
| | - Shufan Liu
- Laboratory of Nutrient Resources and Synthetic Biology, Tianjin Institute of Industrial Biotechnology, Chinese Academy of Science, Tianjin, China
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin University of Science and Technology; College of Bioengineering, Tianjin University of Science and Technology, Tianjin, China
| | - Xin Wu
- Laboratory of Nutrient Resources and Synthetic Biology, Tianjin Institute of Industrial Biotechnology, Chinese Academy of Science, Tianjin, China
- CAS Key Laboratory of Agro-Ecological Processes in Subtropical Region, Institute of Subtropical Agriculture, Chinese Academy of Sciences, Changsha, China
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3
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Lee EW, Liang JJ, McNamara GP. Interventional Radiology Management of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:317-329. [PMID: 38548442 DOI: 10.1016/j.cld.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy (HE) is a clinically severe and devastating complication of decompensated liver disease affecting mortality, quality of life for patients and families, hospital admission rates, and overall health-care costs globally. Depending on the cause of HE, several medical treatment options have been developed and become available. In some refractory HE, such as spontaneous portosystemic shunt-related HE (SPSS-HE) or posttransjugular intrahepatic portosystemic shunt HE (post-TIPS HE), advanced interventional radiology (IR) procedures have been used, and shown to be effective in these conditions. This review presents 2 effective IR procedures for managing SPSS-HE and post-TIPS HE.
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Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Division of Liver and Pancreas Transplant Surgery, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Justine J Liang
- Department of Anesthesiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Griffin P McNamara
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Nelaturi P, P Kadamani S, Sambandam R. Alcoholism and Socioeconomic Status among Patients with Hepatic Encephalopathy in Association with Increased Mortality. ADDICTION & HEALTH 2024; 16:1-5. [PMID: 38651030 PMCID: PMC11032619 DOI: 10.34172/ahj.2024.1467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 01/15/2024] [Indexed: 04/25/2024]
Abstract
Background Hepatic encephalopathy (HE) is a complex neuropsychiatric disorder indicated by a deterioration in the functioning of hepatocytes. Impaired brain function is observed in advanced alcoholic liver disease particularly manifesting as HE. The pathophysiology of alcohol-related HE remains unclear. Accordingly, this study aimed to assess alcoholism and socioeconomic status of patients with liver disease compared with stages of HE. Methods This cross-sectional study was conducted on 62 alcoholic patients who have been consuming alcohol for more than 14 years. Patients were recruited based on the assessment of clinical symptoms and diagnosed according to the MELD and Child-Pugh scoring systems. Findings Descriptive statistics including demographic details and clinical features of patients were classified based on alcoholism and socioeconomic status. Patients belonging to the lower- and middle-income classes were more in number with a mean age of 46.66±10.21 and 47.14±6.36 years, respectively compared to upper-middle- and upper-income classes. The amount of alcohol intake was 116.59±45.60 in the middle class and 110.0±62.45 in the upper class. Conclusion Increased progression of HE leads to a rise in the mortality rate due to higher consumption of alcohol. HE is a severe complication in alcohol-related liver cirrhosis that contributes to impaired cognitive function in patients.
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Affiliation(s)
- Prabhudas Nelaturi
- Multidisciplinary Center for Biomedical Research, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission’s Research Foundation (Deemed to be University), Kirumampakkam, Puducherry-607402, India
| | - Sangeetha P Kadamani
- Multidisciplinary Center for Biomedical Research, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission’s Research Foundation (Deemed to be University), Kirumampakkam, Puducherry-607402, India
| | - Ravikumar Sambandam
- Multidisciplinary Center for Biomedical Research, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission’s Research Foundation (Deemed to be University), Kirumampakkam, Puducherry-607402, India
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Yang H, You L, Wang Z, Yang L, Wang X, Wu W, Zhi H, Rong G, Sheng Y, Liu X, Liu L. Bile duct ligation elevates 5-HT levels in cerebral cortex of rats partly due to impairment of brain UGT1A6 expression and activity via ammonia accumulation. Redox Biol 2024; 69:103019. [PMID: 38163420 PMCID: PMC10794929 DOI: 10.1016/j.redox.2023.103019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024] Open
Abstract
Hepatic encephalopathy (HE) is often associated with endogenous serotonin (5-HT) disorders. However, the reason for elevated brain 5-HT levels due to liver failure remains unclear. This study aimed to investigate the mechanism by which liver failure increases brain 5-HT levels and the role in behavioral abnormalities in HE. Using bile duct ligation (BDL) rats as a HE model, we verified the elevated 5-HT levels in the cortex but not in the hippocampus and striatum, and found that this cortical 5-HT overload may be caused by BDL-mediated inhibition of UDP-glucuronosyltransferase 1A6 (UGT1A6) expression and activity in the cortex. The intraventricular injection of the UGT1A6 inhibitor diclofenac into rats demonstrated that the inhibition of brain UGT1A6 activity significantly increased cerebral 5-HT levels and induced HE-like behaviors. Co-immunofluorescence experiments demonstrated that UGT1A6 is primarily expressed in astrocytes. In vitro studies confirmed that NH4Cl activates the ROS-ERK pathway to downregulate UGT1A6 activity and expression in U251 cells, which can be reversed by the oxidative stress antagonist N-acetyl-l-cysteine and the ERK inhibitor U0126. Silencing Hepatocyte Nuclear Factor 4α (HNF4α) suppressed UGT1A6 expression whilst overexpressing HNF4α increased Ugt1a6 promotor activity. Meanwhile, both NH4Cl and the ERK activator TBHQ downregulated HNF4α and UGT1A6 expression. In the cortex of hyperammonemic rats, we also found activation of the ROS-ERK pathway, decreases in HNF4α and UGT1A6 expression, and increases in brain 5-HT content. These results prove that the ammonia-mediated ROS-ERK pathway activation inhibits HNF4α expression to downregulate UGT1A6 expression and activity, thereby increasing cerebral 5-HT content and inducing manic-like HE symptoms. This is the first study to reveal the mechanism of elevated cortical 5-HT concentration in a state of liver failure and elucidate its association with manic-like behaviors in HE.
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Affiliation(s)
- Hanyu Yang
- State Key Laboratory of Natural Medicines, Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, 210009, Nanjing, China; Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Linjun You
- Center for New Drug Safety Evaluation and Research, China Pharmaceutical University, 210009, Nanjing, China
| | - Zhongyan Wang
- Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Lu Yang
- Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Xun Wang
- Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Wenhan Wu
- Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Hao Zhi
- Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Guangmei Rong
- Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Yun Sheng
- Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Xiaodong Liu
- State Key Laboratory of Natural Medicines, Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, 210009, Nanjing, China; Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
| | - Li Liu
- State Key Laboratory of Natural Medicines, Key Laboratory of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, 210009, Nanjing, China; Department of Pharmacology, School of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
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6
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Testino G, Bottaro LC, Andorno E, Bandini F, Balbinot P, Beltramini S, Bottino S, Caltabellotta M, Caputo F, Caviglia E, Curone P, DI Biagio A, Gagliano C, Gandolfo N, Pestarino L, Rollero A, Romairone E, Sampietro L, Torre E, Zuccarelli S, Pellicano R. Hepatic encephalophathy: management and diagnostic therapeutic assistance path of Ligurian Local Health Company 3 (ASL3). Minerva Med 2023; 114:698-718. [PMID: 36952221 DOI: 10.23736/s0026-4806.22.08408-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Hepatic encephalophathy (HE) is a neuropsychiatric syndrome with a prevalence in the cirrhotic population ranging from 20 to 80%. HE is a cause of inappropriate hospitalization, caregiver burdening and increased social costs. There is need to create dedicated care pathways to better manage patients and support family caregivers. The data used for the preparation of this diagnostic therapeutic assistance path (DTAP) are based on a detailed analysis of the scientific literature published before June 30, 2022 (PubMed, Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted in particular the guidelines/ position papers of International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN), Italian Association for the Study of the Liver (AISF), European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), Italian Society on Alcohol (Società Italiana di Alcologia [SIA]) and other relevant papers. DTAP was created based on the most recent recommendations of the international scientific literature. The present DTAP highlight the need for a multidisciplinary activity integrated with territorial medicine in close connection with caregivers. This guarantees improved therapeutic adherence, hospital readmission reduction, improved quality of life for patients and caregivers and a significant reduction in costs.
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Affiliation(s)
- Gianni Testino
- Addiction and Hepatology Unit/Alcohological Regional Centre and Study Centre "Self Help, Community Program and Caregiver Training" ASL3, Genoa, Italy -
| | | | - Enzo Andorno
- Liver Transplantation Unit, San Martino Polyclinic Hospital, Genoa, Italy
| | | | - Patrizia Balbinot
- Addiction and Hepatology Unit/Alcohological Regional Centre and Study Centre "Self Help, Community Program and Caregiver Training" ASL3, Genoa, Italy
| | | | | | | | - Fabio Caputo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Center for the Study and Treatment of Chronic Inflammatory Intestinal Diseases (IBD) and Gastroenterological Manifestations of Rare Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Center for the Study and Treatment of Alcohol-Related Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Internal Medicine, Santissima Annunziata Hospital, University of Ferrara, Ferrara, Italy
| | | | | | - Antonio DI Biagio
- Department of Health Sciences, Infectious Diseases Clinic, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy
| | | | | | | | | | | | | | - Enrico Torre
- Unit of Endocrinology, Metabolic Diseases and Diabetology, ASL3 Liguria, Genoa, Italy
| | | | - Rinaldo Pellicano
- Unit of Gastroenterology, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
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7
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Hepatic Encephalopathy. Crit Care Nurs Clin North Am 2022; 34:331-339. [DOI: 10.1016/j.cnc.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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8
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Ledgerwood C, Villgran V, Mardirossian N, Dumont T, DiSilvio B. Acute Liver Failure. Crit Care Nurs Q 2022; 45:248-257. [PMID: 35617091 DOI: 10.1097/cnq.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute liver failure (ALF) is a rare but life-threatening disease process that can result in rapidly progressive encephalopathy, elevated intracranial pressure, and multiorgan failure. In the United States, the 2 most common causes of ALF in the intensive care unit (ICU) are acetaminophen overdose and hypoxic-ischemic hepatopathy. Less common causes of ALF include alcoholic hepatitis, nonacetaminophen drug-induced liver injury, acute viral hepatitis, Wilson's disease, autoimmune hepatitis, and acute fatty liver of pregnancy. Unfortunately, there are many cases in which the cause of liver failure is indeterminate. ALF is an ICU emergency that requires close monitoring, extensive workup to determine etiology, frequent support of hemodynamic, respiratory, and renal function, administration of targeted therapies depending on the cause, utilization of N-acetylcysteine if appropriate, and consideration for liver transplant in select cases. The primary objective of this article is to define, diagnose, and detail the management of ALF in an ICU setting.
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Affiliation(s)
- Chelsea Ledgerwood
- Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania (Drs Ledgerwood, Villgran, Dumont, and DiSilvio); and Department of Nursing, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania (Mr Mardirossian)
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9
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Safadi R, Rahimi RS, Thabut D, Bajaj JS, Ram Bhamidimarri K, Pyrsopoulos N, Potthoff A, Bukofzer S, Wang L, Jamil K, Devarakonda KR. Pharmacokinetics/pharmacodynamics of L-ornithine phenylacetate in overt hepatic encephalopathy and the effect of plasma ammonia concentration reduction on clinical outcomes. Clin Transl Sci 2022; 15:1449-1459. [PMID: 35238476 PMCID: PMC9199870 DOI: 10.1111/cts.13257] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 12/19/2022] Open
Abstract
Hepatic encephalopathy (HE) is a serious neurocognitive complication of liver dysfunction, often associated with elevated plasma ammonia. Ornithine phenylacetate (OP), a potent ammonia scavenger, is being evaluated for the treatment of acute/overt HE. The pharmacokinetics and pharmacodynamics of OP in patients with HE were characterized in this phase IIb study (NCT01966419). Adult patients hospitalized with an overt HE episode, cirrhosis, and plasma ammonia above the upper limit of normal (ULN) who failed to improve after 48 hours’ standard care were randomly assigned to continuous intravenous OP (10, 15, or 20 g/day, based on Child–Turcotte–Pugh score) or matching placebo for 5 days. Plasma levels of ornithine and phenylacetic acid (PAA) and plasma/urinary levels of phenylacetylglutamine (PAGN) (primary metabolite of PAA) were regularly assessed; plasma ammonia level was the primary pharmacodynamic variable. PAA demonstrated dose‐dependent pharmacokinetics; ornithine and PAGN levels increased with dose. PAGN urinary excretion represented ~50%–60% of administered PAA across all doses. Mean reduction in plasma ammonia with OP at 3 hours postinfusion was significantly greater versus placebo (p = 0.014); and time to achieve plasma ammonia less than or equal to the ULN was significantly reduced (p = 0.028). Achievement of clinical response based on HE stage was associated with a greater reduction in mean plasma ammonia level (p = 0.009). OP effects on plasma ammonia were consistent with its proposed mechanism of action as a primary ammonia scavenger, with a significant association between reduced plasma ammonia and improvement in HE stage. OP should be further evaluated as a promising treatment for hyperammonemia in patients with overt HE.
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Affiliation(s)
- Rifaat Safadi
- Director of The Liver Institute, Hadassah Medical Organization, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Robert S Rahimi
- Baylor Scott and White Hospital, Baylor University Medical Center, Dallas, Texas, USA
| | - Dominique Thabut
- Brain Liver Pitié-Salpêtrière (B-LIPS) Study Group, Paris Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | | | - Nikolaos Pyrsopoulos
- Rutgers New Jersey Medical School and University Hospital, Newark, New Jersey, USA
| | - Amy Potthoff
- Ocera Therapeutics, Inc., Redwood City, California, USA
| | - Stan Bukofzer
- Ocera Therapeutics, Inc., Redwood City, California, USA
| | - Laurene Wang
- INDAPharma, LLC, Chapel Hill, North Carolina, USA
| | - Khurram Jamil
- Mallinckrodt Pharmaceuticals, Hampton, New Jersey, USA
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10
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Martin-Grau M, Marrachelli VG, Monleon D. Rodent models and metabolomics in non-alcoholic fatty liver disease: What can we learn? World J Hepatol 2022; 14:304-318. [PMID: 35317178 PMCID: PMC8891675 DOI: 10.4254/wjh.v14.i2.304] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/13/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) prevalence has increased drastically in recent decades, affecting up to 25% of the world’s population. NAFLD is a spectrum of different diseases that starts with asymptomatic steatosis and continues with development of an inflammatory response called steatohepatitis, which can progress to fibrosis. Several molecular and metabolic changes are required for the hepatocyte to finally vary its function; hence a “multiple hit” hypothesis seems a more accurate proposal. Previous studies and current knowledge suggest that in most cases, NAFLD initiates and progresses through most of nine hallmarks of the disease, although the triggers and mechanisms for these can vary widely. The use of animal models remains crucial for understanding the disease and for developing tools based on biological knowledge. Among certain requirements to be met, a good model must imitate certain aspects of the human NAFLD disorder, be reliable and reproducible, have low mortality, and be compatible with a simple and feasible method. Metabolism studies in these models provides a direct reflection of the workings of the cell and may be a useful approach to better understand the initiation and progression of the disease. Metabolomics seems a valid tool for studying metabolic pathways and crosstalk between organs affected in animal models of NAFLD and for the discovery and validation of relevant biomarkers with biological understanding. In this review, we provide a brief introduction to NAFLD hallmarks, the five groups of animal models available for studying NAFLD and the potential role of metabolomics in the study of experimental NAFLD.
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Affiliation(s)
- Maria Martin-Grau
- Department of Pathology, University of Valencia, Valencia 46010, Spain
| | - Vannina G Marrachelli
- Department of Physiology, University of Valencia, Valencia 46010, Spain
- Health Research Institute INCLIVA, Valencia 46010, Spain
| | - Daniel Monleon
- Department of Pathology, University of Valencia, Valencia 46010, Spain
- Health Research Institute INCLIVA, Valencia 46010, Spain
- CIBER de Fragilidad y Envejecimiento Saludable (CIBERfes), Madrid 28029, Spain
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Hepatic Encephalopathy-Related Hospitalizations in Cirrhosis: Transition of Care and Closing the Revolving Door. Dig Dis Sci 2022; 67:1994-2004. [PMID: 34169435 PMCID: PMC9167177 DOI: 10.1007/s10620-021-07075-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/24/2021] [Indexed: 12/09/2022]
Abstract
Cirrhosis is associated with substantial morbidity and mortality. Development of complications of cirrhosis, including hepatic encephalopathy (HE), portends poorer outcomes. HE is associated with hospital readmission, impaired patient and caregiver quality of life, risk of falls, and mortality. Guidelines recommend lactulose as first-line therapy for HE and rifaximin in combination with lactulose for reducing the risk of HE recurrence. Improving post-discharge outcomes, including readmissions, is an important aspect in the management of patients with HE. Approaches focused on improving management and prevention of HE, including properly titrating lactulose dosing, overcoming medication-related nonadherence, and incorporating rifaximin as therapy to reduce the risk of recurrence, as well as incorporating supportive care initiatives, may ease the transition from hospital to home. Strategies to decrease readmission rates include using hospital navigators, who can offer patient/caregiver education, post-discharge planning, and medication review; and involving pharmacists in post-discharge planning. Similarly, telemedicine offers providers the opportunity to monitor patients with HE remotely and improves outcomes. Providers offering transitional care management may be reimbursed when establishing contact with patients within 2 days post-discharge and conducting an outpatient visit within 7 days or 14 days. Several approaches have been shown to improve outcomes broadly in patients post-discharge and may also be effective for improving outcomes specifically in patients hospitalized with cirrhosis and HE, thus closing the revolving door on rehospitalizations in this population.
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12
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Saab S, Zhao M, Asokan I, Yum JJ, Lee EW. History of Hepatic Encephalopathy Is Not a Contraindication to Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites. Clin Transl Gastroenterol 2021; 12:e00378. [PMID: 34333500 PMCID: PMC8323801 DOI: 10.14309/ctg.0000000000000378] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The outcomes of transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with hepatic encephalopathy (HE) are controversial. We studied the relationship of pre-TIPS HE in patients undergoing TIPS for refractory ascites on all-cause mortality and development of post-TIPS HE. METHODS A single-center retrospective comparison study was performed for patients undergoing TIPS for refractory ascites. Survival by history of pre-TIPS HE was demonstrated with Kaplan-Meier curves. Univariate and multivariate logistic regression analyses were performed to identify the predictors of post-TIPS clinical outcomes for patients with and without pre-TIPS HE. RESULTS We identified 202 TIPS recipients (61% male, mean ± SD; age 59.1 ± 10.2 years; mean model for end-stage liver disease score 17.3 ± 6.9). Pre-TIPS HE did not predispose patients for increased all-cause mortality, increased risk of experiencing HE within 60 days, or increased risk of hospital admission for HE within 6 months. A multivariate analysis demonstrated that total bilirubin (odds ratio [OR] 1.03; P = 0.016) and blood urea nitrogen (OR 1.15; P = 0.002) were predictors for all-cause mortality within 6 months post-TIPS. Age ≥65 years (OR 3.92; P = 0.004), creatinine (OR 2.22; P = 0.014), and Child-Pugh score (OR 1.53; P = 0.006) were predictors for HE within 60 days post-TIPS. Predictors of intensive care admission for HE within 6 months post-TIPS included age ≥65 years (OR 8.84; P = 0.018), history of any admission for HE within 6 months pre-TIPS (OR 8.42; P = 0.017), and creatinine (OR 2.22; P = 0.015). DISCUSSION If controlled, pre-TIPS HE does not adversely impact patient survival or clinical outcomes, such as development of HE within 60 days of TIPS or hospital admission for HE within 6 months. Patients may be able to undergo TIPS for refractory ascites despite a history of HE.
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Affiliation(s)
- Sammy Saab
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
| | - Matthew Zhao
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ishan Asokan
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jung Jun Yum
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
| | - Edward Wolfgang Lee
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Kubota K, Uojima H, Shao X, Iwasaki S, Hidaka H, Wada N, Nakazawa T, Shibuya A, Kako M, Koizumi W. Additional L-Carnitine Reduced the Risk of Hospitalization in Patients with Overt Hepatic Encephalopathy on Rifaximin. Dig Dis 2021; 40:313-321. [PMID: 34348263 DOI: 10.1159/000518067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 06/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Data regarding the additional effect on the recurrence of hepatic encephalopathy (HE) after oral L-carnitine administration are scarce. OBJECTIVE This study aimed to assess the additional effects of L-carnitine in patients who were receiving rifaximin for HE. METHODS This randomized study comprised a screening visit and a 12-week treatment period. Patients who fulfilled the eligibility criteria were randomized to either group A (additional rifaximin) or group B (additional L-carnitine and rifaximin). Group A received 1,200 mg/day of rifaximin. Group B received 1,500 mg/day of L-carnitine and rifaximin at 1,200 mg/day. The endpoints were the changes in the portal systemic encephalopathy (PSE) index and the admission rate from the baseline for the duration of the study in both groups. RESULTS Eighty-three patients were randomized to either group A (n = 42) or group B (n = 41). In group A, the PSE index decreased from 0.35 ± 0.09 at baseline to 0.27 ± 0.11 on the final evaluation day (p = 0.001). In group B, the PSE index decreased from 0.37 ± 0.09 at baseline to 0.24 ± 0.11 on the final evaluation day (p = 0.001). Although there was not a significant reduction in the PSE index in group A compared to that in group B (p = 0.202), the admission rates were 30.9% and 9.8% in groups A and B, respectively. Additional L-carnitine significantly reduced the admission rate (p = 0.028). CONCLUSION L-Carnitine addition reduced the risk of hospitalization for patients who received rifaximin for HE.
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Affiliation(s)
- Kousuke Kubota
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan.,Department of Gastroenterology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Xue Shao
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan.,Department of Hepatopancreatobiliary Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Shuichiro Iwasaki
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hisashi Hidaka
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Naohisa Wada
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takahide Nakazawa
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Akitaka Shibuya
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Makoto Kako
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Wasaburo Koizumi
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
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14
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El-Baz FK, Elgohary R, Salama A. Amelioration of Hepatic Encephalopathy Using Dunaliella salina Microalgae in Rats: Modulation of Hyperammonemia/TLR4. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8843218. [PMID: 33855084 PMCID: PMC8021475 DOI: 10.1155/2021/8843218] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/27/2021] [Accepted: 03/19/2021] [Indexed: 12/28/2022]
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric disease that is developed as a complication of both acute and chronic liver failure affecting psychomotor dysfunction, memory, and concentration. This study is aimed at evaluating the therapeutic effects of Dunaliella salina (D. salina) microalgae in thioacetamide- (TAA-) induced HE in rats. HE was induced by TAA (200 mg/kg; i.p.) for three successive days. Forty male Wister albino rats were divided into 4 groups; the first group was served as a normal, and the second group was injected with TAA and served as TAA control. The third and fourth groups were administered D. salina (100 and 200 mg/kg; p.o.), respectively, after TAA injection for 7 days. The behavioral and biochemical markers as well as histological aspects of HE were estimated. This study revealed that TAA caused behavioral changes, oxidative stress, neuroinflammation, nuclear pyknosis, and neurons degeneration. D. salina improved liver function and decreased oxidative stress and inflammatory mediator as TLR4 protein expression. Also, D. salina elevated HSP-25 and IGF-1 as well as improved brain histopathological alterations. In conclusion, D. salina exerted a therapeutic potential against HE via its antioxidant, antiinflammatory and cytoprotective effects.
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Affiliation(s)
- Farouk K. El-Baz
- Plant Biochemistry Department, National Research Centre (NRC), 33 El Buhouth St., Dokki, Cairo 12622, Egypt
| | - Rania Elgohary
- Narcotics, Ergogenics and Poisons Department, National Research Centre (NRC), 33 El Buhouth St., Dokki, Cairo 12622, Egypt
| | - Abeer Salama
- Pharmacology Department, National Research Centre (NRC), 33 El Buhouth St., Dokki, Cairo 12622, Egypt
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15
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Plasma Arginase-1 Level Is Associated with the Mental Status of Outpatients with Chronic Liver Disease. Diagnostics (Basel) 2021; 11:diagnostics11020317. [PMID: 33669265 PMCID: PMC7920070 DOI: 10.3390/diagnostics11020317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/21/2022] Open
Abstract
While plasma arginase-1 has been suggested as a biomarker of mental status in healthy individuals, it has not been evaluated in patients with chronic liver disease. This cross-sectional study investigated the utility of plasma arginase-1 for screening mental status in patients with chronic liver disease. This study included outpatients with chronic liver disease who underwent regular check-ups at Okayama University Hospital between September 2018 and January 2019. In addition to the standard blood tests, the plasma arginase-1 level was analyzed. The patients’ mental status was assessed using the Japanese version of the General Health Questionnaire-28 (GHQ-28). The associations between mental status and various parameters, including plasma arginase-1, were investigated using logistic regression analysis. Among 114 participating patients, 8 were excluded, comprising 6 with insufficient blood samples for plasma arginase-1 measurement and 2 with incomplete questionnaires. Multivariate binomial logistic regression analysis revealed that plasma arginase-1 was significantly and negatively associated with the GHQ-total score, especially somatic symptoms. Therefore, plasma arginase-1 may be a useful biomarker for assessing the mental status of outpatients with chronic liver disease.
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16
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Chu YY, Wang X, Dai HL. Update on pharmacotherapy of hepatic encephalopathy. Shijie Huaren Xiaohua Zazhi 2021; 29:58-64. [DOI: 10.11569/wcjd.v29.i2.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a central nervous system disease caused by serious liver diseases or various portal vein systemic circulation abnormalities. The pathogenesis and pathophysiology of HE have not been fully elucidated yet, and among others, the most important is still the theory of ammonia intoxication proposed in the 1930s. Therefore, reducing blood ammonia is currently the main therapeutic strategy for HE, along with improving nervous system function. Thanks to the clarification of the mechanism underlying ammonia-induced brain cell injury in recent years, researchers have proposed some novel therapeutic targets and related drugs. This work will make a brief summary regarding the update of HE drugs with regard to ammonia reduction, nervous system improvement, and intervention of ammonia toxicity targets.
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Affiliation(s)
- Yu-Ying Chu
- School of Nursing, Jinzhou Medical University, Jinzhou 121001, Liaoning Province, China
| | - Xue Wang
- School of Nursing, Jinzhou Medical University, Jinzhou 121001, Liaoning Province, China
| | - Hong-Liang Dai
- School of Nursing, Jinzhou Medical University, Jinzhou 121001, Liaoning Province, China
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17
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Cheon SY, Song J. The Association between Hepatic Encephalopathy and Diabetic Encephalopathy: The Brain-Liver Axis. Int J Mol Sci 2021; 22:ijms22010463. [PMID: 33466498 PMCID: PMC7796499 DOI: 10.3390/ijms22010463] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/02/2021] [Accepted: 01/03/2021] [Indexed: 12/13/2022] Open
Abstract
Hepatic encephalopathy (HE) is one of the main consequences of liver disease and is observed in severe liver failure and cirrhosis. Recent studies have provided significant evidence that HE shows several neurological symptoms including depressive mood, cognitive dysfunction, impaired circadian rhythm, and attention deficits as well as motor disturbance. Liver disease is also a risk factor for the development of diabetes mellitus. Diabetic encephalopathy (DE) is characterized by cognitive dysfunction and motor impairment. Recent research investigated the relationship between metabolic changes and the pathogenesis of neurological disease, indicating the importance between metabolic organs and the brain. Given that a diverse number of metabolites and changes in the brain contribute to neurologic dysfunction, HE and DE are emerging types of neurologic disease. Here, we review significant evidence of the association between HE and DE, and summarise the common risk factors. This review may provide promising therapeutic information and help to design a future metabolic organ-related study in relation to HE and DE.
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Affiliation(s)
- So Yeong Cheon
- Department of Biotechnology, College of Biomedical & Health Science, Konkuk University, Chungju 27478, Korea;
| | - Juhyun Song
- Department of Anatomy, Chonnam National University Medical School, Hwasun 58128, Jeollanam-do, Korea
- Correspondence: ; Tel.: +82-61-379-2706; Fax: +82-61-375-5834
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18
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Luo M, Gao L, Niu J, Chen C, Wang H, Chen Y. Liver failure in pregnancy: a review of 25 cases. J OBSTET GYNAECOL 2020; 41:1036-1041. [PMID: 33241706 DOI: 10.1080/01443615.2020.1824214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We retrospectively reviewed the medical records from 25 pregnant women with liver failure from May 2009 to July 2019. Data describing clinical symptoms and manifestations, routine blood analyses, coagulation, and liver and kidney function were extracted. Swansea criteria were assessed to identify variables with prognostic significance for maternal mortality. The results showed that acute fatty liver was the primary cause of liver failure and 8 (88.89%) patients died within 7 days. Swansea diagnostic criteria for assessing the severity of liver failure were consistent with Chinese guidelines and were more systematic and convenient. The incidence of postpartum haemorrhage was 76%, and the velocity of bleeding was approximately 600 mL per hour. Increased Swansea score, hepatic encephalopathy and decreased PWR were important prognostic indicators for mortality. Recovery during the 7 days postpartum period was an important determinant of maternal outcomes.Impact statementWhat is already known on this subject? Liver failure in pregnant women is a rare but potentially devastating disease with a high rate of short-term morbidity and mortality. There are limited reports about clinical predictors of maternal-foetal outcomes and the dilemmas faced in the term of delivery.What the results of this study add? The incidence of postpartum haemorrhage was 76% in pregnant women with liver failure, but the velocity of bleeding was approximately 600 mL per hour. Our study revealed the Swansea score and the ratio of hepatic encephalopathy were significantly higher and platelet-to-white blood cell ratio (PWR) was lower in women who died compared to those who survived. During treatment period, 8 (88.89%) patients died within 7 days.What the implications are of these findings for clinical practice and/or further research? Swansea score, hepatic encephalopathy and PWR were important prognostic indicators for mortality in pregnant women with liver failure. Recovery during the 7 days postpartum period was an important determinant of maternal outcomes. Our findings may prompt researchers to conduct a large multicentre study to evaluate the prognostic indicators for mortality in pregnant women with liver failure.
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Affiliation(s)
- Mengyao Luo
- Department of Obstetrics, The First Hospital of Jilin University, Changchun, Jilin, China.,ZiBo Central Hospital, Zibo, Shandong, China
| | - Lei Gao
- The First Hospital of Jilin University, Phase I Clinical Research Center, Changchun, Jilin, China
| | - Junqi Niu
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Chen Chen
- Department of Obstetrics, The First Hospital of Jilin University, Changchun, Jilin, China
| | - He Wang
- Department of Obstetrics, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Ying Chen
- Department of Obstetrics, The First Hospital of Jilin University, Changchun, Jilin, China
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19
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Han W, Zhang H, Han Y, Duan Z. Cognition-tracking-based strategies for diagnosis and treatment of minimal hepatic encephalopathy. Metab Brain Dis 2020; 35:869-881. [PMID: 32495311 PMCID: PMC7354280 DOI: 10.1007/s11011-020-00539-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/23/2020] [Indexed: 12/11/2022]
Abstract
Minimal hepatic encephalopathy (MHE), which shows mild cognitive impairment, is a subtle complication of cirrhosis that has been shown to affect daily functioning and quality of life. However, until 2014, relevant guidelines do not give much attention to the diagnosis and treatment of MHE, resulting in patients being ignored and denied the benefits of treatment. In this review, we summarize recent cognition-based research about (1) alteration of nerve cells, including astrocytes, microglial cells and neurons, in mild cognitive impairment in MHE; (2) comparison of methods in detecting cognitive impairment in MHE; and (3) comparison of methods for therapy of cognitive impairment in MHE. We hope to provide information about diagnosis and treatment of cognitive impairment in patients with MHE.
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Affiliation(s)
- Weijia Han
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Huanqian Zhang
- Yidu Central Hospital of Weifang Medical College, Shandong, China
| | - Ying Han
- Department of Immunologic Liver Disease, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Zhongping Duan
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China.
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20
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Abstract
Hepatic encephalopathy is a major neuropsychiatric complication of liver disease that affects 30% to 40% of cirrhotic patients. Hepatic encephalopathy is characterized by a brain dysfunction that is associated with neurologic complications. Those complications are associated with cognitive impairments, which negatively impacts patients' physical and mental health. In turn, hepatic encephalopathy poses a substantial economic and use burdens to the health care system. This article reviews the multidimensional aspects of the health care burden posed by hepatic encephalopathy.
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21
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Mahpour NY, Pioppo-Phelan L, Reja M, Tawadros A, Rustgi VK. Pharmacologic Management of Hepatic Encephalopathy. Clin Liver Dis 2020; 24:231-242. [PMID: 32245530 DOI: 10.1016/j.cld.2020.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pharmacologic management of hepatic encephalopathy includes a broad range of therapies. This article covers the specific mainstays of therapies, such as antimicrobials and laxatives, with an established evidence base. This article also covers newer modalities of therapies, such as fecal microbiota transplant, probiotics, bioartificial support systems, small molecular therapies such as l-ornithine l-aspartate, branched chain amino acids, l-carnitine, zinc, and other forms of therapy currently under review.
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Affiliation(s)
- Noah Y Mahpour
- Department of Internal Medicine, Robert Wood Johnson School of Medicine, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901, USA
| | - Lauren Pioppo-Phelan
- Department of Internal Medicine, Robert Wood Johnson School of Medicine, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901, USA
| | - Mishal Reja
- Department of Internal Medicine, Robert Wood Johnson School of Medicine, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901, USA
| | - Augustine Tawadros
- Department of Internal Medicine, Robert Wood Johnson School of Medicine, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901, USA
| | - Vinod K Rustgi
- Center for Liver Diseases and Liver Masses, Robert Wood Johnson School of Medicine, MedEd Building, Room 466, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901, USA.
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22
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Kruger AJ, Aberra F, Black SM, Hinton A, Hanje J, Conteh LF, Michaels AJ, Krishna SG, Mumtaz K. A validated risk model for prediction of early readmission in patients with hepatic encephalopathy. Ann Hepatol 2020; 18:310-317. [PMID: 31047848 DOI: 10.1016/j.aohep.2018.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Hepatic encephalopathy (HE) is a common complication in cirrhotics and is associated with an increased healthcare burden. Our aim was to study independent predictors of 30-day readmission and develop a readmission risk model in patients with HE. Secondary aims included studying readmission rates, cost, and the impact of readmission on mortality. MATERIALS AND METHODS We utilized the 2013 Nationwide Readmission Database (NRD) for hospitalized patients with HE. A risk assessment model based on index hospitalization variables for predicting 30-day readmission was developed using multivariate logistic regression and validated with the 2014 NRD. Patients were stratified into Low Risk and High Risk groups. Cox regression models were fit to identify predictors of calendar-year mortality. RESULTS Of 24,473 cirrhosis patients hospitalized with HE, 32.4% were readmitted within 30 days. Predictors of readmission included presence of ascites (OR: 1.19; 95% CI: 1.06-1.33), receiving paracentesis (OR: 1.43; 95% CI: 1.26-1.62) and acute kidney injury (OR: 1.11; 95% CI: 1.00-1.22). Our validated model stratified patients into Low Risk and High Risk of 30-day readmissions (29% and 40%, respectively). The cost of the first readmission was higher than index admission in the 30-day readmission cohort ($14,198 vs. $10,386; p-value <0.001). Thirty-day readmission was the strongest predictor of calendar-year mortality (HR: 4.03; 95% CI: 3.49-4.65). CONCLUSIONS Nearly one-third of patients with HE were readmitted within 30 days, and early readmission adversely impacted healthcare utilization and calendar-year mortality. With our proposed simple risk assessment model, patients at high risk for early readmissions can be identified to potentially avert poor outcomes.
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Affiliation(s)
- Andrew J Kruger
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Fasika Aberra
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sylvester M Black
- Department of Surgery, Division of Transplantation, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - James Hanje
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lanla F Conteh
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anthony J Michaels
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Somashekar G Krishna
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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23
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Vadhariya A, Chen H, Serna O, Zamil H, Abughosh SM. A retrospective study of drug utilization and hospital readmissions among Medicare patients with hepatic encephalopathy. Medicine (Baltimore) 2020; 99:e19603. [PMID: 32311928 PMCID: PMC7220267 DOI: 10.1097/md.0000000000019603] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hepatic encephalopathy (HE) is a complication occurring in patients with cirrhosis and is associated with neuropsychiatric and motor abnormalities. Symptomatic HE episodes almost always require hospitalization and the frequent recurrence of episodes is associated with poor prognosis and increased medical costs. The utilization of existing therapies for management of HE and adherence to them has yet to be evaluated using real-world claims data.The aim of this study was to evaluate HE drug regimens and adherence and their association with hospital readmissions in Medicare Advantage plan patients.This was a retrospective cohort study of patients discharged from a HE-related hospitalization or emergency room visit. Based on subsequent enrollment in the plan they were categorized into cohorts of 1 month, 3, and 6 months follow-up, and medication regimen was evaluated within the first month. The drugs evaluated included lactulose, rifaximin, and neomycin. Multivariable logistic regression was conducted to evaluate the association of drug regimen and medication adherence measured as proportion of days covered with HE readmissions.There were 347 patients hospitalized for HE with 184 patients having 30-day enrollment and either a drug refill or an outpatient visit in this duration. Medications were not refilled by 67 (36.4%) patients. Various drug regimens had different adherence with mean (standard deviation) proportion of days covered ranging from 0.56 (0.29) to 0.82 (0.16) at 3 months and 0.48 (0.3) to 0.77 (0.15) at 6 months. The results of logistic regression at 3 and 6 months did not show a significant association of medication use or medication adherence with hospital readmissions.Despite availability of therapy, medication utilization was alarmingly low after discharge of patients from HE-related hospitalization. Medication adherence was also low, which may affect the rate of recurrence and costs associated with readmissions. Efforts are needed in both care coordination of these patients to ensure they are prescribed appropriate medications and to enhance adherence to them.
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Affiliation(s)
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX
| | | | - Hani Zamil
- McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Susan M. Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX
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24
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Kurtz CB, Millet YA, Puurunen MK, Perreault M, Charbonneau MR, Isabella VM, Kotula JW, Antipov E, Dagon Y, Denney WS, Wagner DA, West KA, Degar AJ, Brennan AM, Miller PF. An engineered E. coli Nissle improves hyperammonemia and survival in mice and shows dose-dependent exposure in healthy humans. Sci Transl Med 2020; 11:11/475/eaau7975. [PMID: 30651324 DOI: 10.1126/scitranslmed.aau7975] [Citation(s) in RCA: 201] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/08/2018] [Accepted: 12/19/2018] [Indexed: 12/30/2022]
Abstract
The intestine is a major source of systemic ammonia (NH3); thus, capturing part of gut NH3 may mitigate disease symptoms in conditions of hyperammonemia such as urea cycle disorders and hepatic encephalopathy. As an approach to the lowering of blood ammonia arising from the intestine, we engineered the orally delivered probiotic Escherichia coli Nissle 1917 to create strain SYNB1020 that converts NH3 to l-arginine (l-arg). We up-regulated arginine biosynthesis in SYNB1020 by deleting a negative regulator of l-arg biosynthesis and inserting a feedback-resistant l-arg biosynthetic enzyme. SYNB1020 produced l-arg and consumed NH3 in an in vitro system. SYNB1020 reduced systemic hyperammonemia, improved survival in ornithine transcarbamylase-deficient spfash mice, and decreased hyperammonemia in the thioacetamide-induced liver injury mouse model. A phase 1 clinical study was conducted including 52 male and female healthy adult volunteers. SYNB1020 was well tolerated at daily doses of up to 1.5 × 1012 colony-forming units administered for up to 14 days. A statistically significant dose-dependent increase in urinary nitrate, plasma 15N-nitrate (highest dose versus placebo, P = 0.0015), and urinary 15N-nitrate was demonstrated, indicating in vivo SYNB1020 activity. SYNB1020 concentrations reached steady state by the second day of dosing, and excreted cells were alive and metabolically active as evidenced by fecal arginine production in response to added ammonium chloride. SYNB1020 was no longer detectable in feces 2 weeks after the last dose. These results support further clinical development of SYNB1020 for hyperammonemia disorders including urea cycle disorders and hepatic encephalopathy.
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Affiliation(s)
| | - Yves A Millet
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
| | | | | | | | | | | | - Eugene Antipov
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
| | - Yossi Dagon
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
| | | | - David A Wagner
- Metabolic Solutions Inc., 460 Amherst Street, Nashua, NH 03063, USA
| | - Kip A West
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
| | | | | | - Paul F Miller
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
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25
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Testino G, Vignoli T, Patussi V, Scafato E, Caputo F. Management of end-stage alcohol-related liver disease and severe acute alcohol-related hepatitis: position paper of the Italian Society on Alcohol (SIA). Dig Liver Dis 2020; 52:21-32. [PMID: 31757596 DOI: 10.1016/j.dld.2019.09.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/28/2019] [Accepted: 09/23/2019] [Indexed: 02/07/2023]
Abstract
Worldwide, the prevalence of alcohol use disorder (AUD) is 20-30% in men and 10-15% in women, and cirrhosis due to alcohol-related liver disease (ALD) is responsible for 0.9% of global deaths and 47.9% of cirrhosis-related deaths. End-stage ALD (ESALD) is the final condition of alcohol-related cirrhosis, and severe acute alcohol-related hepatitis (SAAH) is a distinct clinical syndrome associated with the consumption of large amounts of alcohol. In some cases, ESALD, and SAAH may need liver transplantation (LT). Thus, the management of ESALD and SAAH in patients affected by AUD may be an essential part of the clinical skills for hepatologists. For these reasons, the national board of the Italian Society on Alcohol have reviewed the most recent data on the management of ESALD, SAAH and LT for ALD in patients with AUD, formulating a position paper with related recommendations regarding four issues of specific clinical interest in this field: (a) the management of hepatic encephalopathy in patients with AUD, and LT in patients with ESALD; (b) the management of SAAH; (c) the management of AUD in patients with ESALD and SAAH; (d) special populations: polydrug addicts.
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Affiliation(s)
- Gianni Testino
- Unit of Addiction and Hepatology ASL3 Liguria, San Martino Hospital, Genova, Italy
| | - Teo Vignoli
- Unit of Addiction Treatment, Lugo, Ravenna, Italy
| | | | - Emanuele Scafato
- National Observatory on Alcohol, National Institute of Health, Roma, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy; "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Medical and Surgical Sciences, University of Bologna, Italy.
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Jaeger V, DeMorrow S, McMillin M. The Direct Contribution of Astrocytes and Microglia to the Pathogenesis of Hepatic Encephalopathy. J Clin Transl Hepatol 2019; 7:352-361. [PMID: 31915605 PMCID: PMC6943208 DOI: 10.14218/jcth.2019.00025] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/07/2019] [Accepted: 10/24/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy is a neurological complication resulting from loss of hepatic function and is associated with poor clinical outcomes. During acute liver failure over 20% of mortality can be associated with the development of hepatic encephalopathy. In patients with liver cirrhosis, 1-year survival for those that develop overt hepatic encephalopathy is under 50%. The pathogenesis of hepatic encephalopathy is complicated due to the multiple disruptions in homeostasis that occur following a reduction in liver function. Of these, elevations of ammonia and neuroinflammation have been shown to play a significant contributing role to the development of hepatic encephalopathy. Disruption of the urea cycle following liver dysfunction leads to elevations of circulating ammonia, which enter the brain and disrupt the functioning of astrocytes. This results in dysregulation of metabolic pathways in astrocytes, oxidative stress and cerebral edema. Besides ammonia, circulating chemokines and cytokines are increased following liver injury, leading to activation of microglia and a subsequent neuroinflammatory response. The combination of astrocyte dysfunction and microglia activation are significant contributing factors to the pathogenesis of hepatic encephalopathy.
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Affiliation(s)
- Victoria Jaeger
- Baylor Scott & White Health, Department of Internal Medicine, Temple, TX, USA
| | - Sharon DeMorrow
- Texas A&M University Health Science Center, Department of Medical Physiology, Temple, TX, USA
- Central Texas Veterans Health Care System, Temple, TX, USA
- University of Texas at Austin, Dell Medical School, Department of Internal Medicine, Austin, TX, USA
- University of Texas at Austin, College of Pharmacy, Austin, TX, USA
| | - Matthew McMillin
- Texas A&M University Health Science Center, Department of Medical Physiology, Temple, TX, USA
- Central Texas Veterans Health Care System, Temple, TX, USA
- University of Texas at Austin, Dell Medical School, Department of Internal Medicine, Austin, TX, USA
- Correspondence to: Matthew McMillin, University of Texas at Austin Dell Medical School, 1601 Trinity Street, Building B, Austin, TX 78701, USA. Tel: +1-512-495-5037, Fax: +1-512-495-5839, E-mail:
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Yanny B, Winters A, Boutros S, Saab S. Hepatic Encephalopathy Challenges, Burden, and Diagnostic and Therapeutic Approach. Clin Liver Dis 2019; 23:607-623. [PMID: 31563214 DOI: 10.1016/j.cld.2019.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is an important cause of morbidity and mortality in patients with cirrhosis. The impact of HE on the health care system is similarly profound. The number of hospital admissions for HE has increased in the last 10-year period. HE is a huge burden to the patients, care givers, and the health care system. HE represents a "revolving door" with readmission, severely affects care givers, and has effects on cognition that can persists after liver transplant. This article reviews the current literature to discuss the challenges and diagnostic and therapeutic approaches to HE.
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Affiliation(s)
- Beshoy Yanny
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA.
| | - Adam Winters
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA
| | - Sandra Boutros
- Department of Surgery, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA; Department of Surgery, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA; Department of Nursing, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA
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De Caro C, Iannone LF, Citraro R, Striano P, De Sarro G, Constanti A, Cryan JF, Russo E. Can we 'seize' the gut microbiota to treat epilepsy? Neurosci Biobehav Rev 2019; 107:750-764. [PMID: 31626816 DOI: 10.1016/j.neubiorev.2019.10.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 02/08/2023]
Abstract
The gut-microbiota, the complex intestinal microbial ecosystem essential to health, is an emerging concept in medicine. Several studies demonstrate a microbiota-gut-brain bidirectional connection via neural, endocrine, metabolic and immune pathways. Accordingly, the gut microbiota has a crucial role in modulating intestinal permeability, to alter local/peripheral immune responses and in production of essential metabolites and neurotransmitters. Its alterations may consequently influence all these pathways that contribute to neuronal hyper-excitability and mirrored neuroinflammation in epilepsy and similarly other neurological conditions. Indeed, pre- and clinical studies support the role of the microbiome in pathogenesis, seizure modulation and responses to treatment in epilepsy. Up to now, researchers have focussed attention above all on the brain to develop antiepileptic treatments, but considering the microbiome, could extend our possibilities for developing novel therapies in the future. We provide here a comprehensive overview of the available data on the potential role of gut microbiota in the physiopathology and therapy of epilepsy and the supposed underlying mechanisms.
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Affiliation(s)
- Carmen De Caro
- Science of Health Department, School of Medicine, University Magna Graecia, Catanzaro, Italy
| | - Luigi Francesco Iannone
- Science of Health Department, School of Medicine, University Magna Graecia, Catanzaro, Italy
| | - Rita Citraro
- Science of Health Department, School of Medicine, University Magna Graecia, Catanzaro, Italy
| | - Pasquale Striano
- Paediatric Neurology and Muscular Diseases Unit, DINOGMI-Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, IRCCS "G. Gaslini" Institute, Genova, Italy
| | - Giovambattista De Sarro
- Science of Health Department, School of Medicine, University Magna Graecia, Catanzaro, Italy
| | - Andrew Constanti
- Department of Pharmacology, UCL School of Pharmacy, 29/39 Brunswick Square, London, United Kingdom
| | - John F Cryan
- UK.APC Microbiome Ireland, University College Cork, Cork, Ireland; Department of Anatomy and Neuroscience, University College Cork, Cork, Ireland
| | - Emilio Russo
- Science of Health Department, School of Medicine, University Magna Graecia, Catanzaro, Italy.
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Wang JY, Bajaj JS, Wang JB, Shang J, Zhou XM, Guo XL, Zhu X, Meng LN, Jiang HX, Mi YQ, Xu JM, Yang JH, Wang BS, Zhang NP. Lactulose improves cognition, quality of life, and gut microbiota in minimal hepatic encephalopathy: A multicenter, randomized controlled trial. J Dig Dis 2019; 20:547-556. [PMID: 31448533 DOI: 10.1111/1751-2980.12816] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Lactulose is effective in the treatment and prevention of overt hepatic encephalopathy (OHE), but there are limited data on its use on microbiota in relations to minimal hepatic encephalopathy (MHE) recovery. The present study aimed to assess the efficacy of lactulose in recovery of MHE in aspects of cognitive function, quality of life, and impact on intestinal microbiota. METHODS This multicenter, open-label randomized controlled trial was conducted in 11 teaching hospitals in China. Participants were randomly allocated on a 2:1 basis to receive lactulose (Gp-L) or no therapy as control (Gp-NL) for 60 days. The primary endpoint was the MHE reversal rate. Gut microbiota were compared between MHE patients and healthy volunteers, as well as lactulose-responders and non-responders. RESULTS A total of 98 cirrhotic patients were included in the study, with 31 patients in the Gp-NL group and 67 patients in the Gp-L group. At day 60, the MHE reversal rate in Gp-L (64.18%) was significantly higher than that in Gp-NL (22.58%) (P = .0002) with a relative risk of 0.46 (95% confidence interval 0.32-0.67). Number needed to treat was 2.4. Further, there was significantly more improvement in physical functioning in Gp-L (4.62 ± 6.16) than in Gp-NL (1.50 ± 5.34) (P = .0212). Proteobacteria was significantly higher in MHE patients compared with healthy volunteers (12.27% vs 4.65%, P < .05). Significant differences were found between lactulose responders and non-responders in Actinobacteria, Bacteroidetes, Firmicutes, and Proteobacteria. CONCLUSIONS Treatment with lactulose significantly improves MHE recovery rate, and gut microbiota change in MHE patients can modulate the effectiveness of this therapy. Chinese Clinical Trial Register (ChiCTR) (ID: ChiCTR-TRC-12002342).
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Affiliation(s)
- Ji Yao Wang
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Fudan University, Shanghai, China.,Center of Evidence-based Medicine, Fudan University, Shanghai, China
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Jiang Bin Wang
- Department of Gastroenterology, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jia Shang
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
| | - Xin Min Zhou
- Department of Gastroenterology, Xijing Hospital Affiliated to Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Xiao Lin Guo
- Department of Gastroenterology, First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Li Na Meng
- Department of Gastroenterology, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - Hai Xing Jiang
- Department of Gastroenterology, First Affiliated Hospital of Guangxi Medical University, Guilin, Guangxi Zhuang Autonomous Region, China
| | - Yu Qiang Mi
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Jian Ming Xu
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Jin Hui Yang
- Department of Hepatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China
| | - Bai Song Wang
- Department of Pharmacology and Biostatistics, Institute of Medical Sciences, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ning Ping Zhang
- Center of Evidence-based Medicine, Fudan University, Shanghai, China
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Xu XY, Ding HG, Li WG, Jia JD, Wei L, Duan ZP, Liu YL, Ling-Hu EQ, Zhuang H, Hepatology CSO, Association CM. Chinese guidelines on management of hepatic encephalopathy in cirrhosis. World J Gastroenterol 2019; 25:5403-5422. [PMID: 31576089 PMCID: PMC6767982 DOI: 10.3748/wjg.v25.i36.5403] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/07/2019] [Accepted: 08/24/2019] [Indexed: 02/06/2023] Open
Abstract
The Chinese Society of Hepatology developed the current guidelines on the management of hepatic encephalopathy in cirrhosis based on the published evidence and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of hepatic encephalopathy (HE) including minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy, emphasizing the importance on screening MHE in patients with end-stage liver diseases. The guidelines emphasized that early identification and timely treatment are the key to improve the prognosis of HE. The principles of treatment include prompt removal of the cause, recovery of acute neuropsychiatric abnormalities to baseline status, primary prevention, and secondary prevention as soon as possible.
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Affiliation(s)
- Xiao-Yuan Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing 100034, China
| | - Hui-Guo Ding
- Hepatology and Digestion Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Wen-Gang Li
- Department of Liver Oncology, Cancer Radiation Therapy Center, Fifth Medical Center, PLA General Hospital, Beijing 100039, China
| | - Ji-Dong Jia
- Hepatology Center, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lai Wei
- Hepatobiliary and Pancreatic Department, Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Zhong-Ping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Yu-Lan Liu
- Department of Gastroenterology, Peking University People's Hospital, Beijing 100044, China
| | - En-Qiang Ling-Hu
- Department of Gastroenterology, First Medical Center, PLA General Hospital, Beijing 100853, China
| | - Hui Zhuang
- Department of Pathogenic Biology, Peking University Health Science Center, Beijing 100191, China
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Zhou R, Fan X, Schnabl B. Role of the intestinal microbiome in liver fibrosis development and new treatment strategies. Transl Res 2019; 209:22-38. [PMID: 30853445 DOI: 10.1016/j.trsl.2019.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/26/2019] [Accepted: 02/14/2019] [Indexed: 02/06/2023]
Abstract
Liver cirrhosis is a major cause of morbidity and mortality worldwide. The most common chronic liver diseases in western countries are alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD). Although these diseases have different causes, liver fibrosis develops via shared mechanisms. The liver and intestinal microbiome are linked by the portal vein and have bidirectional interactions. Changes in the intestinal microbiome contribute to the pathogenesis and progression of liver diseases including ALD, NAFLD, viral hepatitis and cholestatic disorders, based on studies in patients and animal models. Intestinal microbial dysbiosis has been associated with liver cirrhosis and its complications. We review the mechanisms by which alterations in the microbiome contribute to liver fibrosis and discuss microbiome-based treatment approaches.
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Affiliation(s)
- Rongrong Zhou
- Department of Infectious Diseases, Xiangya Hospital, Central South University, and Key Laboratory of Viral Hepatitis, Changsha, Hunan, China; Department of Medicine, University of California San Diego, La Jolla, California
| | - Xuegong Fan
- Department of Infectious Diseases, Xiangya Hospital, Central South University, and Key Laboratory of Viral Hepatitis, Changsha, Hunan, China
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, California; Department of Medicine, VA San Diego Healthcare System, San Diego, California.
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Chela HK, Basra N, Naqvi SH. Hepatic Encephalopathy in the Hospitalized Patient: A Review for Hospitalists. MISSOURI MEDICINE 2019; 116:308-312. [PMID: 31527980 PMCID: PMC6699823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hepatic encephalopathy is a well-recognized complication of decompensated cirrhosis. It is a reversible state of neurocognitive decline, the etiology of which is multifactorial. Diagnosis is predominantly clinical and usually a diagnosis of exclusion. The identification of precipitating factors and their correction is an essential part of the management along with medical therapies such as lactulose and rifaxmin.
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Affiliation(s)
- Harleen Kaur Chela
- Harleen Kaur Chela, MD, and S. Hasan Naqvi, MD, are in the Department of Medicine, Division of Hospital Medicine, University of Missouri - Columbia. Nishchayjit Basra, DO, is in the Department of Medicine, Internal Medicine Residency Program, University of Missouri - Columbia, Columbia, Mo
| | - Nishchayjit Basra
- Harleen Kaur Chela, MD, and S. Hasan Naqvi, MD, are in the Department of Medicine, Division of Hospital Medicine, University of Missouri - Columbia. Nishchayjit Basra, DO, is in the Department of Medicine, Internal Medicine Residency Program, University of Missouri - Columbia, Columbia, Mo
| | - S Hasan Naqvi
- Harleen Kaur Chela, MD, and S. Hasan Naqvi, MD, are in the Department of Medicine, Division of Hospital Medicine, University of Missouri - Columbia. Nishchayjit Basra, DO, is in the Department of Medicine, Internal Medicine Residency Program, University of Missouri - Columbia, Columbia, Mo
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Fasullo M, Rau P, Liu DQ, Holzwanger E, Mathew JP, Guilarte-Walker Y, Szabo G. Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients. World J Hepatol 2019; 11:522-530. [PMID: 31293720 PMCID: PMC6603505 DOI: 10.4254/wjh.v11.i6.522] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/05/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE.
AIM To investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis.
METHODS This is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission.
RESULTS The HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8%) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7%) (P = 0.138). Finally, 10 (11.8%) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8%) (P = 0.220).
CONCLUSION Chronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.
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Affiliation(s)
- Matthew Fasullo
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, United States
| | - Prashanth Rau
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, United States
| | - Dong-Qi Liu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, United States
| | - Erik Holzwanger
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, United States
| | - Jomol P Mathew
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA 01605, United States
| | - Yurima Guilarte-Walker
- Department of Data Sciences and Technology, Information Technology, University of Massachusetts Medical School, Worcester, MA 01605, United States
| | - Gyongyi Szabo
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, United States
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Ruszkowski J, Witkowski JM. Lactulose: Patient- and dose-dependent prebiotic properties in humans. Anaerobe 2019; 59:100-106. [PMID: 31176002 DOI: 10.1016/j.anaerobe.2019.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 01/06/2023]
Abstract
Lactulose is a disaccharide used in clinical practice since 1957 and has since been tested in the treatment of many human disorders, including chronic constipation, hepatic encephalopathy, and chronic kidney disease. Its mode of action is based on the lactulose fermentation by intestinal microbiota. Based on in silico, in vitro and in vivo studies we comprehensively review here the impact of lactulose on human gut/fecal and vaginal microbiota composition and both fecal and blood metabolomes. However, both in vitro and in vivo studies summarized in this review have revealed that the effects of lactulose on human microbiota composition are both patient- and dose-dependent. This highlights the need of heterogeneity indication in clinical trials.
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Affiliation(s)
- Jakub Ruszkowski
- Department of Pathophysiology, Faculty of Medicine, Medical University of Gdańsk, ul. Dębinki 7, 80-211, Gdańsk, Poland.
| | - Jacek M Witkowski
- Department of Pathophysiology, Faculty of Medicine, Medical University of Gdańsk, ul. Dębinki 7, 80-211, Gdańsk, Poland
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Cui Y, Guan S, Ding J, He Y, Li Q, Wang S, Sun H. Establishment and evaluation of a model for predicting 3-month mortality in Chinese patients with hepatic encephalopathy. Metab Brain Dis 2019; 34:213-221. [PMID: 30443767 DOI: 10.1007/s11011-018-0333-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 10/30/2018] [Indexed: 12/28/2022]
Abstract
Hepatic encephalopathy (HE) is a serious complication of liver disease. To establish a model for predicting 3-month mortality in patients with HE in China. This retrospective study included 609 patients with HE admitted to the Peoples' Hospital, Liaocheng City, China (August 2006 to January 2016). Patients were allocated to a modeling (n = 409) or validation (n = 200) group. Demographic/clinical characteristics, laboratory test results, Model for End Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) score were extracted from medical records. A model for predicting death within 3 months after admission was established using logistic regression analysis (modeling group). Model validity (validation group) was assessed using receiver operating characteristic (ROC) curve analysis. 270/409(66.0%) patients died in the modeling group and 142/203(70.0%) died in the validation group. Compared with survivors, patients who died had more severe HE, and higher MELD score, CTP score, incidence of complications including hepatorenal syndrome (HRS) and upper gastrointestinal bleeding, and values for laboratory parameters including red blood cell count(RBC) and total bilirubin(TBIL)(P < 0.05). Regression analysis revealed RBC, TBIL, HE stage, HRS and upper gastrointestinal bleeding as independent factors associated with death (P < 0.05). The area under the ROC curve (AUC) for the model was 0.931.The model had a higher Youden index than MELD or CTP scores and predicted death in the validation group with a sensitivity of 83.1% and specificity of 93.4%. The established model has superior performance to MELD and CTP scores for predicting mortality in patients with HE.
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Affiliation(s)
- Yanping Cui
- Department of Liver Disease, Liaocheng People's Hospital, Liaocheng, China
| | - Shan Guan
- Department of Liver Disease, Liaocheng People's Hospital, Liaocheng, China
| | - Jie Ding
- Central Laboratory, Liaocheng People's Hospital, Liaocheng, China
| | - Yukai He
- Department of Liver Disease, Liaocheng People's Hospital, Liaocheng, China
| | - Qingfang Li
- Department of Liver Disease, Liaocheng People's Hospital, Liaocheng, China
| | - Sikui Wang
- Department of Liver Disease, Liaocheng People's Hospital, Liaocheng, China
| | - Huiling Sun
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, 252004, China.
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Espíritu-Ramírez P, Ortega-Balderas NY, Sevilla-Tapia L, Montiel-Martínez AG, Pastor-Flores AR, Palomares LA, Torres-Vega MA. Gene Therapy for Treatment of Chronic Hyperammonemia in a Rat Model of Hepatic Encephalopathy. Ann Hepatol 2018; 17:1026-1034. [PMID: 30600292 DOI: 10.5604/01.3001.0012.7203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Hepatic encephalopathy (HE), caused by hyperammonemia resulting from liver disease, is a spectrum of neuropsychiatric and motor disorders that can lead to death. Existing therapies are deficient and alternative treatments are needed. We have shown that gene therapy with a baculovirus vector containing the glutamine synthetase (Bac-GS) gene is efficient for reducing ammonia levels in an acute hyperammonemia rat model. However, the most common condition resulting from liver disease is chronic hyperammonemia. In this work, Bac-GS was evaluated in bile-duct ligated rats, a chronic liver disease model with hyperammonemia and some characteristics of Type C HE. MATERIAL AND METHODS Bac-GS was tested for mediating GS overexpression in HeLa cells and H9C2 myotubes. For determining the utility of Bac-GS for the reduction of ammonia levels in a chronic hyperammonemia animal model, four groups of rats were treated: control, sham, ligated with Bac-GS and ligated with Bac-GFP. Baculoviruses were injected i.m. 18 days post-surgery. Blood was drawn 2, 3 and 4 weeks post-surgery and plasma ammonia concentrations were quantified. RESULTS In protein lysates of cells and myotubes transduced with Bac-GS, a 44 kDa band corresponding to GS was detected. Significant results were obtained in the hyperammonemic bile-duct ligated rat model, as plasma ammonia was reduced to normal levels 3 days after treatment with Bac-GS. Furthermore, a transitory effect of Bac-GS was observed. CONCLUSION Our results show that gene therapy by delivering GS is a promising alternative for treatment of hyperammonemia in acute-on-chronic liver failure patients with HE.
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Affiliation(s)
- Plácido Espíritu-Ramírez
- Departamento de Gastroenterología. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Nancy Y Ortega-Balderas
- Departamento de Gastroenterología. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Laura Sevilla-Tapia
- Departamento de Gastroenterología. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Ana G Montiel-Martínez
- Laboratorio de Bioingeniería de Tejidos, Facultad de Odontología. Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Ana R Pastor-Flores
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Cuernavaca, Morelos, Mexico
| | - Laura A Palomares
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Cuernavaca, Morelos, Mexico
| | - Miguel A Torres-Vega
- Departamento de Gastroenterología. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
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Kibrit J, Khan R, Jung BH, Koppe S. Clinical Assessment and Management of Portal Hypertension. Semin Intervent Radiol 2018; 35:153-159. [PMID: 30087517 DOI: 10.1055/s-0038-1660793] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The development of portal hypertension in a patient with cirrhosis portends a poor prognosis. Untreated or progressive portal hypertension has serious clinical outcomes, which are often fatal. It is important to recognize portal hypertension early to delay progression and to treat complications of portal hypertension as they arise. This review will focus on the clinical assessment and management of portal hypertension.
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Affiliation(s)
- Jacob Kibrit
- Division of Gastroenterology and Hepatology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Ruben Khan
- Division of Gastroenterology and Hepatology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Barbara H Jung
- Division of Gastroenterology and Hepatology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Sean Koppe
- Division of Gastroenterology and Hepatology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
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Lee EW, Saab S, Kaldas F, Fletcher S, Busuttil RW, Durazo F, McWilliams JP, DiNorcia J, Padia SA, Kee ST. Coil-Assisted Retrograde Transvenous Obliteration (CARTO): An Alternative Treatment Option for Refractory Hepatic Encephalopathy. Am J Gastroenterol 2018; 113:1187-1196. [PMID: 29899437 DOI: 10.1038/s41395-018-0109-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 04/04/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Overt hepatic encephalopathy (OHE) is a serious complication of liver dysfunction, which is associated with severe morbidity/mortality and healthcare resource utilization. OHE can be medically refractory due to spontaneous portosystemic shunts (SPSSs) and therefore a new treatment option for these SPSSs is critical. METHODS This is a retrospective study of 43 patients with medically refractory OHE, who underwent CARTO (Coil-Assisted Retrograde Transvenous Obliteration) procedures between June 2012 and October 2016. The patient demographic characteristics, technical and clinical outcomes with an emphasis on HE improvement, and complications are reviewed and analyzed. RESULTS The overall clinical success rate was 91% with a significant HE improvement. Eighty-one percent of patients had clinically significant improvement from OHE and 67% of patients had complete resolution of their HE symptoms during our follow-up period of 893 ± 585 days (range 36-1881 days, median 755.0 days). The median WH score improved from 3 (range 2-4) pre-CARTO to 1 (range 0-4) post-CARTO (p < 0.001). The median ammonia level significantly decreased from 134.5 pre-CARTO to 70.0 post-CARTO (p < 0.001) in 3 days. The overall mean survival was 1465.5 days (95% CI of 1243.0 and 1688.0 days). Only three patients had recurrent HE symptoms. There were 39.6% minor complication rate including new or worsened ascites and esophageal varices, and only 2.3% major complication rate requiring additional treatment (one patient with bleeding esophageal varices requiring treatment). No procedure-related death is noted. CONCLUSIONS CARTO appears to be a safe and effective treatment option for refractory overt hepatic encephalopathy (OHE) due to spontaneous portosystemic shunts. CARTO could be an excellent addition to currently available treatment options for these patients.
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Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA.,Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA.,Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA.,Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Fady Kaldas
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA.,Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Savannah Fletcher
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Ronald W Busuttil
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA.,Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Francisco Durazo
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA.,Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Justin P McWilliams
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Joseph DiNorcia
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA.,Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Siddharth A Padia
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
| | - Stephen T Kee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. UCLA Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA. Division of Hepatology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California- Los Angeles, Los Angeles, CA, USA
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Rabei R, Mathevosian S, Tasse J, Madassery S, Arslan B, Turba U, Ahmed O. Primary constrained TIPS for treating refractory ascites or variceal bleeding secondary to hepatic cirrhosis. Br J Radiol 2018; 91:20170409. [PMID: 29166137 DOI: 10.1259/bjr.20170409.pmid29166137;pmcid:pmc5965479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE To report an initial experience using a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) technique for treating cirrhotic patients with refractory ascites or variceal bleeding. METHODS All patients undergoing primary constrained (n = 9) and conventional (n = 18) TIPS between July 2014 and June 2016 were retrospectively reviewed. Preprocedure demographics, Child-Pugh, model for end-stage liver disease and technical variables were recorded. Outcomes measured included technical and clinical success, complications, 30-day mortality, as well as necessity for TIPS revision. Average (SD) and median follow-up was 237 (190) and 226 days. RESULTS All constrained and conventional TIPS were technically successful (100%). Clinical success as defined as a reduction or improvement in presenting symptoms was 88.9% (8/9) and 100% (18/18) in the constrained and conventional groups, respectively (p = 1). The average reduction in portosystemic gradient was lower in the constrained group, 6.1 mmHg compared with 10.6 mmHg in the conventional group (p = 0.73). The rate of hepatic encephalopathy following TIPS placement was higher in the conventional group [16.7% (3/18)] compared with 0% in the constrained group (p = 0.52). The percentage of patients requiring TIPS revision was lower in the constrained group, although the results were not significant (11.1 vs 22.2%, p = 0.63). CONCLUSION Primary constrained TIPS is a feasible modification to conventional TIPS with similar technical and clinical success rates. A trend towards a smaller reduction in the portosystemic gradient and need for revision was observed in the constrained group. Advances in knowledge: Primary constrained TIPS allows for greater stepwise control over shunt diameter and may represent an improved technique for patients at risk for hepatic encephalopathy.
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Affiliation(s)
- R Rabei
- 1 Chicago Medical School , Rosalind Franklin University , North Chicago, IL , USA
| | - S Mathevosian
- 1 Chicago Medical School , Rosalind Franklin University , North Chicago, IL , USA
| | - J Tasse
- 2 Rush University Medical Center , Chicago, IL , USA
| | - S Madassery
- 2 Rush University Medical Center , Chicago, IL , USA
| | - B Arslan
- 2 Rush University Medical Center , Chicago, IL , USA
| | - U Turba
- 2 Rush University Medical Center , Chicago, IL , USA
| | - O Ahmed
- 2 Rush University Medical Center , Chicago, IL , USA
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40
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The Pharmabiotic Approach to Treat Hyperammonemia. Nutrients 2018; 10:nu10020140. [PMID: 29382084 PMCID: PMC5852716 DOI: 10.3390/nu10020140] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/22/2018] [Accepted: 01/26/2018] [Indexed: 12/12/2022] Open
Abstract
Ammonia is constantly produced as a metabolic waste from amino acid catabolism in mammals. Ammonia, the toxic waste metabolite, is resolved in the liver where the urea cycle converts free ammonia to urea. Liver malfunctions cause hyperammonemia that leads to central nervous system (CNS) dysfunctions, such as brain edema, convulsions, and coma. The current treatments for hyperammonemia, such as antibiotics or lactulose, are designed to decrease the intestinal production of ammonia and/or its absorption into the body and are not effective, besides being often accompanied by side effects. In recent years, increasing evidence has shown that modifications of the gut microbiota could be used to treat hyperammonemia. Considering the role of the gut microbiota and the physiological characteristics of the intestine, the removal of ammonia from the intestine by modulating the gut microbiota would be an ideal approach to treat hyperammonemia. In this review, we discuss the significance of hyperammonemia and its related diseases and the efficacy of the current management methods for hyperammonemia to understand the mechanism of ammonia transport in the human body. The possibility to use the gut microbiota as pharmabiotics to treat hyperammonemia and its related diseases is also explored.
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Rabei R, Mathevosian S, Tasse J, Madassery S, Arslan B, Turba U, Ahmed O. Primary constrained TIPS for treating refractory ascites or variceal bleeding secondary to hepatic cirrhosis. Br J Radiol 2017; 91:20170409. [PMID: 29166137 DOI: 10.1259/bjr.20170409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To report an initial experience using a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) technique for treating cirrhotic patients with refractory ascites or variceal bleeding. METHODS All patients undergoing primary constrained (n = 9) and conventional (n = 18) TIPS between July 2014 and June 2016 were retrospectively reviewed. Preprocedure demographics, Child-Pugh, model for end-stage liver disease and technical variables were recorded. Outcomes measured included technical and clinical success, complications, 30-day mortality, as well as necessity for TIPS revision. Average (SD) and median follow-up was 237 (190) and 226 days. RESULTS All constrained and conventional TIPS were technically successful (100%). Clinical success as defined as a reduction or improvement in presenting symptoms was 88.9% (8/9) and 100% (18/18) in the constrained and conventional groups, respectively (p = 1). The average reduction in portosystemic gradient was lower in the constrained group, 6.1 mmHg compared with 10.6 mmHg in the conventional group (p = 0.73). The rate of hepatic encephalopathy following TIPS placement was higher in the conventional group [16.7% (3/18)] compared with 0% in the constrained group (p = 0.52). The percentage of patients requiring TIPS revision was lower in the constrained group, although the results were not significant (11.1 vs 22.2%, p = 0.63). CONCLUSION Primary constrained TIPS is a feasible modification to conventional TIPS with similar technical and clinical success rates. A trend towards a smaller reduction in the portosystemic gradient and need for revision was observed in the constrained group. Advances in knowledge: Primary constrained TIPS allows for greater stepwise control over shunt diameter and may represent an improved technique for patients at risk for hepatic encephalopathy.
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Affiliation(s)
- R Rabei
- 1 Chicago Medical School , Rosalind Franklin University , North Chicago, IL , USA
| | - S Mathevosian
- 1 Chicago Medical School , Rosalind Franklin University , North Chicago, IL , USA
| | - J Tasse
- 2 Rush University Medical Center , Chicago, IL , USA
| | - S Madassery
- 2 Rush University Medical Center , Chicago, IL , USA
| | - B Arslan
- 2 Rush University Medical Center , Chicago, IL , USA
| | - U Turba
- 2 Rush University Medical Center , Chicago, IL , USA
| | - O Ahmed
- 2 Rush University Medical Center , Chicago, IL , USA
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Abstract
The provision of anesthesia for a liver transplant program requires a dedicated team of anesthesiologists. Liver transplant anesthesiologists must have an understanding of liver physiology and anatomy; the spectrum of clinical disease associated with liver dysfunction; the impact of warm and cold ischemia times, surgical techniques in liver transplantation, and the impact of ischemia-reperfusion syndrome; and optimal practices to protect the liver. The team must provide a 24-hour service, be actively involved in the selection committee process, and stay current with advances in the subspecialty.
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Affiliation(s)
- Dieter Adelmann
- Department of Anesthesiology and Perioperative Care, University of California San Francisco, Box O648, 4th Floor MUE, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Kate Kronish
- Department of Anesthesiology and Perioperative Care, University of California San Francisco, Box O648, 4th Floor MUE, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Michael A Ramsay
- Department of Anesthesiology, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA.
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Aravinthan AD, Barbas AS, Doyle AC, Tazari M, Sapisochin G, Cattral MS, Ghanekar A, McGilvray ID, Selzner M, Greig PD, Bhat M, Selzner N, Grant DR, Lilly LB, Renner EL. Characteristics of liver transplant candidates delisted following recompensation and predictors of such delisting in alcohol-related liver disease: a case-control study. Transpl Int 2017; 30:1140-1149. [DOI: 10.1111/tri.13008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/29/2017] [Accepted: 07/04/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aloysious D. Aravinthan
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
- Nottingham Digestive Diseases Centre; University of Nottingham and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre; Nottingham University Hospitals NHS Trust; Nottingham UK
| | - Andrew S. Barbas
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Adam C. Doyle
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Mahmood Tazari
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Gonzalo Sapisochin
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Mark S. Cattral
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Anand Ghanekar
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Ian D. McGilvray
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Markus Selzner
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Paul D. Greig
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Mamatha Bhat
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Nazia Selzner
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - David R. Grant
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Leslie B. Lilly
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
| | - Eberhard L. Renner
- Multiorgan Transplant Program; Toronto General Hospital; University of Toronto; Toronto ON Canada
- Department of Medicine; Max Rady College of Medicine/Rady Faculty of Health Sciences; University of Manitoba; Winnipeg MB Canada
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Abbas N, Makker J, Abbas H, Balar B. Perioperative Care of Patients With Liver Cirrhosis: A Review. Health Serv Insights 2017; 10:1178632917691270. [PMID: 28469455 PMCID: PMC5398291 DOI: 10.1177/1178632917691270] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 11/29/2016] [Indexed: 12/14/2022] Open
Abstract
The incidence of cirrhosis is rising, and identification of these patients prior to undergoing any surgical procedure is crucial. The preoperative risk stratification using validated scores, such as Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease, perioperative optimization of hemodynamics and metabolic derangements, and postoperative monitoring to minimize the risk of hepatic decompensation and complications are essential components of medical management. The advanced stage of cirrhosis, emergency surgery, open surgeries, old age, and coexistence of medical comorbidities are main factors influencing the clinical outcome of these patients. Perioperative management of patients with cirrhosis warrants special attention to nutritional status, fluid and electrolyte balance, control of ascites, excluding preexisting infections, correction of coagulopathy and thrombocytopenia, and avoidance of nephrotoxic and hepatotoxic medications. Transjugular intrahepatic portosystemic shunt may improve the CTP class, and semielective surgeries may be feasible. Emergency surgery, whenever possible, should be avoided.
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Affiliation(s)
- Naeem Abbas
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Naeem Abbas, Divisions of Gastroenterology and Hepatology, Department of Medicine, Bronx-Lebanon Hospital Center, 1650 Selwyn Ave, Suite 10C, Bronx, NY 10457, USA.
| | - Jasbir Makker
- Division of Gastroenterology, Bronx-Lebanon Hospital Center, Bronx, NY, USA
| | - Hafsa Abbas
- Department of Internal Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
| | - Bhavna Balar
- Division of Gastroenterology, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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