Severity Of Liver Dysfunction Research Articles

Heart Rate Turbulence Predicts Survival Independently From Severity of Liver Dysfunction in Patients With Cirrhosis.

BackgroundReduced heart rate variability (HRV) is an independent predictor of mortality in patients with cirrhosis. However, conventional HRV indices can only be interpreted in individuals with normal sinus rhythm. In patients with recurrent premature ventricular complexes (PVCs), the predictive capacity of conventional HRV indices is compromised. Heart Rate Turbulence (HRT) represents the biphasic change of the heart rate after PVCs. This study was aimed to define whether HRT parameters could predict mortality in cirrhotic patients.Materials and Methods24 h electrocardiogram recordings were collected from 40 cirrhotic patients. Turbulence Onset was calculated as HRT indices. The enrolled patients were followed up for 12 months after the recruitment in relation to survival and/or transplantation.ResultsDuring the follow-up period, 21 patients (52.5%) survived, 12 patients (30%) died and 7 patients (17.5%) had liver transplantation. Turbulence Onset was found to be strongly linked with mortality on Cox regression (Hazard ratio = 1.351, p < 0.05). Moreover, Turbulence Onset predicted mortality independently of MELD and Child-Pugh’s Score.ConclusionThis study provides further evidence of autonomic dysfunction in cirrhosis and suggests that HRT is reliable alternative to HRV in patients with PVCs.

Study of Thyroid Function Tests in Cirrhosis of Liver And Correlation of Thyroid Function Tests Levels With Severity of Liver Dysfunction

Background: One of the leading causes of morbidity and mortality in the world is chronic liver diseases. Thyroid hormones regulate the basal metabolic rate of all cells, including hepatocytes, and thereby modulate hepatic function. The liver in turn metabolizes the thyroid hormones and regulates their systemic endocrine effects. Thyroid dysfunction may perturb liver function, liver disease modulates thyroid hormone metabolism, and a variety of systemic diseases affect both organs. Keeping in mind the above view we have done this study by highlighting the association between thyroid function tests with severity of liver dysfunction in cirrhosis of liver by using child Pugh scoring Methods: All patients aged 30-80 years with cirrhosis of liver who are attending Rajarajeshwari Medical College and Hospital. Detailed history, physical examination and drug history was taken as per pre-designed performa. Relevant investigations were done for assessing thyroid function and liver cirrhosis. Severity of liver dysfunction was graded by using Child Pugh Scoring Results: The prevalence of hypothyroidism among patients with liver cirrhosis was 64%. Majority of the cases had a high TSH and TSH levels were directly correlated severity of liver disease. Total T3 levels were low in majority of the cases and it was inversely correlated with severity of liver disease. FT3 was low in most of the cases with child B and child C score; it was inversely correlated with severity of liver disease. FT3 was found to be a more sensitive marker than total T3 for assessing severity of liver disease. Conclusion: Thyroid dysfunction is common in cirrhosis of liver hence thyroid function tests should be carried out in all cirrhotic patients to assess the severity and prognostication of such patients.

Breath Biopsy Assessment of Liver Disease Using an Exogenous Volatile Organic Compound-Toward Improved Detection of Liver Impairment.

INTRODUCTION:Liver cirrhosis and its complication — hepatocellular carcinoma (HCC) — have been associated with increased exhaled limonene. It is currently unclear whether this increase is more strongly associated with the presence of HCC or with the severity of liver dysfunction.METHODS:We compared the exhaled breath of 40 controls, 32 cirrhotic patients, and 12 cirrhotic patients with HCC using the Breath Biopsy platform. Breath samples were analyzed by thermal desorption–gas chromatography–mass spectrometry. Limonene levels were compared between the groups and correlated to bilirubin, albumin, prothrombin time international normalized ratio, and alanine aminotransferase.RESULTS:Breath limonene concentration was significantly elevated in subjects with cirrhosis-induced HCC (M: 82.1 ng/L, interquartile range [IQR]: 16.33–199.32 ng/L) and cirrhosis (M: 32.6 ng/L, IQR: 6.55–123.07 ng/L) compared with controls (M: 6.2 ng/L, IQR: 2.62–9.57 ng/L) (P value = 0.0005 and 0.0001, respectively) with no significant difference between 2 diseased groups (P value = 0.37). Levels of exhaled limonene correlated with serum bilirubin (R2 = 0.25, P value = 0.0016, r = 0.51), albumin (R2 = 0.58, P value = 5.3e-8, r = −0.76), and international normalized ratio (R2 = 0.29, P value = 0.0003, r = 0.51), but not with alanine aminotransferase (R2 = 0.01, P value = 0.36, r = 0.19).DISCUSSION:Exhaled limonene levels are primarily affected by the presence of cirrhosis through reduced liver functional capacity, as indicated by limonene correlation with blood metrics of impaired hepatic clearance and protein synthesis capacity, without further alterations observed in subjects with HCC. This suggests that exhaled limonene is a potential non-invasive marker of liver metabolic capacity (see Visual abstract, Supplementary Digital Content 1, http://links.lww.com/CTG/A388).

Management of Patients with Cirrhosis and Portal Hypertension Requiring Surgery

AbstractCirrhosis significantly increases surgical morbidity and mortality as it causes derangement of multiple organ systems and physiological processes. As such, chronic liver disease and the resultant portal hypertension present distinct perioperative challenges. The risk conveyed by liver disease is dependent on its etiology, the severity of liver dysfunction, the degree to which other organ systems are affected, and the type and timing of surgery to be performed. Careful preoperative planning as well as informed intra- and postoperative decision-making strategies are key factors in ensuring acceptable outcomes in the surgical management of cirrhotic patients. This review will discuss the challenges that cirrhosis with portal hypertension presents to the surgeon, intensivist, and anesthesiologist alike, and identifies key perioperative strategies to mitigate these risks.

Glutathione and Related Antioxidant Capacities But Not Vitamin B-6 Had Significant Association with Severity of Liver Dysfunction in Liver Cirrhotic Patients

Abstract Objectives Liver cirrhosis is often associated with increased oxidative stress and decreased antioxidant capacities. Vitamin B-6 and glutathione (GSH) are antioxidant nutrients. Inadequate vitamin B-6 status may indirectly limit GSH synthesis and further affect the antioxidant capacities. The purpose of this study was to assess whether individual or the combination of vitamin B-6 and GSH supplementation had effects on antioxidant capacities and clinical outcomes in patients with liver cirrhosis. Methods This was a double-blind randomized clinical trial and a follow-up study. 61 liver cirrhotic patients were randomly assigned to placebo, vitamin B-6 (50 mg pyridoxine/d), GSH (500 mg/d) or B-6 + GSH groups for 12 weeks. After the end of supplementation, 61 patients were followed until the end of the study. Baseline and 12 weeks of fasting blood samples were drawn to measure levels of plasma GSH, oxidized GSH (GSSG), trolox equivalent antioxidant capacity (TEAC), activities of glutathione S-transferase (GSH-St), glutathione peroxidase (GSH-Px), glutathione reductase (GSH-Rd), superoxide dismutase (SOD) and catalase. The severity of liver dysfunction (Child-Turcotte-Pugh score) was evaluated at baseline, 12 weeks after baseline, and the end of the follow-up time. Results The median follow-up time was 984 d, 21 patients were lost of follow-up during follow-up period. After 12 weeks of supplementation, neither vitamin B-6 nor GSH supplementation had effects on indicators of oxidative stress and antioxidant capacities. However, high levels of GSH, GSH/GSSG ratio, and GSH-St activity at baseline (week 0) but not at week 12 had significant effect on low Child-Turcotte-Pugh scores at week 0, week12 and the end of follow-up in all patients after adjusting for potential confounders. Conclusions Although GSH supplementation had no significant effect on reducing oxidative stress and increase antioxidant capacities, the decreased glutathione and its related enzyme activity should be considered by clinicians in the treatment of liver cirrhotic patients. Funding Sources This study was funded by a grant from the Ministry of Science and Technology, Taiwan (MOST 104–2320-B-040–009-MY3) and Taichung Veterans General Hospital, Taiwan (TCVGH-1084601C).

Recombinant Alkaline Phosphatase Prevents Acute on Chronic Liver Failure

The lipopolysaccharide (LPS)– toll-like receptor-4 (TLR4) pathway plays an important role in liver failure. Recombinant alkaline phosphatase (recAP) deactivates LPS. The aim of this study was to determine whether recAP prevents the progression of acute and acute-on-chronic liver failure (ACLF). Eight groups of rats were studied 4-weeks after sham surgery or bile duct ligation and were injected with saline or LPS to mimic ACLF. Acute liver failure was induced with Galactosamine-LPS and in both models animals were treated with recAP prior to LPS administration. In the ACLF model, the severity of liver dysfunction and brain edema was attenuated by recAP, associated with reduction in cytokines, chemokines, liver cell death, and brain water. The activity of LPS was reduced by recAP. The treatment was not effective in acute liver failure. Hepatic TLR4 expression was reduced by recAP in ACLF but not acute liver failure. Increased sensitivity to endotoxins in cirrhosis is associated with upregulation of hepatic TLR4, which explains susceptibility to development of ACLF whereas acute liver failure is likely due to direct hepatoxicity. RecAP prevents multiple organ injury by reducing receptor expression and is a potential novel treatment option for prevention of ACLF but not acute liver failure.

The influence of combined abdominal and thoracic trauma on the bile excretory function of the liver in the period of early manifestations of traumatic disease and their correction with thiotriazoline

Introduction. Traumatism is one of the challenging issues of today's urban society. Multiple and combined lesions, which are characterized by significant severity and high mortality and lead to multiorgan dysfunction and insufficiency, dominate the structure of traumas. In recent years studies of the functional state of the liver have been widely used as a model for development of multiorgan dysfunction in conditions of severe experimental trauma.Objective of the research: to find out the character of disorders of bile excretory function of the liver in conditions of the combined abdominal and thoracic trauma of rats in the early period of a traumatic disease, and to evaluate the effectiveness of their correction with thiotriazoline.Materials of the research and their discussion. The experiments were conducted on 86 non-linear white male rats weighing 200-220 g. All animals were divided into five groups: a control and four experimental ones. Injuries were inflicted under thiopental sodium anesthesia. The control group included intact animals, which were only injected into anesthesia. Animals with simulated thorax trauma were in the first experimental group. In the second experimental group a blunt abdominal trauma was simulated. In the third experimental group, these traumas were combined. In the fourth experimental group of animals with a combined trauma, thiotriazoline was administered intraperitoneally at a dose of 9.1 mg per kg-1. In 1, 3, and 7 days after injuries were caused under conditions of thiopental sodium anesthesia, the common bile duct was catheterized in animals and bile was taken for 60 minutes. The rate of bile excretion was set. The concentration of total bile acids and conjugated bilirubin was determined in bile, and their excretion rate was calculated.Results of the research and their discussion. In conditions of causing isolated thoracic trauma, abdominal trauma and their combination, a significant disorder of the bile-excreting function of the liver emerges, that is, first of all, manifested by a decrease in the speed of bile excretion and excretion of its main components - cholates and conjugated bilirubin. The severity of liver dysfunction can be divided as follows: isolated thoracic trauma ← isolated abdominal trauma ← combined trauma. In conditions of isolated thoracic trauma, the investigated parameters in comparison with the control reach a minimum level up to the 3d day and normalize to the 7th day. After causing an isolated abdominal trauma the rate of bile excretion and the rate of excretion of total bile acids decrease after a day.However, all investigated parameters reach a minimum value after 3 days and remain at the same level up to the 7 day. After a combined trauma, the indicators gradually decrease to the 7th day and in each subsequent period become significantly smaller than in the previous one. The use of thiotriazoline for the correction of the detected disorders in the group of animals with combined trauma compared with animals without correction contributed to a significant increase in the rate of bile excretion, excretion of total bile acids and conjugated bilirubin. Although, by the 7th day the indicators did not reach the level of the control group, it can be stated that thiotriazoline exerts a positive effect on the biliary function of the liver.Conclusions. Combined abdominal and thoracic trauma contributes to a greater reduction in liver functional capacity compared with isolated lesions. They are based on the suppression of the rate of bile excretion and excretion of total bile acids and conjugated bilirubin. The use of thiotriazoline at a dose of 9.1 mg / kg-1 for animals with combined abdominal trauma is accompanied by a significant reduction in biliary function of the liver.

Liver function trends after biliary decompression in obstructive jaundice: a clinico-pathological-biochemical study

Background: Liver functions tests suggest the underlying cause, estimate the severity, assess prognosis and monitor efficacy of therapy. Severity of liver dysfunction when performed serially may predict prognosis and may be helpful in assessing response to medical therapy or a surgical intervention.Methods: The data was collected in thirty cases of surgical obstructive jaundice in terms of age, sex, etiology, clinical presentation, surgical intervention for biliary drainage and the laboratory liver biochemical and coagulation profiles on a day prior to surgical intervention and post-operatively on 1st week and 4th week were recorded.Results: Of total 30 patients 56.66% were females. Patients with 73.68% of benign disease and 100% of malignant disease were of age more than 40 years. 63.33% of patients had benign cause for biliary obstruction. Choledochoithiasis and periampullary carcinoma were two most common causes of obstructive jaundice. The commonest complaints were; yellowish discolouration of sclera and skin, high colored urine (100%) and acholic stool (70%). Hepatomegaly, palpable gallbladder and ascites were observed in only malignant conditions. Serum bilirubin and transaminases were significantly higher in patients with malignant lesions on pre-operative and postoperative assessment. After decompression the rate of fall of serum bilirubin, serum glutamic-oxaloacetic transaminase and SGPT were almost identical in both benign and malignant biliary obstructions. However, a better biochemical recovery profile was observed in patients with benign lesions, as they returned to normal by 4 weeks but remained at 2 to 3 times of the normal in malignant lesions.Conclusions: Sequential biochemical assessment of liver functions has diagnostic as well as prognostic value in surgical obstructive jaundice.

A study to assess the echocardiographic changes among chronic liver disease in a tertiary care center

Background: Cirrhosis is associated with numerous cardiac abnormalities; however scanty information is available about the changes associated with it in Indian diaspora. which include increased cardiac output, left ventricular diastolic dysfunction, increased wall thickness of cardiac chambers, and pulmonary arterial hypertension. These concomitant cardiac abnormalities in patients with cirrhosis have been termed as ‘Cirrhotic Cardiomyopathy’. Objective of this study assess the Echocardiographic Changes among Chronic Liver disease in a tertiary care center. Method: Thirty patients with cirrhosis (alcoholic and non-alcoholic) were enrolled for the study at Department of Gastroenterology, Command Hospital, Air force, Bangalore from October 2007 to June 2009. Thirty age and sex matched controls without cardiovascular disease were included for comparison. Data collection was done by clinical history, examination and investigations. All subjects underwent Echocardiographic study was at 6 and 12 months and controls at the start of study.Results: Mean age of the study population was 54.5±15 yrs, males constituted 93% of the study population. Majority of the patients were in Child class B (43.3%) and Child A (40%). Interventricular septal thickness showed significant change compared to Control. There was no evidence of systolic dysfunction noted in the study population. There was no correlation between severity of cirrhosis and echocardiographic Changes.Conclusion: This study demonstrates that Indian patients with cirrhosis do have diastolic dysfunction. In the absence of other risk factors for cardiac disease, this dysfunction can be attributed only to cirrhotic cardiomyopathy. There is no correlation of cardiac status with severity of liver dysfunction.

P3466Cardiac output in end-stage liver disease increases with the severity of liver dysfunction

Abstract Background End-stage liver disease is associated with significant systemic and haemodynamic alterations that affect cardiac function. Cirrhotic cardiomyopathy remains an ill-defined entity among cardiologists. Understanding the complex interplay between liver dysfunction and cardiac function can lead to a better understanding of the compensatory mechanisms of the heart in liver failure. Purpose To investigate whether severity of liver disease affects baseline cardiac output in a large contemporary cohort of patients undergoing liver transplant work-up. Methods Consecutive patients that underwent pre-liver transplant (LT) workup between 2010–2017 were included. All patients underwent a resting echocardiogram. Cardiac output (CO) was prospectively recorded at baseline by pulsed-wave Doppler examination of the left ventricular outflow tract from the apical window and systemic vascular resistance (SVR) was calculated as 80 x (mean arterial pressure (MAP)/CO). Severity of liver disease was characterized by the model of end-stage liver disease (MELD) and Child-Pugh scores. Results 560 patients were included (mean age 57.5±7.7, 74.8% male). Mean MELD score was 19±7 and Child-Pugh Score was 9±3. There was an inverse linear relationship between the severity of liver disease by the MELD score and baseline SVR (rho 0.40, P&lt;0.001). As SVR reduced, there was also a significant rise in baseline CO with a strong inverse correlation between the two variables (rho 0.86, p&lt;0.001). There was a significant linear correlation between the severity of liver disease and baseline CO with both the scores (MELD Score rho 0.42, p&lt;0.001; Child Pugh rho 0.44, p&lt;0.001) (Figure). Baseline CO in LT Patients by Severity Conclusions Baseline CO increased with the severity of liver dysfunction due to a reduced afterload. A higher resting CO may lead to patients encroaching on their cardiac reserve at rest. This provides a pathophysiological insight suggesting a limited role for beta-blockers, particularly in patients with advanced liver cirrhosis.

High Prevalent Hypovitaminosis D Is Associated with Dysregulation of Calcium-parathyroid Hormone-vitamin D Axis in Patients with Chronic Liver Diseases.

Background and Aims: Although hypovitaminosis D is common among patients with chronic liver disease (CLD), the data are inconsistent on its prevalence and its relationship with CLD. This study aimed to estimate the prevalence of hypovitaminosis D among patients with CLD and to determine the relationship between hypovitaminosis D and severity of liver dysfunction, and calcium (Ca), phosphate (PO4) and parathyroid hormone (PTH) levels in CLD.Methods: The study included 236 CLD patients attending the Department of Hepatology, Rajiv Gandhi Government General Hospital (Chennai, India). Serum levels of 25-hydroxyvitamin D (25(OH)D), PTH, Ca, and PO4 were estimated. Severity of liver dysfunction was graded using the Child–Turcotte–Pugh (CTP) score.Results: The first report from our population showed that 162 of 236 (68.6%) CLD patients had hypovitaminosis D (25(OH)D levels of <30 ng/mL), with higher frequency (124/162) 76.5% among CTP B, C patients. Significant negative correlation (r = −0.288, p = 0.0001) between 25(OH)D and CTP scores was noted in hypovitaminosis D conditions. Level of 25(OH)D was correlated negatively with PTH (r = −0.537, p = 0.0001), positively with Ca (r = 0.657, p = 0.0001), and positively with PO4 (r = 0.477, p = 0.0001) in sufficient vitamin D conditions.Conclusions: Hypovitaminosis D is associated with higher CTP scores and is strongly associated with dysregulation of the Ca-PTH-vitamin D axis in CLD. Timely measurement of vitamin D levels is essential, along with levels of PTH, Ca and PO4, to manage CLD patients.

Hepatitis C virus related cirrhosis decreased as indication to liver transplantation since the introduction of direct-acting antivirals: A single-center study.

AIMTo evaluate waiting list (WL) registration and liver transplantation (LT) rates in patients with hepatitis C virus (HCV)-related cirrhosis since the introduction of direct-acting antivirals (DAAs).METHODSAll adult patients with cirrhosis listed for LT at Padua University Hospital between 2006-2017 were retrospectively collected using a prospectively-updated database; patients with HCV-related cirrhosis were divided by indication for LT [dec-HCV vs HCV/ hepatocellular carcinoma (HCC)] and into two interval times (2006-2013 and 2014-2017) according to the introduction of DAAs. For each patient, indications to LT, severity of liver dysfunction and the outcome in the WL were assessed and compared between the two different time periods. For patients receiving DAA-based regimens, the achievement of viral eradication and the outcome were also evaluated.RESULTSOne thousand one hundred and ninty-four [male (M)/female (F): 925/269] patients were included. Considering the whole cohort, HCV-related cirrhosis was the main etiology at the time of WL registration (490/1194 patients, 41%). HCV-related cirrhosis significantly decreased as indication to WL registration after DAA introduction (from 43.3% in 2006-2013 to 37.2% in 2014-2017, P = 0.05), especially amongst dec-HCV (from 24.2% in 2006-2013 to 15.9% in 2014-2017, P = 0.007). Even HCV remained the most common indication to LT over time (289/666, 43.4%), there was a trend towards a decrease after DAAs introduction (from 46.3% in 2006-2013 to 39% in 2014-2017, P = 0.06). HCV patients (M/F: 43/11, mean age: 57.7 ± 8 years) who achieved viral eradication in the WL had better transplant-free survival (log-rank test P = 0.02) and delisting rate (P = 0.002) than untreated HCV patients.CONCLUSIONIntroduction of DAAs significantly reduced WL registrations for HCV related cirrhosis, especially in the setting of decompensated cirrhosis.

Covered Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Portal Hypertension: Looking for the Right Patient and the Right Time

Transjugular intrahepatic portosystemic shunt (TIPS) offers an effective treatment for patients with complications of portal hypertension, specifically prevention of variceal rebleeding and recurrent or refractory ascites. TIPS reduces portal pressure and increases effective blood volume and cardiac output, but long-term adverse effects may include increased risk of liver failure, hepatic encephalopathy, and cardiac dysfunction. As such, TIPS is not indicated for primary prophylaxis of variceal bleeding. Critical to the success of TIPS is a dedicated, multidisciplinary team, along with careful patient selection and appropriate timing of the procedure; for example, in high-risk patients TIPS may offer clinical benefits when performed early in the disease course. Important patient factors to consider before performing TIPS include cardiac and renal function, severity of liver dysfunction, history of hepatic encephalopathy, and inflammatory status. Recent studies indicate that technical considerations, specifically diameter control and downsizing covered stents, may reduce adverse events and increase clinical benefits of TIPS. This review focusses on the optimisation of the use of a covered TIPS endoprosthesis in patients with portal hypertension-related complications, with consideration of evolving practices, patient selection, and multidisciplinary co-operation. Further research and patient stratification are necessary to enhance understanding of the optimal use of covered TIPS and to ensure that the right patients receive TIPS at the right time.

Splenectomy Leads to Amelioration of Altered Gut Microbiota and Metabolome in Liver Cirrhosis Patients.

Dysbiosis of gut microbiota and metabolome is a frequently encountered condition in liver cirrhosis (LC) patients. The severity of liver dysfunction was found to be correlated with the degree of microbial dysbiosis. Several clinical studies have indicated liver function improvement after therapeutic splenectomy for LC-induced hypersplenism. We sought to determine whether such post-splenectomy outcome is pertinent to modulation of the abnormal gut microenvironment in LC patients. A cross-sectional study including 12 LC patients and 16 healthy volunteers was first conducted, then a before–after study in the cohort of patients was carried out before and 6 months after splenectomy. Fecal samples were collected in hospital. Temporal bacterial (n = 40) and metabolomics (n = 30) profiling was performed using 16s rRNA gene sequencing and ultra performance liquid chromatography/mass spectrometer (UPLC/MS), respectively. Our results revealed that microbial composition in patients was clearly different from that in healthy controls (HCs), evidenced by considerable taxonomic variation. Along with improved liver function (Child–Pugh score), the patients also displayed similar gut microbiota profile and predicted metagenome function to that of HCs after splenectomy. Enterobacteriaceae and Streptococcaceae, two LC-enriched families showing positive relation with Child–Pugh score, exhibited significantly decreased abundance after splenectomy. At the genus level, 11 genera were differentially abundant between patients and HCs, but 9 genera of them restituted to normal levels by certain degree after splenectomy. PICRUSt analysis showed that the relative abundance of 17 KEGG pathways was partially restored after splenectomy. Four of them were amino acid-related pathways: lysine degradation, tryptophan degradation, amino acid metabolism, and protein digestion and absorption. These findings were supported by metabonomics results which showed that relative abundance of amino acid and corresponding catabolites changed toward normal. In addition to the variations in the relative abundances of bacteria and metabolites, the correlation between them also altered in patients after splenectomy. Dysbiosis in gut microbiome and related metabolism of LC patients was partially corrected after splenectomy. Whether the improved gut microenvironment could prevent LC-related complications and delay the progress of LC is a propitious objective for future study. Trial registration: ChiCTR-OOB-15007409. Registered November 15, 2015.

Intensive Care of Pulmonary Complications Following Liver Transplantation.

Chronic liver disease has been associated with pulmonary dysfunction both before and after liver transplantation. Post-liver transplantation pulmonary complications can affect both morbidity and mortality often necessitating intensive care during the immediate postoperative period. The major pulmonary complications include pneumonia, pleural effusions, pulmonary edema, and atelectasis. Poor clinical outcomes have been known to be associated with age, severity of liver dysfunction, and preexisting lung disease as well as perioperative events related to fluid balance, particularly transfusion and fluid volumes. Delineating each and every one of these pulmonary complications and their associated risk factors becomes paramount in guiding specific therapeutic strategies.

Erectile dysfunction in cirrhosis is impacted by liver dysfunction, portal hypertension, diabetes and arterial hypertension.

BackgroundAlthough several risk factors for erectile dysfunction may be present in patients with cirrhosis, data on the actual prevalence and cause of erectile dysfunction is limited. The International Index of Erectile Function‐5 (IIEF‐5) is a well‐validated survey to determine the presence and severity of erectile dysfunction in men. We assessed (i) the prevalence and severity of erectile dysfunction, and (ii) risk factors for erectile dysfunction in patients with cirrhosis.MethodsIn this prospective study, erectile dysfunction was defined as: absent (>21 IIEF‐5‐points), mild (12‐21) and severe (5‐11). Patients with overt hepatic encephalopathy, active alcohol abuse, extrahepatic malignancy, previous urologic surgery, previous liver transplantation and severe cardiac conditions were excluded.ResultsAmong n = 151 screened patients, n = 41 met exclusion criteria and n = 30 were sexually inactive. Thus, a final number of n = 80 male patients with cirrhosis were included. Patient characteristics: age: 53 ± 9 years; model for end‐stage liver disease score (MELD): 12.7 ± 3.9; Child‐Pugh score (CPS) A: 30 (37.5%), B: 35 (43.8%), C: 15 (18.7%); alcohol: 38 (47.5%), viral: 25 (31.3%), alcohol/viral: 7 (8.8%) and others: 10 (12.5%). The presence of erectile dysfunction was found in 51 (63.8%) patients with 44 (55%) and 7 (8.8%) suffering from mild‐to‐moderate and moderate‐to‐severe erectile dysfunction. Mean MELD and hepatic venous pressure gradient (HVPG) were significantly higher in patients with erectile dysfunction (P = .021; P = .028). Child‐Pugh score C, MELD, creatinine, age, arterial hypertension, diabetes, low libido, low testosterone and high HVPG were associated with the presence of erectile dysfunction. Interestingly, beta‐blocker therapy was not associated with an increased risk. In multivariate models, arterial hypertension (OR: 6.36 [1.16‐34.85]; P = .033), diabetes (OR: 7.40 [1.31‐41.75]; P = .023), MELD (OR: 1.19 [1.03‐1.36]; P = .015) and increasing HVPG (n = 48; OR: 1.11 [1.002‐1.23]; P = .045) were independent risk factors for the presence of erectile dysfunction.ConclusionAbout two‐thirds of male patients with cirrhosis show erectile dysfunction. Severity of liver dysfunction, portal hypertension, arterial hypertension and diabetes were identified as risk factors for erectile dysfunction.

Oral mucosa lesions and gingival bleeding can indicate the progression of liver disease in children and adolescents aged two to 18 years

This study assessed correlations between systemic disturbances of paediatric chronic liver diseases (CLD) and oral symptoms in subjects aged 2-18years. It was carried out during outpatient appointments at the Children's Memorial Health Institute, Warsaw, Poland, from 2010 to 2015 and comprised 52 CLD patients with a mean age of 12.3±4.6. We also recruited 54 generally healthy controls with a mean age of 12.0±3.7 from the Department of Paediatric Dentistry at the Medical University of Warsaw. The study used various measures, including the Child-Pugh score, which assesses CLD prognosis. We also assessed the causes of liver disease and the medication taken by the patients with CLD. A total of 24 patients received a Child-Pugh score of seven or more points, while 28 patients were awarded five or six points. More severe cases of gingivitis and a greater prevalence of oral lesions were evident in patients suffering from liver disease. Oral candidiasis, telangiectasia, bald tongue, cracked strawberry lip, yellowish-brown gum discoloration, petechiae and gingival bleeding all correlated with the severity of liver dysfunction, coagulopathy, protein, bilirubin and creatinine levels and portal hypertension. This study found that oral lesions and gingival bleeding may indicate the progression of liver failure.

The Relationship between Liver Dysfunction, Electrocardiographic Abnormalities and Metabolism in Rat

Introduction: Liver disorders may lead to many critical complications such as electrical heart abnormalities. The aim of this study was to investigate the relationship between the severity of liver dysfunctions, electrocardiogram variables and oxygen consumption. Methods: Female Sprague Dawley rats were divided into 4 groups of sham, partial portal vein ligation (PPVL), common bile duct ligation (CBDL), and combination of them (CBDL+ PPVL). 28 days after the first surgery, animals were anesthetized; ECG recorded and right femoral artery and vein cannulated. Blood gas parameters and complete blood count were measured and the arterial-venous oxygen content difference (A-VO2) calculated. Results: QT interval and QTc in the CBDL+PPVL and CBDL groups were longer than those of the sham and PPVL groups. Furthermore, there were abnormal and bizarre T waves in the CBDL and CBDL+PPVL groups. In the CBDL+PPVL group, arterial O2 pressure was lower while arterial CO2 pressure and plasma concentration of HCO3- were higher than those of the other groups. A-VO2 in the CBDL+PPVL group was also lower than those of the other groups, and in the CBDL group was less than that of the PPVL group. Conclusions: In this study, we detected bizarre T waves and increased QT interval and QTc in the ECG of cirrhotic rats, which could be partly linked to the severity of liver dysfunction and reduction of metabolism.

Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Background/Aims: Continuous renal replacement therapy (CRRT) is a treatment for acute kidney injury (AKI) patients. It has become a controversy about whether patients with liver dysfunction should perform CRRT with regional citrate anticoagulation (RCA). Methods: This retrospective observational study enrolled 145 AKI patients (275 CRRT sessions) who received CRRT with RCA and had no history of chronic liver disease. Circuit survival time, blood pressure, trans-membrane pressure (TMP), acid-base and electrolyte status were recorded and analyzed. The severity of liver dysfunction was determined by total bilirubin (TBil) and international normalized ratio (INR), while the accumulation degree of citrates was quantified by total/ ionized calcium (tCa/iCa) raito. Results: Our results showed that there was no correlation of tCa/iCa ratio with TBil or INR. And tCa/iCa ratio was not related to the disturbances of pH, lactates, sodium, magnesium, blood pressure or TMP despite that high tCa/iCa ratios might be related to the decrease of circuit survival time. TBil did not correlate with the above indexes, except for lactates levels. INR did not correlate with the above indexes except for lactates levels and blood pressure. In addition, neither was TBil, INR, nor tCa/iCa ratio, related with fatal outcomes (22.76% of the patients). Conclusion: The present study demonstrated that, with proper monitoring and adjustment of citrates and calcium infusion, applying RCA in CRRT is reasonably safe for AKI patients with acute liver dysfunction, as long as circuit time stays below roughly 50 hours.

Predictors of Seven-Day Mortality in Patients with Advanced Oncologic Liver Disease Admitted to a Palliative Care Unit

Context and objectives: A specific prognostic tool is lacking for end-stage oncological liver diseases. In addition to various factors, bilirubin, which reflects the severity of liver dysfunction, may be associated with mortality in this population. We aimed to assess how bilirubin influence survival in patients admitted in palliative care units with advanced oncologic liver diseases and to develop a prognostic model combining bilirubin with other factors. Methods: Data were collected retrospectively from 652 patients with oncologic liver diseases, accounting for 25% of all admissions in our palliative care units from 2011 to 2016. Age, gender, chronic liver diseases, infections including spontaneous bacterial peritonitis, gastrointestinal bleeding, encephalopathy, Eastern Cooperative Oncology Group score (ECOG), oral intake, jaundice, dyspnea, bilirubin, albumin and urea variables collected within 24 hours before or after admission were analyzed. Univariate and multivariate survival analyses were performed to identify the predictive value of bilirubin and other variables for 7-day survival. Results: Bilirubin value was collected in 398 patients. Univariate analysis showed that male sex, chronic liver diseases, encephalopathy, ECOG, oral intake, jaundice, bilirubin and urea blood levels, were associated with 7-day survival. Multivariate analysis showed that bilirubin>25 μ mol/L, urea>15 mmol/L, ECOG=4 and reduced oral intake, were independently correlated with survival. Accuracy of the model based on these factors to predict 7-day mortality is high (AUC=0.90). Conclusion: Bilirubin is an independent prognostic factor for 7 day-survival among patients with end-stage oncologic liver disease. Combining bilirubin, urea, ECOG and oral intake increases short term prognostication accuracy in this subgroup of patients.