RESUMO
INTRODUCTION AND AIMS: We aimed to explore the impact of infection diagnosed upon admission and of other clinical baseline parameters on mortality of cirrhotic patients with emergency admissions. MATERIAL AND METHODS: We performed a prospective observational monocentric study in a tertiary care center. The association of clinical parameters and established scoring systems with short-term mortality up to 90 days was assessed by univariate and multivariable Cox regression analysis. Akaike's Information Criterion (AIC) was used for automated variable selection. Statistical interaction effects with infection were also taken into account. RESULTS: 218 patients were included. 71.2% were male, mean age was 61.1 ± 10.5 years. Mean MELD score was 16.2 ± 6.5, CLIF-consortium Acute on Chronic Liver Failure-score was 34 ± 11. At 28, 90 and 365 days, 9.6%, 26.0% and 40.6% of patients had died, respectively. In multivariable analysis, respiratory organ failure [Hazard Ratio (HR) = 0.15], albumin substitution (HR = 2.48), non-HCC-malignancy (HR = 4.93), CLIF-C-ACLF (HR = 1.10), HCC (HR = 3.70) and first episode of ascites (HR = 0.11) were significantly associated with 90-day mortality. Patients with infection had a significantly higher 90-day mortality (36.3 vs. 20.1%, p = 0.007). Cultures were positive in 32 patients with resistance to cephalosporins or quinolones in 10, to ampicillin/sulbactam in 14 and carbapenems in 6 patients. CONCLUSION: Infection is common in cirrhotic ED admissions and increases mortality. The proportion of resistant microorganisms is high. The predictive capacity of established scoring systems in this setting was low to moderate.
Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/terapia , Serviço Hospitalar de Emergência , Cirrose Hepática/terapia , Admissão do Paciente , Idoso , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/microbiologia , Infecções Bacterianas/mortalidade , Técnicas de Apoio para a Decisão , Farmacorresistência Bacteriana , Feminino , Alemanha , Nível de Saúde , Humanos , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Centros de Atenção Terciária , Fatores de Tempo , Resultado do TratamentoRESUMO
Hepatic involvement in AL amyloidosis may present as acute liver failure. Historically, liver transplantation in these cases has achieved poor outcomes due to progress of amyloidosis and non-hepatic organ damage. In the era of bortezomib treatment, the prognosis of AL amyloidosis has been markedly improved and may also result in better post-transplant outcomes. We present a case of isolated acute liver failure caused by AL amyloidosis, bridged to transplantation with bortezomib and treated with sequential orthotopic liver transplantation (OLT) and autologous stem cell transplantation. The patient is in stable remission 3 years after OLT.
Assuntos
Amiloidose/terapia , Antineoplásicos/uso terapêutico , Bortezomib/uso terapêutico , Falência Hepática Aguda/terapia , Transplante de Fígado , Transplante de Células-Tronco de Sangue Periférico , Amiloidose/complicações , Humanos , Amiloidose de Cadeia Leve de Imunoglobulina , Falência Hepática Aguda/etiologia , Masculino , Pessoa de Meia-Idade , Transplante AutólogoRESUMO
BACKGROUND: The nephrotoxic potential of intravenous iodinated contrast (IC) is controversial. Cirrhotic patients are often submitted to imaging procedures involving IC and small changes in renal function may have detrimental effects. MATERIAL AND METHODS: Retrospective analysis of hospitalized patients with elective imaging by either contrast-enhanced CT or MRI. Contrast induced acute kidney injury (CI-AKI) was diagnosed if there was either an increase of SCr by 25% or by 44 µmol/L or a decrease of estimated glomerular filtration rate by 25% by day 3. RESULTS: Between 2004 and 2012 152 patients (female: 30.3%, age: 60 ± 10.8 years, MELD 13 ± 6) were included in this study of which 84 (55.3%) had received IC and 68 (44,7%), who served as controls, MRI with gadolinium based contrast (non-IC). Baseline parameters were well matched except for age (61.7 vs. 56.9) years in the IC vs. non-IC groups, p = 0.005). 15 patients (17.9%) receiving IC and 4 patients (5.9%) not receiving IC (p = 0.026) reached the composite end-point for CI-AKI. In multivariable regression analysis INR [B = 0.252 (95% CI: 0.108-0.397), p = 0.001]; IC [B = 0.136 (95% CI: 0.023-0.248), p = 0.019] and serum sodium [B = 0.011 (95% CI: 0.001-0.023); p = 0.080] were independently associated with changes of SCr. In conclusion IC may cause renal dysfunction in cirrhotic patients. Patients subjected to imaging using IC should be closely monitored.
Assuntos
Injúria Renal Aguda/induzido quimicamente , Meios de Contraste/efeitos adversos , Iopamidol/análogos & derivados , Rim/efeitos dos fármacos , Cirrose Hepática/complicações , Imageamento por Ressonância Magnética/efeitos adversos , Compostos Organometálicos/efeitos adversos , Tomografia Computadorizada por Raios X/efeitos adversos , Injúria Renal Aguda/sangue , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/fisiopatologia , Administração Intravenosa , Idoso , Biomarcadores/sangue , Meios de Contraste/administração & dosagem , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Coeficiente Internacional Normatizado , Iopamidol/administração & dosagem , Iopamidol/efeitos adversos , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Compostos Organometálicos/administração & dosagem , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
INTRODUCTION: Blood ammonia-measurements are often performed in the emergency departments to diagnose or rule out hepatic encephalopathy (HE). However, the utility and correct interpretation of ammonia levels is a matter of discussion. At this end the present prospective study evaluated whether blood ammonia levels coincide with HE which was also established by the West Haven criteria and the critical flicker frequency, respectively. MATERIAL AND METHODS: In 59 patients with known cirrhosis ammonia-levels were determined and patient were additionally categorized by the West-Haven criteria and were also evaluated psychophysiologically using the critical flicker frequency, CFF for the presence of HE. RESULTS: When false positive and false negative results were collapsed the determination of blood ammonia levels alone resulted in 40.7% in a misdiagnoses of HE compared to the West-Haven criteria (24/59 when using West-Haven criteria, 95% confidence interval [CI], 28.1% to 54.3%) and 49.2% when compared with the results of the CFF (29/59, when using CFF, 95% CI, 35.9% to 62.5%). DISCUSSION: Ammonia blood levels do not reliably detect HE and the determination of blood ammonia can not be regarded a useful screening test for HE. Its use as sole indicator for a HE in the Emergency Department may frequently result in frequent misinterpretations.
Assuntos
Amônia/sangue , Erros de Diagnóstico/estatística & dados numéricos , Serviço Hospitalar de Emergência , Fusão Flicker , Encefalopatia Hepática/diagnóstico , Cirrose Hepática/complicações , Idoso , Biomarcadores/sangue , Erros de Diagnóstico/prevenção & controle , Feminino , Encefalopatia Hepática/sangue , Encefalopatia Hepática/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Estudos Prospectivos , Curva ROCRESUMO
INTRODUCTION: Hepatorenal syndrome type I (HRS I) may be a consequence of circulatory dysfunction in cirrhotic patients with portal hypertension. This uncontrolled interventional pilot study examines the hemodynamic and renal effects of large volume plasma expansion in HRS I. MATERIAL AND METHODS: 14 cirrhotic patients (8 m, 6 f, age 60 (58-65) years) with HRS I received large volume plasma expansion with up to 400 mL of 20% human albumin solution per 12 over 48 h under hemodynamic monitoring by transpulmonary thermodilution. Creatinine clearances (ClCreat) were calculated for 12-h periods. Plasma expansion was withheld if criteria of volume overload [Extravascular lung Water Index (ELWI) > 9 mL/kg or Global End-Diastolic Volume Index (GEDI) > 820 mL/m(2)] were met. Paracentesis was performed according to clinical necessity and treatment continued for 48 h thereafter. Serum creatinine values were observed for 12 days. RESULTS: Patients received 1.6 (1.5-2.0) g of albumin per kg bodyweight and day for 48 to 96 h. During the treatment period, GEDVI [724 (643-751) mL/m(2) vs. 565 (488-719) mL/m(2) ; p = 0.001], cardiac index (CI) [4.9 (4.1-6.15) L/min/m(2) vs. 3.9 (3.4-5.0) L /min/m(2) ; p = 0.033], urinary output [25 (17-69) mL/h vs. 17 (8-39) mL/h; p = 0.016) and ClCreat [20 (15-47) vs. 12 (6-17); p = 0.006] increased whereas systemic vascular resistance index (SVRI), plasma renin activity (PRA) and plasma aldosterone were significantly reduced. At 48 h there were two complete responses (serum creatinine < 133 µmol/L) and on day 12, 8 patients had a complete response. CONCLUSION: HRS I may respond to large volume plasma expansion with or without paracentesis.
Assuntos
Albuminas/uso terapêutico , Síndrome Hepatorrenal/terapia , Substitutos do Plasma/uso terapêutico , Idoso , Creatinina/urina , Feminino , Hemodinâmica/efeitos dos fármacos , Síndrome Hepatorrenal/etiologia , Humanos , Hipertensão Portal/complicações , Rim/efeitos dos fármacos , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Paracentese , Projetos Piloto , Termodiluição , Resultado do Tratamento , Resistência Vascular/efeitos dos fármacosRESUMO
The transjugular porto-systemic stent-shunt (TIPS) reduces portal pressure in cirrhotic patients and is used as a nonsurgical treatment for refractory ascites, recurrent variceal hemorrhage or hepatorenal syndrome. There are concerns regarding a negative impact on cirrhotic cardiomyopathy and deterioration of hyperkinetic circulatory dysfunction. We analyzed a prospectively maintained database containing hemodynamic data on cirrhotic ICU patients. Hemodynamic monitoring was performed using transpulmonary thermodilution (PiCCO, Pulsion Medical Systems, Munich, Germany). Renal perfusion was assessed by Doppler ultrasound during studies of portal and TIPS perfusion before and after the procedure. Complete data sets of 8 patients (4 male, 4 female, age 60 years (52-67), Child-Pugh-Turcotte score 10 (8-12)) were available. After TIPS, there was a substantial increase of GEDVI (646 ml/m2 (580-737) to 663 mL/m2 (643-792); p=0.036) that was even more pronounced at 24 hours (716 mL/m2 (663-821); P=0.012). CI increased from 3.3 L/min/m2 (3.1-4.2) to 3.9 L/min/m2 (3.6-5.3) (p=0.012) and 3.9 L/min/m2 (3.7-5.2) (p=0.017), respectively. There was a significant decrease of renal RI from 0.810 (0.781-0.864) to 0.746 (0.710-0.798) (p=0.028) and a transient increase of fractional excretion of sodium. SVRI (1737 dyn*s/cm5/m2 (1088 . 2115) vs. 1917 dyn*s/cm5/m2 (1368-2177) was not significantly altered immediately after TIPS but decreased to 1495 dyn*s/cm5/m2 (833- 1765) at 24 hours (p=0.036). There were no significant changes of mean arterial pressure (MAP). In conclusion, TIPS resulted in a pronounced increase of central blood volume. The observed hemodynamic effects are compatible with a preload driven increase of cardiac output and secondary decreases in SVRI and RI.