- Email: [email protected]
Restless Leg Syndrome in Patients with Chronic Liver Disease
biochemical parameters were compared with immediate post-therapy parameters. Results: A total of 62 patients were included in the study (median age 54 [range 31–70] years), 82% males). The etiologies of cirrhosis were: cryptogenic 58%, alcohol 32%, viral 6% and mixed etiology 3%. The baseline median Child-Turcotte-Pugh (CTP) score and MELD scores were 10 (range 6–13) and 17 (range 6.4–33). All patients were able to successfully complete the 5-day therapy with GCSF without any significant adverse effect requiring stoppage of therapy. Compared to baseline values there was a significant increase in median WBC count post therapy (5.1 103/mm3 versus 16.9 103/ mm3; P < 0.01). Other hematologic, biochemical and clinical parameters including CTP and MELD scores and spleen size remained unchanged. Compared to baseline there was significant (14-fold) mobilization in CD34+ stem cells into peripheral blood (1.0 106/L versus 14.0 106/L). Conclusion: A 5-day course GCSF in the dose of 300 mcg b.i.d. is a safe therapy patient with advanced cirrhosis. It leads to an effective mobilization of CD34+ cells into the peripheral blood. Large randomized controlled studies are required to study whether this mobilization of CD34+ cells leads to significant liver regeneration and long-term improvement in liver functions.
spine. Osteopenia and osteoporosis were defined according to WHO criteria. All patients underwent 25-hydroxyvitamin-D, sex hormone (testosterone in male and LH and Estradiol in female) and parathyroid hormone (PTH) along with routine investigations. Fibroscan was done in all patients. Results: 215 patients (Male-179) with mean age 50.9 11 years were enrolled. Etiology of cirrhosis was alcohol in 98 (45.6%), non-alcoholic steatohepatitis (NASH) in 52 (24.2%), Post necrotic in 35 (16.3%) and Cryptogenic in 28 (13%). Mean CTP was 10 2.4 and MELD score was 18.6 8.9.Prevalance of HOD was 66%. Normal BMD was seen in 34% (n-73, group-A), Osteopenia 44.2% (n-95, group-B) and osteoporosis 21.8% (n-47, group-C). Patients in groupA and B had significantly more weight (71.7 15 vs 72.1 15 vs 62.7 12, P = 0.001) and BMI (26.3 6 vs 26.4 5 vs 23.2 5, P = 0.001) than group-C. There was no statistical difference in age, gender distribution, serum calcium, phosphorus, creatinine, vitamin-D, TSH and PTH among all these groups. Fibroscan in patients with HOD was significantly higher as compared to those with normal BMD in cirrhotic patients. Conclusions: Hepatic osteodystrophy was seen in 2/3rd of patients with liver cirrhosis. Low BMI and weight were associated with osteoporosis. Fibroscan can predict osteopenia and osteoporosis in patients with liver cirrhosis.
Corresponding author: Ashish Kumar. Email: [email protected]
PROSPECTIVE STUDY OF PREVALANCE OF HEPATIC OSTEODYSTROPHY IN PATIENTS WITH NON-CHOLEASTATIC LIVER CIRRHOSIS AND ITS PREDICTIVE FACTORS Rinkesh Kumar Bansal, Mandhir Kumar, Munish Kumar Sachdeva, Piyush Ranjan Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India Background and Objectives: Patients with liver cirrhosis are more prone to develop bone disease i.e. hepatic osteodystrophy (HOD) and includes osteopenia and osteoporosis. Aim of this study was to determine prevalence of HOD in patients with liver cirrhosis and to determine the predictive factors for HOD. Methods: Consecutive patients with liver cirrhosis admitted at Sir Ganga Ram Hospital, New Delhi between August 2012 and July 2013 were enrolled. Patients with Chronic renal failure, hyperparathyroidism and those on steroids were excluded. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA) at the lumbar
Corresponding author: Rinkesh Kumar Bansal. Email: [email protected]
RESTLESS LEG SYNDROME IN PATIENTS WITH CHRONIC LIVER DISEASE Amit Goel*, Avani Sasi*, Amit Goel*, Shankar Lal Jat*, Vimal Paliwaly, Rakesh Aggarwal* Department of Gastroenterology, and yDepartment of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
*
Journal of Clinical and Experimental Hepatology | March 2014 | Vol. 4 | No. S2 | S39–S54
S49
Cirrhosis and Complications
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
ABSTRACTS
22ND ANNUAL CONFERENCE – 2014
Cirrhosis and Complications
Background: Restless leg syndrome (RLS), characterized by irresistible urge to move limbs at rest which improves with limb movement, is observed in patients with iron deficiency anemia, diabetes mellitus, hypothyroidism, and chronic kidney disease (CKD). Recently two studies from Milwaukee and Japan showed that 62 % and 16.8 % of patients with chronic liver disease (CLD) had RLS. Aims: We undertook this study to (i) determine the prevalence of RLS in our patients with CLD, (ii) assess its relationship with severity of CLD, and (iii) determine the impact of presence of RLS on quality of life (QoL). Methods: Adult patients with clinically stable CLD attending our gastroenterology outpatient facility between November 2013 and January 2014 were prospectively enrolled irrespective of disease severity or etiology. Healthy controls were drawn from among family members accompanying patients in outpatient or inpatient facilities. All subjects were screened for possible RLS using diagnostic criteria as per the International RLS Study Group; a neurologist re-evaluated those with suspected RLS for confirmation of RLS and assessment of its severity using a validated Hindi translation of RLS severity scoring system. All subjects also completed the Hindi version of WHO BREF QoL instrument. Intergroup comparisons used chi-squared test. An interim analysis is reported. Results: The study included 57 cases (44 [77%] male; median [range] age 47 [18–68] years) and 22 controls (19 [86%] male; 33 [19–63] years); the two groups were comparable in gender distribution (P = 0.54), age (P = 0.12) and educational level (P = 0.53). Causes of CLD were: cryptogenic 17 (30%), alcohol 14 (25%), hepatitis C 14 (25%), hepatitis B 9 (16%) and autoimmune hepatitis 3 (5%). The number of patients in Child-Pugh class A, B, and C were 30 (52.6%), 19 (33.3%), and 8 (14%), respectively. Diagnosis of RLS was suspected in 4/57 (7%) cases and 2/22 (9%) controls, and was confirmed in 2 (4%) cases and 1 (5%) control. The cases with RLS were 50 and 58 years old, were in ChildPugh class A and C and both ethanol related CLD. Conclusion: Our initial data indicate that RLS is less frequent in Indian patients with CLD, than in other parts of the world. Further data are needed to confirm this finding, which could be related to difference in age or etiology of patients with CLD. Corresponding author: Amit Goel. Email: [email protected]
RELATIVE ADRENAL INSUFFICIENCY IN CIRRHOTIC PATIENTS WITH ASCITES y
Virendra Singh*, Rajiv Ranjan Singh*, Rama Walia , Naresh Sachdeva*, Ashish Bhallaz, Navneet Sharmaz, Yogesh Chawla*
S50
Department of Hepatology yDepartment of Endocrinology, and Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
* z
Background and Aims: Relative adrenal insufficiency (RAI) has been reported in critically ill patients with cirrhosis and is associated with poor outcome. Its prevalence and impact on survival in non-critically ill cirrhosis patients is largely unknown. We evaluated the prevalence of RAI and its relationship to clinical course in non-septic cirrhosis patients with ascites. Methods: The study included 66 consecutive hemodynamically stable, non-septic cirrhosis patients admitted with ascites. A 250-mg adrenocorticotropic hormone stimulation test (Synacthen 250 mgi.v.) was performed within 24 hours of admission. RAI was defined by a delta cortisol lower than 9 mg/dL and/or a peak cortisol lower than 18 mg/dL. Transcortin, calculated free cortisol (cFC), and free cortisol index (FCI) were assessed in all patients, with FCI >12 representing normal adrenal function. Patients were followed up for 3 months. Results: Sixty six patients (56 males and 10 females) with cirrhosis and ascites participated in the study. The mean Child-Pugh (CTP) and model for end stage liver disease (MELD) scores were 10.6 1.9 and 21.5 7.3, respectively. Hepatorenal syndrome (HRS) was present in 9 (13.6%) patients. The prevalence of RAI in patients with cirrhosis and ascites was 47% (31/ 66). The prevalence of RAI in patients with and without spontaneous bacterial peritonitis (SBP), renal failure and type 1 HRS was comparable. Hyponatremia at inclusion was present in significantly greater number of patients with RAI (42% versus 17%, P = 0.026). Patients with RAI had lower serum levels of total cholesterol, high density cholesterol (HDL) and low density cholesterol (LDL) than patients without RAI. There was a significant correlation of prevalence of RAI with the severity of liver disease with significantly higher prothrombin time, international normalized ratio (INR), MELD scores and CTP class in patients with RAI than those without RAI. During follow up, there was no association between RAI and the risk to develop new infections, severe sepsis, type 1 HRS and death. Conclusions: RAI is common in non-septic cirrhotic patients with ascites. It is likely to be a feature of liver disease per se which increases in prevalence with increasing severity of liver disease. However, it does not affect the short term outcome in these patients. Corresponding author: Virendra Singh. Email: [email protected]
© 2014, INASL
spine. Osteopenia and osteoporosis were defined according to WHO criteria. All patients underwent 25-hydroxyvitamin-D, sex hormone (testosterone in male and LH and Estradiol in female) and parathyroid hormone (PTH) along with routine investigations. Fibroscan was done in all patients. Results: 215 patients (Male-179) with mean age 50.9 11 years were enrolled. Etiology of cirrhosis was alcohol in 98 (45.6%), non-alcoholic steatohepatitis (NASH) in 52 (24.2%), Post necrotic in 35 (16.3%) and Cryptogenic in 28 (13%). Mean CTP was 10 2.4 and MELD score was 18.6 8.9.Prevalance of HOD was 66%. Normal BMD was seen in 34% (n-73, group-A), Osteopenia 44.2% (n-95, group-B) and osteoporosis 21.8% (n-47, group-C). Patients in groupA and B had significantly more weight (71.7 15 vs 72.1 15 vs 62.7 12, P = 0.001) and BMI (26.3 6 vs 26.4 5 vs 23.2 5, P = 0.001) than group-C. There was no statistical difference in age, gender distribution, serum calcium, phosphorus, creatinine, vitamin-D, TSH and PTH among all these groups. Fibroscan in patients with HOD was significantly higher as compared to those with normal BMD in cirrhotic patients. Conclusions: Hepatic osteodystrophy was seen in 2/3rd of patients with liver cirrhosis. Low BMI and weight were associated with osteoporosis. Fibroscan can predict osteopenia and osteoporosis in patients with liver cirrhosis.
Corresponding author: Ashish Kumar. Email: [email protected]
PROSPECTIVE STUDY OF PREVALANCE OF HEPATIC OSTEODYSTROPHY IN PATIENTS WITH NON-CHOLEASTATIC LIVER CIRRHOSIS AND ITS PREDICTIVE FACTORS Rinkesh Kumar Bansal, Mandhir Kumar, Munish Kumar Sachdeva, Piyush Ranjan Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India Background and Objectives: Patients with liver cirrhosis are more prone to develop bone disease i.e. hepatic osteodystrophy (HOD) and includes osteopenia and osteoporosis. Aim of this study was to determine prevalence of HOD in patients with liver cirrhosis and to determine the predictive factors for HOD. Methods: Consecutive patients with liver cirrhosis admitted at Sir Ganga Ram Hospital, New Delhi between August 2012 and July 2013 were enrolled. Patients with Chronic renal failure, hyperparathyroidism and those on steroids were excluded. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA) at the lumbar
Corresponding author: Rinkesh Kumar Bansal. Email: [email protected]
RESTLESS LEG SYNDROME IN PATIENTS WITH CHRONIC LIVER DISEASE Amit Goel*, Avani Sasi*, Amit Goel*, Shankar Lal Jat*, Vimal Paliwaly, Rakesh Aggarwal* Department of Gastroenterology, and yDepartment of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
*
Journal of Clinical and Experimental Hepatology | March 2014 | Vol. 4 | No. S2 | S39–S54
S49
Cirrhosis and Complications
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
ABSTRACTS
22ND ANNUAL CONFERENCE – 2014
Cirrhosis and Complications
Background: Restless leg syndrome (RLS), characterized by irresistible urge to move limbs at rest which improves with limb movement, is observed in patients with iron deficiency anemia, diabetes mellitus, hypothyroidism, and chronic kidney disease (CKD). Recently two studies from Milwaukee and Japan showed that 62 % and 16.8 % of patients with chronic liver disease (CLD) had RLS. Aims: We undertook this study to (i) determine the prevalence of RLS in our patients with CLD, (ii) assess its relationship with severity of CLD, and (iii) determine the impact of presence of RLS on quality of life (QoL). Methods: Adult patients with clinically stable CLD attending our gastroenterology outpatient facility between November 2013 and January 2014 were prospectively enrolled irrespective of disease severity or etiology. Healthy controls were drawn from among family members accompanying patients in outpatient or inpatient facilities. All subjects were screened for possible RLS using diagnostic criteria as per the International RLS Study Group; a neurologist re-evaluated those with suspected RLS for confirmation of RLS and assessment of its severity using a validated Hindi translation of RLS severity scoring system. All subjects also completed the Hindi version of WHO BREF QoL instrument. Intergroup comparisons used chi-squared test. An interim analysis is reported. Results: The study included 57 cases (44 [77%] male; median [range] age 47 [18–68] years) and 22 controls (19 [86%] male; 33 [19–63] years); the two groups were comparable in gender distribution (P = 0.54), age (P = 0.12) and educational level (P = 0.53). Causes of CLD were: cryptogenic 17 (30%), alcohol 14 (25%), hepatitis C 14 (25%), hepatitis B 9 (16%) and autoimmune hepatitis 3 (5%). The number of patients in Child-Pugh class A, B, and C were 30 (52.6%), 19 (33.3%), and 8 (14%), respectively. Diagnosis of RLS was suspected in 4/57 (7%) cases and 2/22 (9%) controls, and was confirmed in 2 (4%) cases and 1 (5%) control. The cases with RLS were 50 and 58 years old, were in ChildPugh class A and C and both ethanol related CLD. Conclusion: Our initial data indicate that RLS is less frequent in Indian patients with CLD, than in other parts of the world. Further data are needed to confirm this finding, which could be related to difference in age or etiology of patients with CLD. Corresponding author: Amit Goel. Email: [email protected]
RELATIVE ADRENAL INSUFFICIENCY IN CIRRHOTIC PATIENTS WITH ASCITES y
Virendra Singh*, Rajiv Ranjan Singh*, Rama Walia , Naresh Sachdeva*, Ashish Bhallaz, Navneet Sharmaz, Yogesh Chawla*
S50
Department of Hepatology yDepartment of Endocrinology, and Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
* z
Background and Aims: Relative adrenal insufficiency (RAI) has been reported in critically ill patients with cirrhosis and is associated with poor outcome. Its prevalence and impact on survival in non-critically ill cirrhosis patients is largely unknown. We evaluated the prevalence of RAI and its relationship to clinical course in non-septic cirrhosis patients with ascites. Methods: The study included 66 consecutive hemodynamically stable, non-septic cirrhosis patients admitted with ascites. A 250-mg adrenocorticotropic hormone stimulation test (Synacthen 250 mgi.v.) was performed within 24 hours of admission. RAI was defined by a delta cortisol lower than 9 mg/dL and/or a peak cortisol lower than 18 mg/dL. Transcortin, calculated free cortisol (cFC), and free cortisol index (FCI) were assessed in all patients, with FCI >12 representing normal adrenal function. Patients were followed up for 3 months. Results: Sixty six patients (56 males and 10 females) with cirrhosis and ascites participated in the study. The mean Child-Pugh (CTP) and model for end stage liver disease (MELD) scores were 10.6 1.9 and 21.5 7.3, respectively. Hepatorenal syndrome (HRS) was present in 9 (13.6%) patients. The prevalence of RAI in patients with cirrhosis and ascites was 47% (31/ 66). The prevalence of RAI in patients with and without spontaneous bacterial peritonitis (SBP), renal failure and type 1 HRS was comparable. Hyponatremia at inclusion was present in significantly greater number of patients with RAI (42% versus 17%, P = 0.026). Patients with RAI had lower serum levels of total cholesterol, high density cholesterol (HDL) and low density cholesterol (LDL) than patients without RAI. There was a significant correlation of prevalence of RAI with the severity of liver disease with significantly higher prothrombin time, international normalized ratio (INR), MELD scores and CTP class in patients with RAI than those without RAI. During follow up, there was no association between RAI and the risk to develop new infections, severe sepsis, type 1 HRS and death. Conclusions: RAI is common in non-septic cirrhotic patients with ascites. It is likely to be a feature of liver disease per se which increases in prevalence with increasing severity of liver disease. However, it does not affect the short term outcome in these patients. Corresponding author: Virendra Singh. Email: [email protected]
© 2014, INASL