- Email: [email protected]
Ascitic Fluid Ultrafiltration and Reinfusion Therapy (AURT)
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Corresponding author: Balasubramaniyan Vairappan. Email: [email protected]
UTILITY OF VARIOUS CLINICAL PARAMETERS AS A PREDICTOR OF CARDIAC DYSFUNCTION IN PATIENTS WITH LIVER CIRRHOSIS Varun Bogadi*, K. Panduranga Raoy, Prabhakar Bodduy, Ramesh Bhashyakarlay *
Department of Gastroenterology and Hepatology, Osmania Medical College Hyderabad, Andhra Pradesh, India, and y Department of Gastroenterology, Osmania Medical College Hyderabad, Andhra Pradesh, India Background: Cirrhosis-related cardiovascular abnormalities play a major role in the pathogenesis of multiple life-threatening complications including hepatorenal syndrome, ascites, spontaneous bacterial peritonitis, gastroesophageal varices, and hepatopulmonary syndrome. Unrecognized cardiac dysfunction is a cause for increased mortality in the peri trans-Plant period (arrhythmias and overt heart failure) and after TIPS (pulmonary edema). Aim: To find the prevalence of cardiac dysfunction in patients with cirrhosis. To study utility of various clinical parameters as a marker of cardiac dysfunction in patients with liver cirrhosis. Methods: Total of 85 patients with cirrhosis were included in the study after satisfying the inclusion and exclusion criteria between sep 2011 to sep 2013.All of them underwent evaluation for presence of cardiac dysfunction by 2D-Echo (systolic/diastolic dysfunction) and ECG (QT Prolongation). Serum pro-BNP was measured in all the patients. Patients were divided into two groups group Aathose with cardiac dysfunction, group B a those without cardiac dysfunction. Clinical and biochemical indices in both the groups were compared. Results: Out of 85 patients' child A- 18, Child B-39, Child C-28. A total of 38(44.7%) patients had cardiac dysfunc-
tion. Prevalence of cardiac dysfunction was more in child C 21/28 (75%) compared to child B 15/39 (38.46%) and child A 2/18 (11.11%). Patients with cardiac dysfunction are more likely to have higher INR, lower Albumin, higher bilirubin, lower serum Na, higher CTP score, lower mean arterial pressure, prolonged QTc, higher MELD Score and higher pro-BNP levels. Presence of cardiac dysfunction is a surrogate marker for advanced liver disease patients in group A (cardiac dysfunction) show more tendencies to have renal dysfunction, hyponatremia and thrombocytopenia. Conclusions: Prevalence of cardiac dysfunction in patients with liver cirrhosis is 44.7%. INR more than 1.4, serum albumin <2.8, mean arterial pressure #75 mm of Hg, QTc>0.44, CTP Score $10, MELD>20,Serum pro-BNP with a cut-off of 100 ng/ml and 167 ng/ml can be used as clinical predictors of underlying cardiac dysfunction. These patients should undergo detailed cardiac evaluation. Corresponding author: Varun Bogadi. Email: [email protected]
ASCITIC FLUID ULTRAFILTRATION AND REINFUSION THERAPY (AURT) Piyush Mathur*, Rajasekara Chakravarthi*, Sethu Babuy, Vikranth Reddy*, N. Subramanyamz, Santosh Hedau* *
Department of Nephrology, Osmania Medical College, Hyderabad, India yDepartment of Gastroentrology, Osmania Medical College, Hyderabad, India, and zDepartment of Nuclear Medicine, Osmania Medical College, Hyderabad, India Background: Refractory ascites accounts for severe morbidity in patients of chronic liver disease. These patients despite on salt restriction and diuretics have poor quality of life and require repeated paracentesis which leads to significant protein loss requiring albumin infusion. The morbidity and mortality correlates with the severity of ascites. Methods: We have done Ascitic Fluid Ultra filtration and Reinfusion Therapy (AURT) in four patients with refractory ascites due to hepatic cirrhosis of varied etiology. We used percutaneously placed tenkhoff PD catheter and HD pump and dialyzer for ultra filtration. Initial sessions were done for 2 to3 hours daily for 3 days with 2.5 to 3 liters of ultra filtration daily. First two to three sessions were done as inpatient and subsequently as outpatients. Results: Around 7 to 10 liter of ascitic fluid was ultra filtered during first two to three sessions. At time of discharge body weight of these patients were reduced by 7 to 8 kg and diuretics were stopped after initiation of AURT. All these patients showed improved quality of life and renal function and first patient also showed improved S. albumin level.
Journal of Clinical and Experimental Hepatology | March 2014 | Vol. 4 | No. S2 | S39–S54
S45
Cirrhosis and Complications
Conclusion: Our study is the first demonstration of evidence that the significant association between hyperammonaemia and portal hypertension. Treatment of hyperammonemia with OCR-002 reduces the severity of portal hypertension in a clinically relevant model of cirrhosis through restoration of the hepatic eNOS activity, by modulating for NF-kb driven inflammatory signaling and expression of the eNOS regulators, DDAH1-ADMA and caveolin-1. Thus, our data provide the rationale for evaluating OCR-002 in the treatment of portal hypertension. Keywords: eNOS dysfunction, Hyperammonemia, Inflammation, L-Ornithine Phenylacetate, Portal hypertension.
ABSTRACTS
Conclusion: We conclude that AURT is safe alternative to repeated paracentesis with albumin infusion. Corresponding author: Piyush Mathur. Email: [email protected]
RENAL AND HEPATIC HEMODYNANAMICS IN CHRONIC LIVER DISEASE Vishwanath Reddy, K. R. Thankappan, M. G. Srinivas, K. Sridhar, Venkata Reddy Department of Gastroenterology, Narayana Medical College, Nellore, India
Cirrhosis and Complications
Background: Patients with advanced chronic liver diseases often exhibit an abnormal hemodynamics. There are limited studies on simultaneous evaluation of liver and renal blood flow using Doppler methods in real time. Aims and Objectives: To calculate the renal and hepatic arterial Resistive index, Pulsatility index in patients with chronic liver disease, its correlation with severity and usefulness of RI as a noninvasive predictor of response to diuretic therapy and oesophageal varices. Methods: This was a prospective observational study with 57 patients of newly diagnosed cirrhosis of liver. Results: This study shows mean renal resistive index (RRI) is 0.72 0.06 and renal pulsatality index (RPI) is 1.48 0.29 which is higher than normal values (0.57–0.67, 0.88–1.12). This study also shows there is increase in mean RRI and RPI to higher grades of cirrhosis. Furthermore, RRI and RPI positively correlated with Child's score and significant. Hepatic artery resistance index (HRI) and pulsatality index (HPI) mean values of the same were 0.64 0.04 and 1.07 0.05. The mean HRI and HPI was significantly low in Child C compared to Child A and Child B class, where as there was no significant difference in HPI and HRI between Child A and Child B. Furthermore, HRI and HPI negatively correlated with Child score and were significant. High value of RRI is non-invasive predictor of inadequate response to ascites on predictive analysis than any other indices, RRI, RPI showed a positive correlation with occurrence of esophageal varices and HPI showed negative correlation, type of wave forms with oesophageal varices was statistically significant with P < 0.05 and monophasic waveforms were associated with large varices. Conclusion: RRI and PI are abnormal in most of the patients with cirrhosis and show a significant positive correlation with increasing grade of cirrhosis, were as HRI shows negative correlation with increasing grade of cirrhosis. RRI is a noninvasive predictor of response to diuretic treatment of ascites. High level of RRI correlates S46
22ND ANNUAL CONFERENCE – 2014
with presence of oesophageal varices, presence of hepatic vien monophasic waveform predicts the incidence of large varices. Corresponding author: Vishwanath Reddy. Email: [email protected]
ANALYSIS OF CAUSES OF SEPSIS AND ITS OUTCOME IN HOSPITALIZED PATIENTS WITH CIRRHOSIS OF THE LIVER Varghese Thomas, Roji Ray Department of Gastroenterology, Government Medical College Calicut, Kerala, India Background: Bacterial infections occur frequently in those with cirrhosis and it may be present at admission or develop during hospital stay. Furthermore these infections can be fatal in patients with cirrhosis. Aims: To analyse the causes of infection in hospitalized cirrhotic patients and its impact on clinical outcome. Methods: Patients with cirrhosis who were admitted to department of gastroenterology from January 2012 to January 2013 were studied retrospectively. Clinical, hematological and biochemical parameters as well as CTP and MELD scores were compared between those with and without infections. Results: A total of 234 patients were studied of which 191 (81.6%) were males. The most common etiology of cirrhosis was alcohol (n = 115; 49.1%). 64 (27.4%) had evidence of infection. 53 (82.8%) had a single focus of infection while the rest had multiple foci of infection. Most common infections were SBP (n = 34; 53.1%), pneumonia (n = 12; 18.7%), urinary tract infection (n = 8; 12.5%), and cellulitis (n = 5; 7.8%). One patient each had tuberculosis, septic arthritis and pyoderma. Majority of infections were community acquired (n = 57; 89.1%). Mean total count, INR and albumin were 12403/mm3 (SD 3754), 1.93 (SD 0.64) and 2.62 (SD 0.34) in those with infection and 6305/mm3 (SD 1870), 1.36(SD 0.33) and 2.90 (SD 0.43) respectively in those without infection (P =< 0.001). The mean CTP and MELD scores were 11.4 (SD 1.68) and 19.9 (SD 6.30) in those with infection while it was 8.5 (SD 2.06) and 12.1 (SD 4.29) in those without infection (P < 0.001). There was increased incidence of encephalopathy (n = 38; 59.4%), acute kidney injury (n = 19; 29.7%) and decompensation (n = 59; 92.2%) in those with infection whereas incidence of upper GI bleed was low (n = 2; 3.1%). Though diabetes mellitus was more in patients with infection it was not statistically significant. Mortality was more in patients with infection (n = 14; 21.9%) compared to those without infection (n = 6; 3.5%) (P < 0.001). Multiple infections increased the chance of mortality. © 2014, INASL
Corresponding author: Balasubramaniyan Vairappan. Email: [email protected]
UTILITY OF VARIOUS CLINICAL PARAMETERS AS A PREDICTOR OF CARDIAC DYSFUNCTION IN PATIENTS WITH LIVER CIRRHOSIS Varun Bogadi*, K. Panduranga Raoy, Prabhakar Bodduy, Ramesh Bhashyakarlay *
Department of Gastroenterology and Hepatology, Osmania Medical College Hyderabad, Andhra Pradesh, India, and y Department of Gastroenterology, Osmania Medical College Hyderabad, Andhra Pradesh, India Background: Cirrhosis-related cardiovascular abnormalities play a major role in the pathogenesis of multiple life-threatening complications including hepatorenal syndrome, ascites, spontaneous bacterial peritonitis, gastroesophageal varices, and hepatopulmonary syndrome. Unrecognized cardiac dysfunction is a cause for increased mortality in the peri trans-Plant period (arrhythmias and overt heart failure) and after TIPS (pulmonary edema). Aim: To find the prevalence of cardiac dysfunction in patients with cirrhosis. To study utility of various clinical parameters as a marker of cardiac dysfunction in patients with liver cirrhosis. Methods: Total of 85 patients with cirrhosis were included in the study after satisfying the inclusion and exclusion criteria between sep 2011 to sep 2013.All of them underwent evaluation for presence of cardiac dysfunction by 2D-Echo (systolic/diastolic dysfunction) and ECG (QT Prolongation). Serum pro-BNP was measured in all the patients. Patients were divided into two groups group Aathose with cardiac dysfunction, group B a those without cardiac dysfunction. Clinical and biochemical indices in both the groups were compared. Results: Out of 85 patients' child A- 18, Child B-39, Child C-28. A total of 38(44.7%) patients had cardiac dysfunc-
tion. Prevalence of cardiac dysfunction was more in child C 21/28 (75%) compared to child B 15/39 (38.46%) and child A 2/18 (11.11%). Patients with cardiac dysfunction are more likely to have higher INR, lower Albumin, higher bilirubin, lower serum Na, higher CTP score, lower mean arterial pressure, prolonged QTc, higher MELD Score and higher pro-BNP levels. Presence of cardiac dysfunction is a surrogate marker for advanced liver disease patients in group A (cardiac dysfunction) show more tendencies to have renal dysfunction, hyponatremia and thrombocytopenia. Conclusions: Prevalence of cardiac dysfunction in patients with liver cirrhosis is 44.7%. INR more than 1.4, serum albumin <2.8, mean arterial pressure #75 mm of Hg, QTc>0.44, CTP Score $10, MELD>20,Serum pro-BNP with a cut-off of 100 ng/ml and 167 ng/ml can be used as clinical predictors of underlying cardiac dysfunction. These patients should undergo detailed cardiac evaluation. Corresponding author: Varun Bogadi. Email: [email protected]
ASCITIC FLUID ULTRAFILTRATION AND REINFUSION THERAPY (AURT) Piyush Mathur*, Rajasekara Chakravarthi*, Sethu Babuy, Vikranth Reddy*, N. Subramanyamz, Santosh Hedau* *
Department of Nephrology, Osmania Medical College, Hyderabad, India yDepartment of Gastroentrology, Osmania Medical College, Hyderabad, India, and zDepartment of Nuclear Medicine, Osmania Medical College, Hyderabad, India Background: Refractory ascites accounts for severe morbidity in patients of chronic liver disease. These patients despite on salt restriction and diuretics have poor quality of life and require repeated paracentesis which leads to significant protein loss requiring albumin infusion. The morbidity and mortality correlates with the severity of ascites. Methods: We have done Ascitic Fluid Ultra filtration and Reinfusion Therapy (AURT) in four patients with refractory ascites due to hepatic cirrhosis of varied etiology. We used percutaneously placed tenkhoff PD catheter and HD pump and dialyzer for ultra filtration. Initial sessions were done for 2 to3 hours daily for 3 days with 2.5 to 3 liters of ultra filtration daily. First two to three sessions were done as inpatient and subsequently as outpatients. Results: Around 7 to 10 liter of ascitic fluid was ultra filtered during first two to three sessions. At time of discharge body weight of these patients were reduced by 7 to 8 kg and diuretics were stopped after initiation of AURT. All these patients showed improved quality of life and renal function and first patient also showed improved S. albumin level.
Journal of Clinical and Experimental Hepatology | March 2014 | Vol. 4 | No. S2 | S39–S54
S45
Cirrhosis and Complications
Conclusion: Our study is the first demonstration of evidence that the significant association between hyperammonaemia and portal hypertension. Treatment of hyperammonemia with OCR-002 reduces the severity of portal hypertension in a clinically relevant model of cirrhosis through restoration of the hepatic eNOS activity, by modulating for NF-kb driven inflammatory signaling and expression of the eNOS regulators, DDAH1-ADMA and caveolin-1. Thus, our data provide the rationale for evaluating OCR-002 in the treatment of portal hypertension. Keywords: eNOS dysfunction, Hyperammonemia, Inflammation, L-Ornithine Phenylacetate, Portal hypertension.
ABSTRACTS
Conclusion: We conclude that AURT is safe alternative to repeated paracentesis with albumin infusion. Corresponding author: Piyush Mathur. Email: [email protected]
RENAL AND HEPATIC HEMODYNANAMICS IN CHRONIC LIVER DISEASE Vishwanath Reddy, K. R. Thankappan, M. G. Srinivas, K. Sridhar, Venkata Reddy Department of Gastroenterology, Narayana Medical College, Nellore, India
Cirrhosis and Complications
Background: Patients with advanced chronic liver diseases often exhibit an abnormal hemodynamics. There are limited studies on simultaneous evaluation of liver and renal blood flow using Doppler methods in real time. Aims and Objectives: To calculate the renal and hepatic arterial Resistive index, Pulsatility index in patients with chronic liver disease, its correlation with severity and usefulness of RI as a noninvasive predictor of response to diuretic therapy and oesophageal varices. Methods: This was a prospective observational study with 57 patients of newly diagnosed cirrhosis of liver. Results: This study shows mean renal resistive index (RRI) is 0.72 0.06 and renal pulsatality index (RPI) is 1.48 0.29 which is higher than normal values (0.57–0.67, 0.88–1.12). This study also shows there is increase in mean RRI and RPI to higher grades of cirrhosis. Furthermore, RRI and RPI positively correlated with Child's score and significant. Hepatic artery resistance index (HRI) and pulsatality index (HPI) mean values of the same were 0.64 0.04 and 1.07 0.05. The mean HRI and HPI was significantly low in Child C compared to Child A and Child B class, where as there was no significant difference in HPI and HRI between Child A and Child B. Furthermore, HRI and HPI negatively correlated with Child score and were significant. High value of RRI is non-invasive predictor of inadequate response to ascites on predictive analysis than any other indices, RRI, RPI showed a positive correlation with occurrence of esophageal varices and HPI showed negative correlation, type of wave forms with oesophageal varices was statistically significant with P < 0.05 and monophasic waveforms were associated with large varices. Conclusion: RRI and PI are abnormal in most of the patients with cirrhosis and show a significant positive correlation with increasing grade of cirrhosis, were as HRI shows negative correlation with increasing grade of cirrhosis. RRI is a noninvasive predictor of response to diuretic treatment of ascites. High level of RRI correlates S46
22ND ANNUAL CONFERENCE – 2014
with presence of oesophageal varices, presence of hepatic vien monophasic waveform predicts the incidence of large varices. Corresponding author: Vishwanath Reddy. Email: [email protected]
ANALYSIS OF CAUSES OF SEPSIS AND ITS OUTCOME IN HOSPITALIZED PATIENTS WITH CIRRHOSIS OF THE LIVER Varghese Thomas, Roji Ray Department of Gastroenterology, Government Medical College Calicut, Kerala, India Background: Bacterial infections occur frequently in those with cirrhosis and it may be present at admission or develop during hospital stay. Furthermore these infections can be fatal in patients with cirrhosis. Aims: To analyse the causes of infection in hospitalized cirrhotic patients and its impact on clinical outcome. Methods: Patients with cirrhosis who were admitted to department of gastroenterology from January 2012 to January 2013 were studied retrospectively. Clinical, hematological and biochemical parameters as well as CTP and MELD scores were compared between those with and without infections. Results: A total of 234 patients were studied of which 191 (81.6%) were males. The most common etiology of cirrhosis was alcohol (n = 115; 49.1%). 64 (27.4%) had evidence of infection. 53 (82.8%) had a single focus of infection while the rest had multiple foci of infection. Most common infections were SBP (n = 34; 53.1%), pneumonia (n = 12; 18.7%), urinary tract infection (n = 8; 12.5%), and cellulitis (n = 5; 7.8%). One patient each had tuberculosis, septic arthritis and pyoderma. Majority of infections were community acquired (n = 57; 89.1%). Mean total count, INR and albumin were 12403/mm3 (SD 3754), 1.93 (SD 0.64) and 2.62 (SD 0.34) in those with infection and 6305/mm3 (SD 1870), 1.36(SD 0.33) and 2.90 (SD 0.43) respectively in those without infection (P =< 0.001). The mean CTP and MELD scores were 11.4 (SD 1.68) and 19.9 (SD 6.30) in those with infection while it was 8.5 (SD 2.06) and 12.1 (SD 4.29) in those without infection (P < 0.001). There was increased incidence of encephalopathy (n = 38; 59.4%), acute kidney injury (n = 19; 29.7%) and decompensation (n = 59; 92.2%) in those with infection whereas incidence of upper GI bleed was low (n = 2; 3.1%). Though diabetes mellitus was more in patients with infection it was not statistically significant. Mortality was more in patients with infection (n = 14; 21.9%) compared to those without infection (n = 6; 3.5%) (P < 0.001). Multiple infections increased the chance of mortality. © 2014, INASL