Complication Of Cirrhosis Research Articles

Effectiveness of human albumin solution in the treatment of patients with cirrhosis

Objectives: Human serum albumin is synthesized in the liver and is the main plasma protein responsible for plasma oncotic pressure. Studies on the use of Human albumin solution (HAS) in patients with cirrhosis, for prevention of cirrhosis complications or for treatment are ongoing. The beneficial role of albumin beyond volume expansion is an evolving field, and further research is needed to understand the role of albumin in modulating biological functions and disease processes, particularly in liver disease and sepsis, but also in other diseases with albumin dysfunction. Materials and methods: We investigated the effectiveness of HAS through the patients with cirrhosis who received 3 consecutive days (2x1 per day) 190-210 g / L protein were retrospectively analyzed. Results: Albumin infusion was found to be beneficial for serum albumin levels in the patient with high Child-Pugh scores. Conclusions: The complications of cirrhosis can be reduced, particularly in patients awaiting transplantation, by support with HAS treatment.

VARICEAL VERSUS NON-VARICEAL ETIOLOGY OF GASTROINTESTINAL BLEEDING IN PATIENTS WITH CIRRHOSIS AND RELATED SECONDARY COMPLICATIONS

Liver cirrhosis is a highly prevalent worldwide disease and in the last decade, there has been an increase of 13%. Patients with advanced liver disease are at higher risk of developing life-threatening decompensations; one of these main complications is the presence of upper gastrointestinal bleeding, representing a frequent cause of hospital admission and mortality. Broad knowledge of these complications is essential to improve the diagnostic and therapeutic approach in these patients. To compare the different complications related to upper gastrointestinal bleeding of variceal vs. non-variceal origin and the characteristics of these patients. Case-control study conducted in a cohort. The cohort was made up of cirrhotic patients due to any etiology who were admitted for hospitalization at our unit in a period from January 2017 to May 2021; two groups were extracted, those with variceal bleeding formed the cases group and, those with non-variceal hemorrhage the control group and a comparison between groups was made using X2 or Fisher's exact test or Student's test accordingly to the type and distribution of each variable, considering significant a value of p <0.01 A total of 294 cirrhotic patients with gastrointestinal bleeding were included, 169 men (57.5%); mean age 54.6 ± 11.9 years; mean days of hospital stay 2.19 ± 2.74. Regarding the etiology of liver cirrhosis, the main etiology was alcohol in 39.7% (117), followed by viral etiology in 6.4% (18), NASH in 5.8% (17) and, less frequently due to autoimmune causes in 3.4% (10), however, up to 44.7% remained with indeterminate etiology. Regarding the origin of gastrointestinal bleeding, 209 (71.1%) were of variceal origin and 85 (28-9%) were of non-variceal origin. A total of 94 (32%) developed acute kidney injury (AKI), and only the variceal origin was related to a higher risk of developing AKI 57/209 vs. 37/85, p <0.01 (OR = 1.6; 95% CI: 1.2-2.2) but there was no difference regarding the etiology of gastrointestinal bleeding and development of other complications such as encephalopathy, ascites, jaundice, infections, need a transfusion, severe hypovolemic shock, death. See table. The etiology (variceal vs. non-variceal) of the gastrointestinal bleeding has no impact on the development of other complications in cirrhosis; therefore, therapeutic prophylaxis and surveillance strategies should be prioritized in the patient with cirrhosis, regardless of the origin of bleeding. The risk of AKI should always be considered and monitored when the origin of the bleeding is variceal since this study shows the closest relationship between these two complications. The authors declare that there is no conflict of interest

Inical Characteristics, Evaluation, Treatment, and Prognosis of Cryptogenic Cirrhosis

The term cryptogenic cirrhosis (CC) implies that the underlying etiology is uncertain and devoid of definitive clinical, serological, and histological criteria for a specific type of cirrhosis. CC denotes a spectrum of underlying causes, among whom, the majority of evidence implicates non-alcoholic steatohepatitis (NASH) led progression as the most frequent route. CC is held accountable for around 5% of cirrhosis cases today. Cirrhosis complications like liver failure and hepatocellular carcinoma appear as the first presenting feature of the disease, as in other hepatic diseases. The hepatocarcinogenic risk of CC is substantial, with hepatocellular carcinoma’s reported annual cumulative incidence ranging between 2.6% to 3.5%. The diagnosis of CC relies on the exclusion of distinctly recognizable diseases and involves a careful clinical assessment including risk history and family history, followed by laboratory testing including serology, autoantibodies, immunoglobulin concentrations, biomarkers for Wilson’s disease and Celiac disease, and lastly histological assessment for the prominent type and inflammation distribution, and typical presenting features of cirrhotic tissues. The definitive treatment of CC involves transplantation. In cases suspected to be linked with NASH, medical management until transplantation can be beneficial to the patient. The management of CC involves collaboration of primary care with gastroenterology, hepatology, and transplant consultation, and nutritional counseling. Data regarding survival post-transplantation is limited and has shown conflicting results.

Post-paracentesis ascitic fluid leak in patients with cirrhosis of liver and its management: a prospective study

Background and Aim: Ascites is the most common complication of decompensated cirrhosis of liver requiring paracentesis for diagnostic and therapeutic purpose. Ascitic fluid leak can develop after paracentesis in patients with cirrhosis leading to significant morbidity if persistent. We aimed to study the incidence and predictors of post-paracentesis leak in patients with ascites.

Unmasking Hypoxia in Cirrhosis Patients: Six-Minute Walk Test as a Screening Tool for Hepatopulmonary Syndrome.

Background:Hepatopulmonary syndrome (HPS) is one of the complications of advanced cirrhosis which has a serious impact on prognosis of patient. Finding arterial deoxygenation early and initiating higher-level treatment is one of the most critical strategies in the therapy of HPS. In this study, we aimed to assess the utility of six-minute walk test (6MWT) in the diagnosis of HPS.Materials and Methods:We have enrolled 100 consecutive cirrhosis patients referred to the Liver Clinic of a tertiary care centre of India for >1 year. The Child-Pugh score and the MELD score were used to determine the severity of cirrhosis. All the patients underwent transthoracic contrast echocardiography, arterial blood gas measurements on room air, 6MWT, and chest imaging.Results:A total of 100 patients were included in the study after fulfilling the inclusion criteria. HPS was present in 21 out of 100 patients (21%). Median (twenty fifth to seventy fifth percentile) MELD score in patients with HPS was 29 (26–33), which was significantly higher as compared to patients without HPS 22 (14.5–26); P <.0001. The 6MWT was positive in 20 (95.23%) HPS patients, while only 1 patient (4.77%) of HPS had negative 6MWT. If 6MWT is positive, then there was 76.92% probability of HPS and if 6MWT is negative, then 98.65% chances of no HPS.Conclusion:The 6MWT is a simple and effective screening test for HPS, it helps in identifying the patients early who have a potential to deteriorate. This simple intervention would help in prioritizing patients for liver transplantation as liver transplant is the only effective treatment for HPS.

Prevention of Hepatorenal Syndrome, as a Complication of Liver Cirrhosis

Prevention of Hepatorenal Syndrome, as a Complication of Liver Cirrhosis

Utility of Fractional Excretion of Urea (FeUrea) for differentiating AKI phenotypes in patients with cirrhosis and ascites.

Background and Aim: Acute renal failure (AKI) is a common complication of decompensated cirrhosis and confers a poor prognosis. AKI in these patients may result from functional decrease in renal function as in prerenal azotaemia (PRA) and Hepato-renal syndrome (HRS) or due to structural renal abnormalities as in acute tubular necrosis (ATN). These phenotypes of AKI have therapeutic and prognostic implications. However, in clinical practice, approaches to determine the cause of AKI in these patients are suboptimal.

Determinants of Re Bleeding and Mortality in Cirrhotic Patients after Variceal Bleeding

Background: Variceal bleeding (VB) is the most serious complication of liver cirrhosis and carries a high mortality rate. Methods: The retrospective analysis on 263 cirrhotic patients with variceal bleeding in Taipei Medical University Shuang Ho hospital from 2012 to 2018. Aim: determine determinants of re-bleeding and mortality. Results: Patients’ characters were median age (56 years), male (73.4%), HCC (28.1%), ascites (53.2%), portal vein thrombosis (PVT, 6.4%), mean MELD score (17.5); mean Child-Tourette-Pugh score (CTP=8.2) and active bleeding at endoscopy (44.8%). Variceal re-bleeding occurred 4.1% at day-five, 11.0% at week-six and 28.1% at year-one. CTP score&gt;7, MELD score&gt;16, bilirubin&gt;30mg/dL, hepatic encephalopathy and HCC predicted early and late re-bleeding. Old age, renal injury, active bleeding, albumin&lt;2.8 g/dL, ascites, bacterial infection and PVT determined early re-bleeding. The mortality after first VB was 3.8%, 14.1% and 25.8% at day-5, week-6 and year-1 respectively. Old age, CTP&gt;7, MELD&gt;16, renal injury, ascites, hepatic encephalopathy, bacterial infection and HCC were determined early and late mortality. Early variceal re-bleeding was associated with early mortality. Use of non-selective beta-blocker or variceal ligation reduced mortality at year-1 (Odds Ratio; OR 0.03 and OR 0.3) and combination therapy reduced early re-bleeding (OR 7.5). Conclusion: Re-bleeding and mortality rate after VB were substantially high in hepatic decompensation, renal injury, presence of HCC, PVT and infection. Early identification of variceal bleeding patients who are at substantially high risk would probably benefit from early trans-jugular intrahepatic portosystemic shunt or liver transplantation.

Sarcopenia in Cirrhosis of Liver Assesed by Hand Grip Dynamometry and Its Association with Clinical Profile

Background: Sarcopenia is a complication of liver cirrhosis, which contributes directly to its complications and pre as well as post-transplant survival. There is paucity of Indian data on sarcopenia in cirrhosis.

Risk factors of surgical treatment in patients with liver cirrhosis

To optimize selection of patient for surgical treatment of comorbidities and complications of liver cirrhosis (LC) via analysis of perioperative risk factors. There were 610 patients with LC and comorbidities who underwent surgical treatment between 2015 and 2021 at the Regional Clinical Hospital No. 2. Thirty (4.9%) patients died. We analyzed Child-Pugh and MELD scores, Mayo Postoperative Surgical Risk Score and Charlson comorbidity index to predict postoperative mortality. Perioperative risk in patients with LC depends on the type of surgery, degree of surgical invasiveness, liver function, and severity of LC-associated complications. A thorough preoperative assessment of patients and adequate perioperative management are required to reduce the risk of mortality.

Combined Transarterial Chemoembolization with Microwave Ablation versus Microwave Alone for Treatment of Medium Sized Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer-related deaths. The only definitive treatment for both HCC and cirrhosis is liver transplantation, but long wait times in some regions and a relatively fixed number of donor organs negatively impact access to liver transplantation. The aim of the work was to evaluate and compare the short outcome of patients with medium-sized HCC who will undergo percutaneous microwave ablation (MWA) alone and in combination with TACE. This prospective study included 40 patients with medium-sized HCC lesions who were classified into two groups; Group A that included twenty patients treated by TACE followed by percutaneous MWA after 2 weeks and group B that included twenty patients treated by 2 sessions of percutaneous MWA with 2 weeks interval. Full history taking, clinical examination, laboratory investigation, abdominal ultrasonography and abdominal tri-phasic computed tomography (CT) with contrast were obtained from the two groups. Laboratory and radiological follow up of the cases were done at 1 and 3 months after the treatment. There was no statistically significant difference in the sociodemographic criteria, laboratory measurement and clinical criteria between the cases in the two study groups before initiation of treatment. The response was slightly better in the combined treatment group, but it did not show a statistically significant difference. The incidence of complications was higher in the MWA group. Hepatocellular carcinoma is a common complication of HCV related cirrhosis. Association of TACE-MWA led to better response rates than MWA with fewer complications.

Renal Resistive Index and Intraabdominal Pressure as Predictors of Hepatorenal Syndrome in Decompensated Chronic Liver Disease: A Prospective Cohort study

Background/Aims: Hepatorenal Syndrome(HRS) is a life-threatening complication of cirrhosis characterized by renal arterial vasoconstriction, which preceeds clinically manifest renal dysfunction.Renal Resistive Index(RRI) is used to assess intrarenal arterial vasoconstriction.Raised Intra Abdominal Pressure(IAP) is known to cause reduction in renal blood flow thereby compromising renal function.

Современные подходы к диагностике и лечению минимальной печеночной энцефалопатии у пациентов с циррозом печени

Hepatic encephalopathy (HE) is one of the most common and dangerous complications of cirrhosis. HE is considered a predictor of death within the first year after onset in more than 60% of patients. Recently, studies have focused on minimal HE (MHE) which is characterized by medical, social, and clinical relevance. MHE patients are a risk group for cirrhosis complications and hospital admission. This demonstrates the need for early therapeutic and preventive measures for MHE. This paper provides information on current diagnostic and treatment tools for MHE in cirrhosis and illustrates the efficacy of various therapies on the outcomes and quality of life in these patients. The authors conclude that one should rely on studies establishing the efficacy of rifaximin-α to regress MHE, improve the quality of life and reduce the risks of complications and decompensation in cirrhosis compared to other medications. Meanwhile, further studies are needed to reveal favorable and unfavorable predictors of disease course and to optimize therapeutic and preventive measures in these patients. KEYWORDS: cirrhosis, hepatic encephalopathy, minimal hepatic encephalopathy, psychometric tests, lactulose, L-ornithine-L-aspartate, rifaximin-α FOR CITATION: Bakulin I.G., Ivanova K.N. Up-to-date diagnostic and treatment approaches to minimal hepatic encephalopathy in cirrhosis. Russian Medical Inquiry. 2022;6(5):272–277 (in Russ.). DOI: 10.32364/2587-6821-2022-6-5-272-277

Decompensated cirrhosis and sarcopenia - a tertiary care experience

Background and Aim: Cirrhosis is a leading cause of mortality worldwide. Sarcopenia is also an under-recognized complication of cirrhosis which leads to physical disability and functional decline, thereby leading to poor quality of life. Moreover, it negatively impacts survival, hence is associated with poor prognosis and increased mortality both before and after liver transplantation (LT).

Should we incorporate long-term use of albumin for patients with decompensated cirrhosis into our daily clinical practice?

Ascites is the most frequent complication of cirrhosis and carries with it a high morbidity and mortality. The results of the ANSWER study and others like it open the possibility of considering the prolonged administration of albumin, as an effective and safe treatment in patients with decompensated cirrhosis, capable of modifying their natural history, allowing a better control of ascites, a lower incidence of other complications of portal hypertension, and an increased survival. For this, it is necessary the administration of albumin with the appropriate dose and duration to restore their physiological conditions. However, new studies are needed to confirm the efficacy and safety of prolonged administration of albumin in patients with decompensated cirrhosis and to identify the subpopulation of patients that benefit the most, the appropriate dose and duration, serum-clinical markers of response, the necessary logistics to facilitate its application and its cost-effectiveness in the different health systems.

A narrative review of nutritional abnormalities, complications, and optimization in the cirrhotic patient

The purpose of this manuscript is to identify the pathophysiology of the metabolic abnormalities observed in cirrhosis and to uncover associations, if any, to its complications, such as sarcopenia and hepatic encephalopathy (HE). Liver dysfunction in cirrhosis is known to be a precipitating factor in the disruption of many physiological pathways, specifically nutrient metabolism. As a result, affected patients are highly susceptible to derangements of processes affecting multiple classes of macro- and micronutrients, including proteins, carbohydrates, electrolytes, vitamins, and minerals. These disruptions are thought to be contributory to the pathogenesis of known complications of cirrhosis. Literature research of relevant topics was conducted for the above stated objective; sources were limited to articles from peer-reviewed journals published within the last 30 years. This research established that there is positive correlation between nutrient derangements and the increased risk of complications of cirrhosis, which themselves carry significant morbidity and mortality risk. It also established that some nutrient and electrolyte abnormalities are independent indicators of prognosis and adverse outcomes, such as mortality. This also highlights the importance of comprehension of anomalous metabolism and its complications as it necessitates serious consideration in clinical care. In addition to medical management, cirrhotic patients also require ancillary assessment, such as comprehensive nutritional evaluation, to identify and treat reversible nutritional derangements. This consideration provides the best opportunity to achieve maximal health outcomes in the cirrhotic patient population.

Poor Oral Hygiene Predicts the Presence of Ascitic Fluid Infection in Patients with Decompensated Cirrhosis

Background: Ascitic fluid infection [AFI] is one of the important complications of cirrhosis which has poor prognosis. It may be classified as Spontaneous Bacterial Peritonitis (SBP), culture negative neutrocytic ascites (CNNA) or bacteriascites. Bacterial translocation from GI tract is considered to be the most important mechanism that leads to development of AFI. Poor oral hygiene may cause subclinical or persistent infections in cirrhotic patients may act as independent risk factor for adverse outcomes in cirrhotic patients including AFI. Aim:To assess the correlation between AFI in patients with decompensated cirrhosis having poor oral hygiene. Methods: All in patients of cirrhosis with ascites were examined for ascitic fluid analysis including total protein, albumin, glucose, PMN count. Fluid was also inoculated at bedside for cultures. Oral hygiene was examined for all patients by using the dental mirror. OHI-S was calculated after calculating calculus and Debris index to determine good /poor oral hygiene. Results: A total 200 patients of decompensated cirrhosis were enrolled in the study. With mean age of 50.9 + 9.85. There were 78 % males with a mean BMI of 18.9 + 1.9. Alcohol was the major cause of cirrhosis (72%). Mean MELD and CTP were 18.6+7.43 and 10.2 +1.28 . Mean OHI- S was 1.8+1.07. AFI was found in 28%, SBP and CNNA27% was found in 1% and 27 % respectively. On univariate analysis CTP, MELD, BMI, Haemoglobin, Serum protein and Albumin significantly associated with poor oral hygiene (P < 0.001). Poor oral hygiene was found in 59.6 % in patients with AFI compared to 16.9 % in patients without SBP/CNNA (P < 0.001). S – OHI so predicted presence of AFI with a AUROC of 0.83. Conclusion: We suggest screening for oral hygiene in all patients of decompensated cirrhosis as it may be a harbinger of ascitic fluid infection.

Malnutrition management of hospitalized patients with diabetes/hyperglycemia and liver cirrhosis

Liver cirrhosis is a progressive and chronic disease of the liver, of diverse etiology, which is frequently associated with glucose intolerance and in some cases concurs with type 2 diabetes (DM2). DM2 is associated with adverse outcomes in patients with cirrhosis, including a higher rate of hospitalizations, a higher prevalence of hepatocellular carcinoma, and an increased risk of mortality. Malnutrition is another frequent complication of cirrhosis, the prevalence of which increases with the degree of liver dysfunction, worsening the prognosis. This document describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with liver cirrhosis.

ROLE OF 2D SHEAR WAVE ELASTOGRAPHY FOR PREDICTING THE PRESENCE OF OESOPHAGEAL VARICES IN PATIENTS WITH ADVANCED CHRONIC LIVER DISEASE

BACKGROUND: Liver cirrhosis and portal hypertension are common outcomes of chronic liver disease. Portal hypertension leads to development of oesophageal varices (EV). Oesophageal variceal rupture is the most common (1,2,3) dreaded complication of cirrhosis that proves to be fatal. In fact, the severity of liver disease can be correlated by the presence and grade of varices. Currently, oesophagogastroduodenoscopy (OGD) is the gold standard investigation for detection and grading of EV's. However, it is invasive, costly and frequently requires sedation. The aim of this study is to investigate the diagnostic performance of 2D shear wave elastography for predicting the presence of oesophageal varices in patients with advanced chronic liver disease (CLD). METHODS: Study population included 32 cases with CLD and 30 controls without CLD undergoing OGD from August 2019 to August 2021.Prior to undergoing OGD, liver and spleen stiffness elastography were recorded using 2D-SWE. ROC curve was used to nd the cut off values for liver and spleen stiffness for prediction of EV. RESULTS: Using 2D-SWE, the association between liver/ spleen stiffness and presence of EV in CLD cases was found to be statistically signicant (p value-&lt;0.001). The optimal cut off values obtained for prediction of EV was 12 kPa and 12.6kPa for liver and spleen respectively (sensitivity of 81.8% and specicity of 82.5%; PPV-72%, NPV- 89.2%). CONCLUSION: Liver and spleen stiffness values obtained by 2D-SWE were found to be a signicant predictive factor for detection of presence of EV's in patients with CLD.

Spontaneous Bacterial Peritonitis among Cirrhotic Patients: Prevalence, Clinical Characteristics, and Outcomes.

(1) Background: Spontaneous bacterial peritonitis (SBP) is a feared complication of liver cirrhosis. We investigated the prevalence of SBP, positive ascitic fluid cultures, and risk factors for mortality. (2) Methods: A retrospective analysis of all patients with cirrhosis hospitalized or in follow-up in a single center between 1996 and 2020. The clinical data, long-term complications, and mortality of SBP patients were compared with those of non-SBP patients. Ascitic fluid positive culture was compared with those without growth. (3) Results: We included 1035 cirrhotic patients, of which 173 (16.7%) developed SBP. Ascitic fluid culture growth was found in 47.4% of the SBP cases, with Escherichia coli bacteria detected in 38%, 24.4% grew ESBL-producing bacteria, and 14.5% displayed multidrug resistance. In a Cox regression model, SBP, male sex, prolonged INR at diagnosis, and hepatocellular carcinoma were found to be risk factors for mortality in cirrhotic patients. The long-term all-cause mortality was 60% in non-SBP and 90% in SBP patients. (4) Conclusions: Only a minority of cirrhotic patients developed SBP, 47.4% of which had positive ascitic fluid cultures with high antibiotic resistance. Growth of ESBL and multidrug resistant organisms is becoming more frequent in the clinical setting, reaching SBP mortality of 90%.