- Email: [email protected]
Changes on Cerebral Hemodynamics in Cirrhotic Patients after Liver Transplantation
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
controls. Intestinal permeability decreases after decongestive therapy, suggesting that intestinal decongestion may reverse increased IP in ACLF. To our knowledge, significant increase in IP among patients with ACLF to levels higher than seen in decompensated LC (d-LC) and its ‘normalization’ after splanchnic decongestion have not been reported earlier (Figure 1).
CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Gaurav Pandey. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.093
(44.4%) patients, both were absent in 16 (29.7%) and either were present in 14 (25.9%) patients. The overall performance was poorer in patients with MHE and in patients with extrapyramidal signs compared to the patients who did not have MHE or extrapyramidal signs. Patients with MHE and extrapyramidal signs showed poorer SF 36 scores compared to controls and patients without MHE. There was no significant difference in various SF 36 scores between control subjects and patients without MHE. Conclusion: There is a high prevalence of MHE among patients with cirrhosis. The prevalence of extrapyramidal signs is significantly higher in cirrhotic patients with MHE than in those without MHE. The presence of MHE had an independent relationship to the presence of extrapyramidal signs and Health related Quality of life.
91
The authors have none to declare.
EXTRAPYRAMIDAL SIGNS AND HEALTH RELATED QUALITY OF LIFE IN PATIENTS WITH CIRRHOSIS
Corresponding author: Radha K. Dhiman. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.094
Sunil Taneja, M.N. Pathak, Sahaj Rathi, Ajay Duseja, Yogesh K. Chawla, Radha K. Dhiman Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Background & Aims: The spectrum of neurological dysfunction in cirrhosis varies from mild cognitive impairment to a full blown extrapyramidal syndrome referred to as hepatocerebral degeneration. However there is little information about the clinical significance of extrapyramidal signs associated with cirrhosis, and it is influence on the prevalence of MHE and daily-life activities or health-related quality of life (HRQOL) of patients. Hence this present study was carried out to elucidate the relationship between extrapyramidal signs and cognitive impairment with MHE and quality of life. Methods: Fifty-four patients of cirrhosis without evidence of overt Hepatic encephalopathy were enrolled in the study and were subjected to PHES for diagnosis of MHE. The assessment of extrapyramidal signs was evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS) parts 1, 2 and 3 and HRQOL was measured using SF-36 questionnaire. Results: Out of fifty-four patients MHE was detected in 28 (51.8%) patients. The extrapyramidal signs (UPDRS score 3) were present in 34 (62.9%). Extrapyramidal signs were demonstrated in 24 (85.7%) patients with MHE compared to 10 (38.5%) patients without MHE (P = 0.003). Patients with extrapyramidal signs had higher MELD score (P = 0.008) and serum bilirubin (P = 0.07). Of 54 patients both MHE and extrapyramidal signs were present in 24
92 CHANGES ON CEREBRAL HEMODYNAMICS IN CIRRHOTIC PATIENTS AFTER LIVER TRANSPLANTATION Ricardo Ulises Macías-Rodríguez, Astrid Ruiz-Margáin, Carlos Cantú-Brito, Francisco Javier Cubero, Octavio René García Flores, Elena Larrieta-Carrasco, Aldo Torre Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición ‘‘Salvador Zubirán’’, Mexico City, México
Background and aims: Improvement in cognitive function after LT has been related to decreased cerebral white matter lesions induced by microvascular lesions (leukoaraiosis) secondary to low-grade cerebral edema and systemic inflammation. However most of studies have addressed these changes in the acute setting during and immediately after LT in cirrhosis as well as in acute liver failure and few have evaluated the long-term changes in cerebral hemodynamics in this population, therefore we aimed to investigate the long-term changes on cerebral hemodynamics in cirrhotic patients after LT. Methods: This was a prospective cohort study. We performed Transcranial Doppler Ultrasonography (TCD) measuring Pulsatility index (PI), Resistance index (RI) and breath-holding index (BHI) in the middle cerebral artery pre and post-LT. PI, RI and BHI evaluate
Journal of Clinical and Experimental Hepatology | February 2017 | Vol. 7 | No. S1 | S22–S83
S71
POSTER PRESENTATION
CONFLICTS OF INTEREST
POSTERS
Table 1 Changes in cerebral hemodynamics and inflammatory markers before and after LT. (Results are expressed as mean SD or median (IQR)). Pre-LT (n = 27) RI PI
Post-LT (n = 27)
% change
1.49 0.35 1.21 0.33 16.1 27.3 0.98 0.16 0.84 0.16 12.6 19.9
P value 0.002 0.002
0.78 0.49 0.76 0.52 1.6 (51 0.933 to 100) 21.9 9.5 66.5 0.046 IL-6 (5.0–19.8) (91.8 (pg/mL) (7.8–79.1) 66.5 to 8.4) (91.8 to 80.046 16.6 7.9 (0–17) 63.5 <0.001 TNF-a (2.8–46.3) (100 to 39.6) (pg/mL) BHI
POSTER PRESENTATION
cerebrovascular structural integrity and reactivity, respectively. Neuropsychometric tests and West-Haven criteria were used for HE characterization. To address systemic inflammation, we measured plasma levels of IL-6 and TNF́ a. Descriptive statistics and Wilcoxons test were used. Results: Twenty-seven patients were included (16 males); median follow up after LT was 6 months, median age pre-LT was 47(40-55) years, the main etiology was hepatitis C virus (58%), most of patients were Child-Pugh B (14/27), MELD score was 16(12-20), MELD-Na 18.5, PHES -3 and CFF 38.5 Hz. Previous to the LT 17/27 patients had HE and 11/27 ascites. A decrease in PI and RI was observed in all patients except 3 after LT, and an increase in BHI in 12/27. The changes on cerebral hemodynamics paralleled those in systemic inflammation (Table 1). Clinical improvement in cognition was observed in all patients with overt HE after LT. Conclusions: These results show an improvement in cerebral hemodynamics at long-term after LT in cirrhosis, indicating less arterial cerebral vasoconstriction (decrease in PI/RI) which seems to be influenced by systemic inflammation; this could explain the improvement in cognitive function after LT. TCD could be considered as a useful tool for the assessment of the changes in cerebral hemodynamics pre and post-LT in cirrhosis.
CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Aldo Torre. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.095
S72
93 PROMETHEUS VERSUS PLASMA EXCHANGE — A COMPARISON OF EFFICIENCY OF TWO DIFFERENT MODALITIES OF LIVER DETOXIFICATION IN PATIENTS WITH ACUTE ON CHRONIC LIVER FAILURE Rakhi Maiwall, Guresh Kumar, Meenu Bajpai, Suman Lata Nayak, Ashok Chowdhury, Manoj Kumar Sharma, Brajesh Chander Sharma, Shiv Kumar Sarin Department of Hepatology, Institute of Liver and Biliary Sciences, Delhi, India
Background and Aim: Patients with Acute on Chronic Liver Failure (ACLF) have very high mortality in the absence of liver transplantation (LT). Artificial liver support (ALS) has been shown to provide an effective bridging therapy; though the data is conflicting. We evaluated the transplant-free survival in patients with ACLF treated with ALS; i.e. plasma-exchange (PE) or liver dialysis (FPSA) as compared to standard medical treatment (SMT) and predictors of survival. We also compared the efficacy of PE as compared to FPSA in patients with ACLF. Methods: ACLF patients (n = 636, mean age 42.6 13.9 yr.) received either ALS treatment (Gr. A, n = 74) or continued with SMT (Gr. B, n = 562). Matching (1:1) by propensity risk score (PRS) (n = 46, ALS-23, SMT-23) was done to avoid selection bias. Results: Patients with ACLF underwent Prometheus (n = 22), PE (n = 52) or SMT (n = 636). ALS was not associated with survival benefit either in the pre-match or PRS-matched cohort (Log rank P > 0.05). On subgroup analysis, 47% of ALS-treated patients survived. Non-survivors had more frequently advanced hepatic encephalopathy (HE) which did not improve post-therapy (p < 0.001). A significant improvement in clinical and biochemical parameters and reduction in MELD scores (P < 0.05) was noted with ALS. Comparison of two modalities showed significant improvement in serum bilirubin (P = 0.04), creatinine (P = 0.02) and HE for FPSA (P = 0.04) while in INR for PE (P < 0.001). The adverse effects were mild and well tolerated. Further, a decrease in MELD score to less than 30 was associated with improved survival with FPSA but not PE. Conclusions: ALS significantly improves HE and reduces MELD scores; however do not improve transplant-free survival in patients with ACLF. The efficacy of FPSA is different from PE in patients with ACLF.
© 2017, INASL
controls. Intestinal permeability decreases after decongestive therapy, suggesting that intestinal decongestion may reverse increased IP in ACLF. To our knowledge, significant increase in IP among patients with ACLF to levels higher than seen in decompensated LC (d-LC) and its ‘normalization’ after splanchnic decongestion have not been reported earlier (Figure 1).
CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Gaurav Pandey. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.093
(44.4%) patients, both were absent in 16 (29.7%) and either were present in 14 (25.9%) patients. The overall performance was poorer in patients with MHE and in patients with extrapyramidal signs compared to the patients who did not have MHE or extrapyramidal signs. Patients with MHE and extrapyramidal signs showed poorer SF 36 scores compared to controls and patients without MHE. There was no significant difference in various SF 36 scores between control subjects and patients without MHE. Conclusion: There is a high prevalence of MHE among patients with cirrhosis. The prevalence of extrapyramidal signs is significantly higher in cirrhotic patients with MHE than in those without MHE. The presence of MHE had an independent relationship to the presence of extrapyramidal signs and Health related Quality of life.
91
The authors have none to declare.
EXTRAPYRAMIDAL SIGNS AND HEALTH RELATED QUALITY OF LIFE IN PATIENTS WITH CIRRHOSIS
Corresponding author: Radha K. Dhiman. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.094
Sunil Taneja, M.N. Pathak, Sahaj Rathi, Ajay Duseja, Yogesh K. Chawla, Radha K. Dhiman Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Background & Aims: The spectrum of neurological dysfunction in cirrhosis varies from mild cognitive impairment to a full blown extrapyramidal syndrome referred to as hepatocerebral degeneration. However there is little information about the clinical significance of extrapyramidal signs associated with cirrhosis, and it is influence on the prevalence of MHE and daily-life activities or health-related quality of life (HRQOL) of patients. Hence this present study was carried out to elucidate the relationship between extrapyramidal signs and cognitive impairment with MHE and quality of life. Methods: Fifty-four patients of cirrhosis without evidence of overt Hepatic encephalopathy were enrolled in the study and were subjected to PHES for diagnosis of MHE. The assessment of extrapyramidal signs was evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS) parts 1, 2 and 3 and HRQOL was measured using SF-36 questionnaire. Results: Out of fifty-four patients MHE was detected in 28 (51.8%) patients. The extrapyramidal signs (UPDRS score 3) were present in 34 (62.9%). Extrapyramidal signs were demonstrated in 24 (85.7%) patients with MHE compared to 10 (38.5%) patients without MHE (P = 0.003). Patients with extrapyramidal signs had higher MELD score (P = 0.008) and serum bilirubin (P = 0.07). Of 54 patients both MHE and extrapyramidal signs were present in 24
92 CHANGES ON CEREBRAL HEMODYNAMICS IN CIRRHOTIC PATIENTS AFTER LIVER TRANSPLANTATION Ricardo Ulises Macías-Rodríguez, Astrid Ruiz-Margáin, Carlos Cantú-Brito, Francisco Javier Cubero, Octavio René García Flores, Elena Larrieta-Carrasco, Aldo Torre Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición ‘‘Salvador Zubirán’’, Mexico City, México
Background and aims: Improvement in cognitive function after LT has been related to decreased cerebral white matter lesions induced by microvascular lesions (leukoaraiosis) secondary to low-grade cerebral edema and systemic inflammation. However most of studies have addressed these changes in the acute setting during and immediately after LT in cirrhosis as well as in acute liver failure and few have evaluated the long-term changes in cerebral hemodynamics in this population, therefore we aimed to investigate the long-term changes on cerebral hemodynamics in cirrhotic patients after LT. Methods: This was a prospective cohort study. We performed Transcranial Doppler Ultrasonography (TCD) measuring Pulsatility index (PI), Resistance index (RI) and breath-holding index (BHI) in the middle cerebral artery pre and post-LT. PI, RI and BHI evaluate
Journal of Clinical and Experimental Hepatology | February 2017 | Vol. 7 | No. S1 | S22–S83
S71
POSTER PRESENTATION
CONFLICTS OF INTEREST
POSTERS
Table 1 Changes in cerebral hemodynamics and inflammatory markers before and after LT. (Results are expressed as mean SD or median (IQR)). Pre-LT (n = 27) RI PI
Post-LT (n = 27)
% change
1.49 0.35 1.21 0.33 16.1 27.3 0.98 0.16 0.84 0.16 12.6 19.9
P value 0.002 0.002
0.78 0.49 0.76 0.52 1.6 (51 0.933 to 100) 21.9 9.5 66.5 0.046 IL-6 (5.0–19.8) (91.8 (pg/mL) (7.8–79.1) 66.5 to 8.4) (91.8 to 80.046 16.6 7.9 (0–17) 63.5 <0.001 TNF-a (2.8–46.3) (100 to 39.6) (pg/mL) BHI
POSTER PRESENTATION
cerebrovascular structural integrity and reactivity, respectively. Neuropsychometric tests and West-Haven criteria were used for HE characterization. To address systemic inflammation, we measured plasma levels of IL-6 and TNF́ a. Descriptive statistics and Wilcoxons test were used. Results: Twenty-seven patients were included (16 males); median follow up after LT was 6 months, median age pre-LT was 47(40-55) years, the main etiology was hepatitis C virus (58%), most of patients were Child-Pugh B (14/27), MELD score was 16(12-20), MELD-Na 18.5, PHES -3 and CFF 38.5 Hz. Previous to the LT 17/27 patients had HE and 11/27 ascites. A decrease in PI and RI was observed in all patients except 3 after LT, and an increase in BHI in 12/27. The changes on cerebral hemodynamics paralleled those in systemic inflammation (Table 1). Clinical improvement in cognition was observed in all patients with overt HE after LT. Conclusions: These results show an improvement in cerebral hemodynamics at long-term after LT in cirrhosis, indicating less arterial cerebral vasoconstriction (decrease in PI/RI) which seems to be influenced by systemic inflammation; this could explain the improvement in cognitive function after LT. TCD could be considered as a useful tool for the assessment of the changes in cerebral hemodynamics pre and post-LT in cirrhosis.
CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Aldo Torre. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.095
S72
93 PROMETHEUS VERSUS PLASMA EXCHANGE — A COMPARISON OF EFFICIENCY OF TWO DIFFERENT MODALITIES OF LIVER DETOXIFICATION IN PATIENTS WITH ACUTE ON CHRONIC LIVER FAILURE Rakhi Maiwall, Guresh Kumar, Meenu Bajpai, Suman Lata Nayak, Ashok Chowdhury, Manoj Kumar Sharma, Brajesh Chander Sharma, Shiv Kumar Sarin Department of Hepatology, Institute of Liver and Biliary Sciences, Delhi, India
Background and Aim: Patients with Acute on Chronic Liver Failure (ACLF) have very high mortality in the absence of liver transplantation (LT). Artificial liver support (ALS) has been shown to provide an effective bridging therapy; though the data is conflicting. We evaluated the transplant-free survival in patients with ACLF treated with ALS; i.e. plasma-exchange (PE) or liver dialysis (FPSA) as compared to standard medical treatment (SMT) and predictors of survival. We also compared the efficacy of PE as compared to FPSA in patients with ACLF. Methods: ACLF patients (n = 636, mean age 42.6 13.9 yr.) received either ALS treatment (Gr. A, n = 74) or continued with SMT (Gr. B, n = 562). Matching (1:1) by propensity risk score (PRS) (n = 46, ALS-23, SMT-23) was done to avoid selection bias. Results: Patients with ACLF underwent Prometheus (n = 22), PE (n = 52) or SMT (n = 636). ALS was not associated with survival benefit either in the pre-match or PRS-matched cohort (Log rank P > 0.05). On subgroup analysis, 47% of ALS-treated patients survived. Non-survivors had more frequently advanced hepatic encephalopathy (HE) which did not improve post-therapy (p < 0.001). A significant improvement in clinical and biochemical parameters and reduction in MELD scores (P < 0.05) was noted with ALS. Comparison of two modalities showed significant improvement in serum bilirubin (P = 0.04), creatinine (P = 0.02) and HE for FPSA (P = 0.04) while in INR for PE (P < 0.001). The adverse effects were mild and well tolerated. Further, a decrease in MELD score to less than 30 was associated with improved survival with FPSA but not PE. Conclusions: ALS significantly improves HE and reduces MELD scores; however do not improve transplant-free survival in patients with ACLF. The efficacy of FPSA is different from PE in patients with ACLF.
© 2017, INASL