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Mo1025 Risk of Stroke in Cirrhotic Patients With Atrial Fibrillation
Mo1025
CI: 5.5- 6.05) Conclusion: PCM is strongly associated with AKI and higher mortality in cirrhotics admitted to the hospital. Timely diagnosis and treatment of PCM may positively influence the outcomes in cirrhotics.
Risk of Stroke in Cirrhotic Patients With Atrial Fibrillation Yezaz A. Ghouri, Sachin Batra, Shaheryar Siddiqui, Erik Rahimi, Victor I. Machicao, Michael B. Fallon
Mo1027
Background: Atrial fibrillation (AF) predisposes non-cirrhotic patients to ischemic stroke and requires anticoagulant therapy for prevention. Traditionally, cirrhosis is considered to be a coagulopathic state and may be associated with increased or normal coagulability. The risk of ischemic stroke amongst those with atrial fibrillation and the associated risk scores for predicting ischemic scores are not well studied. We evaluated the risk of ischemic stroke among cirrhotics relative to non-cirrhotics with atrial fibrillation in national inpatient sample (NIS). Methods: A weighted sample of NIS for the year 2008 was analyzed. The risk of stroke associated with cirrhosis, adjusted for demographic and relevant risk factors, was estimated. Using STATA software, among patients with AF, we estimated the risk of cirrhosis with ischemic stroke relative to non-cirrhotic patients using weighted multivariate analysis while adjusting for other risk factors. We also calculated the CHADVasc scores among the sample population. Covariates of interest were characterized using ICD-9 CM codes. Results: The incidence of total stroke (ischemic and hemorrhagic) was significantly lower in cirrhotics when compared to non-cirrhotics. In individuals with AF the risk of ischemic stroke matched by risk factors for stroke demonstrated a lower incidence of ischemic stroke among patients with cirrhosis than non-cirrhotic controls. Multivariate analysis revealed 75% lower risk for stroke among cirrhotic patients with AF than non-cirrhotic AF patients (Odds ratio: 0.24; 95% [CI: 0.12 - 0.49]). The risk of ischemic stroke was lower among cirrhotics with AF for the same CHADVasc scores amongst non-cirrhotics. However, no difference in the risk of stroke was observed in cirrhotics with AF than non-cirrhotic AF patients with respect to hemorrhagic stroke (Odds ratio: 0.24; 95% CI: 0.0.3 - 1.7). The detailed analysis is described in the table. Conclusions: Cirrhotics appears to have a protective effect against ischemic stroke with or without AF. The incidence of hemorrhagic stroke was found to be lower in cirrhotics in general but this effect was not seen among those with AF. The risk of stroke amongst cirrhotics with AF is lower than what is predicted by CHADSVasc. Table showing the incidence of Ischemic stroke among cirrhotic and non-cirrhotic patients with atrial fibrillation
Background: Women may be disadvantaged compared to men with respect to the use of creatinine as the basis for renal insufficiency diagnosis, which may impact their overall prognosis. Aim: To determine the effect of relative creatinine change between genders on 30-day mortality and need for renal replacement therapy (RRT) in a multi-center study. Methods: NACSELD (North American Consortium for the Study of End-Stage Liver Disease) is a 21-center consortium of tertiary-care hepatology centers enrolling infected cirrhotic patients prospectively. Baseline, peak and delta (peak minus baseline) creatinine was compared between genders and its impact on RRT and 30-day mortality was evaluated using logistic regression. Results: 517 cirrhotics (55 years, 21 MELD, 41% HCV) of which 303 men (59%) were included. Child score at baseline was similar between genders (10 vs 10,p= 0.34). Median baseline (0.97 women vs 1.05,p=0.002) and peak creatinine (1.47 women vs1.50,p=0.05) was significantly lower in women with similar delta creatinine (0.31 vs 0.30,p=0.8). 30-day mortality was similar between genders (16% women, 20%men,p=0.3) while significantly higher RRT rates were in women (19% vs 12%,p=0.05). Delta creatinine significant predicted both death and RRT (p<0.0001 both). Both genders were similar with respect to death (p=0.39) but females were twice as likely as men to need RRT at the same level of creatinine [p=0.028, OR= 1.80, 95% CI (1.06, 3.06), figure]. Conclusion: Infected hospitalized cirrhotic women are significantly more likely than men to require RRT at similar creatinine levels. Gender-specific changes in creatinine may be important to determine prognosis.
Mo1028 Serum Ammonia Predicts Mortality in Hospitalized Patients With End-Stage Liver Disease Vilas R. Patwardhan, Z. Gordon Jiang, Gail Piatkowski, Nezam H. Afdhal, Kenneth Mukamal, Michael P. Curry, Elliot B. Tapper Background: Venous ammonia is frequently associated with hepatic encephalopathy (HE), but can be elevated for a number of reasons in patients with cirrhosis, including gastrointestinal bleeding, infection and alterations in renal ammoniagenesis. Though the exact mechanisms are not fully understood, hyperammonemia appears to represent a state of disequilibrium and altered homeostasis in cirrhotic patients. As such, ammonia levels may predict poor short-term outcomes in patients with chronic liver disease. Methods: A single-center retrospective cohort study was performed at a liver transplant center. Laboratory and demographic data were obtained from the electronic medical records of all cirrhotic patients admitted from April 25, 2007 to September 24, 2012 who had venous ammonia measured on admission. Multivariate Cox regression models were generated to investigate the relationship between venous ammonia concentrations and 30- and 90-day survival. Results: Our cohort of 492 cirrhotic patients had a mean age of 57 ± 10.3 years. Sixty-six percent were male, and 72% were Caucasian. Forty patients (8%) had undergone a transvenous intrahepatic porto-systemic shunt (TIPS) procedure prior to their hospital admission. Mean UNOS model for end-stage liver disease (MELD) score on admission was 20.5 + 8.7. The overall mortality rate was 20.2% at 30 days and 32.1% at 90 days. The in-hospital mortality rate was 22.1%. Mean venous ammonia on admission was 73 + 57 μmol/L. In a multivariate Cox proportional hazards model, logarithmic ammonia level (log base 2) was an independent predictor of mortality at 90 days with a hazard ratio (HR) of 1.2 (95% CI 1.0 - 1.4, p = 0.01) after adjustment for age, MELD score, history of TIPS, and serum sodium concentration. Accordingly, for every doubling of ammonia concentration, patients are at a 20% increased hazard of mortality. Additionally, patients with admission venous ammonia concentrations greater than 60 μmol/L had a higher in-hospital mortality (28.5% vs. 16.5%; P<0.001), 30-day mortality (28.5% vs. 13.1%; P<0.001), and 90-day mortality (39.9% vs. 25.5%; P<0.001), compared to those with ammonia concentration less than 60 μmol/L.(Figure 1) Conclusion: Elevated venous ammonia concentration measured at hospital admission independently predicts higher mortality in hospitalized cirrhotic patients after adjustment for MELD score
Mo1026 Protein Calorie Malnutrition Predicts Acute Kidney Injury and Mortality in Cirrhotics: Analysis of the National Inpatient Sample Shaheryar Siddiqui, Sachin Batra, Yezaz A. Ghouri, Erik Rahimi, Victor I. Machicao, Michael B. Fallon Aim and Objectives: Protein Calorie Malnutrition (PCM) has high prevalence in cirrhotic patients and increases with severity of liver disease. However its influence on acute kidney injury (AKI) and outcomes is not well defined. The aim of our study was to assess the effects of PCM in a large national sample of inpatient cirrhotics. Methods: Cirrhotic patients in the National inpatient sample (NIS) from 2007-2009 were analyzed. Patients with chronic kidney disease were excluded. The outcomes of interest were AKI and in-hospital mortality. National estimates were obtained by applying appropriate weights and stratification variables for survey data analysis. Multivariate estimates of the risk were obtained while adjusting for demographic features, etiology, complications of liver disease, comorbid conditions /Charlson Comorbidity index, insurance status and hospital characteristics. Results: The presence of PCM was strongly associated with Caucasian race (68%), and was lowest in African Americans (11%) and Asians (2%). Infections (26% vs. 17%) and AKI (20% vs. 13%) were more prevalent amongst PCM vs. non PCM. Likewise mortality was also higher in the PCM population (14% vs. 8%). In multivariate analysis, PCM was associated with a significantly greater risk of developing AKI (OR 1.65, 95% CI: 1.55-1.76), and in-patient mortality (OR 1.57, 95% CI: 1.46-1.69). AKI itself increases mortality by nearly 6 - fold (OR 5.75, 95%
S-989
AASLD Abstracts
AASLD Abstracts
Differences in Creatinine Between Genders Could Disadvantage Infected Cirrhotic Women: The Nacseld Experience Jacqueline G. O'Leary, Florence Wong, Patrick S. Kamath, K. Rajender Reddy, Heather Patton, Scott W. Biggins, Michael B. Fallon, Guadalupe Garcia-Tsao, Ram M. Subramanian, Benedict Maliakkal, Raza Malik, Leroy R. Thacker, Jasmohan S. Bajaj
CI: 5.5- 6.05) Conclusion: PCM is strongly associated with AKI and higher mortality in cirrhotics admitted to the hospital. Timely diagnosis and treatment of PCM may positively influence the outcomes in cirrhotics.
Risk of Stroke in Cirrhotic Patients With Atrial Fibrillation Yezaz A. Ghouri, Sachin Batra, Shaheryar Siddiqui, Erik Rahimi, Victor I. Machicao, Michael B. Fallon
Mo1027
Background: Atrial fibrillation (AF) predisposes non-cirrhotic patients to ischemic stroke and requires anticoagulant therapy for prevention. Traditionally, cirrhosis is considered to be a coagulopathic state and may be associated with increased or normal coagulability. The risk of ischemic stroke amongst those with atrial fibrillation and the associated risk scores for predicting ischemic scores are not well studied. We evaluated the risk of ischemic stroke among cirrhotics relative to non-cirrhotics with atrial fibrillation in national inpatient sample (NIS). Methods: A weighted sample of NIS for the year 2008 was analyzed. The risk of stroke associated with cirrhosis, adjusted for demographic and relevant risk factors, was estimated. Using STATA software, among patients with AF, we estimated the risk of cirrhosis with ischemic stroke relative to non-cirrhotic patients using weighted multivariate analysis while adjusting for other risk factors. We also calculated the CHADVasc scores among the sample population. Covariates of interest were characterized using ICD-9 CM codes. Results: The incidence of total stroke (ischemic and hemorrhagic) was significantly lower in cirrhotics when compared to non-cirrhotics. In individuals with AF the risk of ischemic stroke matched by risk factors for stroke demonstrated a lower incidence of ischemic stroke among patients with cirrhosis than non-cirrhotic controls. Multivariate analysis revealed 75% lower risk for stroke among cirrhotic patients with AF than non-cirrhotic AF patients (Odds ratio: 0.24; 95% [CI: 0.12 - 0.49]). The risk of ischemic stroke was lower among cirrhotics with AF for the same CHADVasc scores amongst non-cirrhotics. However, no difference in the risk of stroke was observed in cirrhotics with AF than non-cirrhotic AF patients with respect to hemorrhagic stroke (Odds ratio: 0.24; 95% CI: 0.0.3 - 1.7). The detailed analysis is described in the table. Conclusions: Cirrhotics appears to have a protective effect against ischemic stroke with or without AF. The incidence of hemorrhagic stroke was found to be lower in cirrhotics in general but this effect was not seen among those with AF. The risk of stroke amongst cirrhotics with AF is lower than what is predicted by CHADSVasc. Table showing the incidence of Ischemic stroke among cirrhotic and non-cirrhotic patients with atrial fibrillation
Background: Women may be disadvantaged compared to men with respect to the use of creatinine as the basis for renal insufficiency diagnosis, which may impact their overall prognosis. Aim: To determine the effect of relative creatinine change between genders on 30-day mortality and need for renal replacement therapy (RRT) in a multi-center study. Methods: NACSELD (North American Consortium for the Study of End-Stage Liver Disease) is a 21-center consortium of tertiary-care hepatology centers enrolling infected cirrhotic patients prospectively. Baseline, peak and delta (peak minus baseline) creatinine was compared between genders and its impact on RRT and 30-day mortality was evaluated using logistic regression. Results: 517 cirrhotics (55 years, 21 MELD, 41% HCV) of which 303 men (59%) were included. Child score at baseline was similar between genders (10 vs 10,p= 0.34). Median baseline (0.97 women vs 1.05,p=0.002) and peak creatinine (1.47 women vs1.50,p=0.05) was significantly lower in women with similar delta creatinine (0.31 vs 0.30,p=0.8). 30-day mortality was similar between genders (16% women, 20%men,p=0.3) while significantly higher RRT rates were in women (19% vs 12%,p=0.05). Delta creatinine significant predicted both death and RRT (p<0.0001 both). Both genders were similar with respect to death (p=0.39) but females were twice as likely as men to need RRT at the same level of creatinine [p=0.028, OR= 1.80, 95% CI (1.06, 3.06), figure]. Conclusion: Infected hospitalized cirrhotic women are significantly more likely than men to require RRT at similar creatinine levels. Gender-specific changes in creatinine may be important to determine prognosis.
Mo1028 Serum Ammonia Predicts Mortality in Hospitalized Patients With End-Stage Liver Disease Vilas R. Patwardhan, Z. Gordon Jiang, Gail Piatkowski, Nezam H. Afdhal, Kenneth Mukamal, Michael P. Curry, Elliot B. Tapper Background: Venous ammonia is frequently associated with hepatic encephalopathy (HE), but can be elevated for a number of reasons in patients with cirrhosis, including gastrointestinal bleeding, infection and alterations in renal ammoniagenesis. Though the exact mechanisms are not fully understood, hyperammonemia appears to represent a state of disequilibrium and altered homeostasis in cirrhotic patients. As such, ammonia levels may predict poor short-term outcomes in patients with chronic liver disease. Methods: A single-center retrospective cohort study was performed at a liver transplant center. Laboratory and demographic data were obtained from the electronic medical records of all cirrhotic patients admitted from April 25, 2007 to September 24, 2012 who had venous ammonia measured on admission. Multivariate Cox regression models were generated to investigate the relationship between venous ammonia concentrations and 30- and 90-day survival. Results: Our cohort of 492 cirrhotic patients had a mean age of 57 ± 10.3 years. Sixty-six percent were male, and 72% were Caucasian. Forty patients (8%) had undergone a transvenous intrahepatic porto-systemic shunt (TIPS) procedure prior to their hospital admission. Mean UNOS model for end-stage liver disease (MELD) score on admission was 20.5 + 8.7. The overall mortality rate was 20.2% at 30 days and 32.1% at 90 days. The in-hospital mortality rate was 22.1%. Mean venous ammonia on admission was 73 + 57 μmol/L. In a multivariate Cox proportional hazards model, logarithmic ammonia level (log base 2) was an independent predictor of mortality at 90 days with a hazard ratio (HR) of 1.2 (95% CI 1.0 - 1.4, p = 0.01) after adjustment for age, MELD score, history of TIPS, and serum sodium concentration. Accordingly, for every doubling of ammonia concentration, patients are at a 20% increased hazard of mortality. Additionally, patients with admission venous ammonia concentrations greater than 60 μmol/L had a higher in-hospital mortality (28.5% vs. 16.5%; P<0.001), 30-day mortality (28.5% vs. 13.1%; P<0.001), and 90-day mortality (39.9% vs. 25.5%; P<0.001), compared to those with ammonia concentration less than 60 μmol/L.(Figure 1) Conclusion: Elevated venous ammonia concentration measured at hospital admission independently predicts higher mortality in hospitalized cirrhotic patients after adjustment for MELD score
Mo1026 Protein Calorie Malnutrition Predicts Acute Kidney Injury and Mortality in Cirrhotics: Analysis of the National Inpatient Sample Shaheryar Siddiqui, Sachin Batra, Yezaz A. Ghouri, Erik Rahimi, Victor I. Machicao, Michael B. Fallon Aim and Objectives: Protein Calorie Malnutrition (PCM) has high prevalence in cirrhotic patients and increases with severity of liver disease. However its influence on acute kidney injury (AKI) and outcomes is not well defined. The aim of our study was to assess the effects of PCM in a large national sample of inpatient cirrhotics. Methods: Cirrhotic patients in the National inpatient sample (NIS) from 2007-2009 were analyzed. Patients with chronic kidney disease were excluded. The outcomes of interest were AKI and in-hospital mortality. National estimates were obtained by applying appropriate weights and stratification variables for survey data analysis. Multivariate estimates of the risk were obtained while adjusting for demographic features, etiology, complications of liver disease, comorbid conditions /Charlson Comorbidity index, insurance status and hospital characteristics. Results: The presence of PCM was strongly associated with Caucasian race (68%), and was lowest in African Americans (11%) and Asians (2%). Infections (26% vs. 17%) and AKI (20% vs. 13%) were more prevalent amongst PCM vs. non PCM. Likewise mortality was also higher in the PCM population (14% vs. 8%). In multivariate analysis, PCM was associated with a significantly greater risk of developing AKI (OR 1.65, 95% CI: 1.55-1.76), and in-patient mortality (OR 1.57, 95% CI: 1.46-1.69). AKI itself increases mortality by nearly 6 - fold (OR 5.75, 95%
S-989
AASLD Abstracts
AASLD Abstracts
Differences in Creatinine Between Genders Could Disadvantage Infected Cirrhotic Women: The Nacseld Experience Jacqueline G. O'Leary, Florence Wong, Patrick S. Kamath, K. Rajender Reddy, Heather Patton, Scott W. Biggins, Michael B. Fallon, Guadalupe Garcia-Tsao, Ram M. Subramanian, Benedict Maliakkal, Raza Malik, Leroy R. Thacker, Jasmohan S. Bajaj