Complication Of Cirrhosis Research Articles

Гепаторенальний синдром у дитини з муковісцидозом: аналіз клінічного випадку

Hepato-renal syndrome (HRS) is a rare complication that may accompany end-stage cystic fibrosis-associated cirrhosis in patients with cystic fibrosis. There is currently no unified protocol for the diagnosis and treatment of HRS in cystic fibrosis, particularly in pediatric patients. The main approaches to diagnosing the condition are to detect signs of acute renal failure in a patient with severe liver damage in the absence of shock and in the absence of signs of organic kidney damage or the use of nephrotoxic drugs. Treatment is based on the appointment of vasoconstrictors in combination with albumin infusion and the exclusion of factors that promote the development of HRS, but the method of final therapy remains liver transplantation. The article presents an analysis of the clinical case of HRS and its treatment in a child with cystic fibrosis. Immediate detection of liver cirrhosis in patients with cystic fibrosis, exclusion of the risk factors (massive and protracted surgical interventions, significant volume of extracted ascitic rudin, limiting the use of nephrotoxic drugs and high-dose loop diuretics) is a way to prevent the development of severe liver cirrhosis complications. Immediate recognition and proper management of HRS is a way to protect life before liver transplantation, as well as to preserve the quality of life of patients with cystic fibrosis. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors. Key words: cystic fibrosis, hepatorenal syndrome, liver cirrhosis, ascites, terlipressin.

Nutritional Deficiencies and Clinical Practices in Decompensated Cirrhotics With Hepatic Encephalopathy.

BackgroundHepatic encephalopathy (HE), a major complication of end-stage cirrhosis, is often associated with nutritional deficiencies. We aimed to assess the frequency in which vitamins and zinc were tested for and deficient in our cirrhotic population with HE.MethodsWe performed a retrospective chart review of 143 patients with decompensated cirrhosis that were seen in a hepatology clinic from January 2020 to May 2021. Patient demographics and decompensations were recorded. Vitamins and minerals that were evaluated included zinc, vitamin B12, folate, vitamin D, and thiamine. Continuous variables were reported as mean ± standard deviation and categorical variables were calculated as frequency percentages.ResultsOut of 143 patients, 73 were found to have HE. Out of 73, 33 were male, and the average MELD was 15.5 ± 6.3. 44% of patients had NASH cirrhosis, and 30% had alcoholic cirrhosis. Of the minority of patients that had their nutrient levels checked, 17/23 (74%) were deficient in zinc (<60 mcg/dL). 75% of patients were deficient in thiamine. 2/34 (6%) were deficient in folate (<5.9 ng/mL), 2/10 (20%) in vitamin D (<20 ng/mL), and 2/47 (4%) in B12 (<300 pg/mL).ConclusionNutritional deficiencies are common in cirrhotics with HE. Further studies are needed to determine if routine testing and treatment for vitamin and Zinc deficiencies would have a positive impact on the clinical trajectory of HE.

Abnormal brain oxygen homeostasis in an animal model of liver disease

Background & AimsIncreased plasma ammonia concentration and consequent disruption of brain energy metabolism could underpin the pathogenesis of hepatic encephalopathy (HE). Brain energy homeostasis relies on effective maintenance of brain oxygenation, and dysregulation impairs neuronal function leading to cognitive impairment. We hypothesised that HE is associated with reduced brain oxygenation and we explored the potential role of ammonia as an underlying pathophysiological factor.MethodsIn a rat model of chronic liver disease with minimal HE (mHE; bile duct ligation [BDL]), brain tissue oxygen measurement, and proton magnetic resonance spectroscopy were used to investigate how hyperammonaemia impacts oxygenation and metabolic substrate availability in the central nervous system. Ornithine phenylacetate (OP, OCR-002; Ocera Therapeutics, CA, USA) was used as an experimental treatment to reduce plasma ammonia concentration.ResultsIn BDL animals, glucose, lactate, and tissue oxygen concentration in the cerebral cortex were significantly lower than those in sham-operated controls. OP treatment corrected the hyperammonaemia and restored brain tissue oxygen. Although BDL animals were hypotensive, cortical tissue oxygen concentration was significantly improved by treatments that increased arterial blood pressure. Cerebrovascular reactivity to exogenously applied CO2 was found to be normal in BDL animals.ConclusionsThese data suggest that hyperammonaemia significantly decreases cortical oxygenation, potentially compromising brain energy metabolism. These findings have potential clinical implications for the treatment of patients with mHE.Lay summaryBrain dysfunction is a serious complication of cirrhosis and affects approximately 30% of these patients; however, its treatment continues to be an unmet clinical need. This study shows that oxygen concentration in the brain of an animal model of cirrhosis is markedly reduced. Low arterial blood pressure and increased ammonia (a neurotoxin that accumulates in patients with liver failure) are shown to be the main underlying causes. Experimental correction of these abnormalities restored oxygen concentration in the brain, suggesting potential therapeutic avenues to explore.

Nutrition Assessment and Management in Patients with Cirrhosis and Cognitive Impairment: A Comprehensive Review of Literature.

Hepatic encephalopathy (HE) represents a common complication of liver cirrhosis. Protein-calorie malnutrition is frequently encountered in the cirrhotic patient and its most obvious clinical manifestation is sarcopenia. This condition represents a risk factor for HE occurrence because skeletal muscle acts as an alternative site for ammonium detoxification. Preventive intervention through an adequate assessment of nutritional status should be carried out at early stages of the disease and in a multidisciplinary team using both non-instrumental methods (food diary, anthropometric measurements, blood chemistry tests) and instrumental methods (bioimpedance testing, DEXA, CT, indirect calorimetry, dynamometry). Dietary recommendations for patients with HE do not differ from those for cirrhotic patient without HE. Daily caloric intake in the non-obese patient should be 30–40 Kcal/Kg/day with a protein intake of 1–1.5 g/Kg/day, especially of vegetable origin, through 4–6 meals daily. In patients with HE, it is also essential to monitor electrolyte balance, supplementing any micronutrient deficiencies such as sodium and zinc, as well as vitamin deficiencies because they can cause neurological symptoms similar to those of HE. In light of the critical role of nutritional status, this aspect should not be underestimated and should be included in the diagnostic–therapeutic algorithm of patients with HE.

Management of gastric varices: still a matter of debate?

Variceal bleeding is one of the most severe and feared complications of liver cirrhosis because it markedly increases the risk of mortality from cirrhosis. The transjugular intrahepatic portosystemic shunt (TIPS) has emerged as a life-saving procedure. By diverting blood from portal to systemic circulation, TIPS swiftly decreases portal hypertension. The efficacy of TIPS in preventing oesophageal variceal rebleeding is supported by strong evidence.1,2 However, there is less consensus regarding gastric variceal bleeding.

Principles of diagnosis and treatment of alcohol-induced liver fibrosis

Alcohol-related liver diseases are one of the leading causes of death worldwide, primarily due to complications of liver cirrhosis (LC). Early detection of alcohol-induced liver fibrosis (LF) is a difficult task, since often alcoholic liver disease (ALD) is clinically manifested only at late stages. Given that not all alcoholic suffer from ALD, the widespread use of liver biopsy to verify the diagnosis is not advisable. Despite the variety of proposed non-invasive methods for assessing the severity of LF in patients with ALD, none of them has sufficient validation and therefore cannot be recommended for widespread use in clinical practice. The most well-studied transient elastography, due to its suboptimal specificity, can be effectively used only to exclude clinically significant LF or LC. The only proven approach to treat ALD is persistent and total alcohol abstinence. While the therapeutic options for patients with severe forms of acute hepatitis remain unchanged since the 70s of the last century and are based mainly on the use of corticosteroids, currently, there are no approaches to antifibrotic therapy of ALD approved by the guidelines. At the same time, modern achievements in understanding the pathophysiological mechanisms of this disease have served as an impetus for the development of ways to solve the problem. In particular, providing intestinal eubiosis may be an important goal for the prevention and treatment of alcohol-induced LF. Randomized controlled multicenter trials involving a large number of patients are needed to confirm this and other hypotheses related to antifibrotic therapy of ALD and to accept them as a standard of medical care.

A nomogram as an indirect method to identify sarcopenia in patients with liver cirrhosis

Introduction and ObjectivesSarcopenia is one of the most common complications of cirrhosis, associated with an increased risk of morbidity and mortality. It is therefore necessary to perform a proper nutritional evaluation in these patients. Although CT scans are the gold standard for diagnosing sarcopenia, they are not widely used in clinical practice. There is thus a need to find indirect methods for identifying sarcopenia in patients with cirrhosis. Material and methodsThis is a cross-sectional study consecutively including all cirrhotic outpatients who underwent CT scans. ResultsA total of 174 patients met all the inclusion criteria and none of exclusion criteria. Fifty-five patients (31.6%) showed sarcopenia on CT scans. Multivariate analysis revealed that the factors that were independently associated with the presence of sarcopenia on CT scans were: male sex (OR 11.27, 95% CI 3.53–35.95; p<0.001), lower body mass index (BMI) (OR 1.22, 95% CI 1.11–1.34; p<0.001) and lower phase angle by bioelectrical impedance analysis (OR 2.83, 95% CI 1.74–4.6; p<0.001). With the variables identified from the multivariate study we developed a nomogram that allows ruling out the presence of sarcopenia. Our model rules out sarcopenia with an area under the receiver operating characteristic curve value of 0.8. The cutoff point of the probability to rule out sarcopenia was 0.6 (sensitivity 85%, specificity 73%, Youden index 0.58, PPV 82.5% and NPV 91.3%). ConclusionSince CT scans involve exposure to radiation and their availability is limited, we propose using this nomogram as an indirect method to rule out sarcopenia in cirrhotic patients.

Refractory Hepatic Hydrothorax Is an Independent Predictor of Mortality When Compared to Refractory Ascites.

Hepatic hydrothorax (HHT) is an uncommon but significant complication of cirrhosis and portal hypertension, associated with a worse prognosis and mortality. Nearly 25% of patients with HHT will have refractory pleural effusion. It is unclear if refractory HHT has a different prognosis compared to refractory ascites. We aim to evaluate the prognostic significance of refractory HHT when compared to refractory ascites. Forty-seven patients who had refractory HHT in a tertiary care center were identified, and matched, retrospectively, one-to-one by age, gender and MELD-Na with 47 patients with refractory ascites. One-year mortality rate was compared between both groups. Cox proportional hazard regression was used to identify the association between different covariates and primary endpoint. The 1-year mortality was 51.06% in the HHT group compared to 19.15% in the refractory ascites group. The median survival for patients with refractory hepatic hydrothorax was 4.87months while the median survival for patients with refractory ascites exceeded 1year. The presence of HHT was statistically significant in predicting the development of 1-year mortality [Hazard Ratio (HR) 4.45, 95% Confidence Interval (CI) 2.25-8.82; P value < 0.001]. Furthermore, refractory HHT remained associated with one-year mortality after adjusting for all other covariates. In a subgroup of patients with MELD-Na ≤ 20, HHT continued to be a significant predictor of one-year mortality (HR 3.30, 95% CI 1.47-7.40; P value 0.004). Refractory HHT is a significant independent predictor of mortality and offers additional prognostic value.

Review of literature: Renal abnormalities in liver disease

Renal failure is a common complication of liver cirrhosis and of utmost clinical and prognostic relevance. Patients with cirrhosis are more prone to developing acute kidney injury than the non-cirrhotic population. The differential diagnosis of renal dysfunction in advanced liver disease includes pre-renal failure, intrinsic renal failure and hepatorenal syndrome. Hepatorenal syndrome is a complication of advanced cirrhosis characterized by an abrupt deterioration in renal function. In cirrhosis with ascites, hepatorenal syndrome is a specific prerenal dysfunction. It is unresponsive to fluid volume expansion and is associated with an extremely poor prognosis. An accurate assessment of renal function is recommended in all patients with cirrhosis. Liver transplantation remains the definitive treatment for hepatorenal syndrome, but new treatment strategies can be utilized as a bridge to transplantation. This review provides an update on our present understanding of the underlying pathophysiological mechanisms involved, diagnostic criteria, different treatment approaches and strategies to prevent Hepatorenal Syndrome.

Spontaneous bacterial empyema: a tertiary care center experience and a systematic review

ABSTRACT Background Spontaneous bacterial empyema (SBE) is an infection of a preexisting hepatic hydrothorax (HH). We aim to describe the experience in managing SBE in a liver transplant (LT) referral center and assessing the incidence and mortality rates of SBE after conducting a systematic review. Methods 992 patients with cirrhosis were retrospectively reviewed from 2015 to 2020. SBE was diagnosed by (i) positive microbiological culture and polymorphonuclear leukocyte count >250 cells/µL or (ii) negative microbiological culture, compatible clinical course, and polymorphonuclear count >500 cells/µL in pleural fluid. Furthermore, we conducted a comprehensive literature search of MEDLINE, EMBASE, and Google Scholar for studies evaluating SBE. Results Twelve patients (10.4%) had spontaneous bacterial empyema out of 115 patients with HH. Five patients underwent LT, 6 had died, and 1 did not get transplanted and was alive throughout the duration of follow-up. Ten studies were included in the systematic review. Pooled incidence in patients with HH was 19.03%. Only 20.69% of the patients received a LT. Pooled mortality rate was 46.45%, with only 3.45% of the patients dying post-transplant. Conclusion SBE is a severe complication of cirrhosis and HH. LT may provide a survival benefit. Thus, patients should be considered for early transplant.

Practice patterns in endoscopic treatment for gastric varices: A Chinese survey

Gastric varices (GV), a common complication of liver cirrhosis, often cause serious consequences. However, the management of GV remains debated. In this study we aimed to explore the practice patterns of Chinese practitioners in GV treatment and discuss whether these patterns conform to the guidelines in China and around the world. Between October 2020 and January 2021, an online questionnaire was sent to doctors from different regions in China via WeChat. Data on the practice patterns for endoscopic treatment with and without a multidisciplinary discussion team (MDT) clinic for GV were analyzed. Questionnaires were collected from 241 practitioners from 29 provinces in China. Before endoscopic treatment, 100 (41.5%) of the practitioners arranged computed tomography angiography (CTA) examination. In endoscopic tissue adhesive (ETA) treatment, 183 (75.9%) of the practitioners chose ETA combined with lauromacrogol. Approximately one-fourth of all practitioners did not prescribe drugs to reduce portal pressure. Only 75 (31.1%) of physicians preferred using early transjugular intrahepatic portosystemic shunt (TIPS) for patients at a high risk of treatment failure for GV. Compared to those without MDT clinics, practitioners with MDT clinics more often chose early TIPS for high-risk patients (39.0% vs 18.9%, P=0.001). Treatment for GV differ across China. Practitioners with MDT clinics can better use assistant strategies such as CTA to evaluate the risk and efficacy. Further clinical studies are needed, and more guidelines and consensuses are warranted to standardize clinical practice for GV.

THE STUDY OF PORTAL VEIN THROMBOSIS PATIENTS WITH CHRONIC LIVER DISEASE

BACKGROUND: Portal vein thrombosis in the general population is a rare event, but it occurs relatively frequent in patients with cirrhosis and its prevalence increases with severity of the disease. The causal relationships and clinical presentation are often complex .As PVT may cause short term as well as long term complications, correct management by adopting adequate diagnostic and therapeutic measures is paramount OBJECTIVE: To nd out the incidence of portal vein thrombosis in Chronic Liver disease patients and factors and complications associated with it . MATERIALAND METHODS:All the patients of chronic liver disease attending department of General Medicine, Jayarogya Hospital patients were evaluated for detailed history, abdominal ultrasonography, portal vein colour doppler studies ,coagulation prole and other biochemical prole. RESULTS: In this study 9% of patient developed PVT with commonest etiology being chronic alcohol intake. Chronic alcohol intake is a signicant etiological factor for the development of PVTin patients of preexisting CLD. Hemetemesis, Encephalopathy, Splenomegaly and ascites were found signicantly higher proportion in PVT group when compared with non PVT group. Portal vein thrombosis could worsen the rate of hepatic decompensation and survival of cirrhosis. CONCLUSION: Portal vein thrombosis is considered to be a signicant complication of liver cirrhosis. Portal vein thrombosis could hasten the rate of decompensation and worsen the survival of cirrhotic patient. Prognostic value of PVTis cirrhosis remain a grey zone.

Comparison of Low Dose Albumin Versus Full Dose Albumin in Improving Refractory Ascites in Cirrhotic Patients

Background: Refractory ascites is one of the most important complications of cirrhosis &amp; albumin is considered highly effective in controlling it. Objective: To compare efficacy of 10g albumin versus 20g albumin in improving refractory ascites in cirrhotic patients.&#x0D; Methods: This randomized control trial was conducted at department of Gastroenterology, Mayo hospital Lahore for 12 months. After ethical approval, 60 patients of chronic liver disease with refractory ascites were included in the study &amp; were divided into two groups. Group A was administered with 20g albumin whereas; group B was given 10g albumin. Both groups were followed for next 3 days by measuring change in weight, abdominal girth and urine output. Data was analyzed by using SPSS v-21. Results: There was no considerable difference between two groups regarding change in weight, abdominal girth and urine output. There was no significant difference in albumin response for both the groups in reducing ascites (p=0.6022). Conclusion: Low dose albumin is as effective as full dose albumin for reducing refractory ascites among cirrhotic patients. &#x0D;

Brain magnetic resonance imaging radiomics features associated with hepatic encephalopathy in adult cirrhotic patients

PurposeHepatic encephalopathy (HE) is a potential complication of cirrhosis. Magnetic resonance imaging (MRI) may demonstrate hyperintense T1 signal in the globi pallidi. The purpose of this study was to evaluate the performance of MRI-based radiomic features for diagnosing and grading chronic HE in adult patients affected by cirrhosis.MethodsAdult patients with and without cirrhosis underwent brain MRI with identical imaging protocol on a 3T scanner. Patients without history of chronic liver disease were the control population. HE grading was based on underlying liver disease, severity of clinical manifestation, and number of encephalopathic episodes. Texture analysis was performed on axial T1-weighted images on bilateral lentiform nuclei at the level of the foramina of Monro. Diagnostic performance of texture analysis for the diagnosis and grading of HE was assessed by calculating the area under the receiver operating characteristics (AUROC) with 95% confidence interval (CI).ResultsThe final study population consisted of 124 patients, 70 cirrhotic patients, and 54 non-cirrhotic controls. Thirty-eight patients had history of HE with 22 having an HE grade > 1. The radiomic features predicted the presence of HE with an AUROC of 0.82 (95% CI: 0.73, 0.90; P < .0001; 82% sensitivity, 66% specificity). Radiomic features predicted grade 1 HE (AUROC 0.75; 95% CI: 0.61, 0.89; P < .0001; 94% sensitivity, 60% specificity) and grade ≥ 2 HE (AUROC 0.82; 95% CI: 0.71, 0.93; P < .0001, 95% sensitivity, 57% specificity).ConclusionIn cirrhotic patients, MR radiomic is effective in predicting the presence of chronic HE and in grading its severity.

Clinical and Biochemical Factors of Portosystemic Encephalopathy in Cirrhosis

Aim: Responsible factors in patients with portosystemic encephalopathy and their relation with the severity of encephalopathy using “west haven scoring”. Methods: This cross-sectional study was done in the Gastroenterology Department, Hayatabad Medical Complex Peshawar. After ethical approval, a sample of 500 patients was calculated by universally accepted sample calculators. 95% confidence intervals and 5%margin of error. The sample was taken by a non-probability consecutive sampling technique. Results: Out of 500 patients, 307 were male and 193 females. The mean age was 57.36(±17.65 SD). Electrolyte imbalance (79.2%) was the most prevalent responsible factor, followed by infection (47.4%) and dehydration (24.4%). The number of patients with Grade 1, 2, 3 and 4 encephalopathy were 48, 187, 223, 42 respectively. In the majority of patients with encephalopathy, more than one responsible factor was present. Conclusion: Portosystemic encephalopathy is one of the most serious and life-threatening complications of liver failure and cirrhosis. Keywords: Portosystemic encephalopathy, responsible factors, gastrointestinal bleeding.

Direct oral anticoagulant administration in cirrhotic patients with portal vein thrombosis: What is the evidence?

In recent years, the traditional concept that cirrhosis-related coagulopathy is an acquired bleeding disorder has evolved. Currently, it is known that in cirrhotic patients, the hemostatic system is rebalanced, which involves coagulation factors, fibrinolysis and platelets. These alterations disrupt homeostasis, skewing it toward a procoagulant state, which can lead to thromboembolic manifestations, especially when hemodynamic and endothelial factors co-occur, such as in the portal vein system in cirrhosis. Portal vein thrombosis is a common complication of advanced liver cirrhosis that negatively affects the course of liver disease, prognosis of cirrhotic patients and success of liver transplantation. It is still debated whether portal vein thrombosis is the cause or the consequence of worsening liver function. Anticoagulant therapy is the mainstay treatment for acute symptomatic portal vein thrombosis. In chronic portal vein thrombosis, the role of anticoagulant therapy is still unclear. Traditional anticoagulants, vitamin K antagonists and low-molecular-weight heparin are standard-of-care treatments for portal vein thrombosis. In the last ten years, direct oral anticoagulants have been approved for the prophylaxis and treatment of many thromboembolic-related diseases, but evidence on their use in cirrhotic patients is very limited. The aim of this review was to summarize the evidence about the safety and effectiveness of direct oral anticoagulants for treating portal vein thrombosis in cirrhotic patients.

Management of Liver Decompensation in Advanced Chronic Liver Disease: Ascites, Hyponatremia, and Gastroesophageal Variceal Bleeding

Portal hypertension is a major complication of cirrhosis characterized by a pathological hepatic venous pressure gradient (HVPG) ≥ 5 mmHg. The structural changes observed in the liver leading to intrahepatic vascular resistance and, consequently, portal hypertension appear in the early stages of cirrhosis. Clinically significant portal hypertension (HVPG ≥ 10 mmHg) is associated with several clinical consequences, such as ascites, hyponatremia, gastroesophageal variceal bleeding, hepatorenal syndrome, cardiopulmonary complications, adrenal insufficiency, and hepatic encephalopathy. The diagnosis and management of these complications depend on their early identification and treatment. Regarding ascites, diuretics are a useful treatment, although plasma sodium levels must be properly controlled to avoid hyponatremia. The management of hypovolemic hyponatremia usually consists in stopping diuretics and the administration of volume. On the contrary, hypervolemic hyponatremia is managed with fluid and sodium restriction. Transjugular intrahepatic portosystemic shunt (TIPS) should be considered in patients with refractory ascites. Primary prophylaxis of variceal bleeding should be based mainly on non-selective beta-blockers. Management of acute gastroesophageal variceal bleeding includes vasoactive drugs and endoscopic band ligation and, in patients at high risk of failure and rebleeding, preemptive use of TIPS. Secondary prophylaxis with a combination of non-selective beta-blockers and endoscopic band ligation is the treatment of choice. This article focuses on the management of ascites, hyponatremia, and gastroesophageal variceal bleeding.

Small Intestinal Bacterial Overgrowth among Patients with Cirrhosis

Introduction: Acute chronic liver failure, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome are a few of the grave complications of liver cirrhosis that may result in death. For years, small-intestinal bacterial overgrowth (SIBO) has been considered a predisposing factor for these complications in cirrhotic patients. However, data regarding SIBO in cirrhosis patients remain less focused in our country. Therefore, the study was designed to evaluate the risk of SIBO in patients with liver cirrhosis attending a tertiary care hospital, in Bangladesh. The aim of the study was to find out the association of small intestinal bacterial overgrowth (SIBO) with cirrhosis. Methods: This case-control study was carried out in the departments of Gastroenterology and Department of Hepatology, Dhaka medical college hospital during the period from September 2018 to October 2019 with a total of 136 patients equally divided into case and control groups. The case group consisted of patients with cirrhosis, while the control group comprised of healthy age-matched volunteers. Result: Among SIBO positive cases and control most common age group was 41-50 years of age. The majority were males observed in both the case (83.3%) and the control (66.7%) groups. The risk of SIBO was more in the cirrhotic patient as the odds ratio was &gt; 1(OR= 7.8) with 95% CI 2.18-27.96. Overall frequency of SIBO was more among patients with higher CTP score {CTP-B (72.2%), CTP-C (27.8%)} with a p-value &lt;0.05. Conclusion: Cirrhosis is associated with small intestinal bacterial overgrowth (SIBO). The frequency of SIBO also increases in cirrhotic patients with higher CTP scores.

Liver cirrhosis

Liver cirrhosis is a chronic liver infection. It consist of deterioration of liver cells along with fibrosis and infection generating nodules. Patients with cirrhosis frequently have either global malnutrition or alterations in specific aspects of nutritional status, such as micronutrient deficiencies, due to multiple mechanisms, including poor nutritional intake, poor absorption, and increased losses. In addition, one of the most significant nutritional problems in cirrhotic patients is muscle wasting and sarcopenia. Cirrhosis of the liver is more common than previously thought, affecting more than 633,000 adults yearly, according to a study published in the Journal of Clinical Gastroenterology. People with cirrhosis had a mortality rate of 26.4 percent during a two-year interval. Most common cause of the liver cirrhosis is alcohol intake (60 to 70 percent), biliary obstruction (5 to 10 percent), biliary atresia/neonatal hepatitis, chronic Hepatitis B or C (10 percent) and hemochromatosis (5 to 10 percent). Symptoms include jaundice, fatigue, bleeding or bruising easily, nausea, swelling and confusion. But many patients have no symptoms. Cirrhosis can lead to liver failure and liver cancer. Numerous studies have attempted to develop the Child-Pugh-Turcotte (CPT) classification for prognosis of liver cirrhosis. Major complications of cirrhosis are, Ascites, Upper gastrointestinal bleeding.

Global hemostatic profiling in patients with decompensated cirrhosis and bacterial infections

Background & AimsBacterial infections in cirrhosis are associated with increased bleeding risk. To assess the factors responsible for bleeding tendency in patients with bacterial infections, we conducted a prospective study comparing all 3 aspects of hemostasis (platelets, coagulation, and fibrinolysis) in hospitalized patients with decompensated cirrhosis with vs. without bacterial infections.MethodsPrimary hemostasis assessment included whole blood platelet aggregation and von Willebrand factor (VWF). Coagulation assessment included procoagulant factors (fibrinogen, factor II, V, VII, VIII, IX, X, XI, XII, XIII), natural anticoagulants (protein C, protein S, antithrombin) and thrombomodulin-modified thrombin generation test. Fibrinolysis assessment included fibrinolytic factors (plasminogen, t-PA, PAI-1, α2-AP, TAFIa/ai) and plasmin-antiplasmin complex (PAP).ResultsEighty patients with decompensated cirrhosis were included (40 with and 40 without bacterial infections). Severity of cirrhosis and platelet count were comparable between groups. At baseline, patients with cirrhosis and bacterial infections had significantly lower whole blood platelet aggregation, without significant differences in VWF. Regarding coagulation, bacterial infections were associated with reduced procoagulant factors VII and XII, and a significant reduction of all natural anticoagulants. However, thrombomodulin-modified thrombin generation was comparable between the study groups. Finally, although mixed potentially hypo-fibrinolytic (lower plasminogen) and hyper-fibrinolytic (higher t-PA) changes were present in bacterial infections, a comparable level of PAP was detected in both groups. Upon resolution of infection (n = 29/40), platelet aggregation further deteriorated whereas coagulation and fibrinolysis factors returned to levels observed in patients without bacterial infections.ConclusionIn hospitalized patients with decompensated cirrhosis, bacterial infections are associated with reduced whole blood platelet aggregation and a significant decrease of all natural anticoagulants, which may unbalance hemostasis and potentially increase the risk of both bleeding and thrombosis.Lay summaryBacterial infections are a common issue in hospitalized patients with decompensated cirrhosis (i.e. patients hospitalized due to severe complications of advanced chronic liver disease). Patients with decompensated cirrhosis who acquire infections may be at increased risk of bleeding complications following invasive procedures (that is a procedure in which the body is penetrated or entered, for instance by a needle or a tube). As bleeding complications in decompensated cirrhosis are associated with a high risk of further decompensation and death, there is an urgent need to understand the factors responsible for such increased bleeding tendency. Herein, we investigated the alterations of hemostasis (that is the physiological process responsible for clot formation and stability) in patients with decompensated cirrhosis and bacterial infections. We found that development of bacterial infections in these patients is associated with alterations of hemostasis (particularly of platelets and clotting cascade) that may increase the risk of both bleeding and thrombotic complications.