Compensated Liver Cirrhosis Research Articles

Sa1540 - Prospective Analysis of Discordant Results Between Fibromax® and Fibroscan® in Patients with HCV Compensated Liver Cirrhosis before 3D Antiviral Therapy Initiation

Sa1540 - Prospective Analysis of Discordant Results Between Fibromax® and Fibroscan® in Patients with HCV Compensated Liver Cirrhosis before 3D Antiviral Therapy Initiation

Lusutrombopag increases hematocytes in a compensated liver cirrhosis patient

A 56-year-old Japanese man with liver cirrhosis (LC) due to hepatitis C virus was admitted to our hospital for radiofrequency ablation of residual tumor following lusutrombopag administration. Laboratory tests revealed thrombocytopenia and leukopenia. The patient’s LC was managed, and he was classified as Child–Pugh A. After admission, lusutrombopag was administered for 7 days. The platelet count increased to over 50,000/mm3 after 7–14 days and returned to previous levels 50 days after administration. Leukocyte and erythrocyte counts also increased in response to the treatment and stayed elevated for over 120 days. Lusutrombopag acts selectively on human thrombopoietin (TPO) receptors and activates signaling pathways that promote the proliferation and differentiation of bone marrow progenitor cells into megakaryocytes, consequently increasing the blood platelet count. However, the patient treated with lusutrombopag in our case study showed increased blood leukocyte and erythrocyte counts as well. Given that TPO receptors are reportedly expressed in not only megakaryocyte progenitor cells but also hematopoietic progenitors, lusutrombopag may potentially improve pancytopenia caused by LC and can be used for the recovery of blood counts before other treatments.

Real-world efficacy and safety of daclatasvir and asunaprevir therapy for hepatitis C virus-infected cirrhosis patients.

Daclatasvir and asunaprevir combination therapy has shown a high virological response for chronic genotype 1 hepatitis C virus (HCV) infected-patients. However, the real-world efficacy and safety of the therapy for patients with cirrhosis are unknown. A total of 252 patients with genotype 1 HCV infection (158 with chronic hepatitis and 94 with compensated liver cirrhosis) were treated with 24 weeks of daclatasvir and asunaprevir combination therapy. Plasma concentrations of daclatasvir and asunaprevir at day 5 of treatment, end-of-treatment response, sustained virological response (SVR), and the frequencies of adverse events were analyzed. Plasma asunaprevir concentration was significantly higher, and daclatasvir concentration tended to be higher, in cirrhosis patients compared with chronic hepatitis patients. End-of-treatment response was achieved in 95.6% and 94.7% of chronic hepatitis and cirrhosis patients, respectively, and SVR was achieved in 94.3% and 92.6%. Although pre-treatment NS5A drug resistant-associated variants were detected, a high SVR rate was achieved when the population frequency of the variant was low. The frequencies of treatment-related adverse events in cirrhosis patients were similar to those in chronic hepatitis patients. Treatment discontinuation due to adverse events occurred in three and two patients in chronic hepatitis and cirrhosis groups, respectively; however, four out of five patients with treatment discontinuation nonetheless achieved SVR. Patients with compensated liver cirrhosis have similar virological response and tolerance for daclatasvir plus asunaprevir therapy to patients with chronic hepatitis. This combination therapy might offer a safe and effective treatment for chronic HCV infected-patients with compensated cirrhosis.

Study of the clinical application of prealbumin, total bile acid, and red blood cell volume distribution width in chronic liver disease

Objective To explore the clinical application value of the prealbumin (PA), total bile acid (TBA), and red blood cell volume distribution width (RDW) in chronic liver disease. Methods Totally 393 cases of patients with chronic liver disease admitted by Xiangya Hospital of Central South University from March 2015 to March 2016 were selected as group observation, and were divided into chronic hepatitis, compensated liver cirrhosis, decompensated liver cirrhosis and primary liver cancer. At the same time, 200 cases of healthy volunteers were collected as normal control. Serum prealbumin and total bile acids were tested as well as the RDW of all cases. SPSS 17.0 software was used for data statistics processing. The receiver-operating characteristic curve (ROC) was drawn to evaluate the diagnosis value of the indexes in chronic liver disease severity. Results PA in the observation group was significantly lower than normal control, while its TBA and RDW were significantly higher than normal control. All of three parameters in patients, especially with liver cirrhosis and decompensated liver cirrhosis, had higher positive rate. When the clinical diagnosis was taken as gold standard, the best level of PA to diagnose primary liver cancer, chronic hepatitis and decompensated liver cirrhosis was 244.7 mg/L, 238.5 mg/L and 132.8 mg/L, the AUC was 0.973, 0.909 and 0.879, the sensitivity was 92.3%, 95.1% and 85.6%, and the specificity was 95.8%, 72.8% and 79.7%; the best level of RDW to diagnose primary liver cancer, chronic hepatitis and decompensated liver cirrhosis was 13.2%, 13.8% and 14.3%, the AUC was 0.816, 0.827 and 0.818, the sensitivity was 66.7%, 77.4% and 72.2%, and the specificity was 79.5%, 73.8% and 77.3%. When combined detection of PA and RDW, the diagnostic performance had improved significantly. Conclusions Serum prealbumin and total bile acid, as well as the whole blood RDW may objectively reflect the injury of liver metabolism and synthesis function, and for the early diagnosis and prognosis of patients with chronic liver disease has a important clinical significance. Key words: Prealbumin/ME/DU; Bile acids and salts/ME/DU; Erythrocyte volume; Liver diseases/DI/ME

Transient Elastography for Predicting Liver-Related Events in Cirrhotic HIV-Infected Patients

Aim: We assessed liver stiffness measurement (LSM) for the prediction of mortality and decompensation in HIVinfected patients with compensated liver cirrhosis. Method: A prospective cohort study of HIV-infected patients with confirmed liver cirrhosis from 9 hospitals in Spain. LSM was undertaken for each patient; clinical events were collected prospectively after the baseline visit, and patients were followed until death or the censoring date. We used univariate/multivariate Cox proportional hazard models to evaluate the utility of LSM for predicting the first hepatic decompensation or overall mortality. The sensitivity (SEN), specificity (SPE), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were calculated. The LSM cutoff was selected using ROC curves. Results: We included 102 patients with compensated liver cirrhosis; median [interquartile, (IQR)] follow-up was 36 (21-46) months, median (IQR) CD4+ cell count was 415 cells/μL (307-624) and 94% were receiving antiretroviral therapy. The median (IQR) LSM was 17 kPa (11.7-26). Nineteen events were recorded during follow-up. Multivariate analysis showed that time to hepatic decompensation was associated with CD4+ <200 cells/μL (HR, 26; 95% CI, 1.8- 377; p<0.02) and LSM ≥ 25 kPa (HR, 7.2; 95% CI, 1.1-47; p=0.04) and that time to overall mortality was associated with LSM ≥ 25 kPa (HR, 14.3; 95% CI, 1.5-138; p=0.02). The predictive values for decompensation (LSM ≥ 25 kPa) were as follows: SEN, 67%; SPE, 78%; NPV, 96%; PPV, 23%; LR+, 3; LR-, 0.4. The predictive values for overall mortality with this LSM cutoff were as follows: SEN, 86%; SPE, 79%; NPV, 99%; PPV, 23%; LR+, 4; LR-, 0.2. Conclusion: Our data suggest that LSM is an accurate method for the prediction of mortality and decompensation in HIV-infected patients with liver cirrhosis.

THU-240 - Outcome of patients with compensated liver cirrhosis with hepatitis B virus + hepatitis C virus coinfection treated with paritaprevir/ombitasvir/ritonavir, dasabuvir with ribavirin: a national cohort study

THU-240 - Outcome of patients with compensated liver cirrhosis with hepatitis B virus + hepatitis C virus coinfection treated with paritaprevir/ombitasvir/ritonavir, dasabuvir with ribavirin: a national cohort study

Anticardiolipin antibody in egyptian patients with chronic hepatitis c in correlation with liver injury

Background The presence of anticardiolipin (ACL) antibodies in chronic hepatitis C may be owing to induction of neoantigens by chronic viral infection, which may be because of disruption of liver cell membranes. The occurrence of these ACL antibodies may be observed because of recognition of these neoantigens by the immune system. Aim The aim of the work was to study the prevalence and clinical significance of ACL antibodies in chronic hepatitis C infection and their relationship with disease progression. Participants and methods Our study was performed on 90 individuals recruited from Gastroenterology and Hepatology Outpatient Clinics and Internal Medicine Department of Kafr Sheikh Institute. The participants were divided into the following three groups: group A consisted of 30 patients with chronic hepatitis C virus (HCV) infection with compensated liver cirrhosis, group B consisted of 30 patients with chronic HCV infection with decompensated liver cirrhosis, and group C consists of 30 individuals as control. All patients and control were subjected to full history taking, full clinical examination, complete blood count, liver function tests, renal profile, pelvis–abdominal ultrasound, and serum levels of ACL immunoglobulin G and α-fetoprotein. Results The results showed that seven (23%) of the HCV-positive patients in group A and 18 (60%) of the HCV-positive patients in group B were ACL immunoglobulin G-positive in comparison with none in the control group (0%). Conclusion The prevalence of ACL antibodies is increased during HCV infection, and HCV should be regarded as a possible causative factor in the antiphospholipid syndrome.

Endoscopic ultrasound-guided fine needle aspiration cytology from unusual locations

Case 1:A 34-year-old female had breast surgery followed by chemotherapy in 2006. She had local axillary recurrence after 2 year after surgery, for which he received treatment. She had bone lytic lesion in 2011 for which she received radiotherapy and was kept on hormonal therapy. She was doing well. A positron emission tomography scan in 206 showed posterior pericardial lesion measuring 3.2 cm × 1.6 cm. An endoscopic ultrasound-guided fine needle aspiration (EUS FNA) was done from pericardial lesion which was positive for malignancy.Case 2:A 52-year-old male with hepatitis B virus-related compensated liver cirrhosis (Child–Pugh–Turcotte - 6, model for end-stage liver disease - 14) with multicenter hepatocellular carcinoma (HCC) status posttransarterial chemoembolization, planned for living donor liver transplantation after complete workup. He had an isolated 9.5 mm paracaval lymph node at large axis on recent dynamic computed tomography and was referred for EUS FNA as a routine protocol for HCC. We did EUS-FNA with 25-gauge needle transaortic and transvenous, one pass was taken from the lymph node which was positive for malignancy, and LT was deferred.

Impact of Wisteria floribunda Agglutinin-Positive Mac-2-Binding Protein in Patients with Hepatitis C Virus-Related Compensated Liver Cirrhosis.

We aimed to examine the effect of Wisteria floribunda agglutinin-positive Mac-2-binding protein (WFA+-M2BP) level on survival comparing with other laboratory liver fibrosis markers in hepatitis C virus (HCV)-related compensated liver cirrhosis (LC) (n = 165). For assessing prognostic performance of continuous fibrosis markers, we adapted time-dependent receiver operating characteristics (ROC) curves for clinical outcome. In time-dependent ROC analysis, annual area under the ROCs (AUROCs) were plotted. We also calculated the total sum of AUROCs in all time-points (TAAT score) in each fibrosis marker. WFA+-M2BP value ranged from 0.66 cutoff index (COI) to 19.95 COI (median value, 5.29 COI). Using ROC analysis for survival, the optimal cutoff point for WFA+-M2BP was 6.15 COI (AUROC = 0.79348, sensitivity = 80.0%, specificity = 74.78%). The cumulative five-year survival rate in patients with WFA+-M2BP ≥ 6.15 COI (n = 69) was 43.99%, while that in patients with WFA+-M2BP < 6.15 COI (n = 96) was 88.40% (p < 0.0001). In the multivariate analysis, absence of hepatocellular carcinoma (p = 0.0008), WFA+-M2BP < 6.15 COI (p = 0.0132), achievement of sustained virological response (p < 0.0001) and des-γ-carboxy prothrombin < 41 mAU/mL (p = 0.0018) were significant favorable predictors linked to survival. In time-dependent ROC analysis in all cases, WFA+-M2BP had the highest TAAT score among liver fibrosis markers. In conclusion, WFA+-M2BP can be a useful predictor in HCV-related compensated LC.

Non-invasive assessment of liver fibrosis by means of Transient Elastography and Fibrotest in patients with HCV compensated liver cirrhosis

Non-invasive assessment of liver fibrosis by means of Transient Elastography and Fibrotest in patients with HCV compensated liver cirrhosis

Which elastographic method is more feasible in assessing spleen stiffness in patients with HCV compensated liver cirrhosis?

Which elastographic method is more feasible in assessing spleen stiffness in patients with HCV compensated liver cirrhosis?

Effects of home-based exercise and branched-chain amino acid supplementation on aerobic capacity and glycemic control in patients with cirrhosis.

The aim of the current study is to examine whether home-based step exercise at anaerobic threshold (AT) and branched-chain amino acid (BCAA) supplementation improve aerobic capacity, ectopic fat in liver and muscle, and glycemic control in patients with liver cirrhosis. Six female patients with compensated liver cirrhosis received oral BCAA and were instructed to undertake bench step exercises at an intensity that corresponded to AT, with a goal of performing 140min of exercise per week at home for 12months. Fat deposition in liver (liver to spleen ratio) and intramuscular adipose tissue content were assessed at baseline and after 6 and 12months by computed tomography. Glycemic control indices (homeostasis model assessment of insulin resistance, hemoglobin A1c [HbA1c ], glycated albumin [GA] and chronic liver disease [CLD]-HbA1c [average of HbA1c and GA/3]) were also measured. Twelve months of moderate training significantly increased AT, which is an index of aerobic capacity, but no changes were observed in body weight, liver to spleen ratio, or intramuscular adipose tissue content. Glycated albumin significantly decreased (P <0.05) and there tended to be a similar decrease in CLD-HbA1c (P <0.1) after the exercise. The baseline serum triglyceride level correlated with changes in GA (P <0.01) and CLD-HbA1c (P <0.1). The current results suggest that the combination of home-based step exercise at AT and BCAA supplementation enhances aerobic capacity and potentially improves glycemic control in patients with cirrhosis without changes in body weight. The baseline serum serum triglyceride may partially explain the degree of improvement in glycemic control with exercise and BCAA intervention.

Critical comparison of elastography methods to assess chronic liver disease.

Staging of liver fibrosis and diagnosis, or exclusion, of early compensated liver cirrhosis are important in the treatment decisions and surveillance of patients with chronic liver disease. Good diagnostic accuracy, increased availability and the possibility to perform follow-up examinations led to the implementation of noninvasive methods into clinical practice. Noninvasive tests are increasingly included in national and international guidelines, leaving liver biopsy reserved for patients with unexplained discordance or suspected additional aetiologies of liver disease. In addition to staging of liver fibrosis, data on the prognostic value of these methods have increased in the past few years and are of great importance for patient care. This Review focuses on elastography methods for noninvasive assessment of liver fibrosis, disease severity and prognosis. Although liver elastography started with transient elastography, at present all large ultrasonography companies offer an elastography technique integrated in their machines. The goal of this Review is to summarize the methodological problems of noninvasive tests in general, in addition to providing an overview on currently available techniques and latest developments in liver elastography.

TRACE ELEMENTS IN PLASMA AND NUTRITIONAL ASSESSMENT IN PATIENTS WITH COMPENSATED CIRRHOSIS ON A LIVER TRANSPLANT LIST.

- In chronic liver disease, trace element levels in plasma are usually low. However, the specific cause and functional implications of this abnormality are yet not well understood. These element levels may decrease as a result of abnormal liver function in patients with cirrhosis and/or malnutrition. - To evaluate the nutritional status and the profile of trace elements in plasma of patients with cirrhosis on a liver transplant list and to correlate them with disease severity. - This cross-sectional study evaluated 31 male patients diagnosed with compensated liver cirrhosis on a waiting list for liver transplant. Nutritional status was objectively evaluated through anthropometry using Mendenhall score and Blackburn classification, subjectively through the Detsky questionnaire and severity of the disease by MELD and CTP score. Trace elements (Zn, Se, Cu, Ca, Fe, Mg and Mn) in plasma were analyzed by inductively coupled plasma mass spectrometry (ICP-MS). Statistical analysis was performed using Mann-Whitney test. - According to the nutritional assessment 19 (61.3%) were malnourished and 12 (38.7%) were overweight. Regarding disease severity 12 (39%) were classified as Child A, 17 (55%), Child B and 2 (6%) Child C, with 46.9% of patients with MELD score >17. The trace element analysis indicated that 31 (100%) had Mn levels above the reference range, 23 (74.2%) low levels of Cu, 29 (93.5%) with deficiency of Se, and 31 (100%) low levels of Ca and Mg. Disease severity did not show statistical difference between the studied trace elements, in contrast to the nutritional status, in which the malnourished group showed higher levels of Mn (P=0.01) and Fe (P=0.01) and low levels of Zn (P=0.03) when compared to the overweight group. - The results showed that the trace elements in plasma are altered in chronic liver disease; without significant correlation to disease severity, but correlated to nutritional status. Malnutrition is present in the patients studied, nonetheless a new scenario with an increase in the prevalence of overweight was verified regardless of the degree of hepatic decompensation.

Evidence-based clinical practice guidelines for liver cirrhosis 2015.

The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding arethe endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.

Living donor liver transplantation indicated for compensated liver cirrhosis with symptomatic gallstone diseases: report of two cases.

BackgroundSurgical interventions for symptomatic gallstone disease could be dangerous in patients with severe comorbid conditions including liver cirrhosis. Here, we report our experience of living donor liver transplantation (LDLT) indicated for two patients with liver cirrhosis complicated with gallstone diseases.Case 1A 70-year-old woman with a history of hepatitis C virus infection was diagnosed as symptomatic choledocholithiasis. She had open cholecystectomy and choledochotomy with choledocholithotomy, which complicated with postoperative liver failure. Her Child-Pugh score increased from 7 to 12 points and Model for End-Stage Liver Disease (MELD) score from 11 to 36. She underwent LDLT, using the right lobe graft donated by her 47-year-old daughter. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 27.Case 2A 46-year-old man with a history of hepatitis B virus infection was diagnosed as cholecystitis. He had cholecystostomy without any complications and his Child-Pugh score remained to be 9 and MELD score 17, followed by LDLT using the right lobe graft donated by his 45-year-old wife. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 44.ConclusionLDLT is one of treatment options when patients with Child-Pugh B cirrhosis accompanied with gallstone diseases, likely to be deteriorating their liver functions in the near future.

Diagnostic Performance of Shear Wave Elastography for Predicting Esophageal Varices in Patients With Compensated Liver Cirrhosis.

The purpose of this study was to investigate the diagnostic performance of shear wave elastography (SWE) for predicting the presence of esophageal varices and high-risk esophageal varices in patients with compensated cirrhosis and to compare it with other nonspecific predictors and according to the presence of splenomegaly. Clinical data from 103 patients with compensated cirrhosis who underwent sonography, SWE, and endoscopy were collected consecutively. Liver stiffness was measured by SWE. Comparisons of the accuracy of prediction between groups were made by areas under the receiver operating characteristic curves (AUROCs), and regression analyses were performed for the multiple variables related to the presence of esophageal varices and high-risk varices. The optimal cutoff values for predicting the presence of esophageal varices and high-risk varices were 13.9 and 16.1 kPa, respectively. The AUROC of liver stiffness for prediction of esophageal varices was significantly higher than the AUROCs of platelet count, spleen diameter, and platelet count/spleen diameter ratio (P = .025; P = .001; P = .027). For predicting esophageal varices in patients without splenomegaly, the AUROC of liver stiffness was higher than that of the platelet count/spleen diameter ratio. In multivariate logistic regression analysis, liver stiffness and the platelet count/spleen diameter ratio were independent predictors of esophageal varices (P < .001; P = .038). For the presence of high-risk varices, only liver stiffness was a statistically significant independent predictor (P = .012). In patients with compensated cirrhosis, liver stiffness measured by SWE is a new effective noninvasive diagnostic tool for predicting the presence of esophageal varices. It is more accurate than the platelet count/spleen diameter ratio, especially in patients without splenomegaly. In addition, the SWE value was the only effective independent factor for predicting high-risk esophageal varices.

Von Willebrand Factor/thrombocytes (VITRO Score) and its diagnostic role as a non-invasive predictor of decompensation, mortality and portal hypertension in patients with compensated liver cirrhosis

Aim: vWF-Ag and VITRO Score are promising non-invasive markers in diagnosis and prognosis of liver cirrhosis. We hypothesized that VITRO-score can predict mortality and CSPH associated complications in patients with compensated liver cirrhosis.

Is intestinal oxidative stress involved in patients with compensated liver cirrhosis?

Background. Liver cirrhosis is associated with intestinal epithelial barrier dysfunction, which may be affected by oxidative stress. Studies in cirrhotic rats provided evidence for intestinal oxidative stress, but studies in cirrhotic patients are scarce. We have shown intestinal barrier dysfunction in patients with compensated cirrhosis.Aim. The present study aimed to investigate whether oxidative stress occurs in the intestinal mucosa of compensated cirrhotic patients and may contribute to barrier dysfunction.Material and methods. Oxidative stress was studied in duodenal and sigmoid biopsies from 15 cirrhotic patients and 22 controls by analyzing transcription of genes involved in glutathione and uric acid metabolism using quantitative real-time polymerase chain reaction. Protein levels of glutathione and glutathione disulphide were measured and the glutathione/glutathione disulphide ratio was calculated as marker of oxidative stress. In addition, intestinal myeloperoxidase and fecal calprotectin were determined.Results. Gene transcription of glutathione synthetase and glutathione reductase were significantly different in duodenal and sigmoid biopsies of cirrhotic patients vs. controls, but no alterations were found for other genes nor for glutathione, glutathione disulphide, glutathione/glutathione disulphide ratio and intestinal myeloperoxidase and fecal calprotectin concentrations.Conclusion. This study did not find indications for oxidative stress and low-grade inflammation in the small and large intestine of stable compensated cirrhotic patients. Although these preliminary findings need further validation, we found intestinal oxidative stress not to be a major mechanism contributing to epithelial barrier dysfunction in patients with compensated cirrhosis.

Inaccuracies of Hemoglobin A1c in Liver Cirrhosis: A Case Report

Hemoglobin A1c (HbA1c) is the gold standard for the measurement of long-range glycemic control in patients with diabetes mellitus type 2 (T2DM). In a rare subset of patients, this measurement may not be reliable. Inaccuracies of HbA1c in liver cirrhosis are rare, but documented. The objective of this study was to increase awareness about low HbA1c in liver cirrhosis and discuss alternative biomarkers that can be used to measure glycemic control. We present the case of a 61-year-old Caucasian female, with history of hepatitis C and uncontrolled T2DM, who was admitted for evaluation of compensated liver cirrhosis. She was found to have blood glucoses greater than 500 mg/dL; however, her HbA1c was measured at 5.5%. Ultrasound of the abdomen showed liver cirrhosis, ascites, and splenomegaly. Blood work revealed acute kidney injury, anemia of chronic disease, normal albumin level, and low HbA1c. Fructosamine and glycated albumin were high, indicating a hyperglycemic status during the last 3 weeks. HbA1c can be falsely low in liver cirrhosis, and can give a false assumption about control of the diabetic disease process. In this case, other biomarkers can be used to monitor glycemic control; by far frequent finger stick monitoring is the best method. J Endocrinol Metab. 2016;6(1):30-32 doi: http://dx.doi.org/10.14740/jem326w