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207 Terlipressin influence in spontaneous bacterial peritonitis
Category 2b: Cirrhosis and Complications: Clinical Aspects ally be used in routine follow-up of chronic liver disease patients, to yield an early warning signal that cirrhosis has developed and that complications (amongst others: hepatocellular carcinoma) might arise. Our biomarker can easily be implemented in the majority of the existing molecular diagnostics laboratories at low cost.
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cantly increased adverse events (RR 12.48, 95% CI 6.72-12.35). Several of the trials used unclear or inadequate methods for randomisation and betablocker trials are hard to blind properly. Further, publication bias can not be excluded. Conclusions: Non-selective beta-blockers seem to reduce all cause mortality in cirrhotic patients with oesophageal varices compared to no or other interventions. Number needed to treat to save one life is about 17 patients (95% CI 10 to 33 patients) when mortality risk is about 30%.
PERITONITIS
O. Chelarescu 1 , D. Chelarescu 2 , I. Stratan 1 , C. Filip 3 . 1 Anesthesiology and Intensive Care,’Sf. Spiridon’ Hospital, Iasi, Romania; 2 Pharmacology, Univ. Med. Pharm ‘Gr. T. Popa’, Iasi, Romania; 3 Biochemistry, Univ. Med. Pharm ‘Gr. T. Popa’, Iasi, Romania Aim: To determine if treatment with terlipressin improves outcome in cirrhotic spontaneous bacterial peritonitis(SBP) and is safe Method: 55 cirrhotic patients with confirmed diagnosis of SBP were randomly assigned(in a double-blind manner)to receive: Cefotaxime intravenously 1.0 g every 12h for 5 days (C group-28 patients) and Cefotaxime(the same regimen)+Terlipressin 2mg/day, 5 days (C+T group-27 patients). Excluding criteria: presence of septic shock, stage IV hepatic encephalopathy, serum creatinine level >5 mg/dL, massive gastrointestinal hemorrhage. We assessed before therapy, at 24h, 48h, 5 days and also at 10 days from discontinuation of therapy: PMN (in plasma, ascitic fluid), serum levels of C-reactive protein, microbiological analysis of ascitic fluid, systemic vascular resistance(SVR), cardiac output, mean arterial pressure(MAP), recurrence rate of SBP. Results: Mortality rate (mainly due to septic shock) was lower in the C+T group at 48 hours (4 patients in C group vs 1 in C+T group). SVR and MAP increased and cardiac output decreased in the C+T vs.C group(p<0.05). Resolution of SBP at 48 h (PMN<250/mm3 in ascitic fluid) was:18/28 patients(C group)-64.28% vs 23/27 patients(C+T group)-85.18% and at 5 days: 75%(C group) vs 92.59% patients (C+T group)(p<0.05). 71.42% of patients whose PMN didn’t decrease under 250/mm3 at 48h, despite of laboratory data improvement at 5 days, developed SBP recurrence in 10 days after treatment discontinuation. SBP recurrence was significantly lower in the C+T group (7.40%-2 patients) vs.28.57%(8 patients) in C group. SBP resolution after prolonged antibiotic therapy was achieved in 100% in C+T group vs 86% in the C group.
209 NATURAL HISTORY OF ASCITES. STUDY IN 246 CIRRHOTIC PATIENTS 1
S. Coll , M.A. Alvarez 2 , B. Balleste 1 , S. Montoliu 2 , M. Rivera 1 , M. Miquel 2 , J.A. Galeras 1 , J. Santos 2 , I. Cirera 1 , R.M. Morillas 2 , R. Sola 1 , R. Planas 2 . 1 Liver Section, Hospital Del Mar, Barcelona, Spain; 2 Liver Unit,Hospital Germans Trias I Pujol, Badalona, Spain Since the International Ascites Club published the diagnostic criteria of refractory ascites (RA) and hepatorenal syndrome (SHR) in 1996, there have been few studies assessing the natural history of ascites. Aims: To assess the natural history of ascites as well as to identify prognostic factors, including the MELD coefficient, for dilutional hyponatremia (DH), RA, HRS, and survival. Patients: 246 consecutive cirrhotic patients (61.2 ± 11.4 years), followed for 43 ± 3 months after their first ascites. At entry 26 patients were ChildPugh class A, 166 class B and 54 class C. The mean MELD was 10.5 ± 5.07 points. Results: During follow-up 65 (26.4%) patients developed DH, 29 (11.8%) RA, and 22 (8.9%) HRS (type 1: 7; type 2: 15) (corretgir AEEH). The 3year probability of DH, RA and HRS development was 22.5%, 11.1% and 8.8%, respectively. Seventy-three (29.7%) patients died. The probability of survival at 3 years was 77.7%. The independent predictors for survival were baseline age and serum creatinine, as well as DH and RA development. The overall median survival (122 months), decreased to 50, 36 and 3 months when patients developed DH, RA and HRS type 1, respectively. Conclusions: (1) Survival of cirrhotic patients with ascites is mainly influenced by age and serum creatinine at the time of ascites decompensation, as well as by DH and RA development. (2) The probability of RA and HRS is relatively low (approximately 10% at 3 years). 3) MELD coefficient is not useful for long-term prognosis assessment in cirrhosis with ascites.
208 BETA-BLOCKERS REDUCE MORTALITY IN CIRRHOTIC PATIENTS WITH OESOPHAGEAL VARICES WHO HAVE NEVER BLED (COCHRANE REVIEW)
W. Chen, D. Nikolova, S.L. Frederiksen, C. Gluud. The Cochrane Hepato-Biliary Group, Rigshospitalet, Copenhagen, Denmark Aims: Previous meta-analyses (D’Amico et al., 1999) have shown beneficial effects of beta-blockers on bleeding, but mortality was not significantly influenced. We assessed the effects of beta-blockers on mortality in cirrhotic patients with oesophageal varices (irrespective of size), who have never bled. Methods: We searched The Cochrane Library plus other databases until November 2003 for randomised trials comparing beta-blockers versus placebo, no intervention, or other interventions. Results: Non-selective beta-blockers (propranolol or nadolol) were compared to placebo/no intervention (11 randomised trials; 1344 patients), isosorbide-5-mononitrate (three trials; 298 patients), endoscopic sclerotherapy (two trials; 225 patients), or endoscopic ligation (three trials; 352 patients). At the end of maximal follow-up (12-30 months), non-selective beta-blockers significantly (P<0.001) reduced all cause mortality in fixed effect and random effects analyses of all trials (relative risk (RR) 0.80, 95% CI 0.69-0.91, random), trials with placebo/no intervention control (RR 0.80, 95% CI 0.64-0.99, random), or trials with presumed active control (RR 0.78, 95% CI 0.64-0.95). Heterogeneity (I2) was low (<30%). Compared to placebo/no intervention, non-selective beta-blockers signifi-
210 QUANTITATIVE ASSESSMENT OF MUSCULAR MASS BY COMPUTED TOMOGRAPHY: A NEW PROGNOSTIC MARKER IN CANDIDATES FOR LIVER TRANSPLANTATION
S. Buyse 1 , C. Thome-Noun 2 , V. Vilgrain 2 , C. Francoz 1 , D. Sommacale 3 , F. Dondero 3 , J. Belghiti 3 , D. Valla 1 , F. Durand 1 . 1 Hepatology, Hospital Beaujon, Clichy, France; 2 Radiology, Hospital Beaujon, Clichy, France; 3 Digestive Surgery, Hospital Beaujon, Clichy, France Nutritional status probably has a determinant prognostic impact in candidates for liver transplantation (LT). However, conventional nutritional markers are biased in cirrhotic patients because of ascites, edema and liver insufficiency. The aim of this study was to measure muscular and fat parameters by abdominal computed tomography (CT) and to determine their prognostic value. Measurements were performed in 84 cirrhotic patients listed for LT (63 males and 21 females). The size of anterior wall mucles, psoas (longitudinal and transversal axis) and spinal muscles as well as anterior subcutaneous fat were measured with sagittal CT scans at the level of the umbilicus. Transversal axis of psoas and the size of spinal muscle were significantly correlated with Child-Pugh score and subjective global assessment of nutritional status (p=0.01 for both). Multivariate analysis using Cox model showed that transversal psoas/height, creatinine and prothrombin time had a significant influence on the risk of death on the waiting list (p<0.0001, 0.0004 and 0.002, respectively). Spinal mus-
207 TERLIPRESSIN INFLUENCE IN SPONTANEOUS BACTERIAL
67
cantly increased adverse events (RR 12.48, 95% CI 6.72-12.35). Several of the trials used unclear or inadequate methods for randomisation and betablocker trials are hard to blind properly. Further, publication bias can not be excluded. Conclusions: Non-selective beta-blockers seem to reduce all cause mortality in cirrhotic patients with oesophageal varices compared to no or other interventions. Number needed to treat to save one life is about 17 patients (95% CI 10 to 33 patients) when mortality risk is about 30%.
PERITONITIS
O. Chelarescu 1 , D. Chelarescu 2 , I. Stratan 1 , C. Filip 3 . 1 Anesthesiology and Intensive Care,’Sf. Spiridon’ Hospital, Iasi, Romania; 2 Pharmacology, Univ. Med. Pharm ‘Gr. T. Popa’, Iasi, Romania; 3 Biochemistry, Univ. Med. Pharm ‘Gr. T. Popa’, Iasi, Romania Aim: To determine if treatment with terlipressin improves outcome in cirrhotic spontaneous bacterial peritonitis(SBP) and is safe Method: 55 cirrhotic patients with confirmed diagnosis of SBP were randomly assigned(in a double-blind manner)to receive: Cefotaxime intravenously 1.0 g every 12h for 5 days (C group-28 patients) and Cefotaxime(the same regimen)+Terlipressin 2mg/day, 5 days (C+T group-27 patients). Excluding criteria: presence of septic shock, stage IV hepatic encephalopathy, serum creatinine level >5 mg/dL, massive gastrointestinal hemorrhage. We assessed before therapy, at 24h, 48h, 5 days and also at 10 days from discontinuation of therapy: PMN (in plasma, ascitic fluid), serum levels of C-reactive protein, microbiological analysis of ascitic fluid, systemic vascular resistance(SVR), cardiac output, mean arterial pressure(MAP), recurrence rate of SBP. Results: Mortality rate (mainly due to septic shock) was lower in the C+T group at 48 hours (4 patients in C group vs 1 in C+T group). SVR and MAP increased and cardiac output decreased in the C+T vs.C group(p<0.05). Resolution of SBP at 48 h (PMN<250/mm3 in ascitic fluid) was:18/28 patients(C group)-64.28% vs 23/27 patients(C+T group)-85.18% and at 5 days: 75%(C group) vs 92.59% patients (C+T group)(p<0.05). 71.42% of patients whose PMN didn’t decrease under 250/mm3 at 48h, despite of laboratory data improvement at 5 days, developed SBP recurrence in 10 days after treatment discontinuation. SBP recurrence was significantly lower in the C+T group (7.40%-2 patients) vs.28.57%(8 patients) in C group. SBP resolution after prolonged antibiotic therapy was achieved in 100% in C+T group vs 86% in the C group.
209 NATURAL HISTORY OF ASCITES. STUDY IN 246 CIRRHOTIC PATIENTS 1
S. Coll , M.A. Alvarez 2 , B. Balleste 1 , S. Montoliu 2 , M. Rivera 1 , M. Miquel 2 , J.A. Galeras 1 , J. Santos 2 , I. Cirera 1 , R.M. Morillas 2 , R. Sola 1 , R. Planas 2 . 1 Liver Section, Hospital Del Mar, Barcelona, Spain; 2 Liver Unit,Hospital Germans Trias I Pujol, Badalona, Spain Since the International Ascites Club published the diagnostic criteria of refractory ascites (RA) and hepatorenal syndrome (SHR) in 1996, there have been few studies assessing the natural history of ascites. Aims: To assess the natural history of ascites as well as to identify prognostic factors, including the MELD coefficient, for dilutional hyponatremia (DH), RA, HRS, and survival. Patients: 246 consecutive cirrhotic patients (61.2 ± 11.4 years), followed for 43 ± 3 months after their first ascites. At entry 26 patients were ChildPugh class A, 166 class B and 54 class C. The mean MELD was 10.5 ± 5.07 points. Results: During follow-up 65 (26.4%) patients developed DH, 29 (11.8%) RA, and 22 (8.9%) HRS (type 1: 7; type 2: 15) (corretgir AEEH). The 3year probability of DH, RA and HRS development was 22.5%, 11.1% and 8.8%, respectively. Seventy-three (29.7%) patients died. The probability of survival at 3 years was 77.7%. The independent predictors for survival were baseline age and serum creatinine, as well as DH and RA development. The overall median survival (122 months), decreased to 50, 36 and 3 months when patients developed DH, RA and HRS type 1, respectively. Conclusions: (1) Survival of cirrhotic patients with ascites is mainly influenced by age and serum creatinine at the time of ascites decompensation, as well as by DH and RA development. (2) The probability of RA and HRS is relatively low (approximately 10% at 3 years). 3) MELD coefficient is not useful for long-term prognosis assessment in cirrhosis with ascites.
208 BETA-BLOCKERS REDUCE MORTALITY IN CIRRHOTIC PATIENTS WITH OESOPHAGEAL VARICES WHO HAVE NEVER BLED (COCHRANE REVIEW)
W. Chen, D. Nikolova, S.L. Frederiksen, C. Gluud. The Cochrane Hepato-Biliary Group, Rigshospitalet, Copenhagen, Denmark Aims: Previous meta-analyses (D’Amico et al., 1999) have shown beneficial effects of beta-blockers on bleeding, but mortality was not significantly influenced. We assessed the effects of beta-blockers on mortality in cirrhotic patients with oesophageal varices (irrespective of size), who have never bled. Methods: We searched The Cochrane Library plus other databases until November 2003 for randomised trials comparing beta-blockers versus placebo, no intervention, or other interventions. Results: Non-selective beta-blockers (propranolol or nadolol) were compared to placebo/no intervention (11 randomised trials; 1344 patients), isosorbide-5-mononitrate (three trials; 298 patients), endoscopic sclerotherapy (two trials; 225 patients), or endoscopic ligation (three trials; 352 patients). At the end of maximal follow-up (12-30 months), non-selective beta-blockers significantly (P<0.001) reduced all cause mortality in fixed effect and random effects analyses of all trials (relative risk (RR) 0.80, 95% CI 0.69-0.91, random), trials with placebo/no intervention control (RR 0.80, 95% CI 0.64-0.99, random), or trials with presumed active control (RR 0.78, 95% CI 0.64-0.95). Heterogeneity (I2) was low (<30%). Compared to placebo/no intervention, non-selective beta-blockers signifi-
210 QUANTITATIVE ASSESSMENT OF MUSCULAR MASS BY COMPUTED TOMOGRAPHY: A NEW PROGNOSTIC MARKER IN CANDIDATES FOR LIVER TRANSPLANTATION
S. Buyse 1 , C. Thome-Noun 2 , V. Vilgrain 2 , C. Francoz 1 , D. Sommacale 3 , F. Dondero 3 , J. Belghiti 3 , D. Valla 1 , F. Durand 1 . 1 Hepatology, Hospital Beaujon, Clichy, France; 2 Radiology, Hospital Beaujon, Clichy, France; 3 Digestive Surgery, Hospital Beaujon, Clichy, France Nutritional status probably has a determinant prognostic impact in candidates for liver transplantation (LT). However, conventional nutritional markers are biased in cirrhotic patients because of ascites, edema and liver insufficiency. The aim of this study was to measure muscular and fat parameters by abdominal computed tomography (CT) and to determine their prognostic value. Measurements were performed in 84 cirrhotic patients listed for LT (63 males and 21 females). The size of anterior wall mucles, psoas (longitudinal and transversal axis) and spinal muscles as well as anterior subcutaneous fat were measured with sagittal CT scans at the level of the umbilicus. Transversal axis of psoas and the size of spinal muscle were significantly correlated with Child-Pugh score and subjective global assessment of nutritional status (p=0.01 for both). Multivariate analysis using Cox model showed that transversal psoas/height, creatinine and prothrombin time had a significant influence on the risk of death on the waiting list (p<0.0001, 0.0004 and 0.002, respectively). Spinal mus-