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Yalaka RR, Sameer Kumar GS, Mogili KR, Kedarisetty CK, Yalakanti RB. Novel technique of cholangioscopy-guided inwardly migrated stent retrieval. Endoscopy 2023; 55:E996-E997. [PMID: 37604445 PMCID: PMC10442206 DOI: 10.1055/a-2127-5045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
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2
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Yalaka RR, Kedarisetty CK, Narayankar SM, Mogili KR, Shepur MT, Vangara S. A novel technique of migrated biliary stent retrieval. Endoscopy 2022; 54:E522-E523. [PMID: 34695850 DOI: 10.1055/a-1662-3920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Rami Reddy Yalaka
- Department of Gastroenterology and Hepatology, Gleneagles Global Hospital, Hyderabad, India
| | | | - Santhosh M Narayankar
- Department of Gastroenterology and Hepatology, Gleneagles Global Hospital, Hyderabad, India
| | - Kondal Reddy Mogili
- Department of Gastroenterology and Hepatology, Gleneagles Global Hospital, Hyderabad, India
| | - Manjunath T Shepur
- Department of Gastroenterology and Hepatology, Gleneagles Global Hospital, Hyderabad, India
| | - Sasanka Vangara
- Department of Gastroenterology and Hepatology, Gleneagles Global Hospital, Hyderabad, India
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Govindarajan R, Ramamoorthy G, Shanmugam RM, Bavanandam S, Murugesan M, Shanmugam C, Arumugam A, Chellamuthu VP, Venkatraj RK, Sampathkumar K, Rejoice P, Kumar KA, Adamali S, Mariappan K, Rathnavel R, Manivasagam VSC, Velusamy A, Arumugam S, Elikkottil TT, Dev AV, Sen M, Palaniappan A, Dorairaj AJ, Kedarisetty CK, Venkataraman J, Karthikeyan M, Somasundaram A, Ramakrishnan A, Madesh VP, Varghese J, Anupa DK, Leelakrishnan V, Swaminathan M, Kantamaneni R, Dhus JU, Murugan N, Natarajan K, Selvi C, Saithanyamurthi HV, Nadaraj A, Jeyaseelan L, Eapen CE. Rodenticide ingestion is an important cause of acute hepatotoxicity in Tamil Nadu, southern India. Indian J Gastroenterol 2021; 40:373-379. [PMID: 34189713 DOI: 10.1007/s12664-021-01178-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 06/25/2020] [Accepted: 03/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Though rodenticidal hepatotoxicity is reported from India, there is no systematic study to assess its magnitude. This study aimed to assess exposure to rodenticide as a risk factor for acute hepatotoxicity in Tamil Nadu, India. METHODS We retrospectively analyzed acute hepatotoxicity caused by ingestion of hepatotoxin or potentially hepatotoxic drug overdose across 15 hospitals in 6 districts of Tamil Nadu from 1 January 2019 to 30 June 2019. Study exclusion criteria were idiosyncratic drug-induced liver injury and chronic liver diseases. RESULTS Of the 702 patients, 685 gave history of consuming rodenticide; hepatotoxicity in the other patients resulted from paracetamol overdose (n=10) and due to other drugs (n=7); 97% patients had a suicidal intent. Of 671 patients with complete data, ratio of number of patients with hepatotoxicity due to rodenticide to paracetamol overdose was 450:6 (i.e. 75:1). The 451 rodenticidal hepatotoxicity patients (255 males, 75% were 15-34 years old) underwent conservative management (n=396), plasma exchange (n=54) and plasma exchange followed by liver transplant (n=1); 159 patients (35%) had poor outcome (131 died, 28 discharged in moribund state). Based on our observations, we estimate a case burden of 1584 rodenticidal hepatotoxicity patients (95% CI: 265-6119) with poor outcome in 554 patients in Tamil Nadu from January 2019 to June 2019. Population attributable risk for rodenticide as cause of hepatotoxicity was 22.7%. CONCLUSION Rodenticide ingestion was an important cause of acute hepatotoxicity in Tamil Nadu. Most patients were young and one-third had poor outcome. Public health interventions are needed to address this.
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Affiliation(s)
- Ramkumar Govindarajan
- Department of Medical Gastroenterology, Thanjavur Medical College, Thanjavur, 613 004, India
| | - Ganesan Ramamoorthy
- Department of Medical Gastroenterology, Thanjavur Medical College, Thanjavur, 613 004, India
| | | | - Sumathi Bavanandam
- Department of Medical Gastroenterology, Stanley Medical College, Chennai, 600 001, India
| | - Manimaran Murugesan
- Department of Medical Gastroenterology, Stanley Medical College, Chennai, 600 001, India
| | - Chitra Shanmugam
- Department of Medical Gastroenterology, Stanley Medical College, Chennai, 600 001, India
| | - Aravind Arumugam
- Department of Medical Gastroenterology, Government Kilpauk Medical College, Chennai, 600 010, India.,Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, 600 010, India
| | - Vaishnavi Priyaa Chellamuthu
- Department of Medical Gastroenterology, Government Kilpauk Medical College, Chennai, 600 010, India.,Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, 600 010, India
| | | | - Kavitha Sampathkumar
- Department of Medical Gastroenterology, Government Kilpauk Medical College, Chennai, 600 010, India.,Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, 600 010, India
| | - Poppy Rejoice
- Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, 627 011, India
| | - Kandasamy Alias Kumar
- Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, 627 011, India
| | - Shafique Adamali
- Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, 627 011, India
| | - Kannan Mariappan
- Department of Medical Gastroenterology, Government Rajaji Hospital, Madurai Medical College, Madurai, 625 020, India
| | - Ramani Rathnavel
- Department of Medical Gastroenterology, Government Rajaji Hospital, Madurai Medical College, Madurai, 625 020, India
| | | | - Arulselvan Velusamy
- Department of Medical Gastroenterology, Government Medical College, Coimbatore, 641 018, India
| | - Senthilvadivu Arumugam
- Department of Medical Gastroenterology, Government Medical College, Coimbatore, 641 018, India
| | - Thasneem Taj Elikkottil
- Department of Medical Gastroenterology, Government Medical College, Coimbatore, 641 018, India
| | - Anand Vimal Dev
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | - Mousumi Sen
- Department of Forensic Medicine, Christian Medical College, Vellore, 632 004, India
| | - Alagammai Palaniappan
- Department of Gastroenterology, Meenakshi Mission Hospital and Research Centre, Madurai, 625 107, India
| | - Allwin James Dorairaj
- Department of Gastroenterology, Meenakshi Mission Hospital and Research Centre, Madurai, 625 107, India
| | - Chandan Kumar Kedarisetty
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, 600 116, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, 600 116, India
| | - Mugilan Karthikeyan
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, 600 116, India
| | - Aravindh Somasundaram
- Department of Gastroenterology, Kovai Medical Center Hospital, Coimbatore, 641 014, India
| | - Arulraj Ramakrishnan
- Department of Gastroenterology, Kovai Medical Center Hospital, Coimbatore, 641 014, India
| | - Vijaya Prakash Madesh
- Department of Gastroenterology, Kovai Medical Center Hospital, Coimbatore, 641 014, India
| | - Joy Varghese
- Department of Hepatology and Transplant Hepatology, Gleneagles Global Health City Hospital, Chennai, 600 100, India
| | - Dheeraj Kumar Anupa
- Department of Hepatology and Transplant Hepatology, Gleneagles Global Health City Hospital, Chennai, 600 100, India
| | - Venkatakrishnan Leelakrishnan
- Department of Gastroenterology and Hepatology, PSG Institute of Medical Sciences and Research, Coimbatore, 641 004, India
| | - Mukundan Swaminathan
- Department of Gastroenterology and Hepatology, PSG Institute of Medical Sciences and Research, Coimbatore, 641 004, India
| | - Ravindra Kantamaneni
- Department of Gastroenterology and Hepatology, PSG Institute of Medical Sciences and Research, Coimbatore, 641 004, India
| | - Jeyaraj Ubal Dhus
- Department of Medical Gastroenterology and Hepatology, Apollo Hospitals, Chennai, 600 006, India
| | - Natarajan Murugan
- Department of Medical Gastroenterology and Hepatology, Apollo Hospitals, Chennai, 600 006, India
| | - Kartik Natarajan
- Department of Medical Gastroenterology and Hepatology, Apollo Hospitals, Chennai, 600 006, India
| | - Caroline Selvi
- Department of Medical Gastroenterology, Government Royapettah Hospital, Kilpauk Medical College, Chennai, 600 010, India
| | | | - Ambily Nadaraj
- Clinical Epidemiology Unit, Christian Medical College, Vellore, 632 004, India
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Premkumar M, Kedarisetty CK. Cytokine Storm of COVID-19 and Its Impact on Patients with and without Chronic Liver Disease. J Clin Transl Hepatol 2021; 9:256-264. [PMID: 34007808 PMCID: PMC8111101 DOI: 10.14218/jcth.2021.00055] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/11/2021] [Accepted: 04/01/2021] [Indexed: 01/08/2023] Open
Abstract
The coronavirus pandemic has resulted in increased rates of hepatic decompensation, morbidity and mortality in patients suffering from existing liver disease, and deranged liver biochemistries in those without liver disease. In patients with cirrhosis with coronavirus disease 2019 (COVID-19), new onset organ failures manifesting as acute-on-chronic liver failure have also been reported. The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) also directly binds to enterocytes and cholangiocytes via the angiotensin converting enzyme receptor 2, although the lung remains the portal of entry. Superadded with the COVID-19 related bystander hepatitis, a systemic inflammatory response is noted due to unregulated macrophage activation syndrome and cytokine storm. However, the exact definition and diagnostic criteria of the 'cytokine storm' in COVID-19 are yet unclear. In addition, inflammatory markers like C-reactive protein, ferritin, D-dimer and procalcitonin are frequently elevated. This in turn leads to disease progression, activation of the coagulation cascade, vascular microthrombi and immune-mediated injury in different organ systems. Deranged liver chemistries are also noted due to the cytokine storm, and synergistic hypoxic or ischemic liver injury, drug-induced liver injury, and use of hepatotoxic antiviral agents all contribute to deranged liver chemistry. Control of an unregulated cytokine storm at an early stage may avert disease morbidity and mortality. Several immunomodulator drugs and repurposed immunosuppressive agents have been used in COVID-19 with varying degrees of success.
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Affiliation(s)
- Madhumita Premkumar
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandan Kumar Kedarisetty
- Department of Hepatology and Liver transplantation, Gleneagles Global Hospital, Hyderabad, India
- Correspondence to: Chandan Kumar Kedarisetty, Department of Hepatology and Liver Transplantation, Gleneagles Global Hospital, Lakdikapul, Hyderabad 500004, India. ORCID: https://orcid.org/0000-0002-7239-0293. Tel: +91-040-4592-8500, E-mail:
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Kedarisetty CK, Bhardwaj A, Kumar G, Rastogi A, Bihari C, Kumar M, Sarin SK. Efficacy of combining pentoxiphylline and vitamin E versus vitamin E alone in non-alcoholic steatohepatitis- A randomized pilot study. Indian J Gastroenterol 2021; 40:41-49. [PMID: 33772456 DOI: 10.1007/s12664-020-01131-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 08/15/2020] [Accepted: 11/23/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Non-alcoholic steatohepatitis (NASH) is the most prevalent cause of chronic liver disease. Vitamin E (VE), an anti-oxidant, has shown improvement in NAFLD activity score (NAS) but not fibrosis. Pentoxiphylline (PTX), an anti-TNF-alpha agent, has been reported to reduce hepatic inflammation and fibrosis. We evaluated combination of these drugs in NASH patients. METHODS In a prospective study, consecutive histologically proven patients with NASH were randomized to receive either PTX, 400 mg thrice daily and VE 400 IU twice daily (group PTVE, n = 36) or VE alone (group VE, n = 33). Clinical, dietary and biochemical follow-up was done till 12 months. Primary end-point was change in alanine aminotransferase (ALT) levels. RESULTS: Both groups were comparable at baseline. On a strict diet and lifestyle modification regimen, both groups had similar reduction in body mass index and waist circumference. There was a similar reduction in ALT levels in the two groups. Metabolically, patients in PTVE group had greater reduction in fasting insulin levels and homeostatic model assessment of insulin resistance (HOMA-IR) than VE group (p = 0.05). Tumor necrosis factor alpha (TNFα) levels were also significantly lower in PTVE group from 6 months onwards. Twelve (10%) patients had repeat liver biopsy (7 in group PTVE, 5 in group VE) with no difference in reduction of NAS score (p = 0.45). However, there was a significant fibrosis regression in PTVE compared to VE group (p = 0.003). CONCLUSIONS These data show greater efficacy of a combination of PTX and VE in achieving fibrosis regression compared to VE alone with better metabolic homeostasis and amelioration of the pro-inflammatory status. TRIAL REGISTRATION Clinical Trials Registry no. NCT01384578.
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Affiliation(s)
- Chandan Kumar Kedarisetty
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110 070, India. .,Departments of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai 600 116, India.
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi 110 070, India
| | - Guresh Kumar
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi 110 070, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi 110 070, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi 110 070, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110 070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110 070, India.
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Abstract
Alcohol use disorder is the predominant cause of chronic liver disease globally. The standard of care for the treatment of alcoholic hepatitis, corticosteroids, has been shown to provide a therapeutic response in ∼60% of carefully selected patients with a short-term survival benefit. The patients who do not respond to steroids, or are ineligible due to infections or very severe disease, have little options other than liver transplantation. There is, thus, a large unmet need for new therapeutic strategies for this large and sick group of patients. Granulocyte colony stimulating factor (G-CSF) has been shown to favorably modulate the intrahepatic immune milieu and stimulate the regenerative potential of the liver. Initial studies have shown encouraging results with G-CSF in patients with severe alcoholic hepatitis. It has also been found to help steroid nonresponsive patients. There is, however, a need for careful selection of patients, regular dose monitoring and close observation for adverse events of G-CSF. In this review, we analyze the basis of the potential benefits, clinical studies, cautions and challenges in the use of G-CSF in alcoholic hepatitis.
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Affiliation(s)
- Chandan Kumar Kedarisetty
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.,Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Anupam Kumar
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.,Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
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Kedarisetty CK, Samaga BL, Vidyasagar S, Venkataraman J. Oral melatonin improves the detection of parasitemia in malaria. J Infect Dev Ctries 2020; 14:1327-1331. [PMID: 33296347 DOI: 10.3855/jidc.12518] [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] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/11/2020] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Malaria is a growing global threat and a major cause of mortality in the tropics. The gold standard diagnosis is peripheral blood smear examination. It has been demonstrated that melatonin acts as messenger molecule in malaria pathophysiology. This concept was used to evolve a clinical study wherein use of exogenous melatonin could improve the chance of detection of the parasite. METHODOLOGY In a prospective study, 80 consecutive patients seen in the Department of Medicine at Kasturba Hospital, Manipal, suspected to have malarial fever were enrolled with proper informed consent, and randomly assigned to the groups given oral melatonin 3mg (melatonin group, n = 40) or placebo (control group, n = 40). Blood samples were collected for peripheral smear examination at baseline and then at two, three, four and five hours after drug administration. The primary end point was the parasite detection index. RESULTS Baseline characteristics of patients were comparable. In the melatonin group, there was a significant increase of 0.0943 ± 0.22 in the mean parasite index from 0.217 ± 0.42 pre-melatonin to 0.3114 ± 0.5 post-melatonin (p = 0.001), compared to a difference of 0.0025 ± 0.22 in mean parasite index before and after placebo in the control group (p = 0.95). The maximum rise in parasite detection was seen at five hours after melatonin. CONCLUSIONS In a single centre study, for the first time, it has been shown that a significantly higher proportion of patients was diagnosed with malaria on peripheral smear after oral melatonin administration, maximal at five hours after administration of melatonin.
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Affiliation(s)
| | | | - Sudha Vidyasagar
- Department of Medicine, Kasturba Medical College, Manipal, India.
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India.
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Kedarisetty CK, Kumar R. Spur Cells Causing Severe and Transfusion-Refractory Anemia in Patients With Acute-on-Chronic Liver Failure. Cureus 2020; 12:e10568. [PMID: 33110713 PMCID: PMC7579423 DOI: 10.7759/cureus.10568] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/09/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation of chronic liver disease associated with organ failures. Anemia of diverse etiology is common in patients with ACLF. Spur cell anemia (SCA) is a form of acquired hemolytic anemia that occurs rarely in such patients due to dysregulated lipids metabolism. Spur cells are large erythrocytes with spike-like projections, which predispose them for sequestration and destruction in splenic canaliculi. There is a paucity of data on SCA in patients with ACLF. Here we report a series of five ACLF patients who had severe (hemoglobin level < 8 g/dL) and transfusion-refractory SCA with aggressive clinical course and high mortality rate.
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Affiliation(s)
| | - Ramesh Kumar
- Gastroenterology, All India Institute of Medical Sciences, Patna, IND
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Bhadoria AS, Kedarisetty CK, Bihari C, Kumar G, Jindal A, Bhardwaj A, Shasthry V, Benjamin J, Sharma MK, Sarin SK. Positive familial history for metabolic traits predisposes to early and more severe alcoholic cirrhosis: A cross-sectional study. Liver Int 2019; 39:168-176. [PMID: 30188604 DOI: 10.1111/liv.13958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 03/10/2018] [Revised: 08/24/2018] [Accepted: 08/25/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Familial aggregation of metabolic traits in NAFLD is well documented. However, relevance of these traits in alcoholic cirrhosis is not well studied. We aimed to explore the association of family history of metabolic traits with age at diagnosis, severity and complications of alcoholic cirrhosis. METHODS In a cross-sectional study, all consecutive patients with alcoholic cirrhosis presenting to our tertiary care centre were included. Family and personal history, demographic characteristics, medical history, anthropometric measurements and laboratory data were recorded. The amount and duration of alcohol consumption were also carefully recorded. RESULTS Out of 1084 alcoholic cirrhotics (age 48.5 ± 10.1 years, all males), family history for metabolic traits was documented in 688 (63.5%) patients. These patients had younger age at diagnosis, increased incidence of jaundice, ascites, variceal bleed and hepatic encephalopathy with consequently higher MELD and CTP score. These patients developed cirrhosis despite shorter median duration (13 years, IQR 7-20 vs 21, IQR 18-25) and lesser amount of alcohol consumption (74 g/d, IQR 24-96 vs 144, IQR 100-148). Patients with both family and personal history of metabolic traits had a higher risk by 3.3 times (95% CI 2.2-4.8) of an early age at diagnosis, 13.2 times (95% CI 8.7-20.1) of progression to cirrhosis with lesser amount of alcohol consumption and 4.6 times (95% CI 3.1-6.9) with lesser duration of alcohol consumption. CONCLUSIONS Positive family and personal history of metabolic traits predispose to alcoholic cirrhosis with an earlier age at onset and more severity despite lesser exposure to alcohol.
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Affiliation(s)
- Ajeet Singh Bhadoria
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Varsha Shasthry
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jaya Benjamin
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj Kumar Sharma
- 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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Bhardwaj A, Kedarisetty CK, Vashishtha C, Bhadoria AS, Jindal A, Kumar G, Choudhary A, Shasthry SM, Maiwall R, Kumar M, Bhatia V, Sarin SK. Carvedilol delays the progression of small oesophageal varices in patients with cirrhosis: a randomised placebo-controlled trial. Gut 2017; 66:1838-1843. [PMID: 27298379 DOI: 10.1136/gutjnl-2016-311735] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [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: 02/26/2016] [Accepted: 05/20/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Carvedilol is effective in the primary prophylaxis for large oesophageal varices. We investigated its use in preventing progression of small to large oesophageal varices. METHODS Consecutive cirrhotics with small oesophageal varices were prospectively randomised to either carvedilol (n=70) or placebo (n=70) and followed up for a minimum of 24 months. Endoscopy was done at baseline and six monthly intervals. Hepatic vein pressure gradient (HVPG) was measured at baseline and at 12 months. The primary endpoint was development of large varices. RESULTS Baseline characteristics in two groups were comparable. The predominant aetiology of cirrhosis was non-alcoholic fatty liver disease in both the groups. The mean dose of carvedilol administered was 12±1.67 mg/day and the target heart rate achieved was 58±3 bpm. A higher proportion of patients in carvedilol group had non-progression to large varices than placebo (79.4% vs 61.4%; p=0.04); the mean time of non-progression to large varices was 20.8 months (95% CI 19.4 to 22.4) in carvedilol group and 18.7 months (95% CI 17.1 to 20.4) in placebo group (p=0.04). There was a modest reduction of HVPG at 1 year in carvedilol group (-8.64%) compared with placebo (+0.33%) (p=0.22). None of the patients in either group died of variceal bleeding or liver-related causes. No major adverse events were observed in either group. CONCLUSIONS Carvedilol is safe and effective in delaying the progression of small to large oesophageal varices in patients with cirrhosis. TRIAL REGISTRATION NUMBER NCT01196507; post-results.
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Affiliation(s)
- Ankit Bhardwaj
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Chandan Kumar Kedarisetty
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Chitranshu Vashishtha
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ajeet Singh Bhadoria
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ankur Jindal
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Guresh Kumar
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ashok Choudhary
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - S M Shasthry
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Rakhi Maiwall
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Manoj Kumar
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Vikram Bhatia
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Shiv Kumar Sarin
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
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Maiwall R, Sarin SK, Kumar S, Jain P, Kumar G, Bhadoria AS, Moreau R, Kedarisetty CK, Abbas Z, Amarapurkar D, Bhardwaj A, Bihari C, Butt AS, Chan A, Chawla YK, Chowdhury A, Dhiman R, Dokmeci AK, Ghazinyan H, Hamid SS, Kim DJ, Komolmit P, Lau GK, Lee GH, Lesmana LA, Jamwal K, Mamun-Al-Mahtab, Mathur RP, Nayak SL, Ning Q, Pamecha V, Alcantara-Payawal D, Rastogi A, Rahman S, Rela M, Saraswat VA, Shah S, Shiha G, Sharma BC, Sharma MK, Sharma K, Tan SS, Chandel SS, Vashishtha C, Wani ZA, Yuen MF, Yokosuka O, Duseja A, Jafri W, Devarbhavi H, Eapen CE, Goel A, Sood A, Ji J, Duan Z, Chen Y. Development of predisposition, injury, response, organ failure model for predicting acute kidney injury in acute on chronic liver failure. Liver Int 2017; 37:1497-1507. [PMID: 28393476 DOI: 10.1111/liv.13443] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 06/17/2016] [Accepted: 03/31/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM There is limited data on predictors of acute kidney injury in acute on chronic liver failure. We developed a PIRO model (Predisposition, Injury, Response, Organ failure) for predicting acute kidney injury in a multicentric cohort of acute on chronic liver failure patients. PATIENTS AND METHODS Data of 2360 patients from APASL-ACLF Research Consortium (AARC) was analysed. Multivariate logistic regression model (PIRO score) was developed from a derivation cohort (n=1363) which was validated in another prospective multicentric cohort of acute on chronic liver failure patients (n=997). RESULTS Factors significant for P component were serum creatinine[(≥2 mg/dL)OR 4.52, 95% CI (3.67-5.30)], bilirubin [(<12 mg/dL,OR 1) vs (12-30 mg/dL,OR 1.45, 95% 1.1-2.63) vs (≥30 mg/dL,OR 2.6, 95% CI 1.3-5.2)], serum potassium [(<3 mmol/LOR-1) vs (3-4.9 mmol/L,OR 2.7, 95% CI 1.05-1.97) vs (≥5 mmol/L,OR 4.34, 95% CI 1.67-11.3)] and blood urea (OR 3.73, 95% CI 2.5-5.5); for I component nephrotoxic medications (OR-9.86, 95% CI 3.2-30.8); for R component,Systemic Inflammatory Response Syndrome,(OR-2.14, 95% CI 1.4-3.3); for O component, Circulatory failure (OR-3.5, 95% CI 2.2-5.5). The PIRO score predicted acute kidney injury with C-index of 0.95 and 0.96 in the derivation and validation cohort. The increasing PIRO score was also associated with mortality (P<.001) in both the derivation and validation cohorts. CONCLUSIONS The PIRO model identifies and stratifies acute on chronic liver failure patients at risk of developing acute kidney injury. It reliably predicts mortality in these patients, underscoring the prognostic significance of acute kidney injury in patients with acute on chronic liver failure.
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Affiliation(s)
- Rakhi Maiwall
- 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
| | - Suman Kumar
- Department of Clinical Hematology, Command Hospital [Eastern Command], Kolkata, India
| | - Priyanka Jain
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ajeet Singh Bhadoria
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Richard Moreau
- UMR_S1149, Center for Research in Inflammation (CRI), Inserm and Paris Diderot University, Paris, France.,DHU Unity, Liver unit, Beaujon hospital, APHP, Clichy, France
| | | | - Zaigham Abbas
- Department of Gastroenterology, Ziauddin University Hospital, Karachi, Pakistan
| | - Deepak Amarapurkar
- Department of Gastroenterology and Hepatology, Bombay Hospital and Medical Research, Mumbai, India
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Amna Subhan Butt
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Albert Chan
- Department of Surgery, Division of Hepatobiliary and Pancreatic surgery, and Liver Transplantation, The University of Hong Kong, Hong Kong, China
| | - Yogesh Kumar Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Chowdhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - RadhaKrishan Dhiman
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Abdul Kadir Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Hasmik Ghazinyan
- Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia
| | - Saeed Sadiq Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Dong Joon Kim
- Center for Liver and Digestive Diseases, Hallym University Chuncheon Sacred Heart Hospital, Gangwon-Do, Korea
| | - Piyawat Komolmit
- Department of Medicine, Division of Gastroenterology and Hepatology, Chulalongkorn University, Bangkok, Thailand
| | - George K Lau
- Department of Hepatology, The Institute of Translational Hepatology, Beijing 302 Hospital, Beijing, China
| | - Guan Huei Lee
- Department of Medicine, National University Health System, Singapore, Singapore
| | | | - Kapil Jamwal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Mamun-Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Suman Lata Nayak
- Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Qin Ning
- Department of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Viniyendra Pamecha
- Department of Hepatobiliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Salimur Rahman
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mohamed Rela
- Institute of Liver diseases and Transplantation, Global Health city, Chennai, India
| | - Vivek A Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Samir Shah
- Department of Hepatology, Global Hospitals, Mumbai, India
| | - Gamal Shiha
- Department of Internal Medicine, Egyptian Liver Research Institute and Hospital, Cairo, Egypt
| | | | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kapil Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Soek Siam Tan
- Department of Hepatology Selayang Hospital, Selangor, Malaysia
| | | | | | - Zeeshan A Wani
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Harshad Devarbhavi
- Department of Gastroenterology, St.John's Medical College and Hospital, Bangalore, India
| | - C E Eapen
- Department of Gastroenterology and Hepatology, CMC, Vellore, India
| | - Ashish Goel
- Department of Gastroenterology, Rome, NY, USA
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Jia Ji
- Department of Gastroenterology, Liver Research Center, Beijing, China
| | - Z Duan
- Department of Gastroenterology, Nanjing First Hospital, Nanjing, China
| | - Y Chen
- Department of Gastroenterology, East Brunswick, NJ, USA
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Kedarisetty CK, Anand L, Bhardwaj A, Bhadoria AS, Kumar G, Vyas AK, David P, Trehanpati N, Rastogi A, Bihari C, Maiwall R, Garg HK, Vashishtha C, Kumar M, Bhatia V, Sarin SK. Combination of granulocyte colony-stimulating factor and erythropoietin improves outcomes of patients with decompensated cirrhosis. Gastroenterology 2015; 148:1362-70.e7. [PMID: 25749502 DOI: 10.1053/j.gastro.2015.02.054] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [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: 05/11/2014] [Revised: 02/27/2015] [Accepted: 02/28/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Patients with decompensated cirrhosis have significantly reduced survival without liver transplantation. Granulocyte colony-stimulating factor (G-CSF) has been shown to increase survival in patients with acute-on-chronic liver failure, and erythropoietin promoted hepatic regeneration in animal studies. We performed a double-blind, randomized, placebo-controlled trial to determine whether co-administration of these growth factors improved outcomes for patients with advanced cirrhosis. METHODS In a prospective study, consecutive patients with decompensated cirrhosis seen at the Institute of Liver and Biliary Sciences, New Delhi (from May 2011 through June 2012) were randomly assigned to groups given subcutaneous G-CSF (5 μg/kg/d) for 5 days and then every third day (12 total doses), along with subcutaneous darbopoietin α(40 mcg/wk) for 4 weeks (GDP group, n = 29), or only placebos (control group, n = 26). All patients also received standard medical therapy and were followed for 12 months. Histology was performed on liver biopsies. The primary end point was survival at 12 months. RESULTS Baseline characteristics of patients were comparable; alcohol intake was the most common etiology of cirrhosis. A higher proportion of patients in the GDP group than controls survived until 12 months (68.6% vs 26.9%; P = .003). At 12 months, Child-Turcotte Pugh scores were reduced by 48.6% in the GDP group and 39.1% in the control group, from baseline (P = .001); Model for End Stage Liver Disease scores were reduced by 40.4% and 33%, respectively (P = .03). The need for large-volume paracentesis was significantly reduced in GDP group, compared with controls (P < .05). A lower proportion of patients in the GDP group developed septic shock (6.9%) during follow-up compared with controls (38.5%; P = .005). No major adverse events were observed in either group. CONCLUSIONS In a single-center randomized trial, a significantly larger proportion of patients with decompensated cirrhosis given a combination of G-CSF and darbopoietin α survived for 12 months more than patients given only placebo. The combination therapy also reduced liver severity scores and sepsis to a greater extent than placebo. Clinicaltrials.gov ID: NCT01384565.
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Affiliation(s)
| | - Lovkesh Anand
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Biostatistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ajeet Singh Bhadoria
- Department of Biostatistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashish Kumar Vyas
- Department of Biostatistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Paul David
- Department of Biostatistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nirupama Trehanpati
- Department of Biostatistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Hitendra Kumar Garg
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikram Bhatia
- 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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Abstract
Acute-on-chronic liver failure is a distinct syndrome characterized by a rapid progression of liver disease culminating in organ failure and death. The only definitive treatment is liver transplantation. However, there is a possible element of reversibility and hepatic regeneration if the acute insult can be tided over. Exogenously administered growth factors may stimulate hepatocytes, hepatic progenitor cells and bone marrow-derived cells to supplement hepatic regeneration. The proposed review is intended to provide an in-depth analysis of the individual components of hepatic and bone marrow niches and highlight the growing role of various growth factors in liver regeneration in health and in liver failure.
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Affiliation(s)
| | - Lovkesh Anand
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Arshi Khanam
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Anupam Kumar
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- 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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Kumar N, Kedarisetty CK, Kumar S, Khillan V, Sarin SK. Antitubercular therapy in patients with cirrhosis: Challenges and options. World J Gastroenterol 2014; 20:5760-5772. [PMID: 24914337 PMCID: PMC4024786 DOI: 10.3748/wjg.v20.i19.5760] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/31/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Tuberculosis (TB) has been a human disease for centuries. Its frequency is increased manyfold in patients with liver cirrhosis. The gold standard of TB management is a 6-mo course of isoniazid, rifampicin, pyrazinamide and ethambutol. Although good results are seen with this treatment in general, the management of patients with underlying cirrhosis is a challenge. The underlying depressed immune response results in alterations in many diagnostic tests. The tests used for latent TB have many flaws in this group of patients. Three of four first-line antitubercular drugs are hepatotoxic and baseline liver function is often disrupted in patients with underlying cirrhosis. Frequency of hepatotoxicity is increased in patients with liver cirrhosis, frequently leading to severe liver failure. There are no established guidelines for the treatment of TB in relation to the severity of liver disease. There is no consensus on the frequency of liver function tests required or the cut-off used to define hepatotoxicity. No specific treatment exists for prevention or treatment of hepatotoxicity, making monitoring even more important. A high risk of multidrug-resistant TB is another major worry due to prolonged and interrupted treatment.
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