Hyponatremia in Cirrhosis: An Update Alukal, Joseph J; John, Savio; Thuluvath, Paul J
The American journal of gastroenterology,
11/2020, Letnik:
115, Številka:
11
Journal Article
Recenzirano
Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis ...and portal hypertension leads to splanchnic vasodilation, and this leads to the activation of compensatory mechanisms such as renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system, and antidiuretic hormone (ADH) to ameliorate low circulatory volume. The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume, resulting in the development of ascites. These compensatory mechanisms lead to impairment of the kidneys to eliminate solute-free water in decompensated cirrhosis. Nonosmotic secretion of antidiuretic hormone (ADH), also known as arginine vasopressin, further worsens excess water retention and thereby hyponatremia. The management of hyponatremia in this setting is a challenge as conventional therapies for hyponatremia including fluid restriction and correction of hypokalemia are frequently inefficacious. In this review, we discuss the pathophysiology, complications, and various treatment modalities, including albumin infusion, selective vasopressin receptor antagonists, or hypertonic saline for patients with severe hyponatremia and those awaiting liver transplantation.
Hyponatremia in Cirrhosis: An Update Alukal, Joseph J; John, Savio; Thuluvath, Paul J
The American journal of gastroenterology,
11/2020, Letnik:
115, Številka:
11
Journal Article
Recenzirano
Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis ...and portal hypertension leads to splanchnic vasodilation, and this leads to the activation of compensatory mechanisms such as renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system, and antidiuretic hormone (ADH) to ameliorate low circulatory volume. The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume, resulting in the development of ascites. These compensatory mechanisms lead to impairment of the kidneys to eliminate solute-free water in decompensated cirrhosis. Nonosmotic secretion of antidiuretic hormone (ADH), also known as arginine vasopressin, further worsens excess water retention and thereby hyponatremia. The management of hyponatremia in this setting is a challenge as conventional therapies for hyponatremia including fluid restriction and correction of hypokalemia are frequently inefficacious. In this review, we discuss the pathophysiology, complications, and various treatment modalities, including albumin infusion, selective vasopressin receptor antagonists, or hypertonic saline for patients with severe hyponatremia and those awaiting liver transplantation.
There is a paucity of studies on older patients (≥65 years) who develop acute on chronic liver failure (ACLF). The objectives of our study were to determine clinical characteristics and outcomes of ...older patients listed for liver transplantation (LT).
Adults listed for LT with estimated ACLF (Est-ACLF) between 2005 and 2021 were identified using the United Network for Organ Sharing database and subdivided into older and younger age (18-64 years) groups. Kaplan-Meier survival analyses were used to evaluate survival, and a competing-risk model (Fine-Gray) was used to evaluate risk factors for survival on the waitlist. Logistic regression was done to evaluate risk factors.
A total of 4313 older (14%) and 26,628 younger (86%) patients were listed for LT, and 2142 (49.6%) and 16,931 (63.5%) were transplanted, respectively. Older patients had a higher 30-day waitlist mortality than younger patients (20.4% vs 16.7%; P < .0001); this was more pronounced in Est-ACLF-2 (23.7% vs 14.8%; P < .0001) and Est-ACLF-3 (43.3% vs 29.9%; P < .0001). One-year post-LT, patient survival in older patients with Est-ACLF grades 1, 2, and 3 were 86.4%, 85.5%, and 77% respectively; younger patients had better survival across all Est-ACLF grades. When adjusted for transplant eras, respiratory failure was the only independent risk factor for increased 1-year post-LT mortality in older patients.
Older patients with Est-CLF had significantly higher waitlist mortality than younger patients, but had acceptable 1-year post-LT survival including those with Est-ACLF-3; therefore, age alone should not be considered as a contraindication for LT. Older patients with respiratory failure should be carefully selected for LT.
Background and Aims
Patients with acute on chronic liver failure (ACLF-3) have a very high short-term mortality without liver transplantation (LT). Our objective was to determine whether early LT ...(ELT; ≤ 7 days from listing) had an impact on 1 year patient (PS) in patients with ACLF-3 compared to late LT (LLT; days 8–28 from listing).
Methods
All adults with ACLF-3 listed for LT with the United Network for Organ Sharing (UNOS) between 2005 and 2021 were included. We excluded status one patients and those with liver cancer or listed for multi-organ or living donor transplants. ACLF patients were identified using the European Association for the Study of the Liver-Chronic Liver Failure criteria. Patients were categorized as ACLF-3a and ACLF-3b.
Results
During the study period, 7607 patients were listed with ACLF-3 (3a-4520, 3b-3087); 3498 patients with ACLF-3 underwent ELT and 1308 had LLT. The overall 1 year PS after listing was 64.4% in ACLF-3a and 50% in ACLF-3b. In 4806 ACLF-3 patients who underwent LT, 1 year PS was 86.2%, but those who had ELT had higher survival (87.1 vs. 83.6%,
P
= 0.001) than the LLT group. These survival benefits were seen in both ACLF-3a and ACLF-3b. On multivariable analysis, age (HR 1.02, CI 1.01–1.03), diabetes (HR 1.40, CI 1.16–1.68), respiratory failure (HR 1.76, CI 1.50–2.08), donor risk index > 1.7 (HR 1.24, CI 1.06–1.45), and LLT (HR 1.20, CI 1.02–1.43) were independent predictors of higher 1 year mortality while higher albumin (HR 0.89, CI 0.80–0.98) was associated with reduced mortality.
Conclusion
Early LT (≤ 7 days from listing) in ACLF-3 is associated with better 1 year survival compared to late LT (days 8–28 from listing).
A model that can predict short-term mortality in patients with the Budd-Chiari syndrome (BCS) with a high degree of accuracy is currently lacking. The primary objective of our study was to develop an ...easy-to-use in-hospital mortality prediction model in patients with BCS using easily available clinical variables.
Data were extracted from the National Inpatient Sample to identify all adult patients with a listed diagnosis of BCS from 2008 to 2017 using ICD-9 or ICD-10 codes. After identifying independent risk factors of in-hospital mortality, we developed a prediction model using logistic regression analysis. The model was built and validated in a training and a validation data set, respectively. Using the model, we risk stratified patients into low-, intermediate-, and high-risk groups.
Between 2008 and 2017, we identified a total of 5,306 (weighted sample size 26,110) discharge diagnosis of patients with BCS, with an overall in-hospital mortality of 7.14%. The independent risk factors that predicted mortality were age of 50 years or older, ascites, sepsis, acute respiratory failure, acute liver failure, hepatorenal syndrome, and cancers. The mortality prediction model that incorporated these risk factors had an area under the receiver operating characteristic curve of 0.87 (95% CI 0.85-0.95) for the training data and 0.89 (95% CI 0.86-0.92) for the validation data. Patients with low-, intermediate-, and high-risk scores had a predicted in-patient mortality of 4%, 30%, and 66%, respectively.
Using a national administrative database, we developed a reliable in-patient mortality prediction model with an excellent accuracy. The model was able to risk stratify patients into low-, intermediate-, and high-risk groups.
There is a paucity of data on the outcome of liver transplantation (LT) in Budd‐Chiari Syndrome (BCS) patients who are listed as status 1. The objective of our study was to determine patient or graft ...survival following LT in status 1 BCS patients.
We utilized United Network for Organ Sharing (UNOS) database to identify all adult patients (> 18 years of age) listed as status 1 with a primary diagnosis of BCS in the United States from 1998 to 2018, and analyzed their outcomes and compared it to non‐status 1 BCS patients.
Four hundred and forty‐six patients with BCS underwent LT between 1998 and 2018, and of these 55 (12.3%) were listed as status 1. There was no difference in long‐term post‐liver transplant or “intention‐to‐treat” survival from the time of listing to death or the last day of follow‐up between status 1 and non‐status 1 groups. Graft and patient survival at 5 years for status 1 patients were 75% and 82%, respectively. Cox regression analysis showed that patients listed as status 1 (aHR: 0.45, p < .02) were associated with a better survival.
BCS patients listed as status 1 have excellent survival following emergency LT.
Emergency liver transplantation for acute liver failure secondary to Budd Chiari Syndrome yields 82% 5‐year survival.
Gastrointestinal failure (GIF) is frequent in patients managed in the intensive care units and manifests as gut paralysis or ileus. GIF is often associated with sepsis or multiorgan failure. In ...critically ill patients, the precipitating causes of GIF include inflammation, sepsis, electrolyte abnormalities, and acidosis. It is possible that GIF is associated with an increase in bacterial translocation, especially in those with cirrhosis and portal hypertension, and this may play a significant pathogenic or prognostic role in acute-on-chronic liver failure (ACLF). The critical care literature suggests that GIF is associated with a higher mortality risk. In this review, we summarize the evidence for a potential association between GIF and ACLF and propose treatment options for the management of GIF. Moreover, we suggest GIF to be considered as another organ failure when the severity of ACLF is assessed.
Reply to Morton Alukal, Joseph J; Thuluvath, Paul J
The American journal of gastroenterology
116, Številka:
4
Journal Article
Recenzirano
In another study, the ΔNa between direct and indirect ISE assays increased as serum albumin decreased, but in their study of 300 critically patients, the mean ΔNa was 2.1 mmol/L, with no difference ...noted when serum albumin was 4 g/dL (5). ...most studies reporting ΔNa were in critically ill patients. ...one implication is the impact of underestimation of sNa on Model for End-Stage Liver Disease-Na score and thereby on organ allocation.
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