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172 BEDSIDE REAGENT STRIP ANALYSIS OF ASCITES CAN RELIABLY RULE OUT SPONTANEOUS BACTERIAL PERITONITIS AND IS A COST-EFFECTIVE STRATEGY
POSTERS 172 BEDSIDE REAGENT STRIP ANALYSIS OF ASCITES CAN RELIABLY RULE OUT SPONTANEOUS BACTERIAL PERITONITIS AND IS A COST-EFFECTIVE STRATEGY J.J. Kuiper, H.R. van Buuren, R.A. de Man. Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands E-mail: [email protected] Background and Aims: Spontaneous bacterial peritonitis (SBP) is a serious complication in patients with decompensated cirrhosis of the liver. Timely diagnosis of SBP is essential to prevent complications like sepsis and hepatorenal syndrome. The golden standard for diagnosis of SBP is an ascitic polymorphonuclear (PMN) count ≥250/mm3 , but this test is time-consuming and is not uniformly available, especially during after-office hours. Reagent strip testing of ascites for diagnosing SBP may be a promising bedside diagnostic tool. The aim of this study was to assess the reliability of reagent strip testing for diagnosing or excluding SBP and to assess its clinical implication. Methods: Consecutive samples of ascites obtained from patients with cirrhosis and ascites were included. All samples were tested simultaneously for ascitic PMN-count using standard laboratory methodology as well as reagent strips (Combur-10® , Roche Diagnostics). The reagent strip had 4 outcomes: 0, 25, 100, 500 leukocytes/ml. The strips were independently analyzed visually by a dedicated observer and at the same time by an electronic analyzer (Urisys 1100® , Roche Diagnostics). Results: 157 samples of ascites were analyzed. According to the laboratory PMN-count SBP was diagnosed in 12 (7.6%) samples. Automated analysis of these samples indicated the presence of ≥100 leukocytes/ml in all cases. Using this cut-off value resulted in the diagnostic test characteristics of the reagent strip as depicted in the table. Reagent strip results
Visual Automated
Sensitivity
Specificity
Positive predictive value
Negative predictive value
75% (95% CI 42.8–93.3) 100% (95% CI 69.9–100)
98.6% (95% CI 94.6–99.7) 93.1 (95% CI 87.3–96.5)
81.8% (95% CI 47.8–96.8) 54.5% (95% CI 32.6–74.9)
97.9 (95% CI 93.6–99.5) 100% (95% CI 96.6–100)
Conclusion: In this population with a relatively low prevalence of SPB a negative reagent strip result reliably ruled out SBP. A positive test should be followed by conventional work-up (PMNcount and culture). Using an automated analyzer was not superior to standard visual reading of the strips. Using reagent strips would have obviated the need for more laborious and expensive laboratory studies in more than 90 cases. This suggests that using this simple and quick bedside test may result in a significant lowering of costs. 173 RIGTH ATRIAL PRESSURE IS NOT ADEQUATE TO CALCULATE THE PORTAL PRESSURE GRADIENT IN CIRRHOSIS. A CLINICAL-HEMODYNAMIC CORRELATION STUDY V. La Mura, J.G. Abraldes, A. Berzigotti, E. Erice, A. Flores-Arroyo, J.C. Garc´ıa-Pagan, ´ J. Bosch. Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona and Centro de Investigaci´ on Biom´edica en Red de Enfermedades Hep´ aticas y Digestivas (Ciberehd), Barcelona, Spain E-mail: [email protected] Background and Aims: Measurement of hepatic venous pressure gradient (HVPG), the difference between “wedge” and “free” hepatic venous pressure, is the preferred method for estimating portal pressure. However it has been suggested that the gradient between wedge hepatic venous pressure and right atrial pressure (RAP) (Hepatic Atrial Pressure Gradient, HAPG), rather than the HVPG,
might reflect better the hemodynamics at the varices. This study was aimed at investigating: 1. whether HAPG at baseline and during treatment with nonselective beta-blockers correlate with prognosis in patients with cirrhosis and portal hypertension; 2. to compare its prognostic value with that of HVPG, and 3. whether measuring HAPG adds significant information to measurements of HVPG. Methods: 154 cirrhotic patients with varices with a complete hemodynamic study at baseline and during the chronic treatment for primary (n = 71) or secondary (n = 83) prophylaxis for bleeding. Patients were followed for up to two years, and portal hypertensive related bleeding and bleeding-free survival were analyzed. Results: HVPG was, in all cases, equal or lower than HAPG (mean difference: 3.2 mmHg, p < 0.001). Agreement between HAPG and HVPG in patients with cirrhosis was only modest, especially in those patients with increased intra-abdominal pressure. One hundred and two patients were HVPG non-responders and 52 HVPG responders to non-selective beta-blockers, while 101 were HAPG non-responders and 53 HAPG responders (k = 0.610). HVPG response showed an excellent predictive value for bleeding risk and bleeding free survival, while HAPG did not. Conclusions: The excellent prognostic information provided by HVPG response to drug therapy is lost if HAPG response is considered. RAP should not be used for the calculation of portal pressure gradient in patients with cirrhosis. 174 VON WILLEBRAND FACTOR LEVELS CORRELATE WITH THE SEVERITY OF PORTAL HYPERTENSION AND INDEPENDENTLY PREDICT THE CLINICAL OUTCOME OF CIRRHOTIC PATIENTS WITH PORTAL HYPERTENSION V. La Mura, J.C. Reverter, A. Flores-Arroyo, M. Hernandez-Guerra, ´ J.G. Abraldes, J.C. Garc´ıa-Pagan. ´ Liver Unit, Hospital Clinic-IDIBAPS and CIBERehd, Barcelona, Spain E-mail: [email protected] Background and Aim: Endothelial dysfunction is an early key event in several vascular diseases and is considered one of the main mechanisms involved in the increased hepatic vascular tone of cirrhotic livers. Von-Willebrand factor (vWF), P-selectin, 8-isoPGF2a (Isoprostrans) are surrogate markers of endothelial function that have been found increased in cirrhotic patients. Our study was aimed at exploring the correlation of these markers to systemic and hepatic hemodynamic and their possible relation to the development of portal-hypertension related events. Patients and Methods: In 42 consecutive stable cirrhotic patients submitted to the evaluation of portal hypertension the hepatic venous pressure gradient (HVPG), cardio-pulmonary pressures, and vWF, P-Selectin and Isoprostans in blood samples from the hepatic and peripheral vein were measured. Eight-teen healthy subjects, matched for age and sex, were used as controls. Patients were followed every 6 months up to 2 years, death, liver transplantation or the end of the study. Results: In all patients, peripheral levels of vWF were increased (median value: 226 UI/dl) above those observed in controls. There was a trend for higher hepatic than peripheral vWF levels (225±16 U/dL vs 222±17 U/dL, p = 0.074). Peripheral vWF levels significantly correlated with HVPG (r = 0.5; p = 0.003), Child–Pugh score (r = 0.4; p = 0.018) and MELD (r = 0.3; p = 0.032). During follow-up 15 patients had portal hypertension-related events (bleeding, ascites or encephalopathy), 2 patients were transplanted and 7 patients died. Cirrhotic patients with peripheral vWF >median (226 UI/dl) had a higher 2-year probability of presenting portal hypertension-related complications (70% vs. 20%; p = 0.002) and lower transplant-free survival (45% vs 94%, p = 0.001) than cirrhotic patients with lower values.
Journal of Hepatology 2010 vol. 52 | S59–S182
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Visual Automated
Sensitivity
Specificity
Positive predictive value
Negative predictive value
75% (95% CI 42.8–93.3) 100% (95% CI 69.9–100)
98.6% (95% CI 94.6–99.7) 93.1 (95% CI 87.3–96.5)
81.8% (95% CI 47.8–96.8) 54.5% (95% CI 32.6–74.9)
97.9 (95% CI 93.6–99.5) 100% (95% CI 96.6–100)
Conclusion: In this population with a relatively low prevalence of SPB a negative reagent strip result reliably ruled out SBP. A positive test should be followed by conventional work-up (PMNcount and culture). Using an automated analyzer was not superior to standard visual reading of the strips. Using reagent strips would have obviated the need for more laborious and expensive laboratory studies in more than 90 cases. This suggests that using this simple and quick bedside test may result in a significant lowering of costs. 173 RIGTH ATRIAL PRESSURE IS NOT ADEQUATE TO CALCULATE THE PORTAL PRESSURE GRADIENT IN CIRRHOSIS. A CLINICAL-HEMODYNAMIC CORRELATION STUDY V. La Mura, J.G. Abraldes, A. Berzigotti, E. Erice, A. Flores-Arroyo, J.C. Garc´ıa-Pagan, ´ J. Bosch. Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona and Centro de Investigaci´ on Biom´edica en Red de Enfermedades Hep´ aticas y Digestivas (Ciberehd), Barcelona, Spain E-mail: [email protected] Background and Aims: Measurement of hepatic venous pressure gradient (HVPG), the difference between “wedge” and “free” hepatic venous pressure, is the preferred method for estimating portal pressure. However it has been suggested that the gradient between wedge hepatic venous pressure and right atrial pressure (RAP) (Hepatic Atrial Pressure Gradient, HAPG), rather than the HVPG,
might reflect better the hemodynamics at the varices. This study was aimed at investigating: 1. whether HAPG at baseline and during treatment with nonselective beta-blockers correlate with prognosis in patients with cirrhosis and portal hypertension; 2. to compare its prognostic value with that of HVPG, and 3. whether measuring HAPG adds significant information to measurements of HVPG. Methods: 154 cirrhotic patients with varices with a complete hemodynamic study at baseline and during the chronic treatment for primary (n = 71) or secondary (n = 83) prophylaxis for bleeding. Patients were followed for up to two years, and portal hypertensive related bleeding and bleeding-free survival were analyzed. Results: HVPG was, in all cases, equal or lower than HAPG (mean difference: 3.2 mmHg, p < 0.001). Agreement between HAPG and HVPG in patients with cirrhosis was only modest, especially in those patients with increased intra-abdominal pressure. One hundred and two patients were HVPG non-responders and 52 HVPG responders to non-selective beta-blockers, while 101 were HAPG non-responders and 53 HAPG responders (k = 0.610). HVPG response showed an excellent predictive value for bleeding risk and bleeding free survival, while HAPG did not. Conclusions: The excellent prognostic information provided by HVPG response to drug therapy is lost if HAPG response is considered. RAP should not be used for the calculation of portal pressure gradient in patients with cirrhosis. 174 VON WILLEBRAND FACTOR LEVELS CORRELATE WITH THE SEVERITY OF PORTAL HYPERTENSION AND INDEPENDENTLY PREDICT THE CLINICAL OUTCOME OF CIRRHOTIC PATIENTS WITH PORTAL HYPERTENSION V. La Mura, J.C. Reverter, A. Flores-Arroyo, M. Hernandez-Guerra, ´ J.G. Abraldes, J.C. Garc´ıa-Pagan. ´ Liver Unit, Hospital Clinic-IDIBAPS and CIBERehd, Barcelona, Spain E-mail: [email protected] Background and Aim: Endothelial dysfunction is an early key event in several vascular diseases and is considered one of the main mechanisms involved in the increased hepatic vascular tone of cirrhotic livers. Von-Willebrand factor (vWF), P-selectin, 8-isoPGF2a (Isoprostrans) are surrogate markers of endothelial function that have been found increased in cirrhotic patients. Our study was aimed at exploring the correlation of these markers to systemic and hepatic hemodynamic and their possible relation to the development of portal-hypertension related events. Patients and Methods: In 42 consecutive stable cirrhotic patients submitted to the evaluation of portal hypertension the hepatic venous pressure gradient (HVPG), cardio-pulmonary pressures, and vWF, P-Selectin and Isoprostans in blood samples from the hepatic and peripheral vein were measured. Eight-teen healthy subjects, matched for age and sex, were used as controls. Patients were followed every 6 months up to 2 years, death, liver transplantation or the end of the study. Results: In all patients, peripheral levels of vWF were increased (median value: 226 UI/dl) above those observed in controls. There was a trend for higher hepatic than peripheral vWF levels (225±16 U/dL vs 222±17 U/dL, p = 0.074). Peripheral vWF levels significantly correlated with HVPG (r = 0.5; p = 0.003), Child–Pugh score (r = 0.4; p = 0.018) and MELD (r = 0.3; p = 0.032). During follow-up 15 patients had portal hypertension-related events (bleeding, ascites or encephalopathy), 2 patients were transplanted and 7 patients died. Cirrhotic patients with peripheral vWF >median (226 UI/dl) had a higher 2-year probability of presenting portal hypertension-related complications (70% vs. 20%; p = 0.002) and lower transplant-free survival (45% vs 94%, p = 0.001) than cirrhotic patients with lower values.
Journal of Hepatology 2010 vol. 52 | S59–S182
S75