Background and Aims
Data about the prognosis of salvage transjugular intrahepatic portosystemic shunt (TIPS) using covered stents for refractory variceal bleeding caused by portal hypertension are ...scarce. We aimed to assess survival and to identify predictors of mortality in these patients.
Approach and Results
One hundred sixty‐four patients with cirrhosis from five centers treated with salvage TIPS between 2007 and 2017 were retrospectively divided into a derivation cohort (83 patients) and a validation cohort (81 patients). Comparisons were performed using the Mann‐Whitney and Fischer’s exact test. Six‐week overall survival (OS) was correlated with variables on the day of the TIPS using Kaplan‐Meier curves with log‐rank test and univariate/multivariate analyses using the Cox model. Eighty‐three patients were included in the derivation cohort (male, 78%; age, 55 years, alcohol‐associated cirrhosis, 88%; Model for End‐Stage Liver Disease MELD, 19 15‐27; arterial lactate, 3.7 mmol/L 2.0‐8.3). Six‐week OS rate was 58%. At multivariate analysis, the MELD score (OR, 1.064; 95% CI, 1.005‐1.126; P = 0.028) and arterial lactate (OR, 1.063; 95% CI, 1.013‐1.114; P = 0.032) were associated with 6‐week OS. Six‐week OS rates were 100% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15 and 5% in patients with lactate ≥12 mmol/L and/or MELD score ≥ 30. The 81 patients of the validation cohort had similar MELD and arterial lactate level but lower creatinine level (94 vs 106 µmol/L, P = 0.008); 6‐week OS was 67%. Six‐week OS rates were 86% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15 and 10% for patients with lactate ≥12 mmol/L and/or MELD score ≥ 30. In the overall cohort, rebleeding rate was 15.8% at 6 weeks, and the acute‐on‐chronic liver failure grade (OR, 1.699; 95% CI, 1.056‐1.663; P = 0.040) was independently associated with rebleeding.
Conclusions
After salvage TIPS, 6‐week mortality remains high and can be predicted by MELD score and lactate. Survival rate at 6 weeks was >85% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15, while mortality was >90% for lactate ≥12 mmol/L and/or MELD score ≥ 30.
Background and Aims
To measure the impact of socio‐economic environment on the incidence of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA).
Method
The study used data from ...the French Network of Cancer Registries (FRANCIM) between 2006 and 2016. Classification of patients into HCC and iCCA was performed according to the topographical and morphological codes of the 3rd edition of the International Classification of Diseases for Oncology. Patient addresses were geolocalized and assigned to an IRIS, the smallest French geographic unit. Socio‐economic environment was assessed by the European Deprivation Index (EDI). Sex‐ and age‐standardized incidence rates with 95% confidence intervals (CI) were estimated per 100 000 inhabitants, by national quintiles, for each IRIS, sex and age group. Quintile 1 (Q1) characterized the most affluent areas. A Poisson regression was performed to model the impact of deprivation.
Results
We included 22 249 cases (79.64% HCC, 16.97% iCCA). Incidence rates were 11.46 and 2.39 per 100 000 person‐years for HCC and iCCA, respectively. There was an over‐incidence of HCC in quintiles 2, 3, 4 and 5 compared to quintile 1: Q1 10.28 9.9–10.66 per 100 000 person‐years, Q2 11.43 10.48–12.47 (p < .0001), Q3 11.81 10.82–12.89 (p < .0001), Q4 12.26 11.25–13.37 (p < .001) and Q5 11.53 10.57–12.57 (p < .0001). By contrast, there was no difference for iCCa. Deprivation was significantly associated with HCC in men (p = .0018) and women (p = .0009), but not with iCCA (p = .7407).
Conclusion
The incidence of HCC is related to socio‐economic environment, unlike iCCA. HCC and iCCA should be studied separately in epidemiological studies.
A total of 2%–10% of patients with vascular liver disease (VLD) have paroxysmal nocturnal hemoglobinuria (PNH). Eculizumab reduces complement‐mediated haemolytic activity in PNH. This study was aimed ...at assessing the impact of eculizumab on VLD outcome. Retrospective cohort of PNH patients, in Valdig registry, who had VLD diagnosed between 1997 and 2019 is considered. Eculizumab was the exposure of interest. Studied outcomes were death, venous thrombosis, bleeding, arterial ischemic event, infection, and liver‐related complications. We compared survival and new thrombotic events from PNH/VLD cohort to Envie2 non‐PNH cohort. Sixty‐two patients (33 women), median age 35 years (28–48) and median follow‐up VLD diagnosis 4.7 years (1.2–9.5), were included. Clone size was 80% (70–90), median hemoglobin concentration was 10.0 g/dl (8–11), and lactate dehydrogenase (LDH) was 736 IU (482–1744). Forty‐two patients (68%) had eculizumab; median exposure time was 40.1 9.3–72.6 months. Mortality was significantly lower in exposed versus nonexposed period: 2.6 versus 8.7 per 100 (PY), incidence rate ratio (IRR) was 0.29, 95% CI (0.1–0.9), p = .035. Thrombosis recurrence occurred less frequently during the exposure to eculizumab: 0.5 versus 2.8 per 100 PY, IRR 0.22 (0.07–0.64). Other secondary end points (i.e., bleeding, arterial ischemic lesions, infection, and liver complications) were less common during the exposure to eculizumab, although not reaching statistical significance. Six‐year thrombosis‐free survival was 70%, 95% CI 0.60–0.83 for PNH cohort and 83%, 95% CI 0.70–1.00 for non‐PNH Envie 2 patients, (p < .001). In conclusion, patients with PNH and VLD are at higher risk of recurrent thrombosis than non‐PNH patients. Eculizumab is significantly associated with a lower mortality and less thrombotic recurrence in patients with PNH and VLD.
Non-invasive diagnosis and follow-up of vascular liver diseases Rautou, Pierre-Emmanuel; Elkrief, Laure; Decraecker, Marie ...
Clinics and research in hepatology and gastroenterology,
January 2022, 2022-01-00, 20220101, 2022-01, Letnik:
46, Številka:
1
Journal Article
Recenzirano
Odprti dostop
•In patients with known cirrhosis, screening for portal vein thrombosis by Doppler ultrasound is needed every six months.•The diagnosis of portal vein thrombosis must be confirmed by 4-phase CT.•The ...evaluation of a Budd-Chiari syndrome should include contrast-enhanced MRI/CT.•After haematopoietic stem cell transplantation or chemotherapy, sinusoidal obstruction syndrome must be considered in case of abnormal liver blood tests.
Vascular disorders of the liver are rare diseases, some of which are diagnosed mainly with non-invasive tests and others by liver biopsy. Non-invasive methods can be used to diagnose and monitor these diseases. However, their evaluation needs to be performed by expert centers. Liver biopsy is needed each time there is an unexplained abnormality.
Abstract
Background
The Hepatic hydrothorax is a pleural effusion related to portal hypertension; its diagnosis and therapeutic management may be difficult. The aims of this article are which ...follows: To gather the practices of hepatogastroenterologists or pulmonologists practitioners regarding the diagnosis and management of the hepatic hydrothorax.
Methods
Practitioners from 13 French- speaking countries were invited to answer an online questionnaire on the hepatic hydrothorax diagnosis and its management.
Results
Five hundred twenty-eight practitioners (80% from France) responded to this survey. 75% were hepatogastroenterologists, 20% pulmonologists and the remaining 5% belonged to other specialities. The Hepatic hydrothorax can be located on the left lung for 64% of the responders (66% hepatogastroenterologists vs 57% pulmonologists;
p
= 0.25); The Hepatic hydrothorax can exist in the absence of clinical ascites for 91% of the responders (93% hepatogastroenterologists vs 88% pulmonologists;
p
= 0.27). An Ultrasound pleural scanning was systematically performed before a puncture for 43% of the responders (36% hepatogastroenterologists vs 70% pulmonologists;
p
< 0.001). A chest X-ray was performed before a puncture for 73% of the respondeurs (79% hepatogastroenterologists vs 54% pulmonologists;
p
< 0.001). In case of a spontaneous bacterial empyema, an albumin infusion was used by 73% hepatogastroenterologists and 20% pulmonologists (
p
< 0.001). A drain was used by 37% of the responders (37% hepatogastroenterologists vs 31% pulmonologists;
p
= 0.26).An Indwelling pleural catheter was used by 50% pulmonologists and 22% hepatogastroenterologists (
p
< 0.01). TIPS was recommended by 78% of the responders (85% hepatogastroenterologists vs 52% pulmonologists;
p
< 0.001) and a liver transplantation, by 76% of the responders (86% hepatogastroenterologists vs 44% pulmonologists;
p
< 0.001).
Conclusions
The results of this large study provide important data on practices of French speaking hepatogastroenterologists and pulmonologists; it appears that recommendations are warranted.
Patients with primary biliary cholangitis who have an inadequate response to therapy with ursodeoxycholic acid are at high risk for disease progression. Fibrates, which are agonists of peroxisome ...proliferator-activated receptors, in combination with ursodeoxycholic acid, have shown potential benefit in patients with this condition.
In this 24-month, double-blind, placebo-controlled, phase 3 trial, we randomly assigned 100 patients who had had an inadequate response to ursodeoxycholic acid according to the Paris 2 criteria to receive bezafibrate at a daily dose of 400 mg (50 patients), or placebo (50 patients), in addition to continued treatment with ursodeoxycholic acid. The primary outcome was a complete biochemical response, which was defined as normal levels of total bilirubin, alkaline phosphatase, aminotransferases, and albumin, as well as a normal prothrombin index (a derived measure of prothrombin time), at 24 months.
The primary outcome occurred in 31% of the patients assigned to bezafibrate and in 0% assigned to placebo (difference, 31 percentage points; 95% confidence interval, 10 to 50; P<0.001). Normal levels of alkaline phosphatase were observed in 67% of the patients in the bezafibrate group and in 2% in the placebo group. Results regarding changes in pruritus, fatigue, and noninvasive measures of liver fibrosis, including liver stiffness and Enhanced Liver Fibrosis score, were consistent with the results of the primary outcome. Two patients in each group had complications from end-stage liver disease. The creatinine level increased 5% from baseline in the bezafibrate group and decreased 3% in the placebo group. Myalgia occurred in 20% of the patients in the bezafibrate group and in 10% in the placebo group.
Among patients with primary biliary cholangitis who had had an inadequate response to ursodeoxycholic acid alone, treatment with bezafibrate in addition to ursodeoxycholic acid resulted in a rate of complete biochemical response that was significantly higher than the rate with placebo and ursodeoxycholic acid therapy. (Funded by Programme Hospitalier de Recherche Clinique and Arrow Génériques; BEZURSO ClinicalTrials.gov number, NCT01654731 .).
Understanding of nonalcoholic steatohepatitis (NASH) is hampered by the lack of a suitable model. Our aim was to investigate whether long term high saturated-fat feeding would induce NASH in rats.
21 ...day-old rats fed high fat diets for 14 weeks, with either coconut oil or butter, and were compared with rats feeding a standard diet or a methionine choline-deficient (MCD) diet, a non physiological model of NASH.
MCDD fed rats rapidly lost weight and showed NASH features. Rats fed coconut (86% of saturated fatty acid) or butter (51% of saturated fatty acid) had an increased caloric intake (+143% and +30%). At the end of the study period, total lipid ingestion in term of percentage of energy intake was higher in both coconut (45%) and butter (42%) groups than in the standard (7%) diet group. No change in body mass was observed as compared with standard rats at the end of the experiment. However, high fat fed rats were fattier with enlarged white and brown adipose tissue (BAT) depots, but they showed no liver steatosis and no difference in triglyceride content in hepatocytes, as compared with standard rats. Absence of hepatic lipid accumulation with high fat diets was not related to a higher lipid oxidation by isolated hepatocytes (unchanged ketogenesis and oxygen consumption) or hepatic mitochondrial respiration but was rather associated with a rise in BAT uncoupling protein UCP1 (+25-28% vs standard).
Long term high saturated fat feeding led to increased "peripheral" fat storage and BAT thermogenesis but did not induce hepatic steatosis and NASH.
Hepatitis E virus (HEV) may be resistant to immunosuppression reduction and ribavirin treatment in kidney transplant recipients because of mutant strains and severe side effects of ribavirin which ...conduct to dose reduction. Sofosbuvir efficacy is controversial. Peg-interferon 2 alpha (PEG-IFN) is currently contraindicated due to a high risk of acute humoral and cellular rejection. The present study assessed, for the first time, the effect of PEG-IFN in a kidney transplant recipient infected with HEV. We conclude that prolonged treatment with PEG-IFN in kidney transplant recipients infected with HEV could be considered as a salvage option.
Background & Aims: To assess the success rate of a
self-propelling nasojejunal feeding tube in patients with acute pancreatitis.
Methods: All patients admitted for acute pancreatitis were included.
A ...self-propelling nasojejunal feeding tube was introduced into the stomach,
and gastrointestinal motility was stimulated using metoclopramide. If the tube
failed to advance to the ligament of Treitz, a nasojejunal tube was placed
endoscopically. Results: A total of 108 patients, 94 with necrotizing
pancreatitis (Balthazar D/E) and 14 with nonnecrotizing pancreatitis
(Balthazar B/C), were referred for artificial nutrition. In 11 cases, ileus
persisted and parenteral nutrition was initiated. Among the remaining 97
patients, 5 refused tube placement. The self-propelling feeding tube was
inserted in 92 patients with successful migration to the ligament of Treitz in
61% (n = 56) and failure in 39% (n = 36). Of the 36 patients with an initial
failed placement, endoscopic placement of a nasojejunal tube was successful
80% of the time (29 patients). The success rate of a nasojejunal
self-propelling feeding tube placement correlated directly with the severity
of the acute pancreatitis (92% in B/C vs 61% in D vs 48% in E; P <
.05). Conclusions: Use of a self-propelling nasojejunal tube is a
simple technique that can be successfully performed in the majority of
patients with acute pancreatitis. The utility of this procedure in the most
severe cases of acute pancreatitis continues to pose a challenge.
PDF
