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231 Terlipressin and albumin therapy for patients with advanced cirrhosis and severe renal failure
02B. Cirrhosis and complications
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USEFULNESS OF THE M E A S U R E M E N T OF CRITICAL FLICKER F R E Q U E N C Y IN THE DIAGNOSIS OF MINIMAL HEPATIC ENCEPHALOPATHY (MHE)
M. Romero-Gomez 1 J. Cordoba2, R. Jover3, J.A. Del-Olmo4, M. Ramlrez 1, M. Flavia 2, L. Comapfiy 3, D. Nufiez 1, J.M. Rodrigo4, V. Felipo 5. 1Hepatology Unit, UCMDD, Hospital Universitario de
Valme, Sevilla, Spain," :Hepatology Unit, Service of Internal Medicine, Hospital de Vall d'Hebron, Barcelona, Spain," 3Digestive Unit, Hospital General de Alicante, Alicante, Spain," 4Hepatology Unit, Hospital Cl{nico Universitario de Valencia, Spain," 5Centro de Investigaci6n Principe Felipe, Valencia, Spain Introduction: MHE is usually diagnosed by a combination of five psychometric tests, named PHES tests [PHES, Psychometric hepatic encephalopathy score]. Patients suffering from MHE showed higher risk to develop overt hepatic encephalopathy and traffic accidents together with a decreased quality of life. More than a 60% of the hepatologists do not investigate the presence of MHE. Aim: To know the usefulness of the critical flicker frequency on the diagnosis of MHE. Patients and Methods: 114 cirrhotic patients and 103 control patients who performed the PHES tests were included. CFF was measured in patients and controls using Hepatonorm| Patients with a lower score than -4 in the PHES tests (corrected according to Spanish normality tables available at http://www.redeh.org/), were diagnosed as having MHE. Results: In the control group, the mean CFF was similar for males (43.2+3.7Hz) and females (42.1+3.5 Hz; p ns) and it was not related to age (r 0.078; p ns) and education years (r 0.056; p ns) either. The score for the PHES tests (r 0.54; p <0.001) and the score for each test separately (NCT-A (r 0.51; p 0.0001), LD (r 0.56; p 0.001), NCT-B (r 0.45; p 0.001), DST (r 0.31; p 0.001) and SD (r 0.30; p 0.001) correlated to the mean CFF. We also find a relation with the Child@ugh (r 0.22; p 0.018) but not the MELD score (r 0.11; p ns). In cirrhotic patients with MHE, we found a lower mean CFF (35.6+4.1Hz) than in patients without MHE (40.5+3.7Hz) or healthy control (42.7+3.6Hz); p 0.001. The under curve area of CFF in the diagnosis of MHE was 0.79 (95% CI: 0.7 0.88). The sensitivity was 72% and the specificity was 77% when using 38 Hz as the threshold. The CFF was altered in 77% of the patients with MHE (27 out of 35) comparing with 26% of cirrhotic patients without MHE (21 out of 79); p < 0,001. Conclusions: The measurement of the CFF is an easy, reliable and sure method to diagnose MHE and is not influenced by age or education level. Acknowledgement: Red EH G03/155
r
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TERLIPRESSIN AND ALBUMIN T H E R A P Y FOR PATIENTS WITH ADVANCED CIRRHOSIS AND SEVERE RENAL FAILURE
M. Serrano, J.M. Pascasio, J.M. Sousa, E. De la Santa, M. Sayago, M.T. Ferrer, J.L. Mfirquez, M. Garzdn, I. Grilo, M. Cabanillas. Dep.
(b) Clinical aspects
$93
Cr level; No Response (NR): no decrease or reduction ~<50% from the highest Cr level. Results: Age:55.5• years (36 64). Sex:13 men (81.3%). PughChild score (P C): 8.8• (7 12). MELD: 27.5• (20 40). Etiology: 93.8% Alcohol (2 HCV and 1 HBV). Severity of RF was similar in cases of INF-RF and HRS-I (Cr 4.3• vs 4.6• p NS). At the end of treatment, we observed a significant improvement in Urea (105.1• vs 170.4• p 0.0001), Cr (1.6• vs 4.5• p 0.0001), serum Na (132.9• vs 126.1• p 0.002) and mean arterial pressure (mAP) (81.6• vs 66.7• p 0.001). 12 patients had TR (75%), 2 PR (12.5%) and 2 NR (12.5%). RF reappeared in 3 patients (18.8%), all of them improving again with further treatment (2 TR and 1 PR). After a median follow-up time of 80 days (18~08), 6 patients died (37.5%) and 8 (50%) were transplanted (one of them died after LT).TLP mean dose was 0.8• mg/4h (0.5 2) and the median time of treatment 6.5 days (3 28). There were adverse reactions in 75% of patients, being the most common the central venous pressure (CVP) increase. Treatment response and survival did not have significant association with either the type of RF or other pre-treatment parameters: age, P C, MELD, urea, Cr, Na, mAP and CVR Only the degree of treatment response was correlated with survival: NR 0%, PR 50% and TR 75% (p 0.02). (See figure.) SURVIVALFUNCTION TREATMENT
10-
RESPONSE INR
08-
> 08tn
~0,402-
00-
~oo
4o
L
800
Follow up (Days}
Conclusions: (1) TLP+ALB has shown beneficial effects in both types of RF with TR in 75% of patients. (2) More than 60% of patients survived and 50% could be transplanted without worsening the post-transplantation prognosis. (3) Survival was related to treatment response, not depending on pre-treatment degree of hepatic insufficiency and type or severity of RF. (4) TLP+ALB could be used, not only in HRS-I, but also in INF-RF, because clinical outcome, progress and prognosis may be similar for both types of RF.
Gastroenterology and Hepatology/HHUU Virgen del Roc{o, Seville, Spain Aim: To determine the results of terlipressin plus albumin therapy (TLP + ALB) in cirrhosis patients with severe renal failure (RF) caused by hepatorenal syndrome type I (HRS-I) or severe infection (INF-RF). Methods: We studied 16 consecutive cirrhosis patients with RF (serum creatinine >2.5 mg/dl) caused by HRS-I (8 patients)and INF-RF (8 patients).They were treated with intravenous terlipressin (0.5 2 mg/4h) plus albumin. All patients took off diuretics and were on albumin during previous 48 hours without improvement. We assessed the treatment response and the posterior clinical outcome, reaching liver transplantation (LT) or death. Definitions: Total Response (TR): decrease of serum creatinine (Cr) to <1.5 mg/dl; Partial Response (PR): reduction >50% from the highest
[•
CRITICAL FLICKER FREQUENCY: DIAGNOSTIC TOOL FOR MINIMAL HEPATIC ENCEPHALOPATHY
R Sharma 1, B.C. Sharma 1, S.K. Sarin 1, V. Puri 2. 1Department of
Gastroenterology, 2Department of Neurology, G.B. Pant Hospital New Delhi, India B a c k g r o u n d and Aims: Minimal hepatic encephalopathy (MHE) is associated with poorer quality of life and increased work disability. Diagnosis required cumbersome psychometric and neurophysiological tests. We evaluated Critical Flicker Frequency (CFF) to diagnose MHE.
•
USEFULNESS OF THE M E A S U R E M E N T OF CRITICAL FLICKER F R E Q U E N C Y IN THE DIAGNOSIS OF MINIMAL HEPATIC ENCEPHALOPATHY (MHE)
M. Romero-Gomez 1 J. Cordoba2, R. Jover3, J.A. Del-Olmo4, M. Ramlrez 1, M. Flavia 2, L. Comapfiy 3, D. Nufiez 1, J.M. Rodrigo4, V. Felipo 5. 1Hepatology Unit, UCMDD, Hospital Universitario de
Valme, Sevilla, Spain," :Hepatology Unit, Service of Internal Medicine, Hospital de Vall d'Hebron, Barcelona, Spain," 3Digestive Unit, Hospital General de Alicante, Alicante, Spain," 4Hepatology Unit, Hospital Cl{nico Universitario de Valencia, Spain," 5Centro de Investigaci6n Principe Felipe, Valencia, Spain Introduction: MHE is usually diagnosed by a combination of five psychometric tests, named PHES tests [PHES, Psychometric hepatic encephalopathy score]. Patients suffering from MHE showed higher risk to develop overt hepatic encephalopathy and traffic accidents together with a decreased quality of life. More than a 60% of the hepatologists do not investigate the presence of MHE. Aim: To know the usefulness of the critical flicker frequency on the diagnosis of MHE. Patients and Methods: 114 cirrhotic patients and 103 control patients who performed the PHES tests were included. CFF was measured in patients and controls using Hepatonorm| Patients with a lower score than -4 in the PHES tests (corrected according to Spanish normality tables available at http://www.redeh.org/), were diagnosed as having MHE. Results: In the control group, the mean CFF was similar for males (43.2+3.7Hz) and females (42.1+3.5 Hz; p ns) and it was not related to age (r 0.078; p ns) and education years (r 0.056; p ns) either. The score for the PHES tests (r 0.54; p <0.001) and the score for each test separately (NCT-A (r 0.51; p 0.0001), LD (r 0.56; p 0.001), NCT-B (r 0.45; p 0.001), DST (r 0.31; p 0.001) and SD (r 0.30; p 0.001) correlated to the mean CFF. We also find a relation with the Child@ugh (r 0.22; p 0.018) but not the MELD score (r 0.11; p ns). In cirrhotic patients with MHE, we found a lower mean CFF (35.6+4.1Hz) than in patients without MHE (40.5+3.7Hz) or healthy control (42.7+3.6Hz); p 0.001. The under curve area of CFF in the diagnosis of MHE was 0.79 (95% CI: 0.7 0.88). The sensitivity was 72% and the specificity was 77% when using 38 Hz as the threshold. The CFF was altered in 77% of the patients with MHE (27 out of 35) comparing with 26% of cirrhotic patients without MHE (21 out of 79); p < 0,001. Conclusions: The measurement of the CFF is an easy, reliable and sure method to diagnose MHE and is not influenced by age or education level. Acknowledgement: Red EH G03/155
r
•
TERLIPRESSIN AND ALBUMIN T H E R A P Y FOR PATIENTS WITH ADVANCED CIRRHOSIS AND SEVERE RENAL FAILURE
M. Serrano, J.M. Pascasio, J.M. Sousa, E. De la Santa, M. Sayago, M.T. Ferrer, J.L. Mfirquez, M. Garzdn, I. Grilo, M. Cabanillas. Dep.
(b) Clinical aspects
$93
Cr level; No Response (NR): no decrease or reduction ~<50% from the highest Cr level. Results: Age:55.5• years (36 64). Sex:13 men (81.3%). PughChild score (P C): 8.8• (7 12). MELD: 27.5• (20 40). Etiology: 93.8% Alcohol (2 HCV and 1 HBV). Severity of RF was similar in cases of INF-RF and HRS-I (Cr 4.3• vs 4.6• p NS). At the end of treatment, we observed a significant improvement in Urea (105.1• vs 170.4• p 0.0001), Cr (1.6• vs 4.5• p 0.0001), serum Na (132.9• vs 126.1• p 0.002) and mean arterial pressure (mAP) (81.6• vs 66.7• p 0.001). 12 patients had TR (75%), 2 PR (12.5%) and 2 NR (12.5%). RF reappeared in 3 patients (18.8%), all of them improving again with further treatment (2 TR and 1 PR). After a median follow-up time of 80 days (18~08), 6 patients died (37.5%) and 8 (50%) were transplanted (one of them died after LT).TLP mean dose was 0.8• mg/4h (0.5 2) and the median time of treatment 6.5 days (3 28). There were adverse reactions in 75% of patients, being the most common the central venous pressure (CVP) increase. Treatment response and survival did not have significant association with either the type of RF or other pre-treatment parameters: age, P C, MELD, urea, Cr, Na, mAP and CVR Only the degree of treatment response was correlated with survival: NR 0%, PR 50% and TR 75% (p 0.02). (See figure.) SURVIVALFUNCTION TREATMENT
10-
RESPONSE INR
08-
> 08tn
~0,402-
00-
~oo
4o
L
800
Follow up (Days}
Conclusions: (1) TLP+ALB has shown beneficial effects in both types of RF with TR in 75% of patients. (2) More than 60% of patients survived and 50% could be transplanted without worsening the post-transplantation prognosis. (3) Survival was related to treatment response, not depending on pre-treatment degree of hepatic insufficiency and type or severity of RF. (4) TLP+ALB could be used, not only in HRS-I, but also in INF-RF, because clinical outcome, progress and prognosis may be similar for both types of RF.
Gastroenterology and Hepatology/HHUU Virgen del Roc{o, Seville, Spain Aim: To determine the results of terlipressin plus albumin therapy (TLP + ALB) in cirrhosis patients with severe renal failure (RF) caused by hepatorenal syndrome type I (HRS-I) or severe infection (INF-RF). Methods: We studied 16 consecutive cirrhosis patients with RF (serum creatinine >2.5 mg/dl) caused by HRS-I (8 patients)and INF-RF (8 patients).They were treated with intravenous terlipressin (0.5 2 mg/4h) plus albumin. All patients took off diuretics and were on albumin during previous 48 hours without improvement. We assessed the treatment response and the posterior clinical outcome, reaching liver transplantation (LT) or death. Definitions: Total Response (TR): decrease of serum creatinine (Cr) to <1.5 mg/dl; Partial Response (PR): reduction >50% from the highest
[•
CRITICAL FLICKER FREQUENCY: DIAGNOSTIC TOOL FOR MINIMAL HEPATIC ENCEPHALOPATHY
R Sharma 1, B.C. Sharma 1, S.K. Sarin 1, V. Puri 2. 1Department of
Gastroenterology, 2Department of Neurology, G.B. Pant Hospital New Delhi, India B a c k g r o u n d and Aims: Minimal hepatic encephalopathy (MHE) is associated with poorer quality of life and increased work disability. Diagnosis required cumbersome psychometric and neurophysiological tests. We evaluated Critical Flicker Frequency (CFF) to diagnose MHE.