Complication Of Chronic Liver Disease Research Articles

Small varices in chronic liver diseases.

Gastroesophageal varices are common complications of chronic liver diseases (CLDs) and portal hypertension. Small varices have the risk of progressing to larger varices, causing bleeding or even death. Thus, early detection and appropriate management of small varices are necessary. The purpose of this review is to summarize the advance in the recent 5years about diagnosing and managing the small varices in CLDs. The diagnosing methods of small varices in recent studies include improved endoscopic examinations, such as capsule endoscopy, and many noninvasive methods, including blood tests, ultrasound, computed tomography and magnetic resonance. For the management of small varices, though it is controversial, prevention using nonselective beta-blockers is still an essential part. In this review, we summarize the classification of varices, the invasive and noninvasive diagnostic methods, their performances, and the emerging progression in the management of small varices in the recent 5 years. We hope that this review provides relevant information to understand better and appropriately manage small varices.

The effect of holding a workshop (group and face-to-face training method) on nutrition adjustment on anthropometric indices in children with chronic liver disease

Complications of chronic liver disease (CLD) in children play an important role in mortality and disability. This disease is one of the health problems of the country and due to its chronic and irreversible disease, it needs care and treatment education programs. Therefore, this study was performed to determine the effect of nutrition adjustment training program on anthropometric indices in children with CLD. This clinical trial study was performed on 75 children (45 in the intervention group and 30 in the control group) with CLD in the nutrition clinic of Ghaem Educational-Research Center in Mashhad. Children and caregivers with inclusion criteria entered the study after completing written consent. Anthropometric indices (abdominal circumference, body water level, body fat, height, weight, body mass index, arm circumference) were measured and recorded in children at the beginning of the study. Children and their caregivers were randomly divided into control and intervention groups. The intervention group underwent nutritional adjustment (calculation of energy and carbohydrates, lipids and proteins, vitamins and minerals, calculation and selection of diet) training (face to face) for 6 sessions (each session 90-120 min, three times a week for 2 weeks). Twelve weeks after the start of the study, children in both intervention and control groups were evaluated for anthropometric indices. The collected data were analyzed by SPSS software version 16 and descriptive and analytical statistical tests (Mann-Whitney and Wilcoxon). The results of Wilcoxon statistical test showed that children in the intervention group at the end of the study compared to the beginning of the study had significant changes in scores around the abdomen (P = 0.001), total body water (P = 0.009), total fat (0.001 > P), height (P = 0.001), weight (P < 0.001), body mass index (P < 0.001), arm circumference (P < 0.001). The mean scores at the end of the study increased compared to the beginning of the study, but the mean scores of the studied indices in the control group did not change significantly. The results of this study showed that diet adjustment training program can be effective on anthropometric indices of children with CLD. For this purpose, the use of this educational method is recommended to improve the anthropometric indices of these children.

Epidemiology and High Rate of Procedure-Related In-Hospital Complications of Chronic Liver Disease in Germany

Epidemiology and High Rate of Procedure-Related In-Hospital Complications of Chronic Liver Disease in Germany

Ultrasonographic Determination of Portal Vein Diameter Among Adults with and without Chronic Liver Disease at Selected Referral Hospitals in Southern Ethiopia.

BackgroundMeasuring portal vein diameter (PVD) is a feasible method of detecting portal vein hypertension, which is a primary and fatal complication of chronic liver disease (CLD) and is usually diagnosed very late. However, there is a paucity of morphometric information on portal vein diameter in the Ethiopian population. Hence, it is important to determine the portal vein diameter among adults with and without chronic liver disease.PurposeThe study aimed to identify how PVD is affected by age, sex, and anthropometric measurements in patients with and without CLD.MethodsA cross-sectional study was conducted among 220 participants (110 CLD patients and 110 controls) who have visited the radiology unit at selected Hospitals. Patients with CLD were selected consecutively as they present while controls were selected by a systematic sampling technique. A structured questionnaire was used to collect the data. Correlation and independent t-test were used to assess the relations. A statistically significant association was declared at P-value <0.05.ResultsMean portal vein diameter for CLD patients was 17.03±1.97 mm with a range of 12.8−20.8mm and 10.79±1.27mm with a range of 7.70–13.25mm for the control group. Age, weight, and body mass index had a positive correlation with portal vein diameter in both groups. The mean portal vein diameter increased by 21.34% during deep inspiration in the control group.ConclusionThe mean portal vein diameter among patients with CLD was higher than that of the control group. A significant gender-based difference was recorded in the portal vein diameter of the control group only. Ultrasonography is a non-invasive, readily available diagnostic tool for portal vein pathology.RecommendationIt is recommended for clinicians to take into consideration age, sex and anthropometric measurements while measuring PVD.

Weil’s disease: A diagnostic dilemma

Leptospirosis is a zoonotic disease that predominantly occurs in tropical and subtropical areas. It is caused by the spirochete Leptospira interrogans complex and may lead to syndromes that can vary from a subclinical infection or a mild febrile infection to a severe icterohemorrhagic condition. This is a case report on a 52-year-old farmer who had presented with upper gastrointestinal (GI) bleed. He was initially thought to be a case of complications of Chronic Liver Disease. However, he was later found to have icterus, renal failure, and hemorrhagic manifestations and his IgM ELISA for leptospira was positive. It was later confirmed by MAT. He was treated with antibacterials and supportive measures and his clinical and biochemical parameters improved. The occurrence of Weil’s disease in the month of November and its occurrence in the state of Assam, India was unpredictable and hence posed as a diagnostic dilemma. It is a curable disease and hence needs timely intervention and treatment. This highlights the need for a better understanding of the natural course of this disease and improvement of public health measures.

Prevalence of Bleeding and Thrombosis in Critically Ill Patients with Chronic Liver Disease.

Hemorrhage and venous thromboembolism (VTE) are recognized complications of chronic liver disease (CLD), but their prevalence and risk factors in critically ill patients are uncertain. We studied a retrospective cohort of patients with CLD nonelectively admitted to a specialist intensive care unit (ICU) determining the prevalence and timing of major bleeding and VTE (early, present on admission/diagnosed within 48 hours; later, diagnosed >48 hours post-ICU admission). Associations with baseline clinical and laboratory characteristics, multiorgan failure (MOF), blood product administration, and mortality were explored. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression. Of 623 patients with median age 52, bleeding (>48 hours after admission) occurred in 87 (14%) patients. Bleeding was associated with greater illness severity and increased mortality. Gastrointestinal bleeding accounted for 72% of events, secondary to portal hypertension in >90%. Procedure-related bleeding was uncommon. VTE occurred in 125 (20%) patients: early VTE in 80 (13%) and involving the portal vein in 85%. Later VTE affected 45 (7.2%) patients. Hepatocellular carcinoma (HCC) and nonalcoholic liver disease were independently associated with early VTE (OR: 2.79, 95% CI: 1.5-5.2 and OR: 2.32, 95% CI: 1.4-3.9, respectively), and HCC, sepsis, and cryoprecipitate use with late VTE (OR: 2.45, 95% CI: 1.11-5.43; OR: 2.26, 95% CI: 1.2-4.3; and OR: 2.60, 95% CI: 1.3-5.1). VTE was prevalent on admission to critical care and less commonly developed later. Bleeding was associated with MOF and increased mortality. Severe MOF was not associated with an increased rate of VTE which was linked with HCC, and specific etiologies of CLD.

Changes in Platelet Counts and Thrombocytopenia Risk in Patients with Chronic Liver Disease with Different Etiologies Using Real-World Japanese Data.

IntroductionThrombocytopenia, a common complication of chronic liver disease (CLD), adversely affects the treatment in patients requiring invasive procedures. Multiple pathophysiological mechanisms contribute to the development of thrombocytopenia; thus, its incidence could differ among CLD etiologies. We investigated the risk of decline in platelet counts and developing thrombocytopenia across different CLDs in a real-world Japanese setting.MethodsA Japanese claims database including 25 million patients (April 2008–August 2018) was used. Patients with at least one CLD diagnosis were classified into nine mutually exclusive categories: hepatitis B, hepatitis C, hepatitis B and C, unspecified viral hepatitis, autoimmune hepatitis, toxin/drug-induced hepatitis, alcoholic hepatitis, nonalcoholic steatohepatitis, and others. A random effects model was used to estimate the changes in platelet counts; proportional hazard analyses were used to examine factors associated with the incidence of thrombocytopenia based on the diagnosis. Patients with laboratory test data as variables were included in each analysis.ResultsThe simulation included 68,536 patients. The mean values representing changes in the platelet count were significantly negative in the hepatitis C patients and negative, though non-significant, in the hepatitis B, toxin/drug-induced hepatitis, alcoholic hepatitis, and nonalcoholic steatohepatitis patients. In the proportional hazard analysis, 708 of 22,728 patients had thrombocytopenia. The hazard ratio (HR) was significantly high for patients with hepatitis B (HR, 2.879; p < 0.001), hepatitis C (HR, 1.876; p < 0.001), and hepatitis B and C (HR, 2.992; p < 0.001).ConclusionA decreasing tendency in platelet counts was observed in most CLD etiologies, with hepatitis C showing a significant decrease. The incidence of thrombocytopenia was mostly associated with hepatitis B and/or C. Further research is warranted to elucidate the discrepancy between the decline in platelet counts and thrombocytopenia diagnosis, considering the factors relevant to the diagnosis, such as the frequency of outpatient visits and CLD treatment.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-02008-x.

Elastography as a predictor of liver cirrhosis complications after hepatitis C virus eradication in the era of direct-acting antivirals.

Chronic inflammation due to hepatitis C virus (HCV) infection leads to liver fibrosis and rearrangement of liver tissue, which is responsible for the development of portal hypertension (PH) and hepatocellular carcinoma (HCC). The advent of direct-acting antiviral drugs has revolutionized the natural history of HCV infection, providing an overall eradication rate of over 90%. Despite a significant decrease after sustained virological response (SVR), the rate of HCC and liver-related complications is not completely eliminated in patients with advanced liver disease. Although the reasons are still unclear, cirrhosis itself has a residual risk for the development of HCC and other PH-related complications. Ultrasound elastography is a recently developed non-invasive technique for the assessment of liver fibrosis. Following the achievement of SVR, liver stiffness (LS) usually decreases, as a consequence of reduced inflammation and, possibly, fibrosis. Recent studies emphasized the application of LS assessment in the management of patients with SVR in order to define the risk for developing the complications of chronic liver disease (functional decompensation, gastrointestinal bleeding, HCC) and to optimize long-term prognostic outcomes in clinical practice.

Simultaneous embolization of a spontaneous porto-systemic shunt and intrahepatic arterioportal fistula: A case report

BACKGROUNDHepatic encephalopathy (HE) is a frequent and debilitating complication of chronic liver disease. Recurrent HE is strongly linked with spontaneous portosystemic shunts (SPSSs). Intrahepatic arterioportal fistulas (IAPFs) occur rarely but pose a major clinical challenge and may lead to or worsen portal hypertension. Herein, we present a rare case of recurrent HE secondary to a SPSS combined with an IAPF.CASE SUMMARYA 63-year-old female with primary biliary cirrhosis presented with recurrent disturbance of consciousness for 4 mo. SPSS communicating the superior mesenteric vein with the inferior vena cava and IAPF linking the intrahepatic artery with the portal vein were found on contrast-enhanced abdominal computed tomography. The patient did not respond well to medical treatment. Therefore, simultaneous embolization of SPSS and IAPF was scheduled. After embolization, the symptoms of HE showed obvious resolution.CONCLUSIONThe presence of liver vascular disorders should not be neglected in patients with chronic liver disease, and interventional therapy is a reasonable choice in such patients.

Differences between sporadic hyperplastic gastric polyps and portal hypertensive gastric polyps: a review.

Portal hypertension (PH) is one of the most severe complications of chronic liver diseases. It is defined as an increase in pressure in the portal venous system which results in a portosystemic gradient >5 mmHg. In the western world, cirrhosis is the most frequent cause of PH, mainly due to nonalcoholic fatty liver disease and alcoholic liver disease. Patients with PH have esophageal varices in 68-73% of cases, portal hypertensive gastropathy in 51-73% and hyperplastic polyps (HPs) in 0.9-2%. Recent studies have shown that HPs found in PH patients are different from classical HPs. They constitute a new entity called portal hypertensive polyps (PHPs). The main difference between sporadic HPs and PHP is the presence of larger and more numerous vascular capillaries in the lamina propria. The clinical course of PHPs is unknown. Their physiopathology seems different from HPs: the increased congestion caused by higher portal pressure in the stomach may induce capillaries proliferation and neoangiogenesis. PHPs may be responsible for symptoms, such as pyloric obstruction, iron deficiency and anemia. Their prevalence in portal hypertensive and cirrhotic patients is from 1% to 8%. PHPs can be single or numerous, in the antrum or the gastric corpus. Their size ranges from 2 to 3 cm. PHPs seem to disappear or shrink with the treatment of PH. They should be resected in case of symptom and if >10 mm, after Helicobacter pylori eradication if present. However, their recurrence is frequent (40-79%), thus surveillance endoscopy is mandatory, at the same time as esophageal varices.

Hepatopulmonary Syndrome and Portopulmonary Hypertension: Pulmonary Vascular Complications of Liver Disease.

Pulmonary vascular disease is a frequent complication of chronic liver disease and portal hypertension, affecting up to 30% of patients. There are two distinct pulmonary vascular complications of liver disease: hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). HPS affects 25% of patients with chronic liver disease and is characterized by intrapulmonary vasodilatation and abnormal arterial oxygenation. HPS negatively impacts quality of life and is associated with a 2-fold increased risk of death compared to controls with liver disease without HPS. Angiogenesis, endothelin-1 mediated endothelial dysfunction, monocyte influx, and alveolar type 2 cell dysfunction seem to play important roles in disease pathogenesis but there are currently no effective medical therapies. Fortunately, HPS resolves following liver transplant (LT) with improvements in hypoxemia. POPH is a subtype of pulmonary arterial hypertension (PAH) characterized by an elevated mean pulmonary arterial pressure and pulmonary vascular resistance in the setting of normal left-sided filling pressures. POPH affects 5% to 6% of patients with chronic liver disease. Although the pathogenesis has not been fully elucidated, endothelial dysfunction, inflammation, and estrogen signaling have been identified as key pathways involved in disease pathogenesis. POPH is typically treated with PAH targeted therapy and may also improve with liver transplantation in selected patients. This article highlights what is currently known regarding the diagnosis, management, pathobiology, and outcomes of HPS and POPH. Ongoing research is needed to improve understanding of the pathophysiology and outcomes of these distinct and often misunderstood pulmonary vascular complications of liver disease. © 2021 American Physiological Society. Compr Physiol 11:1-22, 2021.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications.

Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.

Association between the albumin-bilirubin (ALBI) score and severity of portopulmonary hypertension (PoPH): A data-mining analysis.

Portopulmonary hypertension (PoPH) is a severe complication of chronic liver disease. We aimed to investigate the etiology of chronic liver disease and the factors associated with the severity of PoPH. Echocardiography was undergone in 833 patients with chronic liver disease during 2005-2019 and 13 patients (1.6%) were diagnosed with PoPH in this observational study. At the diagnosis of PoPH, liver function was evaluated by albumin-bilirubin (ALBI) score. Severe PoPH was defined as (1) mean pulmonary arterial pressure (mPAP)≥50mmHg or (2) mPAP: 35-49mmHg and pulmonary vascular resistance≥400dyne/s/cm5 . Factors associated with severe PoPH were evaluated by decision-tree analysis. In patients with PoPH, the leading etiology of chronic liver disease was hepatitis C virus (HCV) (46.2% [sustained virological response (SVR): 23.1% and non-SVR: 15.4%]). Severe PoPH was observed in 53.8% of patients and the 5-year survival rate was 48.1%. There was a significant correlation of mPAP with ALBI score (r=0.6456, p=0.0171). In the decision-tree and random forest analyses, the most impacted classifier for severe PoPH was the ALBI score. In patients with ALBI score≥-1.45, all patients showed severe PoPH, while the prevalence of severe PoPH was 25.0% in patients with ALBI score<-1.45. We found that HCV including SVR was the major etiology of chronic liver disease in patients with PoPH. Moreover, we revealed that the ALBI score was the most impacted factor associated with severe PoPH. Thus, ALBI score may be useful for the estimation of pulmonary vascular resistance.

Evaluation of diagnostic accuracy of C-Reactive protein as a biomarker of spontaneous bacterial peritonitis in patients having decompensated chronic liver disease.

Objective: The objective of this study was to evaluate the diagnostic accuracy of C Reactive Protein (CRP) in diagnosing spontaneous bacterial peritonitis (SBP) in patients with decompensated chronic liver disease. Study Design: Cross Sectional study. Setting: Department of Medicine Sheikh Khalifa Bin Zayed Hospital Rawalakot Azad Kashmir. Period: Feb 2018 to Dec 2018. Material &amp; Methods: One hundred subjects with decompensated liver disease were recruited in this study after fulfilling inclusion criteria. The patients’ medical record number, age and gender was recorded upon admission. Baseline investigations including complete blood count, urine examination and chest X ray were done. Abdominal ultrasound was performed for detecting the presence of ascitic fluid. SBP was diagnosed if &gt; 250 mm3 neutrophils are detected in the ascitic fluid. Serum CRP was detected and reported in mg/L. Results: SBP was detected in 32.8% of the patients having decompensated chronic liver disease. CRP levels were &gt; 29.5mg/L in 36% of the patients while in 64% patients the CRP levels were &lt; 29.5mg/L. The sensitivity of CRP for the diagnosis of SBP was calculated as 83.61% while the specificity was calculated as 87.2%. A positive predictive value was estimated as 76.12% and a negative predictive value was 91.59% while the diagnostic accuracy was calculated as 86.02% from the given data. Conclusion: CRP is a reliable diagnostic biomarker for spontaneous bacterial peritonitis in subjects having complications of chronic liver disease.

Rifaximin-α reduces gut-derived inflammation and mucin degradation in cirrhosis and encephalopathy: RIFSYS randomised controlled trial

Rifaximin-α is efficacious for the prevention of recurrent hepatic encephalopathy (HE), but its mechanism of action remains unclear. We postulated that rifaximin-α reduces gut microbiota-derived endotoxemia and systemic inflammation, a known driver of HE. In a placebo-controlled, double-blind, mechanistic study, 38 patients with cirrhosis and HE were randomised 1:1 to receive either rifaximin-α (550mg BID) or placebo for 90 days. 50% reduction in neutrophil oxidative burst (OB) at 30 days. changes in psychometric hepatic encephalopathy score (PHES) and neurocognitive functioning, shotgun metagenomic sequencing of saliva and faeces, plasma and faecal metabolic profiling, whole blood bacterial DNA quantification, neutrophil toll-like receptor (TLR)-2/4/9 expression and plasma/faecal cytokine analysis. Patients were well-matched: median MELD (11 rifaximin-α vs. 10 placebo). Rifaximin-α did not lead to a 50% reduction in spontaneous neutrophil OB at 30 days compared to baseline (p= 0.48). However, HE grade normalised (p= 0.014) and PHES improved (p= 0.009) after 30 days on rifaximin-α. Rifaximin-α reduced circulating neutrophil TLR-4 expression on day 30 (p= 0.021) and plasma tumour necrosis factor-α (TNF-α) (p <0.001). Rifaximin-α suppressed oralisation of the gut, reducing levels of mucin-degrading sialidase-rich species, Streptococcus spp, Veillonella atypica and parvula, Akkermansia and Hungatella. Rifaximin-α promoted a TNF-α- and interleukin-17E-enriched intestinal microenvironment, augmenting antibacterial responses to invading pathobionts and promoting gut barrier repair. Those on rifaximin-α were less likely to develop infection (odds ratio 0.21; 95% CI 0.05-0.96). Rifaximin-α led to resolution of overt and covert HE, reduced the likelihood of infection, reduced oralisation of the gut and attenuated systemic inflammation. Rifaximin-α plays a role in gut barrier repair, which could be the mechanism by which it ameliorates bacterial translocation and systemic endotoxemia in cirrhosis. ClinicalTrials.gov NCT02019784. In this clinical trial, we examined the underlying mechanism of action of an antibiotic called rifaximin-α which has been shown to be an effective treatment for a complication of chronic liver disease which effects the brain (termed encephalopathy). We show that rifaximin-α suppresses gut bacteria that translocate from the mouth to the intestine and cause the intestinal wall to become leaky by breaking down the protective mucus barrier. This suppression resolves encephalopathy and reduces inflammation in the blood, preventing the development of infection.

Management strategies for chronic liver disease-related thrombocytopenia

Chronic liver disease causes bleeding and coagulation system abnormalities through a variety of mechanisms. Thrombocytopenia is a common complication of chronic liver disease. Patients with chronic liver disease, especially liver cirrhosis, often face more invasive examinations or surgeries, which brings great challenges to clinical diagnosis and treatment. Traditional platelet transfusion is the main clinical intervention. With the approval of thrombopoietin receptor agonists, the current management standards for chronic liver disease-related thrombocytopenia may face changes. This article reviews the current main non-pharmacological and pharmacological interventions for chronic liver disease-related thrombocytopenia, and put forwards the corresponding clinical management improvement strategies based on the efficacy and limitations of these interventions.

Chronic Liver Diseases- Experience at Tertiary Care Centre of Northern India

Introduction: It is important to determine the epidemiological factors like etiology, age, sex, mode of clinical presentation and pattern of development of complications of chronic liver disease, so as to design optimal and cost effective preventive and treatment strategies for the same. Aim: To determine etiology of Chronic liver disease in Northern India. Material and Methods: This was a prospective study done at Medical Gastroenterology Department, PGIMS,Rohtak conducted over a period of ten years i.e. 01.01.2011 to 31.12.2020, on 1000 confirmed patients of chronic liver disease (CLD). Results: The most common etiology seen was Alcoholic liver disease (48.9%), followed by Nonalcoholic liver disease (26.4%), Chronic Hepatitis B (12.3%), Chronic Hepatitis C (9%), Cryptogenic (2.7%) and Autoimmune liver disease related (0.7%). Conclusion: The present study reveals that alcohol is most common cause of chronic liver disease in Northern India. The males of middle age group with rural background are at significant risk of developing CLD, thus requiring immediate social and medical intervention.

P-15 WAITING LIST FOR LIVER TRANSPLANTATIOS: CLINICAL AND ECONOMIC BURDEN, RETROSPECTIVE STUDY

Burden of disease is an indicator that relates to health status. United States (US) and European epidemiological data have shown that the burden of chronic liver disease has increased significantly in recent decades. There are no studies evaluating the impact of complications of chronic liver disease on the waiting list for deceased donor liver transplantation (LTx). To determine the clinical and economic burden of complications of liver disease in wait-listed patients from the perspective of a transplant center. The study retrospectively analyzed medical records of 104 patients wait-listed for deceased donor LTx from October 2012 to May 2016 and whose treatment was fully provided at the study transplant center. Clinical data were obtained from electronic medical records, while economic data were collected from a hospital management software. To allocate all direct medical costs, two methods were used: full absorption costing and micro-costing. The most common complication was refractory ascites (20.2%), followed by portosystemic encephalopathy (12.5%). The mean number of admissions per patient was 1.37 ± 3.42. Variceal hemorrhage was the complication with longest median length of stay (18 days), followed by hepatorenal syndrome (13.5 days). Hepatorenal syndrome was the costliest complication (mean cost of $3565), followed by spontaneous bacterial peritonitis ($2576) and variceal hemorrhage ($1530). The burden of chronic liver disease includes a great cost for health systems. In addition, it is likely to be even greater as a result of the insidious course of the disease.

Role of Flash Glucose Monitoring System in Diabetic Patients with Chronic Liver Disease

Background: Diabetic patients show serious complications of chronic liver disease. The monitoring of glucose in diabetic patients with chronic liver disease is very challenging. Generally, the glycaemic control monitoring in chronic liver disease patients is the same as in a person who does not have any liver disease. Flash glucose monitoring system is a way to measure glucose levels of body without pricking the body. It is an innovative method of measuring glucose levels. A flash glucose monitor is a small sensor. This sensor is a small sticky chip and is attached on the skin of the arm. One side of the chip has a small needle that goes inside the skin. It records glucose levels throughout day and night continuously. Levels of glucose can be assessed whenever wanted. Materials and Methods: The study was conducted in the Medical Ward 1, Bahawal Victoria Hospital, Bahawalpur and the Department of Pathology, Quaid-e-Azam Medical College, Bahawalpur from 1st January 2018 to June 2020. Freestyle Libre Sensor flash glucose monitoring system (by CoolPlus Medical) was used to measure glucose of subcutaneous interstitial fluid. The disposable sensor was applied to the back of the arm for up to 14 days. Sensor is calibrated by the factory with no automatic alarms. Results: We noticed that the results of the patients who had co-existing disease of chronic hepatitis and diabetes mellitus had same results of glucose readings when measured by flash glucose monitoring system and by finger prick for glucose measurement by glucometer. Conclusion: Flash glucose monitoring system is way better than self monitoring blood glucose method by glucometer in diabetic patients with chronic liver disease. Keywords: Diabetes, glucose, monitoring, chronic liver disease, complications

Ramucirumab in patients with previously treated advanced hepatocellular carcinoma: Impact of liver disease aetiology.

Hepatocellular carcinoma (HCC) is a common complication of chronic liver disease with diverse underlying aetiologies. REACH/REACH-2 were global phase III studies investigating ramucirumab in advanced HCC (aHCC) following sorafenib treatment. We performed an exploratory analysis of outcomes by liver disease aetiology and baseline serum viral load. Meta-analysis was conducted in patients with aHCC and alpha-fetoprotein (AFP) ≥400ng/mL (N=542) from REACH/REACH-2 trials. Individual patient-level data were pooled with results reported by aetiology subgroup (hepatitis B [HBV] or C [HCV] and Other). Pre-treatment serum HBV DNA and HCV RNA were quantified using Roche COBAS AmpliPrep/COBAS TaqMan. Overall survival (OS) and progression-free survival (PFS) were evaluated using the Kaplan-Meier method and Cox proportional hazard model (stratified by study). Baseline characteristics were generally balanced between arms in each subgroup (HBV: N=225, HCV: N=127, Other: N=190). No significant difference in treatment effect by aetiology subgroup was detected (OS interaction P-value = .23). Median OS (ramucirumab vs placebo) in months was 7.7 versus 4.5 (HR 0.74, 95% CI 0.55-0.99) for HBV, 8.2 versus 5.5 (HR 0.82, 95% CI 0.55-1.23) for HCV and 8.5 versus 5.4 (HR 0.56, 95% CI 0.40-0.79) for Other. Ramucirumab showed similar overall safety profiles across subgroups. Worst outcomes were noted in patients with a detectable HBV load. Use of HBV antiviral therapy, irrespective of viral load, was beneficial for survival, liver function and liver-specific adverse events. Ramucirumab improved survival across aetiology subgroups with a tolerable safety profile, supporting its use in patients with aHCC and elevated AFP.