- Email: [email protected]
Role of Hepatic Venous Pressure Gradient (HVPG) as a Predictor of Response to Endoscopic Variceal Ligation (EVL) in Patients of Cirrhosis with Esophageal Varices
CIRRHOSIS AND COMPLICATIONS
Table 1 Comparison of Thromboelastography and Conventional Coagulation Study. No of patients
PTT (s)
INR
Platelet count (lac/cumm)
Thromboelastography
CTP B
13 15
54.69 19.22 54.94 19.11
1.59 0.47 1.60 0.47
1.12 0.57 1.06 0.49
No transfusion needed No transfusion needed
CTP C
21
55.75 19.85
1.70 0.75
1.11 0.54
Transfusion needed in 1 patient
Total
49
55.20 19.14
1.67 0.72
1.14 0.59
Transfusion needed in 1 patient
CTP A
Conclusion: Thromboelastography use in patients with cirrhosis of liver, undergoing invasive procedures to assess bleeding and thrombosis in place of conventional coagulation tests, prevents erroneous prophylactic transfusions. VWF assay predict thrombosis risk in CLD. Corresponding author: Apurva Shah. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.231
Cirrhosis And Complications
NATURAL COURSE OF COMPENSATED CRYPTOGENIC CIRRHOSIS: EVIDENCE OF PHENOTYPIC DIVERSITY Saptarshi Bishnu, Saswata Chatterjee, Sk Ahammed, Kausik Das, Abhijit Chowdhury School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata, India
Background and Aims: Cryptogenic cirrhosis is a heterogeneous entity consisting of either liver disease of known etiologies with different phenotypic presentations or relatively rare etiologies. Clinical course of cryptogenic cirrhosis is not as well described as with well-defined etiologies. Our study was designed to understand the natural course, phenotypic heterogeneity and morbidity profile of compensated cryptogenic liver disease prospectively in an inception cohort. Methods: This prospective cohort study was conducted in the hepatology department of a tertiary care hospital between January 2000 and December 2012. Consecutive cryptogenic cirrhosis patients in compensated state, above 18 years of age, attending the outpatient department were included in the study. Cryptogenic liver disease was diagnosed by exclusion of other possible etiologies. Cohort was sub-classified into three categories; probable nonalcoholic steatohepatitis (NASH), cryptic autoimmunity and undetermined etiology, based on clinical, biochemical and autoimmune serology status. Results: Consecutive patients (n = 136; ‘probable NASH’ 16, ‘cryptic autoimmunity’ 36 and S42
‘undetermined etiology’ 84) with first diagnosis of compensated cryptogenic cirrhosis were included and followed up for 195 person-year. Demographic data is presented in Table. Cirrhosis was diagnosed in 4th decade or above (43.56 14.49 years). ‘Probable NASH’ phenotype had older age at diagnosis of cirrhosis, relatively later development of second complication after first decompensation with variceal bleed and lower risk of HCC. ‘Cryptic autoimmunity’ subtype had male predominance, longer compensated state and longer survival following decompensation. HCC was recorded in 3% (n = 2) during compensated state. Mortality at first decompensation was 2.27% (n = 3). Risk of decompensation increased with increase in age of diagnosis of cirrhosis [HR 1.032 (1.006–1.060); P = 0.017] and in ‘undetermined etiology’ phenotype [HR 1.292 (1.015–1.645); P = 0.037]. Conclusions: Phenotypic diversity of cryptogenic cirrhosis was evident in temporal course of disease, risk of decompensation and hepatocellular cancer (HCC). ‘Undetermined etiology’ phenotype progressed faster towards decompensation. Corresponding author: Saptarshi Bishnu. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.232
ROLE OF HEPATIC VENOUS PRESSURE GRADIENT (HVPG) AS A PREDICTOR OF RESPONSE TO ENDOSCOPIC VARICEAL LIGATION (EVL) IN PATIENTS OF CIRRHOSIS WITH ESOPHAGEAL VARICES Ghulam Mohmad Gulzar, Shoiab Mohammad, Mohammad Sultan Alai, Gul Javid, Altaf Shah, Showkat Zargar Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
Background and Aims: Portal hypertension is a major hallmark of cirrhosis characterized by life threatening variceal bleeding. HVPG is the gold standard for diagnosing portal hypertension. Our aim © 2015, INASL
was to look at HVPG as a predictor of response to EVL in patients of cirrhosis with esophageal varices. Material and Methods: After measuring the baseline HVPG of total 40 cirrhotic patients, EVL was done in all of them. Patients were then assessed for success or failure of eradication of varices and number of EVL sessions required for eradicating varices. Results: Ten patients had HVPG <13 mmHg, 11 patients had 13–15 mmHg, 10 patients had 16– 18 mmHg and 9 patients had >18 mmHg. Mean number of EVL sessions required for variceal eradication in patients with HVPG <12, 13–15, 16–18 and >18 mmHg were 2.10, 2.64, 4.10, 5.33 respectively. A significantly positive correlation was found between HVPG and number of EVL sessions required for eradication of varices with correlation coefficient of 0.844, regression coefficient of 0.344. The patients requiring <4 number of EVL sessions had lower mean HVPG compared to patients requiring >4 EVL sessions (P < 0.001). Post hoc analysis revealed that in comparing patients with <16 HVPG levels with rest of patients with HVPG 16–18, >18 were different in terms of number of sessions (P < 0.001). Varices were eradicated in all patients irrespective of HVPG levels. Conclusion: HVPG has a significant influence on response to EVL, in terms of number of sessions required for variceal eradication. Corresponding author: Ghulam Mohmad Gulzar. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.233
SLOW, CONTINUOUS LOW-DOSE ALBUMIN AND FUROSEMIDE INFUSION (SCLAFI) MOBILIZES LARGE ASCITES SAFELY IN DECOMPENSATED LIVER CIRRHOSIS Gaurav Pande, Kamlesh Kumar, Hemant Nayak, Samir Mohindra, Vivek Saraswat Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
Background: Graded increase of oral diuretics has been the standard therapy for mobilizing large ascites in decompensated liver cirrhosis. Large volume paracentesis (LVP) with or without albumin infusions has been the commonest rescue therapy. Both are sought with complications. Aim: To study the efficacy and safety of lowdose, continuous, in fusion of furosemide with
albumin, administered according to a responseguided protocol in patients with cirrhosis and large ascites. Methods: All cirrhotic patients with large ascites on maximally tolerated dirutics and creatinine <1.5 were enrolled. Baseline blood tests, ascitic fluid examination, urine routine and timed 24-h urine collection for urinary sodium (UNa), potassium (UK), creatinine, albumin, CXR, EKG, eGFR, endogenous creatinine clearance were done. Theraputic ascetic or pleural tap was only done if the patient was too breathless (while baseline testing was being completed). Central line was placed in oliguric/anuric patients. Furosemide infusion at 2 mg/h and albumin 2 g/h (20 g/d) was started. If serum albumin was <2.8 g/dl, 40 g/d of albumin was infusion in the nonoliguric patient for 24–48 h, with monitoring for fluid overload and for serum albumin levels. Blood (electrolytes and creatinine) and urine (electrolytes) samples were collected every 12 h for UNa, UK and if UNa < 80 mmol/L then the rate of furosemide infusion was increased by 1 mg (max 5 mg/h). Aggressive potassium supplementation (oral/iv) was done in all patients. Results: 41 patients with mean age 46.68 5.1 years were enrolled over 1 year. Baseline mean CTP 11.6 1.2 and MELD 26 7.1 calculated. Ascites responded (clinically dry) to the treatment regimen in all patients over a median period of 7.4 2.5 days. Mean 24-h urinary sodium excretion (19 9 vs. 112 24 meq/L; P = 0.001) and urine output (692.8 235.2 ml to 3295.6 971.2 ml/d (P = 0.001) improved. Mean decrease in pre-treatment weight was 13.2 3.7 kg. Mean serum creatinine (1.29 0.8 to 0.85 0.27; P = 0.001), mean serum sodium (125.3 5.2 to 131.8 4.7 meq/L; P = 0.00) and mean eGFR (Cockroft–Gault method) (83.4 50 to 93.9 43.7 ml; P = 0.023) improved significantly. There were no significant side effects or any episode of encephalopathy. Asymptomatic hypokalemia (<3.5) was noted in 23 patients. Mild renal impairment developed in three patients (increase in serum creatinine 0.3 mg/dl) and LVP was additionally required for 2 patients (tense ascites with respiratory compromise). Conclusion: Closely monitored, response-guided use of frusemide infusion with albumin is a safe and effective way of treating large ascites reducing the need for LVP. Corresponding author: Vivek Saraswat. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.234
Journal of Clinical and Experimental Hepatology | June/July 2015 | Vol. 5 | No. S2 | S27–S49
S43
Cirrhosis And Complications
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Table 1 Comparison of Thromboelastography and Conventional Coagulation Study. No of patients
PTT (s)
INR
Platelet count (lac/cumm)
Thromboelastography
CTP B
13 15
54.69 19.22 54.94 19.11
1.59 0.47 1.60 0.47
1.12 0.57 1.06 0.49
No transfusion needed No transfusion needed
CTP C
21
55.75 19.85
1.70 0.75
1.11 0.54
Transfusion needed in 1 patient
Total
49
55.20 19.14
1.67 0.72
1.14 0.59
Transfusion needed in 1 patient
CTP A
Conclusion: Thromboelastography use in patients with cirrhosis of liver, undergoing invasive procedures to assess bleeding and thrombosis in place of conventional coagulation tests, prevents erroneous prophylactic transfusions. VWF assay predict thrombosis risk in CLD. Corresponding author: Apurva Shah. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.231
Cirrhosis And Complications
NATURAL COURSE OF COMPENSATED CRYPTOGENIC CIRRHOSIS: EVIDENCE OF PHENOTYPIC DIVERSITY Saptarshi Bishnu, Saswata Chatterjee, Sk Ahammed, Kausik Das, Abhijit Chowdhury School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata, India
Background and Aims: Cryptogenic cirrhosis is a heterogeneous entity consisting of either liver disease of known etiologies with different phenotypic presentations or relatively rare etiologies. Clinical course of cryptogenic cirrhosis is not as well described as with well-defined etiologies. Our study was designed to understand the natural course, phenotypic heterogeneity and morbidity profile of compensated cryptogenic liver disease prospectively in an inception cohort. Methods: This prospective cohort study was conducted in the hepatology department of a tertiary care hospital between January 2000 and December 2012. Consecutive cryptogenic cirrhosis patients in compensated state, above 18 years of age, attending the outpatient department were included in the study. Cryptogenic liver disease was diagnosed by exclusion of other possible etiologies. Cohort was sub-classified into three categories; probable nonalcoholic steatohepatitis (NASH), cryptic autoimmunity and undetermined etiology, based on clinical, biochemical and autoimmune serology status. Results: Consecutive patients (n = 136; ‘probable NASH’ 16, ‘cryptic autoimmunity’ 36 and S42
‘undetermined etiology’ 84) with first diagnosis of compensated cryptogenic cirrhosis were included and followed up for 195 person-year. Demographic data is presented in Table. Cirrhosis was diagnosed in 4th decade or above (43.56 14.49 years). ‘Probable NASH’ phenotype had older age at diagnosis of cirrhosis, relatively later development of second complication after first decompensation with variceal bleed and lower risk of HCC. ‘Cryptic autoimmunity’ subtype had male predominance, longer compensated state and longer survival following decompensation. HCC was recorded in 3% (n = 2) during compensated state. Mortality at first decompensation was 2.27% (n = 3). Risk of decompensation increased with increase in age of diagnosis of cirrhosis [HR 1.032 (1.006–1.060); P = 0.017] and in ‘undetermined etiology’ phenotype [HR 1.292 (1.015–1.645); P = 0.037]. Conclusions: Phenotypic diversity of cryptogenic cirrhosis was evident in temporal course of disease, risk of decompensation and hepatocellular cancer (HCC). ‘Undetermined etiology’ phenotype progressed faster towards decompensation. Corresponding author: Saptarshi Bishnu. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.232
ROLE OF HEPATIC VENOUS PRESSURE GRADIENT (HVPG) AS A PREDICTOR OF RESPONSE TO ENDOSCOPIC VARICEAL LIGATION (EVL) IN PATIENTS OF CIRRHOSIS WITH ESOPHAGEAL VARICES Ghulam Mohmad Gulzar, Shoiab Mohammad, Mohammad Sultan Alai, Gul Javid, Altaf Shah, Showkat Zargar Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
Background and Aims: Portal hypertension is a major hallmark of cirrhosis characterized by life threatening variceal bleeding. HVPG is the gold standard for diagnosing portal hypertension. Our aim © 2015, INASL
was to look at HVPG as a predictor of response to EVL in patients of cirrhosis with esophageal varices. Material and Methods: After measuring the baseline HVPG of total 40 cirrhotic patients, EVL was done in all of them. Patients were then assessed for success or failure of eradication of varices and number of EVL sessions required for eradicating varices. Results: Ten patients had HVPG <13 mmHg, 11 patients had 13–15 mmHg, 10 patients had 16– 18 mmHg and 9 patients had >18 mmHg. Mean number of EVL sessions required for variceal eradication in patients with HVPG <12, 13–15, 16–18 and >18 mmHg were 2.10, 2.64, 4.10, 5.33 respectively. A significantly positive correlation was found between HVPG and number of EVL sessions required for eradication of varices with correlation coefficient of 0.844, regression coefficient of 0.344. The patients requiring <4 number of EVL sessions had lower mean HVPG compared to patients requiring >4 EVL sessions (P < 0.001). Post hoc analysis revealed that in comparing patients with <16 HVPG levels with rest of patients with HVPG 16–18, >18 were different in terms of number of sessions (P < 0.001). Varices were eradicated in all patients irrespective of HVPG levels. Conclusion: HVPG has a significant influence on response to EVL, in terms of number of sessions required for variceal eradication. Corresponding author: Ghulam Mohmad Gulzar. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.233
SLOW, CONTINUOUS LOW-DOSE ALBUMIN AND FUROSEMIDE INFUSION (SCLAFI) MOBILIZES LARGE ASCITES SAFELY IN DECOMPENSATED LIVER CIRRHOSIS Gaurav Pande, Kamlesh Kumar, Hemant Nayak, Samir Mohindra, Vivek Saraswat Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
Background: Graded increase of oral diuretics has been the standard therapy for mobilizing large ascites in decompensated liver cirrhosis. Large volume paracentesis (LVP) with or without albumin infusions has been the commonest rescue therapy. Both are sought with complications. Aim: To study the efficacy and safety of lowdose, continuous, in fusion of furosemide with
albumin, administered according to a responseguided protocol in patients with cirrhosis and large ascites. Methods: All cirrhotic patients with large ascites on maximally tolerated dirutics and creatinine <1.5 were enrolled. Baseline blood tests, ascitic fluid examination, urine routine and timed 24-h urine collection for urinary sodium (UNa), potassium (UK), creatinine, albumin, CXR, EKG, eGFR, endogenous creatinine clearance were done. Theraputic ascetic or pleural tap was only done if the patient was too breathless (while baseline testing was being completed). Central line was placed in oliguric/anuric patients. Furosemide infusion at 2 mg/h and albumin 2 g/h (20 g/d) was started. If serum albumin was <2.8 g/dl, 40 g/d of albumin was infusion in the nonoliguric patient for 24–48 h, with monitoring for fluid overload and for serum albumin levels. Blood (electrolytes and creatinine) and urine (electrolytes) samples were collected every 12 h for UNa, UK and if UNa < 80 mmol/L then the rate of furosemide infusion was increased by 1 mg (max 5 mg/h). Aggressive potassium supplementation (oral/iv) was done in all patients. Results: 41 patients with mean age 46.68 5.1 years were enrolled over 1 year. Baseline mean CTP 11.6 1.2 and MELD 26 7.1 calculated. Ascites responded (clinically dry) to the treatment regimen in all patients over a median period of 7.4 2.5 days. Mean 24-h urinary sodium excretion (19 9 vs. 112 24 meq/L; P = 0.001) and urine output (692.8 235.2 ml to 3295.6 971.2 ml/d (P = 0.001) improved. Mean decrease in pre-treatment weight was 13.2 3.7 kg. Mean serum creatinine (1.29 0.8 to 0.85 0.27; P = 0.001), mean serum sodium (125.3 5.2 to 131.8 4.7 meq/L; P = 0.00) and mean eGFR (Cockroft–Gault method) (83.4 50 to 93.9 43.7 ml; P = 0.023) improved significantly. There were no significant side effects or any episode of encephalopathy. Asymptomatic hypokalemia (<3.5) was noted in 23 patients. Mild renal impairment developed in three patients (increase in serum creatinine 0.3 mg/dl) and LVP was additionally required for 2 patients (tense ascites with respiratory compromise). Conclusion: Closely monitored, response-guided use of frusemide infusion with albumin is a safe and effective way of treating large ascites reducing the need for LVP. Corresponding author: Vivek Saraswat. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.234
Journal of Clinical and Experimental Hepatology | June/July 2015 | Vol. 5 | No. S2 | S27–S49
S43
Cirrhosis And Complications
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY