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Kalal CR, Maiwall R, Choudhary A, Premkumar M, Kumar G, Vyas AK, Sarin SK. Mannitol Is Comparable to Hypertonic Saline for Raised Intracranial Pressure in Acute Liver Failure (MAHAL Study): A Randomized Controlled Trial. Dig Dis 2021; 40:607-615. [PMID: 34763338 DOI: 10.1159/000520229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 10/13/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Raised intracranial pressure (ICP) due to cerebral edema (CE) is central to development of hepatic encephalopathy in acute liver failure (ALF). Mannitol (MT) and hypertonic saline (HS) have been shown to improve CE. We compared the efficacy and safety of the 2 modalities. METHODS ALF with CE was prospectively randomized in an open study to receive either 5 mL/kg of either 3% HS, as continuous infusion; titrated every 6 hourly to achieve serum sodium of <160 (Group A; n = 26) or 1 g/kg of 20% MN as a IV bolus, repeated every 6 hourly (Group B; n = 25) in addition to standard ALF care. Primary end-point was reduction of ICP defined as optic nerve sheath diameter <5 mm and middle cerebral arterial pulsatility index <1.2 at 12 h. RESULTS Fifty-one patients with ALF, hepatitis E being commonest (33.3%), median jaundice to HE interval of 8 (1-16) days, were randomized to HS (n = 26) or MN (n = 25). Baseline characteristics were comparable including King's college criteria (>2: 38.4% vs.40%). Overall, 61.5% patients in the HS and 56% in the MN group showed reduction in ICP at 12 h (p = 0.25). Rebound increase in ICP indices was noted in 5 (20%) patients in MT and none in HS (p < 0.05) group. New onset acute kidney injury was common in the MT group than in the HS group. The ICU stay and 28-day transplant-free survival were not different between the groups. CONCLUSIONS While both agents had comparable efficacy in reducing ICP and mortality in ALF patients was comparable, HS was significantly better in preventing reducing rebound CE with lower renal dysfunction.
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Affiliation(s)
- Chetan Ramesh Kalal
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Ashok Choudhary
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Madhumita Premkumar
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Bio Stat, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Ashish Kumar Vyas
- Departments of Molecular and Cellular Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
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Duseja A, De A, Taneja S, Choudhury AK, Devarbhavi H, Hu J, Hamid SS, Butt AS, Jafri SMW, Ghazinian H, Chawla YK, Dhiman RK, Duan Z, Chen Y, Tan SS, Lee GH, Lim SG, Kim DJ, Sahu M, Sollano JD, Carpio G, Mohan Prasad VG, Abbas Z, Lesmana LA, Lesmana CR, Eapen CE, Goel A, Sood A, Midha V, Goyal O, Dokmeci AK, Ning Q, Chen T, Ma K, Payawal DA, Lau GKK, Al Mahtab M, Rahman S, Alam MS, Shukla A, Shrestha A, Shah S, Kalal CR, Kumar G, Jain P, Paulson I, Sarin SK. Impact of metabolic risk factors on the severity and outcome of patients with alcohol-associated acute-on-chronic liver failure. Liver Int 2021; 41:150-157. [PMID: 32970356 DOI: 10.1111/liv.14671] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Metabolic risk factors may impact the severity and outcome of alcoholic liver disease. The present study evaluated this effect in patients with alcohol-associated acute-on-chronic liver failure (ACLF). METHODOLOGY One thousand two hundred and sixteen prospectively enrolled patients with ACLF (males 98%, mean age 42.5 ± 9.4 years, mean CTP, MELD and AARC scores of 12 ± 1.4, 29.7 ± 7 and 9.8 ± 2 respectively) from the Asian Pacific Association for the Study of the Liver (APASL) ACLF Research Consortium (AARC) database were analysed retrospectively. Patients with or without metabolic risk factors were compared for severity (CTP, MELD, AARC scores) and day 30 and 90 mortality. Information on overweight/obesity, type 2 diabetes mellitus (T2DM), hypertension and dyslipidaemia were available in 1028 (85%), 1019 (84%), 1017 (84%) and 965 (79%) patients respectively. RESULTS Overall, 392 (32%) patients died at day 30 and 528 (43%) at day 90. Overweight/obesity, T2DM, hypertension and dyslipidaemia were present in 154 (15%), 142 (14%), 66 (7%) and 141 (15%) patients, respectively, with no risk factors in 809 (67%) patients. Patients with overweight/obesity had higher MELD scores (30.6 ± 7.1 vs 29.2 ± 6.9, P = .007) and those with dyslipidaemia had higher AARC scores (10.4 ± 1.2 vs 9.8 ± 2, P = .014). Overweight/obesity was associated with increased day 30 mortality (HR 1.54, 95% CI 1.06-2.24, P = .023). None of other metabolic risk factors, alone or in combination, had any impact on disease severity or mortality. On multivariate analysis, overweight or obesity was significantly associated with 30-day mortality (aHR 1.91, 95% CI 1.41-2.59, P < .001), independent of age, CTP, MELD and AARC scores. CONCLUSION Overweight/obesity and dyslipidaemia increase the severity of alcohol-associated ACLF, and the former also increases the short-term mortality in these patients.
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Affiliation(s)
- Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Harshad Devarbhavi
- Department of Gastroenterology, St John's Medical College Hospital, Bangalore, India
| | - Jinhua Hu
- Liver Failure Treatment and Research Center, 302 Military Hospital of China, Beijing, China
| | | | | | | | - Hasmik Ghazinian
- Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia
| | - Yogesh K Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha K Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Zhongping Duan
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Soek Siam Tan
- Department of Hepatology, Selayang Hospital, Selangor, Malaysia
| | - Guan Huei Lee
- Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Seng Gee Lim
- Medicine, Yong Loo Lin School of Medicine, Singapore
| | | | - Manoj Sahu
- ISM and SUM Hospital, Bhubaneswar, India
| | | | - Gian Carpio
- University of Santo Tomas, Manila, Philippines
| | | | - Zaigham Abbas
- Department of Hepatogastroenterology, Ziauddin University, Karachi, Pakistan
| | | | | | | | | | - Ajit Sood
- Dayanand Medical College and Hospital, Ludhiana, India
| | - Vandana Midha
- Dayanand Medical College and Hospital, Ludhiana, India
| | - Omesh Goyal
- Dayanand Medical College and Hospital, Ludhiana, India
| | | | - Qin Ning
- Tongji Medical College, Wuhan, China
| | - Tao Chen
- Tongji Medical College, Wuhan, China
| | - Ke Ma
- Tongji Medical College, Wuhan, China
| | | | | | | | - Salimur Rahman
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mohd Shahinul Alam
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Akash Shukla
- Seth GS Medical College & Kem Hospital, Mumbai, India
| | | | - Samir Shah
- Hepatology, Global Hospital, Mumbai, India
| | | | - Guresh Kumar
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Irene Paulson
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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