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Sa1027 Plasma Cysteine Levels and Muscle Cramps in Patients With Cirrhosis
classification of Dieases(ICD-9 CM)codes were used to categorize patients. Patients with any discharge diagnosis code of cirrhosis were included in the study. Patient who had a concomitant discharge code of AKI were studied. Prevalence, mortality and length of stay were calculated. Chi square and logistic regression were used for analysis. Results: There were 104,539 cirrhotics admitted with AKI in the year 2008. AKI was more prevalent in cirrhotics as compared to non cirrhotics (14.63% vs. 6.65%, p=<0.001). Cirrhotics with AKI had a significantly higher inpatient mortality as compared to cirrhotics without AKI (23.56% vs. 3.54%, p=<0.001). AKI in cirrhotics lead to a higher mean length of stay (5.46 days vs.10.58 days) and higher average cost of hospitalization ($36k vs. $87k). Conclusion: AKI is more prevalent among hospitalized cirrhotics and leads to higher mortality, length of stay and hospital charges. Further prospective studies are needed to confirm these findings and to look into the factors causing increased mortality and morbidity.
Legend: CI=interval of confidence; PPV=positive predictive value; NPV=negative predictive value; PLR=positive likelihood ratio; NLR=negative likelihood ratio.
Sa1030 Sa1027 Overt Hepatic Encephalopathy in Cirrhosis: Influence of Multiple Clinical Precipitants Resulting in Hospitalization Ganesh Pantham, Nisheet Waghray, Ravi Prakash, Raja Shekhar R. Sappati Biyyani, Kevin D. Mullen
AASLD Abstracts
Plasma Cysteine Levels and Muscle Cramps in Patients With Cirrhosis Irakli Kaloiani, Alisha C. DeCook, Janice L. Petz, Patrick S. Kamath, E. Rolland Dickson, W. Ray Kim
Objectives: Overt hepatic encephalopathy (OHE) is a major cause of significant morbidity and mortality in liver cirrhosis. Previous studies looking into multiple factors causing OHE are limited due to small sample size and focused on individual precipitating factors. We aimed to study the profile of multiple clinical precipitant factors resulting in hospitalizations for the OHE. Methods: Electronic medical records of all patients admitted with primary diagnosis of OHE between 2005 and 2010 were retrospectively reviewed for the etiology of cirrhosis and precipitants of OHE. The diagnosis of liver cirrhosis was confirmed using laboratory and imaging studies. Other causes for altered mental status were excluded with appropriate investigations. OHE was staged using the West Haven criteria. A total of 109 patients are included in the study. Results: 109 cirrhotic patients (70 males and 39 females with a mean age of 55 years) had a total of 200 hospital admissions with a primary diagnosis of OHE. 56 patients were of Child-Pugh class B, 51 patients Child-Pugh class C and 2 unclassified. Per West Haven criteria, 2 patients had grade I, 90 grade II, 15 grade III and 2 in grade IV OHE. Average duration of hospital stay was 4.8 days. Various types of cirrhosis are shown in table 1 and factors identified as precipitants of OHE are shown in the table 2. More than one precipitating factor was identified in 114 (57%) admissions followed by 84 (42%) admissions with 2 precipitants, 26 (13%) with 3 precipitants and 4 (2%) with four precipitants. Conclusions: Lactulose noncompliance is the single most frequent precipitant of OHE followed by constipation, opioids and benzodiazepines and dehydration. Presence of multiple precipitating factors increases the complexity of hospital admissions. Patient and family education regarding lactulose dosing, avoiding precipitating drugs and dehydration will potentially reduce a number of hospital admissions. table 1
Background/Aims: Muscle cramps are common in patients with cirrhosis, particularly when diuretics are used for ascites. Its pathophysiologic mechanism remains uncertain. In this work, we conducted field testing of a questionnaire to measure the extent and severity of muscle cramps in patients with cirrhosis and explored plasma metabolomic biomarkers for muscle cramps. Methods: Patients with an established diagnosis of cirrhosis were prospectively contacted prior to their follow-up appointment in our liver clinic. Patients were asked to fill out a muscle cramps questionnaire (mMCQ) which asks about occurrence, frequency, location and impact (sleep and daily living) of muscle cramps. Blood samples were drawn after a minimum of 12 hours of fasting, which were promptly cold-centrifuged and plasma was separated for metabolomics assays. Results: In this on-going study, 109 patients have been contacted to date, of whom 46 patients have responded to the questionnaire (response rate=42% to date). The respondents were 57.8 ± 11.1 years of age and 59% were men. The mean MELD score was 12.8 ± 5.5. Approximately half (46%) reported history of hepatic encephalopathy and 6.5% refractory ascites requiring therapeutic paracentesis. In this patient cohort, the prevalence of muscle cramps was 76%. Of those who reported muscle cramps, 50% had moderate to severe symptoms (occuring at least daily or causing at least moderate disturbance of activities of daily living). To date, we have assayed 25 amino acid in the plasma samples (n=43), including taurine, threonine, serine, asparagine, glutamic acid, argininosuccinic acid, glutamine, proline, glycine, alanine, citruline, α-amino-N-butyric acid, valine, cysteine, methionine, isoleucine, leucine, tyrosine, phenyl alanine, β-alanine, ornithine, lysine, histidine, arginine, and allo-isoleucine. Of these, plasma cysteine levels were significantly different according to the severity of muscle cramps. In patients without muscle cramps the median plasma level was 59 nmol/mL with an interquartile range (IQR) of 52-75 nmol/mL, compared to those with cramps (median=82 nmol/mL, IQR=61-94). In the figure, patients with severe cramps had the highest cysteine levels (median 90 nmol/ mL, IQR=78-106) compared to those with mild cramps (median:73 nmol/mL, IQR=51-86). Conclusion: Muscle cramps are extremely common in patients with cirrhosis receiving ongoing care at a liver clinic. Plasma cysteine levels may be a potential biomarker for muscle cramps, as they correlate with their occurrence and severity.
Table 2
Sa1028 Iatrogenic Infections in Hospitalized Cirrhotics Predict Mortality Muhammad Ali, Shahryar Ahmad, Nilay Kumar, Gagan Kumar, Kia Saeian Background: Iatrogenic infections are a burden on healthcare and are associated with worse outcomes. We wanted to determine impact of iatrogenic infections on hospitalized patients with cirrhosis. Methods: A retrospective case control design was utilized using the Nationwide Inpatient Sample (NIS) from year 2000-2008. The NIS is the largest all payor discharge database in the US. Appropriate International Classification of Diseases(ICD-9CM)codes were used to identify patients with any discharge diagnosis of iatrogenic infection and any discharge diagnosis of cirrhosis. Data was analyzed using STATA 10. Chi square test and logistic regression were used for analysis. Results: There were 73,394 admissions with iatrogenic infection among admitted cirrhotics from years 2000-2008. This comprised 1.26% of all admissions among patients with cirrhosis. On logistic regression, iatrogenic infections were independently associated with mortality in cirrhotics (OR 1.79, 95% CI 1.71-1.88). Female sex was associated with a lower mortality in cirrhotics with iatrogenic infections whereas teaching status of a hospital was associated with a higher mortality (OR 1.12, 95% CI 1.10-1.13). Cirrhotic patients with iatrogenic infections were more likely to be discharged to a facility as compared to cirrhotic patients without iatrogenic infections (31.50% vs. 15.65%). Patients with iatrogenic infections were also more likely to receive home care (23.26% vs. 11.71%). Conclusions: Iatrogenic infections are associated with higher odds of mortality in hospitalized patients with cirrhosis. Iatrogenic infections lead to higher utilization resources (home care and facility discharge).
Sa1031 Risk Factors for Inpatient Mortality Among Hospitalized Hepatorenal Syndrome Patients- a Nationwide Population Based Study Sravanthi Parasa, Arun Raghav Mahankali Sridhar, Ryan C. Mascarenhas, Kevin Olden BACKGROUND AND AIMS: Hepatorenal syndrome (HRS) is a common complication of advanced cirrhosis, characterized by renal failure and major disturbances in circulatory function. The prognosis is very poor and this condition is associated with a high mortality and morbidity. However, there are few population based studies that are done to evaluate the risk factors for adverse outcomes of HRS. METHODS: We used data from Nationwide Inpatient Sample for year 2008 to perform a cross sectional study of the patients hospitalized for HRS as identified by appropriate International Classification of Diseases, Ninth Revision (ICD9) discharge diagnoses codes. The patients were then categorized into groups - with concomitant diagnosis of alcoholic cirrhosis (AC) and biliary cirrhosis (BC), and cirrhosis as identified by ICD9 diagnosis codes. The demographic characteristics, clinical characteristics and the hospital outcomes of the groups were studied. Univariate and Multivariate logistic regression methods using STATA 12.0 survey commands were used to assess the risk factors for in hospital death among these groups after adjusting for clinically important covariates. RESULTS: There were a total of 23,764 discharges that were diagnosed with HRS of which a total of 8853 (36%) patients died in the hospital. 2219 (9.3%) developed ESRD. The Length Of Stay (LOS) and total hospital charges were significantly higher for patients with an underlying diagnosis of biliary cirrhosis (table1) On multi-variate analysis, among patients with HRS, TIPS procedure was associated with decreased risk of inhospital death (adjusted odds ratio (aOR) 0.46, 95 % Confidence interval (95%CI) (0.24-0.87)), undergoing Hemodialysis was not associated with any decreased risk of inhospital mortality (aOR , 1.14, 95% CI (0.93-1.4)). Risk factors contributing to increase in risk of death are increasing age,
Sa1029 Acute Kidney Injury (AKI) Predicts Mortality in Hospitalized Patient With Cirrhosis Muhammad Ali, Shahryar Ahmad, Adil Jadoon, Nilay Kumar, Gagan Kumar, Kia Saeian Background: Recent studies have indicated a higher incidence of acute kidney injury (AKI) in cirrhotics and its negative impact on mortality. There is lack of nationwide data from the US on prevalence of AKI among hospitalized cirrhotics and its impact on morbidity and mortality. Aim: To determine incidence of AKI in hospitalized patients with cirrhosis and study the impact of AKI on outcomes among hospitalized cirrhotics. Methods: A retrospective case control study design was utilized using the National Inpatient Sample (NIS) from the year 2008. NIS is the largest inpatient discharge database in the US. Appropriate International
AASLD Abstracts
S-950
Legend: CI=interval of confidence; PPV=positive predictive value; NPV=negative predictive value; PLR=positive likelihood ratio; NLR=negative likelihood ratio.
Sa1030 Sa1027 Overt Hepatic Encephalopathy in Cirrhosis: Influence of Multiple Clinical Precipitants Resulting in Hospitalization Ganesh Pantham, Nisheet Waghray, Ravi Prakash, Raja Shekhar R. Sappati Biyyani, Kevin D. Mullen
AASLD Abstracts
Plasma Cysteine Levels and Muscle Cramps in Patients With Cirrhosis Irakli Kaloiani, Alisha C. DeCook, Janice L. Petz, Patrick S. Kamath, E. Rolland Dickson, W. Ray Kim
Objectives: Overt hepatic encephalopathy (OHE) is a major cause of significant morbidity and mortality in liver cirrhosis. Previous studies looking into multiple factors causing OHE are limited due to small sample size and focused on individual precipitating factors. We aimed to study the profile of multiple clinical precipitant factors resulting in hospitalizations for the OHE. Methods: Electronic medical records of all patients admitted with primary diagnosis of OHE between 2005 and 2010 were retrospectively reviewed for the etiology of cirrhosis and precipitants of OHE. The diagnosis of liver cirrhosis was confirmed using laboratory and imaging studies. Other causes for altered mental status were excluded with appropriate investigations. OHE was staged using the West Haven criteria. A total of 109 patients are included in the study. Results: 109 cirrhotic patients (70 males and 39 females with a mean age of 55 years) had a total of 200 hospital admissions with a primary diagnosis of OHE. 56 patients were of Child-Pugh class B, 51 patients Child-Pugh class C and 2 unclassified. Per West Haven criteria, 2 patients had grade I, 90 grade II, 15 grade III and 2 in grade IV OHE. Average duration of hospital stay was 4.8 days. Various types of cirrhosis are shown in table 1 and factors identified as precipitants of OHE are shown in the table 2. More than one precipitating factor was identified in 114 (57%) admissions followed by 84 (42%) admissions with 2 precipitants, 26 (13%) with 3 precipitants and 4 (2%) with four precipitants. Conclusions: Lactulose noncompliance is the single most frequent precipitant of OHE followed by constipation, opioids and benzodiazepines and dehydration. Presence of multiple precipitating factors increases the complexity of hospital admissions. Patient and family education regarding lactulose dosing, avoiding precipitating drugs and dehydration will potentially reduce a number of hospital admissions. table 1
Background/Aims: Muscle cramps are common in patients with cirrhosis, particularly when diuretics are used for ascites. Its pathophysiologic mechanism remains uncertain. In this work, we conducted field testing of a questionnaire to measure the extent and severity of muscle cramps in patients with cirrhosis and explored plasma metabolomic biomarkers for muscle cramps. Methods: Patients with an established diagnosis of cirrhosis were prospectively contacted prior to their follow-up appointment in our liver clinic. Patients were asked to fill out a muscle cramps questionnaire (mMCQ) which asks about occurrence, frequency, location and impact (sleep and daily living) of muscle cramps. Blood samples were drawn after a minimum of 12 hours of fasting, which were promptly cold-centrifuged and plasma was separated for metabolomics assays. Results: In this on-going study, 109 patients have been contacted to date, of whom 46 patients have responded to the questionnaire (response rate=42% to date). The respondents were 57.8 ± 11.1 years of age and 59% were men. The mean MELD score was 12.8 ± 5.5. Approximately half (46%) reported history of hepatic encephalopathy and 6.5% refractory ascites requiring therapeutic paracentesis. In this patient cohort, the prevalence of muscle cramps was 76%. Of those who reported muscle cramps, 50% had moderate to severe symptoms (occuring at least daily or causing at least moderate disturbance of activities of daily living). To date, we have assayed 25 amino acid in the plasma samples (n=43), including taurine, threonine, serine, asparagine, glutamic acid, argininosuccinic acid, glutamine, proline, glycine, alanine, citruline, α-amino-N-butyric acid, valine, cysteine, methionine, isoleucine, leucine, tyrosine, phenyl alanine, β-alanine, ornithine, lysine, histidine, arginine, and allo-isoleucine. Of these, plasma cysteine levels were significantly different according to the severity of muscle cramps. In patients without muscle cramps the median plasma level was 59 nmol/mL with an interquartile range (IQR) of 52-75 nmol/mL, compared to those with cramps (median=82 nmol/mL, IQR=61-94). In the figure, patients with severe cramps had the highest cysteine levels (median 90 nmol/ mL, IQR=78-106) compared to those with mild cramps (median:73 nmol/mL, IQR=51-86). Conclusion: Muscle cramps are extremely common in patients with cirrhosis receiving ongoing care at a liver clinic. Plasma cysteine levels may be a potential biomarker for muscle cramps, as they correlate with their occurrence and severity.
Table 2
Sa1028 Iatrogenic Infections in Hospitalized Cirrhotics Predict Mortality Muhammad Ali, Shahryar Ahmad, Nilay Kumar, Gagan Kumar, Kia Saeian Background: Iatrogenic infections are a burden on healthcare and are associated with worse outcomes. We wanted to determine impact of iatrogenic infections on hospitalized patients with cirrhosis. Methods: A retrospective case control design was utilized using the Nationwide Inpatient Sample (NIS) from year 2000-2008. The NIS is the largest all payor discharge database in the US. Appropriate International Classification of Diseases(ICD-9CM)codes were used to identify patients with any discharge diagnosis of iatrogenic infection and any discharge diagnosis of cirrhosis. Data was analyzed using STATA 10. Chi square test and logistic regression were used for analysis. Results: There were 73,394 admissions with iatrogenic infection among admitted cirrhotics from years 2000-2008. This comprised 1.26% of all admissions among patients with cirrhosis. On logistic regression, iatrogenic infections were independently associated with mortality in cirrhotics (OR 1.79, 95% CI 1.71-1.88). Female sex was associated with a lower mortality in cirrhotics with iatrogenic infections whereas teaching status of a hospital was associated with a higher mortality (OR 1.12, 95% CI 1.10-1.13). Cirrhotic patients with iatrogenic infections were more likely to be discharged to a facility as compared to cirrhotic patients without iatrogenic infections (31.50% vs. 15.65%). Patients with iatrogenic infections were also more likely to receive home care (23.26% vs. 11.71%). Conclusions: Iatrogenic infections are associated with higher odds of mortality in hospitalized patients with cirrhosis. Iatrogenic infections lead to higher utilization resources (home care and facility discharge).
Sa1031 Risk Factors for Inpatient Mortality Among Hospitalized Hepatorenal Syndrome Patients- a Nationwide Population Based Study Sravanthi Parasa, Arun Raghav Mahankali Sridhar, Ryan C. Mascarenhas, Kevin Olden BACKGROUND AND AIMS: Hepatorenal syndrome (HRS) is a common complication of advanced cirrhosis, characterized by renal failure and major disturbances in circulatory function. The prognosis is very poor and this condition is associated with a high mortality and morbidity. However, there are few population based studies that are done to evaluate the risk factors for adverse outcomes of HRS. METHODS: We used data from Nationwide Inpatient Sample for year 2008 to perform a cross sectional study of the patients hospitalized for HRS as identified by appropriate International Classification of Diseases, Ninth Revision (ICD9) discharge diagnoses codes. The patients were then categorized into groups - with concomitant diagnosis of alcoholic cirrhosis (AC) and biliary cirrhosis (BC), and cirrhosis as identified by ICD9 diagnosis codes. The demographic characteristics, clinical characteristics and the hospital outcomes of the groups were studied. Univariate and Multivariate logistic regression methods using STATA 12.0 survey commands were used to assess the risk factors for in hospital death among these groups after adjusting for clinically important covariates. RESULTS: There were a total of 23,764 discharges that were diagnosed with HRS of which a total of 8853 (36%) patients died in the hospital. 2219 (9.3%) developed ESRD. The Length Of Stay (LOS) and total hospital charges were significantly higher for patients with an underlying diagnosis of biliary cirrhosis (table1) On multi-variate analysis, among patients with HRS, TIPS procedure was associated with decreased risk of inhospital death (adjusted odds ratio (aOR) 0.46, 95 % Confidence interval (95%CI) (0.24-0.87)), undergoing Hemodialysis was not associated with any decreased risk of inhospital mortality (aOR , 1.14, 95% CI (0.93-1.4)). Risk factors contributing to increase in risk of death are increasing age,
Sa1029 Acute Kidney Injury (AKI) Predicts Mortality in Hospitalized Patient With Cirrhosis Muhammad Ali, Shahryar Ahmad, Adil Jadoon, Nilay Kumar, Gagan Kumar, Kia Saeian Background: Recent studies have indicated a higher incidence of acute kidney injury (AKI) in cirrhotics and its negative impact on mortality. There is lack of nationwide data from the US on prevalence of AKI among hospitalized cirrhotics and its impact on morbidity and mortality. Aim: To determine incidence of AKI in hospitalized patients with cirrhosis and study the impact of AKI on outcomes among hospitalized cirrhotics. Methods: A retrospective case control study design was utilized using the National Inpatient Sample (NIS) from the year 2008. NIS is the largest inpatient discharge database in the US. Appropriate International
AASLD Abstracts
S-950