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Macroscopic hematuria with glomerular bleeding: a peculiar form of acute renal failure in cirrhotic patients
Category 2: Cirrhosis and its complications, pathophysiology and clinical aspects conclusion, in cirrhotic patients the administration of radiocontrast agents does not induce significant changes in renal function, even when ascites and renal dysfunction are present. Cirrhosis does not represent a risk factor for nephrotoxicity induced by radiocontrast agents.
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EFFECT OF CELECOXIB ON RENAL FUNCTION IN CIRRHOTIC PATIENTS WITH ASCITES. A PILOT STUDY
Monica Guevarra I , Raquel Abecasis I , Wlamidimiro Jimenez 2, Hector Rios I , Ruben Terg 1.1Live r Unit, Hospital Udaondo, Buenos
Aires, Argentina; 2HormonalLaboratory, Hospital Clinic, Barcelona, Espana The administration of AINE to patients with cirrhosis and ascites induces a significant impairment in renal function. Selective COX-2 inhibitors would avoid renal side effects. Aim: to assess the effect of celecoxib, on renal function in cirrhotic patients with ascites. Material a n d Methods: Ten patients were included. Exclusion criteria: serum urea > 40 mg/dl, serum creationine > 1.5 mg/dl, bacterial infection, platelet count < 40.000 x m m 3, history of aspirin sensitive asthma, sulfamides allergy, ulcer disease or gastrointestinal hemorrhage. After 5 days on low sodium diet and without diuretics, serum creatinine, serum and urine electrolytes, diuresis after water load, glomerular filtration rate (GFR) by inulin clearance and urinary prostaglandin (PGE2 and 6-ketoPGFla). were determined. After that, patients received celecoxib 200 mg once a day, during 4 days. On the fifth day all determinations were repeated. Results: No significant changes in serum creatinine, GFR PGE2, PG6 KetoFla, urine volume, urinary sodium excretion and diuresis after water load were found after celecoxib. However, 5 out of 10 patients showed a decrease greater than 20% in GFR. Conclusion: Short term administration of celecoxib in a dose of 200 mg/day did not impair renal function in cirrhotic patients with ascites. Nevertheless, the decrease in GFR suggest that more studies are needed to identified the definite role of COX-2 inhibitors in these patients.
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MACROSCOPIC HEMATURIA WITH GLOMERULAR BLEEDING: A PECULIAR FORM OF ACUTE RENAL FAILURE IN CIRRHOTIC PATIENTS
Jf. Cadranel l , N. Soltani l , C. Guettier 2, D. Fleury 3, Jm. Poux 4, D. Hillion 5 , P. Vanhille 3, P. Bataille 6, P. Fievet 1, R. Demontis 1. 1Creil
Hospital, Creil; 2paul Brousse Hospital, Villejuif; 3ValenciennesHospital, Valenciennes; 4Limoges Hospital, Limoges; SPoissy Hospital, Poissy; 6Boulogne Sur Mer Hospital, Boulogne Sur Mer, France Acute renal failure (ARF) with macroscopic hematuria (MH) has been scarcely reported. The aims of this multicenter study was to report 10 cases of ARF with MH in cirrhotic patients (6 M, 4 F) requiring renal replacement therapy (RRT) in 6 of them. Mean age was 61 years (40-83) cause of cirrhosis was alcohol in 6. These patients were hospitalised for MH and ARF. Acute renal failure and cirrhosis were discovered at the same time in 4 of them, 3 patients had ascites and 2 jaundice. According to Child Pugh classification 2 were A, 7: B and 1: C. All patients underwent renal biopsy. All of them sustained with ARF, three were oliguric. Maximum serum creatinine was 790 micromol (450-1600). Proteinuria was 1.8 g/24 h (0.8-4). Immunologic screening was negative in all patients. Renal biopsy showed in all cases glomerular lesions with predominant IgA deposits and marked tubular lesions with large amount of erythrocytes casts in tubular lumen were noted. Six patients required RRT during 81 days (11-240). Two of them died (subit death in 1, terminal liver failure in 1). In the 4 others renal functions recovered leading to cessation of RRT. In the 4 patients who did not required RRT renal function improved in 2 of them, the 2 others died from related cirrhosis complications. Conclusion: we describe here a peculiar form of ARF with MH that can beneficiate from RRT.
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203
RELATIONSHIP BETWEEN EXTRAPYRAMIDAL SIGNS AND MINIMAL HEPATIC ENCEPHALOPATHY IN COMPENSATED LIVER CIRRHOSIS
Rodrigo Jover 1, Luis Company I , Aria Gutierrez 2, Juan Perez-Serra 3, Eva Girona 2, Pedro Zapater I , Jose R. Aparicio l , Miguel Perez-Mateo I .
1Hospital General Universitario, Dept. of Gastroenterology, Alicante; 2Hospital General Universitario, Dept. of Gastroenterology, Elche; 3Hospital VergeDels Lliris, Dep. of Gastroenterology, Alcoi, Spain In compensated liver cirrhosis there are two types of mild neurological disturbance: extrapyramidal signs secondary to manganese deposition in basal ganglia and a mild cognitive deterioration called minimal hepatic encephalopathy (MHE). The aim of this work is to know if there are any relation between this alterations. Methods: 42 patients with liver cirrhosis were included in the study. MEH was diagnosed using manual neuropsychological tests (Trail-Making A, Digit Symbol and Block Design test). Cognitive deterioration was also evaluated using the Mini-Mental State Examination test (MMSE). Extrapyramidal signs were measured with the Columbia scale. Results: 15 patients had MHE (35.7%). 52.4% of patients had significative extrapyramidal signs. The score in Columbia scale was higher in patients diagnosed of MHE (16.0 -4- 10.9 vs. 5.3 -4- 7.1; p = 0.0004). The patients with extrapyramidal signs shows more cognitive deterioration also in the MMSE test (23.9 4- 3.3 vs. 27.3 4- 2.7; p = 0.001. Three factors have influence on extrapyramidal signs in the univariant analysis: diagnosis of MHE, Child-Pugh grade and MMSE score. In the multivariant analysis only the diagnosis of MHE was associated with the existence of significative extrapyramidal signs. Conclusion: There is a relation between extrapyramidal signs and the diagnosis of MHE made with manual neuropsychological tests. This result may be due to the the influence of extrapyramidalism on the performance of this kind of tests or it is also possible that there is a pathophysiological relation among this two mild neurological alterations in compensated cirrhotic patients.
~ 2 - ' ] CAROTID DUPLEX ULTRASOUND IN CHRONIC LIVER DISEASE: PREDICTABILITY OF CEREBRAL BLOOD FLOW Manri Kawakami l , Masahiko Koda 2, Yoshikazu Murawaki 2 . lMuikaichi
hospital, Shimane; 2SecondDepartment of lnternal Medicine, Tottori University, Yonago, Japan Aim: Carotid duplex ultrasound enables us to assess atherosclerosis and cerebral blood flow, noninvasibly. Increased carotid artery wall thickness is early event in atherosclerosis. We examined carotid hemodynamics by duplex ultrasound to assess the severity of atherosclerosis and cerebral blood flow in the patients with chronic liver disease. Patients a n d Methods: 20 controls (age: 78.1 q- 11.9 y.o.. male/female = 8/12), 6 patients with chronic hepatitis (78.2 4- 9.7, 2/4), 20 with Pugh A (72.4 4- 8.4, 8/12), 2 with Pugh B (80.5 -4- 5.0, 1/1), 3 with Pugh C (72.3 + 11.7, 1/2) underwent carotid duplex ultrasound and were measured intima-media thickness, diameter stenosis, mean flow velocity, pulsatility index, resistive index and flow volume three times, pulsatility index = (peak systolic velocity- end diastolic velocity)/mean velocity, resistive index = (peak systolic velocity- end diastolic velocity)/peak systolic velocity. Results: Although serum level of total cholesterol were significantly decreased as the severity of liver diseases (ANOVA: F = 6.95. p < 0.0005), there were no significant differences in the intima-media thickness, diameter stenosis, mean flow velocity and flow volume. Pulsatility index in Pugh B (1.69 4- 0.04) and Pugh C (1.70 + 0.01) were significantly higher than controls (1.34 4- 0.18), chronic hepatitis (1.25 4- 0.27) and Pugh A (1.35 4- 0.25). (ANOVA: F = 3.47. p < 0.05). In resistive index, Pugh C (0.78 4- 0.02) was significantly higher than controls (0.70 4- 0.04), chronic hepatitis (0.68 -4- 0.09) and Pugh A (0.70 ± 0.06) (ANOVA: F = 2.60. p < 0.05). Both indices were significantly correlated with blood ammonia. (r = -0.356. p < 0.05; r = -0.316. p < 0.05).
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EFFECT OF CELECOXIB ON RENAL FUNCTION IN CIRRHOTIC PATIENTS WITH ASCITES. A PILOT STUDY
Monica Guevarra I , Raquel Abecasis I , Wlamidimiro Jimenez 2, Hector Rios I , Ruben Terg 1.1Live r Unit, Hospital Udaondo, Buenos
Aires, Argentina; 2HormonalLaboratory, Hospital Clinic, Barcelona, Espana The administration of AINE to patients with cirrhosis and ascites induces a significant impairment in renal function. Selective COX-2 inhibitors would avoid renal side effects. Aim: to assess the effect of celecoxib, on renal function in cirrhotic patients with ascites. Material a n d Methods: Ten patients were included. Exclusion criteria: serum urea > 40 mg/dl, serum creationine > 1.5 mg/dl, bacterial infection, platelet count < 40.000 x m m 3, history of aspirin sensitive asthma, sulfamides allergy, ulcer disease or gastrointestinal hemorrhage. After 5 days on low sodium diet and without diuretics, serum creatinine, serum and urine electrolytes, diuresis after water load, glomerular filtration rate (GFR) by inulin clearance and urinary prostaglandin (PGE2 and 6-ketoPGFla). were determined. After that, patients received celecoxib 200 mg once a day, during 4 days. On the fifth day all determinations were repeated. Results: No significant changes in serum creatinine, GFR PGE2, PG6 KetoFla, urine volume, urinary sodium excretion and diuresis after water load were found after celecoxib. However, 5 out of 10 patients showed a decrease greater than 20% in GFR. Conclusion: Short term administration of celecoxib in a dose of 200 mg/day did not impair renal function in cirrhotic patients with ascites. Nevertheless, the decrease in GFR suggest that more studies are needed to identified the definite role of COX-2 inhibitors in these patients.
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MACROSCOPIC HEMATURIA WITH GLOMERULAR BLEEDING: A PECULIAR FORM OF ACUTE RENAL FAILURE IN CIRRHOTIC PATIENTS
Jf. Cadranel l , N. Soltani l , C. Guettier 2, D. Fleury 3, Jm. Poux 4, D. Hillion 5 , P. Vanhille 3, P. Bataille 6, P. Fievet 1, R. Demontis 1. 1Creil
Hospital, Creil; 2paul Brousse Hospital, Villejuif; 3ValenciennesHospital, Valenciennes; 4Limoges Hospital, Limoges; SPoissy Hospital, Poissy; 6Boulogne Sur Mer Hospital, Boulogne Sur Mer, France Acute renal failure (ARF) with macroscopic hematuria (MH) has been scarcely reported. The aims of this multicenter study was to report 10 cases of ARF with MH in cirrhotic patients (6 M, 4 F) requiring renal replacement therapy (RRT) in 6 of them. Mean age was 61 years (40-83) cause of cirrhosis was alcohol in 6. These patients were hospitalised for MH and ARF. Acute renal failure and cirrhosis were discovered at the same time in 4 of them, 3 patients had ascites and 2 jaundice. According to Child Pugh classification 2 were A, 7: B and 1: C. All patients underwent renal biopsy. All of them sustained with ARF, three were oliguric. Maximum serum creatinine was 790 micromol (450-1600). Proteinuria was 1.8 g/24 h (0.8-4). Immunologic screening was negative in all patients. Renal biopsy showed in all cases glomerular lesions with predominant IgA deposits and marked tubular lesions with large amount of erythrocytes casts in tubular lumen were noted. Six patients required RRT during 81 days (11-240). Two of them died (subit death in 1, terminal liver failure in 1). In the 4 others renal functions recovered leading to cessation of RRT. In the 4 patients who did not required RRT renal function improved in 2 of them, the 2 others died from related cirrhosis complications. Conclusion: we describe here a peculiar form of ARF with MH that can beneficiate from RRT.
~-]
203
RELATIONSHIP BETWEEN EXTRAPYRAMIDAL SIGNS AND MINIMAL HEPATIC ENCEPHALOPATHY IN COMPENSATED LIVER CIRRHOSIS
Rodrigo Jover 1, Luis Company I , Aria Gutierrez 2, Juan Perez-Serra 3, Eva Girona 2, Pedro Zapater I , Jose R. Aparicio l , Miguel Perez-Mateo I .
1Hospital General Universitario, Dept. of Gastroenterology, Alicante; 2Hospital General Universitario, Dept. of Gastroenterology, Elche; 3Hospital VergeDels Lliris, Dep. of Gastroenterology, Alcoi, Spain In compensated liver cirrhosis there are two types of mild neurological disturbance: extrapyramidal signs secondary to manganese deposition in basal ganglia and a mild cognitive deterioration called minimal hepatic encephalopathy (MHE). The aim of this work is to know if there are any relation between this alterations. Methods: 42 patients with liver cirrhosis were included in the study. MEH was diagnosed using manual neuropsychological tests (Trail-Making A, Digit Symbol and Block Design test). Cognitive deterioration was also evaluated using the Mini-Mental State Examination test (MMSE). Extrapyramidal signs were measured with the Columbia scale. Results: 15 patients had MHE (35.7%). 52.4% of patients had significative extrapyramidal signs. The score in Columbia scale was higher in patients diagnosed of MHE (16.0 -4- 10.9 vs. 5.3 -4- 7.1; p = 0.0004). The patients with extrapyramidal signs shows more cognitive deterioration also in the MMSE test (23.9 4- 3.3 vs. 27.3 4- 2.7; p = 0.001. Three factors have influence on extrapyramidal signs in the univariant analysis: diagnosis of MHE, Child-Pugh grade and MMSE score. In the multivariant analysis only the diagnosis of MHE was associated with the existence of significative extrapyramidal signs. Conclusion: There is a relation between extrapyramidal signs and the diagnosis of MHE made with manual neuropsychological tests. This result may be due to the the influence of extrapyramidalism on the performance of this kind of tests or it is also possible that there is a pathophysiological relation among this two mild neurological alterations in compensated cirrhotic patients.
~ 2 - ' ] CAROTID DUPLEX ULTRASOUND IN CHRONIC LIVER DISEASE: PREDICTABILITY OF CEREBRAL BLOOD FLOW Manri Kawakami l , Masahiko Koda 2, Yoshikazu Murawaki 2 . lMuikaichi
hospital, Shimane; 2SecondDepartment of lnternal Medicine, Tottori University, Yonago, Japan Aim: Carotid duplex ultrasound enables us to assess atherosclerosis and cerebral blood flow, noninvasibly. Increased carotid artery wall thickness is early event in atherosclerosis. We examined carotid hemodynamics by duplex ultrasound to assess the severity of atherosclerosis and cerebral blood flow in the patients with chronic liver disease. Patients a n d Methods: 20 controls (age: 78.1 q- 11.9 y.o.. male/female = 8/12), 6 patients with chronic hepatitis (78.2 4- 9.7, 2/4), 20 with Pugh A (72.4 4- 8.4, 8/12), 2 with Pugh B (80.5 -4- 5.0, 1/1), 3 with Pugh C (72.3 + 11.7, 1/2) underwent carotid duplex ultrasound and were measured intima-media thickness, diameter stenosis, mean flow velocity, pulsatility index, resistive index and flow volume three times, pulsatility index = (peak systolic velocity- end diastolic velocity)/mean velocity, resistive index = (peak systolic velocity- end diastolic velocity)/peak systolic velocity. Results: Although serum level of total cholesterol were significantly decreased as the severity of liver diseases (ANOVA: F = 6.95. p < 0.0005), there were no significant differences in the intima-media thickness, diameter stenosis, mean flow velocity and flow volume. Pulsatility index in Pugh B (1.69 4- 0.04) and Pugh C (1.70 + 0.01) were significantly higher than controls (1.34 4- 0.18), chronic hepatitis (1.25 4- 0.27) and Pugh A (1.35 4- 0.25). (ANOVA: F = 3.47. p < 0.05). In resistive index, Pugh C (0.78 4- 0.02) was significantly higher than controls (0.70 4- 0.04), chronic hepatitis (0.68 -4- 0.09) and Pugh A (0.70 ± 0.06) (ANOVA: F = 2.60. p < 0.05). Both indices were significantly correlated with blood ammonia. (r = -0.356. p < 0.05; r = -0.316. p < 0.05).