Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis

BACKGROUND

In patients with cirrhosis and spontaneous bacterial peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients.

METHODS

We randomly assigned 126 patients with cirrhosis and spontaneous bacterial peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in dosages that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization.

RESULTS

The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values.

CONCLUSIONS

In patients with cirrhosis and spontaneous bacterial peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone.

Clinical Course of acute-on-chronic liver failure syndrome and effects on prognosis

Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation (AD) of cirrhosis, organ failure(s), and high 28-day mortality. We investigated whether assessments of patients at specific time points predicted their need for liver transplantation (LT) or the potential futility of their care. We assessed clinical courses of 388 patients who had ACLF at enrollment, from February through September 2011, or during early (28-day) follow-up of the prospective multicenter European Chronic Liver Failure (CLIF) ACLF in Cirrhosis study. We assessed ACLF grades at different time points to define disease resolution, improvement, worsening, or steady or fluctuating course. ACLF resolved or improved in 49.2%, had a steady or fluctuating course in 30.4%, and worsened in 20.4%. The 28-day transplant-free mortality was low-to-moderate (6%-18%) in patients with nonsevere early course (final no ACLF or ACLF-1) and high-to-very high (42%-92%) in those with severe early course (final ACLF-2 or -3) independently of initial grades. Independent predictors of course severity were CLIF Consortium ACLF score (CLIF-C ACLFs) and presence of liver failure (total bilirubin ≥12 mg/dL) at ACLF diagnosis. Eighty-one percent had their final ACLF grade at 1 week, resulting in accurate prediction of short- (28-day) and mid-term (90-day) mortality by ACLF grade at 3-7 days. Among patients that underwent early LT, 75% survived for at least 1 year. Among patients with ≥4 organ failures, or CLIF-C ACLFs >64 at days 3-7 days, and did not undergo LT, mortality was 100% by 28 days.

CONCLUSIONS

Assessment of ACLF patients at 3-7 days of the syndrome provides a tool to define the emergency of LT and a rational basis for intensive care discontinuation owing to futility.

Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems

Little information exists on the effects of transjugular intrahepatic portosystemic shunts (TIPS) in the management of cirrhotic patients with hepatorenal syndrome (HRS). The current study was aimed to prospectively evaluate the effects of TIPS on renal function and vasoactive systems in patients with type I HRS. Glomerular filtration rate (GFR) (inulin clearance), renal plasma flow (RPF) (para-aminohippurate clearance), plasma renin activity (PRA), aldosterone (ALDO), norepinephrine (NE), and endothelin (ET) were determined in baseline conditions and at different time intervals after TIPS in 7 patients with type I HRS. TIPS induced a marked reduction of portal pressure gradient (PPG) (20 +/- 1 to 10 +/- 1 mm Hg; P < .05). Renal function improved in 6 of the 7 patients. Serum creatinine and blood urea nitrogen (BUN) decreased from 5 +/- 0.8 and 109 +/- 7 to 1.8 +/- 0.4 mg/dL and 56 +/- 11 mg/dL, respectively (P < .05 for both), and GFR and RPF increased from 9 +/- 4 and 103 +/- 33 to 27 +/- 7 mL/min and 233 +/- 40 mL/min, respectively (P < .05 for both), 30 days after TIPS. These beneficial effects on renal function were associated with a significant (P < .05) reduction of PRA (18 +/- 5 to 3 +/- 1 ng/mL x h), ALDO (279 +/- 58 to 99 +/- 56 ng/dL), and NE (1,257 +/- 187 to 612 +/- 197 pg/mL). ET did not change significantly (28 +/- 8 to 27 +/- 11 pg/mL). Mean survival was 4.7 +/- 2 months (0.3-17 months). Three patients remained alive more than 3 months after TIPS insertion. In conclusion, TIPS improves renal function and reduces the activity of the renin-angiotensin and sympathetic nervous systems in cirrhotic patients with type I HRS. Nevertheless, the efficacy of TIPS in the management of these patients should be confirmed in controlled investigations.

Reversibility of hepatorenal syndrome by prolonged administration of ornipressin and plasma volume expansion

Hepatorenal syndrome is caused by a marked vasoconstriction of the renal circulation. It is suggested that the renal vasoconstriction is related to an overactivity of vasoconstrictor systems secondary to a vasodilation of the arterial circulation that causes a reduction in effective arterial blood volume. To test this hypothesis, 16 cirrhotic patients with hepatorenal syndrome were treated with a combination of ornipressin, a potent vasoconstrictor agent, and plasma volume expansion with albumin to improve effective arterial blood volume. The combined treatment was administered either for 3 or 15 days (8 patients each), and the effects on renal function, vasoactive systems, and systemic hemodynamics were assessed. The 3-day treatment with ornipressin and albumin was associated with a normalization of the overactivity of renin-angiotensin and sympathetic nervous systems, a marked increase in atrial-natriuretic peptide levels, and only a slight improvement in renal function. However, when ornipressin and albumin were administered for 15 days, a remarkable improvement in renal function was observed, with normalization of serum-creatinine concentration, a marked increase in renal plasma flow and glomerular filtration rate, and a persistent suppression in the activity of vasoconstrictor systems. However, 3 of 8 patients on 15-day therapy treatment had to be discontinued because of ischemic complications. In conclusion, the decrease in effective arterial blood volume and the activation of vasoconstrictor systems play a crucial role in the pathogenesis of hepatorenal syndrome. Although the prolonged administration of ornipressin combined with plasma volume expansion reverses hepatorenal syndrome, this treatment should be used with great caution in clinical practice because of the risk of ischemic complications.

A prognostic model for predicting survival in cirrhosis with ascites

BACKGROUND/AIMS

Parameters evaluating renal function and systemic hemodynamics are of prognostic significance in cirrhosis with ascites but are rarely used in the evaluation of survival of these patients. The aim of the current study was to develop a prognostic model to estimate survival of patients with cirrhosis and ascites.

METHODS

216 Cirrhotic patients admitted to hospital for the treatment of ascites were evaluated. Thirty-two demographic, clinical and laboratory variables, including parameters assessing liver and renal function and systemic hemodynamics, were analyzed as predictive factors of survival by using a Cox regression model.

RESULTS

Four variables had independent prognostic value: renal water excretion, as assessed by measuring diuresis after water load, mean arterial pressure, Child-Pugh class, and serum creatinine. According to these features a prognostic index was calculated that allows to estimate survival in patients with cirrhosis and ascites. The model accurately predicted survival in an independent series of 84 patients with cirrhosis and ascites.

CONCLUSION

A prognostic model that uses four easily available variables and predicts prognosis in cirrhotic patients with ascites has been developed. This model may be useful in the evaluation of patients with ascites for liver transplantation.

Association between dietary meat consumption and incident type 2 diabetes: the EPIC-InterAct study

AIMS/HYPOTHESIS

A diet rich in meat has been reported to contribute to the risk of type 2 diabetes. The present study aims to investigate the association between meat consumption and incident type 2 diabetes in the EPIC-InterAct study, a large prospective case-cohort study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

METHODS

During 11.7 years of follow-up, 12,403 incident cases of type 2 diabetes were identified among 340,234 adults from eight European countries. A centre-stratified random subsample of 16,835 individuals was selected in order to perform a case-cohort design. Prentice-weighted Cox regression analyses were used to estimate HR and 95% CI for incident diabetes according to meat consumption.

RESULTS

Overall, multivariate analyses showed significant positive associations with incident type 2 diabetes for increasing consumption of total meat (50 g increments: HR 1.08; 95% CI 1.05, 1.12), red meat (HR 1.08; 95% CI 1.03, 1.13) and processed meat (HR 1.12; 95% CI 1.05, 1.19), and a borderline positive association with meat iron intake. Effect modifications by sex and class of BMI were observed. In men, the results of the overall analyses were confirmed. In women, the association with total and red meat persisted, although attenuated, while an association with poultry consumption also emerged (HR 1.20; 95% CI 1.07, 1.34). These associations were not evident among obese participants.

CONCLUSIONS/INTERPRETATION

This prospective study confirms a positive association between high consumption of total and red meat and incident type 2 diabetes in a large cohort of European adults.

Increased cerebrovascular resistance in cirrhotic patients with ascites

Studies assessing regional hemodynamics in patients with cirrhosis and ascites have shown vasodilation in the splanchnic circulation and vasoconstriction in the renal circulation and in the brachial and femoral artery vascular territories. The aim of this study was to assess the cerebral vascular resistance in cirrhotic patients with ascites. The resistive index in the middle cerebral artery (an index of the cerebral vascular resistance) and in a renal interlobar artery were measured by Doppler ultrasonography in 7 healthy subjects: 13 patients with compensated cirrhosis and 24 patients with ascites (13 with renal failure). The arterial blood pressure and the activity of the renin-angiotensin and sympathetic nervous systems, as estimated by plasma renin activity and plasma norepinephrine concentration, respectively, were also measured. The resistive index in the middle cerebral artery was significantly increased in patients with ascites (0.68 +/- 0.05, mean +/- SD) as compared with patients without ascites (0.60 +/- 0.01, P < .05) and with healthy patients (0.52 +/- 0.01, P < .01). Renal resistive index was also increased in patients with ascites (0.77 +/- 0.01) compared with the other two groups (0.68 +/- 0.02 and 0.62 +/- 0.00, respectively; P < .001). The resistive index in the middle cerebral artery showed a direct correlation with renal resistive index (r = .73, P < .01), plasma renin activity (r = .61, P < .01), and norepinephrine (r = .53, P < .01). The resistive index in the middle cerebral artery showed an inverse correlation with mean arterial pressure (r = -.45, P < .01). These results indicate that in patients with cirrhosis and ascites there is a cerebral vasoconstriction which is probably related with the arterial hypotension and the overactivity of vasoconstrictor systems.

Decline in influenza vaccine effectiveness with time after vaccination, Navarre, Spain, season 2011/12

Binary file ES_Abstracts_Final_ECDC.txt matches

Increased adrenomedullin levels in cirrhosis: relationship with hemodynamic abnormalities and vasoconstrictor systems

BACKGROUND & AIMS

Arterial vasodilation in cirrhosis may be related to increased circulating levels of vasodilators. This study was designed to assess the circulating levels of adrenomedullin, a recently described vasodilator peptide, in cirrhosis.

METHODS

Plasma adrenomedullin levels were measured in 17 healthy subjects and 34 cirrhotic patients. Hemodynamic parameters, renal function, and levels of vasoactive substances were also assessed.

RESULTS

Patients with ascites had increased adrenomedullin levels (289 +/- 47 pg/mL) compared with healthy subjects and patients without ascites (135 +/- 17 and 142 +/- 32 pg/mL, respectively; P < 0.05). Adrenomedullin levels correlated inversely with arterial pressure, glomerular filtration rate, and renal plasma flow and correlated directly with pulse rate, endothelin levels, and aldosterone and plasma renin activity. In cirrhotic patients, no significant differences in adrenomedullin levels were found between samples obtained from hepatic vein, renal vein, pulmonary artery, and femoral artery. Plasma expansion with albumin suppressed the renin-angiotensin system but did not affect adrenomedullin levels.

CONCLUSIONS

Circulating levels of adrenomedullin are increased in patients with ascites and correlate with hemodynamic and renal abnormalities and activation of vasoconstrictor systems. These increased levels seem to result from a generalized increase in adrenomedullin production from vascular tissue and are not suppressed by plasma expansion. Adrenomedullin may participate in the pathogenesis of arterial vasodilation in cirrhosis.

Hepatorenal syndrome

Hepatorenal syndrome is a common complication in patients with advanced cirrhosis and ascites characterized not only by renal failure but also by marked alterations in systemic hemodynamics and vasoactive systems. Renal failure is due to a marked hypoperfusion of the kidney secondary to renal vasoconstriction. The pathogenesis of hepatorenal syndrome is not completely known but it is thought to be the extreme manifestation of the underfilling of the arterial circulation secondary to an arterial vasodilation, located mainly in the splanchnic circulation. Recently, a new definition and diagnostic criteria of hepatorenal syndrome have been proposed, which has stimulated research in this field. Prognosis of patients with hepatorenal syndrome is very poor. Liver transplantation is the only effective treatment but it is not applicable in all patients due to short survival. New therapies developed during the last few years, such as the use of systemic vasoconstrictors or transjugular intrahepatic portosystemic shunts appear promising, but their usefulness should be evaluated in prospective investigations.

Diuretic requirements after therapeutic paracentesis in non-azotemic patients with cirrhosis. A randomized double-blind trial of spironolactone versus placebo

BACKGROUND/AIMS

Diuretic requirements after mobilization of ascites by paracentesis have never been assessed in cirrhosis. It is also unknown whether diuretics increase the incidence of postparacentesis circulatory dysfunction. The aim of this study was to investigate these features and to assess whether measurement of plasma renin activity and aldosterone prior to paracentesis predicts diuretic response after this procedure.

METHODS

Thirty-six patients with non-azotemic cirrhosis and ascites treated by total paracentesis plus i.v. albumin were randomly assigned to receive placebo (n=17) or spironolactone 225 mg/day (n=19) immediately after paracentesis and followed-up for 4 weeks.

RESULTS

Five patients (three in the placebo and two in the spironolactone group) abandoned the treatment prior to ascites recurrence or the end of the study due to complications or lack of compliance. The analysis was performed in the remaining 31 patients. Ascites recurrence was more common in the placebo group (13 cases, 93%) than in the spironolactone group (3 cases, 18%) (p<0.0001) and occurred within the first 2 weeks of follow-up in more than 50% of patients. Patients developing ascites in the spironolactone group had higher levels of renin (14.1, 20.6, 32.4 ng/ml per h) and aldosterone (120, 149, 288 ng/dl) than those who did not develop ascites (renin: 2.0+/-2.1 ng/ml per h; range 0.1-6.8; aldosterone: 43+/-38 ng/dl; range 4-116). Three patients in the placebo group and two in the spironolactone group developed postparacentesis circulatory dysfunction (defined as an increase in renin at the third day after paracentesis greater than 50% over baseline levels up to a value higher than 4 ng/ml per h).

CONCLUSIONS

Patients with cirrhosis treated by paracentesis should receive diuretics immediately after this procedure to prevent early recurrence of ascites. The administration of 225 mg/day of spironolactone is a good empiric treatment for non-azotemic patients with cirrhosis, because it is effective in most cases and does not increase the incidence of postparacentesis circulatory dysfunction. The determination of plasma levels of renin or aldosterone prior to paracentesis predicts the efficacy of spironolactone in the prevention of ascites recurrence.

Changing epidemiology of invasive pneumococcal disease following increased coverage with the heptavalent conjugate vaccine in Navarre, Spain

The present study evaluated changes in the incidence of invasive pneumococcal disease (IPD) and the pattern of serotypes isolated in Navarre, Spain, after the introduction and increased coverage of the heptavalent pneumococcal conjugate vaccine (PCV7). All cases with isolation of pneumococcus from normally sterile bodily fluids were included. The incidence of IPD in children and adults was compared for the periods 2001-2002 and 2006-2007. By the end of 2002, only 11% of children aged <5 years had received any dose of PCV7, whereas, beginning in 2007, the proportion exceeded 50%. Among the cases of IPD aged <5 years, the percentage of those vaccinated increased from 7% during 2001-2002 to 53% during 2006-2007 (p <0.001). The incidence of IPD from PCV7-serotypes decreased by 85% in children <5 years (p <0.001), by 45% in the population aged 5-64 years (p 0.10) and by 68% in those >or=65 years (p 0.004). By contrast, the incidence of IPD from non-PCV7 serotypes increased by 40% overall (p 0.006). The incidence of IPD from all serotypes did not change significantly in children <5 years (from 83 to 72 per 100 000) or in the total population (from 15.8 to 16.3 per 100 000). The percentage of cases as a result of serotypes 7 and 19A increased significantly in both children and adults. No significant changes were seen in the clinical forms of IPD. The pattern of serotypes causing IPD has changed, in both children and adults, following the increased coverage of PCV7, although the incidence has been reduced only slightly.

Effect of therapeutic paracentesis on plasma volume and transvascular escape rate of albumin in patients with cirrhosis

BACKGROUND/AIMS

Circulatory abnormalities with activation of vasoconstrictor systems after large-volume paracentesis are generally considered secondary to an increased extravasation of fluid from the intravascular compartment to the extravascular space with subsequent reduction in plasma volume. To test this hypothesis, plasma volume, the transvascular escape rate of albumin, the absolute escape rate of albumin and the activity of vasoconstrictor systems were measured in 25 cirrhotic patients with ascites in baseline conditions and 2 days after total paracentesis with plasma volume expansion.

METHODS

Plasma volume and the transvascular escape rate of albumin, the fraction of albumin passing from the intravascular to the extravascular space per unit of time, were assessed through the plasma disappearance curve of radioiodinated human albumin. The absolute escape rate of albumin, the total flux of albumin from intravascular to extravascular space per unit of time, was also calculated.

RESULTS

Eight of the 25 patients (32%) developed marked activation of vasoconstrictor systems after paracentesis. In these patients, plasma renin activity and plasma norepinephrine concentration increased from 6.6+/-2 to 23.4+/-11 ng x ml(-1) x h(-1) and 776+/-229 to 989+/-258 pg/ml, respectively (p<0.05). No significant changes in these parameters were found in the remaining 17 patients. The activation of vasoconstrictor systems occurred in the absence of changes in plasma volume (3456+/-276 vs 3476+/-264 ml, NS), transvascular escape rate of albumin (10.4+/-1 vs 10.9+/-2%/h, NS) and absolute escape rate of albumin (9.9+/-1.9 vs 10.5+/-0.7 g/h, NS).

CONCLUSIONS

These results do not support a contraction of plasma volume as the mechanism responsible for activation of vasoconstrictor systems after paracentesis. Rather, the activation of vasoconstrictor systems in the absence of changes in plasma volume suggests that paracentesis accentuates the impairment of "effective" blood volume present in cirrhotic patients with ascites.

Renal and neurohormonal changes following simultaneous administration of systemic vasoconstrictors and dopamine or prostacyclin in cirrhotic patients with hepatorenal syndrome

BACKGROUND/AIMS

Intravenous ornipressin in cirrhotic patients with hepatorenal syndrome causes marked improvement of systemic hemodynamics and suppression of plasma renin and norepinephrine but only moderate improvement of renal function. This study was designed to investigate whether these beneficial effects could be enhanced by the simultaneous administration of dopamine. The renal effects of the i.v. infusion of norepinephrine plus prostacyclin in patients with hepatorenal syndrome were also assessed.

METHODS

Renal plasma flow, glomerular filtration rate, free water clearance, sodium excretion and the plasma levels of renin and norepinephrine were measured in baseline conditions and during the administration of ornipressin (6 i.u./h) and ornipressin (6 i.u./h) plus dopamine (2 micrograms/kg.min) in nine patients with hepatorenal syndrome. Five additional patients with hepatorenal syndrome were studied prior to and following the administration of norepinephrine (0.45 +/- 0.1 microgram/kg.min) and norepinephrine (0.85 +/- 0.2 microgram/kg.min) plus prostacyclin (5 ng/kg.min).

RESULTS

Despite a significant increase in arterial pressure and marked suppression of plasma renin activity during ornipressin and ornipressin plus dopamine administration, no significant improvement in renal function was observed. Norepinephrine and norepinephrine plus prostacyclin also failed to increase renal perfusion and glomerular filtration rate.

CONCLUSIONS

The combined administration of systemic vasoconstrictors (ornipressin or norepinephrine) and vasodilators (dopamine or prostacyclin), at the doses used in the current study and for a short period of time, does not improve renal function in cirrhotic patients with hepatorenal syndrome. The current study does not confirm a potential role for ornipressin in the treatment of hepatorenal syndrome.

Use of the vaccination register to evaluate influenza vaccine coverage in seniors in the 2010/11 influenza season, Navarre, Spain

People aged 65 and older have a high risk of suffering from complications of influenza, therefore it is recommended that they receive annual influenza vaccination. However, vaccination coverage falls far short of the target of 75%. In this study we use the vaccination register to evaluate the coverage of influenza vaccine in non-institutionalised persons aged 65 and over in Navarre, Spain, in the 2010/11 season (104,427 persons). Vaccination coverage was 58.6%, lower than the 62.7% coverage in the 2009/10 season. In the multivariate analysis, lower coverage was associated with being female, age under 80 or over 94 years, immigrant status and hospitalisation in the previous year. In contrast, persons with major chronic conditions, high level of dependence or those with more visits to the general practitioner in the previous year had higher vaccination coverage. Influenza vaccination in the previous season was a strong predictor of vaccination in the current season (odds ratio: 37.0, 95% confidence interval: 35.7–38.4). The vaccination register has been shown to be useful to monitor the coverage of influenza vaccination in seniors and may help guide strategies to improve coverage.

Oral ciprofloxacin after a short course of intravenous ciprofloxacin in the treatment of spontaneous bacterial peritonitis: results of a multicenter, randomized study

BACKGROUND/AIMS

Oral quinolones have been suggested as treatment of cirrhotic patients with uncomplicated spontaneous bacterial peritonitis. To evaluate the efficacy of oral quinolones in all patients with this complication, oral ciprofloxacin after a short course of intravenous (i.v.) ciprofloxacin was compared to i.v. ciprofloxacin.

METHODS

Eighty patients were allocated to receive ciprofloxacin i.v. 200 mg/12 h for 7 days (group A, n= 40) or i.v. 200 mg/12 h during 2 days followed by oral 500 mg/12 h for 5 days (group B, n=40). All patients with spontaneous bacterial peritonitis admitted to the hospital were included. Twenty-five variables obtained 48 h after treatment were introduced into univariate and multivariate analyses to identify predictors of survival and outcome.

RESULTS

In the baseline condition, no differences were found between the two groups in clinical data, hepatic and renal function tests and Child Pugh score. The infection resolution rate was 76.3 % in group A and 78.4 % in group B, and hospital survival was 77.5% in both groups. In multivariate analysis serum creatinine and serum leukocytes 48 h after treatment were associated with prognosis.

CONCLUSIONS

Oral ciprofloxacin after a short course of i.v. ciprofloxacin is effective in the treatment of spontaneous bacterial peritonitis. This regimen can be applied to all patients admitted to the hospital with this complication, and could be an alternative to treating these patients as outpatients.

2012/13 influenza vaccine effectiveness against hospitalised influenza A(H1N1)pdm09, A(H3N2) and B: estimates from a European network of hospitals

While influenza vaccines aim to decrease the incidence of severe influenza among high-risk groups, evidence of influenza vaccine effectiveness (IVE) among the influenza vaccine target population is sparse. We conducted a multicentre test-negative case-control study to estimate IVE against hospitalised laboratory-confirmed influenza in the target population in 18 hospitals in France, Italy, Lithuania and the Navarre and Valencia regions in Spain. All hospitalised patients aged ≥18 years, belonging to the target population presenting with influenza-like illness symptom onset within seven days were swabbed. Patients positive by reverse transcription polymerase chain reaction for influenza virus were cases and those negative were controls. Using logistic regression, we calculated IVE for each influenza virus subtype and adjusted it for month of symptom onset, study site, age and chronic conditions. Of the 1,972 patients included, 116 were positive for influenza A(H1N1)pdm09, 58 for A(H3N2) and 232 for influenza B. Adjusted IVE was 21.3% (95% confidence interval (CI): -25.2 to 50.6; n=1,628), 61.8% (95% CI: 26.8 to 80.0; n=557) and 43.1% (95% CI: 21.2 to 58.9; n=1,526) against influenza A(H1N1) pdm09, A(H3N2) and B respectively. Our results suggest that the 2012/13 IVE was moderate against influenza A(H3N2) and B and low against influenza A(H1N1) pdm09.

Impairment of renal function during moderate physical exercise in cirrhotic patients with ascites: relationship with the activity of neurohormonal systems

Moderate physical exercise does not affect glomerular filtration rate (GFR) and renal excretory function in normal subjects. This study is aimed at assessing the effects of moderate physical exercise on renal function in 21 nonazotemic cirrhotic patients with ascites. Arterial pressure, heart rate, and renal function were assessed in the patients after 2 hours in the supine position and during 30 minutes of moderate cycloergometric exercise in the sitting position. The activity of the renin-aldosterone and sympathetic nervous systems and the plasma levels of antidiuretic hormone (ADH) and atrial natriuretic peptide (ANP) were determined at the end of each period. Physical exercise induced a marked reduction in GFR (75 +/- 10 to 49 +/- 6 mL/min), free-water clearance (6.1 +/- 1 to 3.4 +/- 1 mL/min), and sodium excretion (7.8 +/- 2 to 4.3 +/- 1 microEq/min) in 10 patients (Group I). In the remaining 11 cases (Group II) there were no changes in these parameters. Renal perfusion significantly decreased in both groups although the reduction was greater in Group I (-34.7% +/- 4.6% vs. -7.5% +/- 3.1%, P < .001). Physical exercise was associated with a significant and comparable increase in arterial pressure, heart rate, and plasma levels of renin, aldosterone, and norepinephrine (NE) in the two groups of patients. The ANP concentration did not change. Patients from Groups I and II differed significantly (P < .05) only in plasma renin activity (PRA) and NE concentration, which were higher in Group I patients both in the supine rest (renin: 4.7 +/- 1.6 vs. 1.4 +/- 0.5 ng/mL x h; NE: 576 +/- 115 vs. 288 +/- 42 pg/ mL) and during exercise (renin: 7.1 +/- 1.8 vs. 2.6 +/- 1 ng/ mL x h; NE: 925 +/- 135 vs. 630 +/- 90 pg/mL). In conclusion, moderate physical exercise has no detrimental effects on renal function in cirrhotic patients with ascites with no or mild activation of the renin-aldosterone and sympathetic nervous systems. However, moderate physical exercise causes a marked impairment in the renal function of patients with ascites with marked stimulation of these vasoconstrictor systems.

Review article: albumin for circulatory support in patients with cirrhosis

Renal function abnormalities and ascites in cirrhosis are the final consequence of a circulatory dysfunction characterized by marked splanchnic arterial vasodilation. This causes a reduction in effective arterial blood volume and the homoeostatic activation of vasoconstrictor and sodium-retaining systems. Albumin is very effective in preventing renal failure associated with large-volume paracentesis and spontaneous bacterial peritonitis, conditions that are known to cause an impairment of circulatory function in patients with cirrhosis and ascites. Moreover, albumin administration improves survival in patients with spontaneous bacterial peritonitis. In patients with hepatorenal syndrome the administration of vasoconstrictor drugs in combination with albumin improves circulatory and renal function markedly and survival slightly. By contrast, the administration of albumin without vasoconstrictors has marginal or no effects on renal function in this setting.

Efficacy of octreotide and sclerotherapy in the treatment of acute variceal bleeding in cirrhotic patients. A prospective, multicentric, and randomized clinical trial

BACKGROUND

Sclerotherapy is the most widely used method for treatment of acute variceal bleeding. Previous reports have suggested that octreotide infusion is as effective as sclerotherapy. Our aim was to investigate the efficacy and safety of octreotide in comparison with sclerotherapy in controlling variceal bleeding.

METHODS

Seventy-six cirrhotic patients were randomized to receive either sclerotherapy (n = 37) or octreotide (n = 39) infusion of 50 microg/h intravenously for 48 h after a bolus of 100 microg, followed by subcutaneous injection of 100 microg/8 h for an additional 72 h.

RESULTS

The two groups were similar in base-line data. A similar initial control of bleeding was obtained in 94.6% for sclerotherapy and 84.6% for octreotide (NS). No difference was observed between sclerotherapy and octreotide in rebleeding (23% versus 33%) and treatment failure (22% versus 36%, respectively). Furthermore, the overall success of treatment was 78% for sclerotherapy and 64% for octreotide. No significant difference in mortality was observed between treatments (eight patients for octreotide and three patients for sclerotherapy, NS).

CONCLUSIONS

These results show that both treatments present a very high and similar initial and final control of bleeding. However, there is a trend that could be clinically important towards better results in the patients treated with sclerotherapy.

Night-shift work and breast and prostate cancer risk: updating the evidence from epidemiological studies

It has been hypothesized that circadian disruption is related to higher cancer risk. Since the International Agency for Research on Cancer classified shift work involving circadian disruption as probably carcinogenic to humans (Group 2A), multiple studies have been conducted to test this hypothesis. The aim of this systematic review was to summarize the findings and evaluate the quality of existing epidemiological studies (case-control and cohort studies) on the relationship between night-shift work and breast and prostate cancer risk. Thirty-three epidemiological studies investigating the relationship between night-shift work and breast (n = 26) or prostate (n = 8) cancer risk were included (one paper included both sites). The Newcastle-Ottawa Scale for the quality of non-randomized studies was used to assess the risk of bias of the publications. The studies included were heterogeneous regarding population (general population, nurses working in rotating shifts, and other) and measurement of exposure to night-shift work (ever vs. never exposure, short vs. long-term, rotating vs. permanent) and, thus, a diversity of outcomes were observed even within the same type of cancer. In summary, 62.5% works found some type of association between night-shift work and increased risk of cancer, for both breast and prostate. The risk of bias scored an average of 7.5 over 9 stars. Due to the limitations inherent in these studies, the evidence of a possible association between night-shift work and breast or prostate cancer risk remains uncertain and more studies providing greater control of exposure and confounding factors are required. Despite the lack of conclusive evidence, application of the precautionary principle seems advisable.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Determination of lanthanides in international geochemical reference materials by reversed-phase high-performance liquid chromatography using error propagation theory to estimate total analysis uncertainties

The weighted least-squares (WLS) regression method was successfully applied to establish calibration curves with variable amounts of lanthanides ranging from 0.002 to 0.430 microg. These curves were employed for the analysis of 13 lanthanides (La-Nd, Sm-Tb, and Ho-Lu) in 12 international geochemical reference materials (IGRM). The separation of the lanthanide group was achieved in approximately 15 min. Dysprosium could not be determined in IGRM because of its co-elution with Yttrium. A linear gradient program of alpha-HIBA eluent with a concentration ranging from 0.05 to 0.5 M (0.1 M OS, pH 3.8 with NH(4)OH, and a flow-rate of 1.0 ml/min) was employed. The detection was performed with a UV-vis system at 658 nm using a post-column reagent of Arsenazo III (0.5 ml/min). With this set of RP-HPLC conditions together with the use of both the ordinary least-squares (OLS) and the WLS regressions, we report the results of the measurements along with the total propagated uncertainties in individual concentration values. The uncertainties were obtained by combining standard errors in both regression parameters (slope and intercept) with those related to the chromatographic peak areas. The straight-line slopes and intercepts calculated by the WLS method provided not only considerably smaller errors than the conventional OLS method but also a much better estimation of the limits of detection. The concentrations calculated were compared with the "most probable" concentration values of these reference materials reported in the literature. Statistically significant agreement was consistently observed between the HPLC data and the literature values. The total uncertainties in estimated concentration values for the WLS were consistently smaller than the respective errors for the OLS.

Review article: pharmacological treatment of hepatorenal syndrome

Hepatorenal syndrome (HRS) is a common complication of advanced cirrhosis characterized not only by renal failure but also by marked alterations in systemic haemodynamics and activity of endogenous vasoactive systems. Renal failure is due to a severe vasoconstriction of the renal circulation. The pathogenesis of HRS is not completely understood but it is probably the result of extreme underfilling of the arterial circulation secondary to arterial vasodilation located in the splanchnic circulation. As well as the renal circulation, all other extrasplanchnic vascular beds appear to be vasoconstricted. The diagnosis of HRS is currently based on the exclusion of nonfunctional causes of renal failure; prognosis of patients with HRS is very poor. Liver transplantation is the best option in selected patients, but it is not always applicable as survival expectancy is short. Vasoconstrictor drugs with preferential effect on the splanchnic circulation (vasopressin analogues with a predominant V1 receptor effect, such as terlipressin--Glypressin) are very effective in improving renal function, with reversal of HRS being achieved in approximately two-thirds of patients. There is no agreement as to the terlipressin treatment regimen that is associated with a greater efficacy and lower incidence of side-effects. It appears that the administration of albumin together with terlipressin improves the therapeutic response rate. The impact of treatment on the natural course of HRS remains to be assessed in prospective investigations, but it seems that the reversal of HRS is associated with improved survival. Finally, treatment of patients with HRS with terlipressin before transplantation seems to improve post-transplantation outcome.