Secondary hepatic dysfunction in pediatric intensive care unit: Risk factors and outcome

BackgroundHepatic dysfunction has a significant role in intensive care unit patients’ morbidity and mortality.AimTo study the frequency, risk factors and outcome of secondary hepatic dysfunction in children admitted to the pediatric intensive care unit.MethodsSecondary hepatic dysfunction was defined as the development of abnormal liver functions in a patient without a previous liver disease during intensive care unit stay. The following data were collected: age, gender, indication of admission, type of organ dysfunction, presence of sepsis, shock, need for inotropic support or mechanical ventilation, administered medications and mortality scores. Liver function tests were done on admission and at 7-day intervals.ResultsOne hundred and fifty-one patients were included. Forty-three (28.5%) acquired secondary hepatic dysfunction. Several risk factors were significantly associated with secondary hepatic dysfunction: sepsis (p<0.001), cardiovascular events (p<0.001), hypoxia (p<0.001), number of administered antibiotics (P = 0.001), use of inotropes (p<0.001) and mechanical ventilation (p = 0.001). Secondary hepatic dysfunction was significantly associated with mortality and prolonged length of stay (P=<0.001).ConclusionSecondary hepatic dysfunction is a common finding in the pediatric intensive care unit. Sepsis, cardiovascular events and hypoxia, are the main risk factors for secondary hepatic dysfunction. Mortality and prolonged length of stay are strongly related to secondary hepatic dysfunction.     

Liver fibrosis in young Egyptian beta-thalassemia major patients: relation to hepatitis C virus and compliance with chelation

Background. The main causes of liver fibrosis in transfusion-dependent thalassemia major are hepatitis C virus (HCV) infection and hepatic iron overload. The study aimed to assess liver fibrosis in Egyptian adolescents and young adult poly-transfused beta thalassemia patients infected with HCV using liver FibroScan in relation to iron overload and Liver iron concentration (LIC).Material and methods. Fifty-one regularly transfused beta thalassemia patients above 12 years old were subjected to measurement of serum alanine transaminase (ALT), serum ferritin (SF), HCV (antibody and RNA), LIC assessed by hepatic R2* and transient elastography (TE) (FibroScan). FibroTest and liver biopsy were done to 25 patients.Results. Eighty two% of studied thalassemia patients were HCV antibody positive; 21(49%) of them were viremic (HCV RNA positive); median LIC was 12 mg/gm dry weight. There were strong positive correlation between the degree of liver stiffness and Ishak fibrosis score assessed in liver biopsy specimens (P = 0.002) and between FibroScan and FibroTest results (P < 0.001). Patients with HCV viremia showed significantly higher ALT, γ-glutamyl transpeptidase (GGT), SF, LIC and increased liver stiffness compared to patients with no viremia (P = 0.0001, 0.001, 0.012, 0.006 and 0.001) respectively. Liver cirrhosis (TE values > 12.5kPa) was encountered in 23.5% and variable degrees of liver fibrosis (TE values > 6–12.5 kPa) in 35% of studied thalassemic patients.Conclusion. Young beta thalassemia patients with active hepatitis C infection may have hepatic cirrhosis or fibrosis at young age when accompanied with hepatic siderosis. Non invasive Liver FibroScan and Fibro-Test were reliable methods to assess liver fibrosis in young thalassemic-patients.     

Rapid identification system of frontal dysfunction in subclinical hepatic encephalopathy

Introduction and aim. Liver disease is associated with cognitive dysfunction also at early stages, and minimal hepatic encephalopathy, affecting 20-70% of patients, is frequently under-recognized. The main purpose of this work was to demonstrate that a substantial number of patients, enrolled due to an acute confusional state in absence of a diagnosis of liver disease, suffers of hepatic encephalopathy.Material and methods. Before a diagnosis of a well-compensated liver diseases was performed, 410 patients with an acute confusional state were enrolled in this study.Results. Even in the presence of minimal alterations of hepatic function, the psychometric tests applied demonstrated early signs of cerebral frontal alteration. The alteration was associated with the severity of liver disease, paralleling the progression of the patient to minimal hepatic failure or chronic liver disease.Conclusions. These psychometric tests are essential to detect early and subclinical frontal failure. Frontal dysfunction may be a useful tool in the follow-up of these patients.     

The Italian experience on paediatric liver transplantation: 1988–1999 report

Background. Liver transplantation is the treatment of choice for end-stage liver disease in both adult and paediatric patients. The Italian experience in paediatric liver transplantation during the period 1988–1999 is reported herein.Patients and methods. This report concerns 228 liver transplantations performed in 207 patients (100 male, 107 female, mean age 5.1±4.4 years) in 11 Italian centres. The mean waiting time on the transplantation list was 6. 1±8.9 months and the main indications for the procedure were biliary atresia, inborn metabolic disorders, liver cirrhosis, liver neoplasms, Alagille syndrome, and fulminant hepatic failure.Results. The cumulative survival rate was 77%, 76%, 73%, and 71 at 1, 3, 5, and 7 years. The overall prevalence of acute rejection was 54%. Survival was significantly affected by re-transplantation (p=0.0002), by United Network for Organ Sharing 4 status at transplantation (p=0.016), and, among the indications for the procedure, by fulminant hepatic failure (p=0.004). Fifty patients (24%) died during the observation period. The main causes of death were primary non-function of the graft and sepsisConclusions. This study shows that liver transplantation in paediatric age, in Italy, is an effective procedure providing a 5-year survival rate comparable to that attained in the largest published series.     

Drug Induced Liver Injury at a Tertiary Hospital in India: Etiology,Clinical Features and Predictors of Mortality

Introduction and aimsDrug-induced liver injury (DILI) is rare; however, it is one of the important causes of acute liver failure which results in significant morbidity or mortality.Material and MethodsPatients with suspected DILI were enrolled based on predefined criteria and followed up for at least 6 months or until normalization of liver tests. Causality assessment was done by applying the Roussel Uclaf Causality Assessment Method model.ResultsWe collected data from 82 individuals diagnosed with DILI at our hospital from 2014 through 2015 (41 men; median age, 38 years). The most commonly implicated drugs were antitubercular therapy (ATT) (49%), antiepileptic drugs (12%), complementary and alternative medicine (CAM) in 10%, antiretroviral drugs (9%) and non-steroidal anti-inflammatory drugs (6%). 8 out of 13 deaths were liver related. Also, liver related mortality was significantly higher for ATT DILI (17.5%) vs. those without (2.4%) (P = 0.02). There was no significant difference in overall as well as liver related mortality in hepatocellular, cholestatic or mixed pattern of injury. Laboratory parameters at one week after discontinuation of drug predicted mortality better than those at the time of DILI recognition. On multivariate logistic regression analysis, jaundice, encephalopathy, MELD (Model for end stage liver disease) score and alkaline phosphatase at one week, independently predicted mortality.ConclusionDILI results in significant overall mortality (15.85%). ATT, anti-epileptic drugs, CAM and antiretroviral drugs are leading causes of DILI in India. Presence of jaundice, encephalopathy, MELD score and alkaline phosphatase at one week are independent predictors of mortality.     

移植前及预处理期间肝功能异常对异基因造血干细胞移植效果的影响

 目的 探讨异基因造血干细胞移植(allo-HSCT)患者移植前和预处理期间肝功能异常的特征及其与肝脏合并症和预后的关系。方法 回顾性分析196例allo-HSCT治疗血液系统疾病患者,采集其移植前和预处理期间肝功能数据,观察其对造血重建、移植相关肝脏并发症、生存和移植相关死亡的影响。结果 196例患者中,38例移植前存在肝功能异常,159例预处理期间发生肝功能异常,28例(17.6%)出现3度肝损害,无4度肝损害出现。移植前和预处理期间肝功能异常对造血重建时间、肝静脉阻塞病(HVOD)、肝脏急性移植物抗宿主病(aGVHD)和慢性移植物抗宿主病(cGVHD)发生无显著影响。单因素分析显示年龄(P=0.022)、移植前疾病状态高危(P=0.003)、移植前AST(P=0.019)和TBil水平升高(P=0.015)、Ⅲ~Ⅳ度肝脏aGVHD(P=0.000)和HVOD(P=0.000)是影响总生存(OS)率的危险因素。多因素Cox回归分析显示移植前疾病状态为高危(P=0.002)、Ⅲ~Ⅳ度肝脏aGVHD(P=0.000)是影响OS率的独立危险因素,同时也是影响移植相关死亡(TRM)率的独立危险因素(P值分别为0.002和0.000),而移植前和预处理期间肝功能异常对OS率和TRM率无显著影响。结论 1~2度肝功能异常患者,在密切监测肝功能、充分保肝治疗及积极预防HVOD基础上,可考虑进行allo-HSCT。
        

Risk and Prognosis of Acute Liver Injury Among Hospitalized Patients with Hemodynamic Instability: A Nationwide Analysis

Introduction and aim. Critically ill patients in states of circulatory failure are at risk of acute liver injury, from mild elevations in aminotransferases to substantial rises consistent with hypoxic hepatitis or “shock liver”. The present study aims to quantify the national prevalence of acute liver injury in patients with hemodynamic instability, identify risk factors for its development, and determine predictors of mortality.Material and methods. The 2009-2010 Nationwide Inpatient Sample was interrogated using ICD-9-CM codes for hospital admissions involving states of hemodynamic lability. Multivariable logistic regression was used to evaluate the risks of acute liver injury and death in patients with baseline liver disease, congestive heart failure, malnutrition, and HIV.Results. Of the 2,865,446 patients identified in shock, 4.60% were found to have acute liver injury. A significantly greater proportion of patients with underlying liver disease experienced acute liver injury (22.03%) and death (28.47%) as compared to those without liver disease (3.18% and 18.82%, respectively). The odds of developing acute liver injury were increased in all baseline liver diseases studied, including all-cause cirrhosis, hepatitis B, hepatitis C, alcoholic liver disease, and non-alcoholic fatty liver disease, as well as in congestive heart failure and malnutrition. All-cause cirrhosis and alcoholic liver disease, however, conferred the greatest risk. Similar trends were seen with mortality. HIV was not a predictor for acute liver injury.Conclusion. Liver injury is a major concern among patients with protracted circulatory instability, especially those suffering from underlying liver disease, heart failure, or malnutrition.     

Role of conservative management in tubercular abdominal cocoon: a case series

Background

Sclerosing encapsulating peritonitis (Abdominal cocoon) is an uncommon cause of intestinal obstruction and tuberculosis is an important etiology. Appropriate management of this entity is still uncertain.

Methods

We did a retrospective analysis of patients with abdominal cocoon who were seen over a two year period at a tertiary care center in North India. We included patients with tubercular abdominal cocoon (TAC) who were managed primarily with antitubercular therapy in the present report. The diagnosis of TAC was made using combination of criteria (radiological or surgical findings of cocoon with evidence of tuberculosis in form of microbiological, histological or biochemical evidence). The clinical presentation, outcome and need for surgery for these patients were retrieved from the records of these cases maintained in a database.

Results

Of 18 patients with abdominal cocoon, 15 patients had underlying tuberculosis. The median age was 28 years (interquartile range 24) and 12 (80%) were males. Three patients had confirmed tuberculosis on basis of microbiological evidence. All had abdominal pain for 1–9 months, and 11 had intestinal obstruction. Twelve patients had positive Mantoux test, none had HIV. Pulmonary tuberculosis was noted in four patients, pleural in five, splenic and intestinal in two each, hepatic and mediastinal lymph-nodal in one each. Thirteen patients were started on usual 4-drug anti-tubercular therapy (ATT) while two cirrhotics needed modified ATT. Three patients were on steroids with ATT and all three improved. One patient was lost to follow up. Of the rest 14 patients, 2 underwent surgery, 1 at initial presentation while another after 4 months of ATT. Overall five patients developed intestinal obstruction while on ATT, one needed surgery and one died of liver failure while others improved with conservative means.

Conclusion

TAC can be managed conservatively in a subset of patients.

     

Assessment of hepatic fibrosis and necroinflammation among inactive HBsAg carriers in Egypt

Introduction. The inactive hepatitis B surface antigen (HBsAg) carrier state is usually characterized by minimal or absent liver pathology. However, in developing countries, owing to the very early age of infection with hepatitis B virus (HBV), this state is reached after a very prolonged immune tolerant and immune reactive phase, during which considerable liver damage may have occurred. The extent of liver damage in inactive HBsAg carriers has not been thoroughly assessed in developing countries. We thus sought to characterize liver pathology among Egyptian inactive HBsAg carriers.Material and methods. Liver biopsy was conducted on 30 inactive HBsAg carriers [positive for HBsAg; negative for HBeAg; positive for antibody to HBeAg (anti-HBe); HBV-DNA levels < 2,000 IU/mL; persistently normal serum alanine aminotransferase (ALT)]. Liver histopathology was assessed according to the Ishak scoring system.Results. Among the studied carriers, 6.7% had no hepatic fibrosis, 73.3% had stage 1 fibrosis, and 20% had stage 2 fibrosis. The majority (80%) of carriers had minimal hepatic necroinflammation (grades 2-4), while 20% had mild hepatic necroinflammation (grade 5). All patients with stage 2 fibrosis were males, while no gender predilection was observed for necroinflammation. Age, ALT and HBV-DNA levels did not differ significantly according to fibrosis or ne-croinflammatory scores. Conclusion. Our study findings do not support the presence of significant hepatic fibrosis or necroinflammation among Egyptian inactive HBsAg carriers. However, follow-up studies on these carriers may be required to monitor any further pathological progress of the disease.     

Liver retransplantation in adults: a 20–year experience of one center in southern Brazil

Introduction. Liver retransplantation (LReTx) is the therapeutic option for hepatic graft failure. Survival after LReTx is poorer than after primary liver transplantation. Given the organ shortage, it is essential to optimize the use of this resource.Objective. To evaluate rates, indications and patient survival after LReTx and identify factors associated with mortality following LReTx.Material and methods. We conducted a retrospective cohort study of all adults undergoing LReTx based on registry data from the Liver Transplantation Group (Complexo Hospitalar Santa Casa de Porto Alegre), southern Brazil.Results. Between June 16, 1991 and July 19, 2011, 824 patients underwent 866 liver transplants. Forty-two procedures corresponded to LReTx (4.8% of all liver transplants performed). Thirty-eight patients who underwent a single LReTx procedure were included in this study. The leading indication for LReTx was hepatic artery thrombosis (HAT) (31.6%), followed by primary nonfunction (PNF) (18.4%). The main indication for early LReTx was PNF (58.3%) and for late LReTx was HAT (38.5%). During the follow-up period, 26 patients (68.4%) died after LReTx. Patient survival at 1 and 3 years after LReTx was 44.7% and 44.7%, respectively. Patients infected with hepatitis C virus, serum albumin < 2.5 g/dL and receiving mechanical ventilation immediately before LReTx had a significantly lower survival rate than the other patients.Conclusion. Considering the increased mortality when the graft loss is delayed, it is necessary to define the minimum acceptable results to indicate LReTx and identify the patients who would most benefit from this treatment.     

Incidence and prognostic factors associated with biliary atresia in western India

Aim:To estimate the incidence of Biliary Atresia(BA) amongst Neonatal Cholestatic Syndromes (NCS) and determine prognostic factors in BA patients who have undergone Kasai’s portoenterostomy. Study design-Retrospective analysis. Setting-Pediatric Hepatobiliary Clinic at B.J. Wadia Children’s Hospital, Mumbai.Methods and materials: 32 patients diagnosed with BA referred to the clinic from May 2005 to July 2007 were included in the study. All patients underwent a detailed history, clinical examination and were tested for Liver function tests (LFT), USG abdomen, Liver biopsy, intra-operative cholangiogram and CMV tests. Patients were followed up for a period of 1 month to 7 years post operatively and complications such as cholangitis, progress to liver cell failure and cirrhosis was noted.Results: Incidence of BA amongst NCS (n = 88) was 36.4%. 8 patients of BA (25%) were lost to follow up. Out of the remaining, 10 (41.7%) improved and 14 (58.3%) did not improve. The mean age of presentation was 89 ± 55.8days. 1 patient (25%) out of 4 with bile duct size of < 100 microns showed an improvement whereas 3 (37.5%) out 8 patients with bile duct size 100-200 microns showed improvement and 4 (50%) with bile duct size of > 200 microns had improvement post Kasai surgery. Those with bile duct sizes > 200 microns had better prognosis than those with sizes 100-200 microns (Odd’s ratio = 1.8) and < 100 microns (Odd’s ratio = 3). 12 patients (50%) were operated before 3 months of age and 50% of them responded to surgery. The remaining 12 patients were operated after 3 months of age and only 33% showed any improvement. (Odd’s ratio = 2). Other parameters like SGOT (P = 0.598), SGPT (p = 0.901), total Bilirubin (p = 0.349), Direct Bilirubin (p = 0.429), Alkaline Phosphatase (p = 0.605) and GGTP (p = 0.480), cirrhosis (p = 0.417), degree of fibrosis (p = 0.384), degree of inflammation (p = 0.964) and Cholangitis (P = 0.388) had no effect on the outcome.Conclusion: Biliary Atresia is a common cause of NCS in India. Children with Bile duct size > 200 microns have a good prognosis. Portoenterostomy before 3 months of age has a better outcome.     

Postprandial serum cholylglycine in the detection of hepatotoxicity induced by antituberculous agents

Background: Measurement of bile acid levels has been proven helpful in the detection of hepatic abnormalities when routine liver function test results are normal or only slightly elevated. We compared the effectiveness of postprandial serum cholylglycine (CG), as determined by RIA, with commonly used liver function tests (SGOT, SGPT, alkaline phosphatase, gamma-glutamyl transpeptidase) in order to detect liver injury in patients receiving antituberculous agents. Method: We studied 100 patients receiving antituberculous agents. Laboratory tests were carried out before the initiation of therapy and after 1, 2, 3 and 8 weeks of treatment. The risk of hepatotoxicity in relation to age (>35 years) and/or the addition of pyrazinamide to the 6-month isoniazid–rifampin regimen was also assessed. Results: The percentage of patients with hepatic dysfunction detected by abnormal serum CG levels was significantly greater than that detected with conventional liver function tests. Neither age over 35 years nor the use of pyrazinamide was associated with a greater number of abnormalities in liver function tests. Conclusion: Postprandial serum CG by RIA proved to be a sensitive parameter for detecting hepatotoxicity by antituberculous agents.     

IGF-I and IGFBP-3 serum levels in patients hospitalized for complications of liver cirrhosis

Background. IGF-I and IGFBP-3 are part of IGF system and, due to their predominantly hepatic synthesis, they seem to correlate with hepatic dysfunction intensity. Aims. To investigate the significance of IGF-I and IGFBP-3 in patients with decompensated liver disease.Material and methods. Cross-sectional study that included cirrhotic patients admitted to hospital due to complications of the disease, in whom IGF-I and IGFBP-3 serum levels were measured by chemiluminescence. Results. Seventy-four subjects with a mean age of 53.1 ± 11.6 years were included in the study, 73% were males. IGF-I levels were positively correlated with IGFBP-3 and albumin, and negatively correlated with Child-Pugh, MELD, creatinine, INR and aPTT ratio. IGFBP-3 levels were positively correlated with IGF-I and albumin, and negatively correlated with Child-Pugh, MELD, creatinine, INR, total bilirubin and aPTT ratio. Significantly lower scores of IGF-I and IGFBP-3 were observed in patients with higher MELD values and higher Child-Pugh classes (P < 0.05).Conclusions. In cirrhotic patients admitted to hospital due to complications of the disease, IGF-I and IGFBP-3 serum levels were associated with variables related to liver dysfunction and to more advanced liver disease. The levels of these markers seem to undergo little influence from other clinical and laboratory variables, therefore mainly reflecting hepatic functional status.     

Chemical shift magnetic resonance imaging is helpful in detecting hepatic steatosis but not fibrosis in patients with nonalcoholic fatty liver disease (NAFLD)

Background & Aim: Imaging modalities have a role in the diagnosis of patients with nonalcoholic fatty liver disease. Aim of the present study was to evaluate the role of chemical shift magnetic resonance imaging in assessing hepatic steatosis and fibrosis in patients with nonalcoholic fatty liver disease.Methods: Chemical shift magnetic resonance imaging was done in 10 biopsy proven patients (7 females, mean age 41 ± 9.2 years) with nonalcoholic fatty liver disease. Objective measurements of signal intensity (SI) were done and a ratio was calculated (SI out-of-phase liver/ SI out-of-phase kidney)/ (SI in-phase liver/ SI in-phase kidney). A lower ratio indicated a higher signal drop and hence higher fat content. The ratio was correlated with hepatic steatosis on histology (< 33% and > 33%). Patients were classified as having histological NASH or no NASH and MRI was assessed in diagnosing hepatic fi-brosis as seen on liver histology.Results: Six patients had > 33% hepatic steatosis on histology. Five patients (50%) had evidence of histological NASH. MRI was not helpful in differentiating patients with and without his-tological NASH. One patient amongst NASH patients did not have fibrosis, one had stage 1, 2 had stage 2 and one had stage 4 fibrosis. SI ratio ranged between 0.350.69 in 6 patients with steatosis > 33% and was in the range of 0.69-1.20 in four patients with steatosis < 33% on histology. Fibrotic changes seen in 4 patients on biopsy were not detected on MRI.Conclusion: Chemical shift MRI provides objective data on fat infiltration in patients with NAFLD without giving information about hepatic fibrosis.     

Antifibrotic effect of heparin on liver fibrosis model in rats

AIM: To evaluate the effect of chronic thrombin inhibition by heparin on experimentally induced chronic liver injury (liver fibrosis) in rats.METHODS: Chronic liver injury (liver fibrosis) was induced in Wistar rats by oral administration of carbon tetrachloride (CCl₄) for 7 wk, an animal model with persistent severe hepatic fibrosis. Intravenous administration of the thrombin antagonist (heparin) started 1 wk after the start of CCl₄ intoxication for 6 wk. After completion of treatment (7 wk), markers of hepatic dysfunction were measured and changes evaluated histopathologically.RESULTS: Higher serum glutamate oxaloacetate transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT), alkaline phosphatase (ALP), total, direct and indirect bilirubin levels, as well as lower fibrinogen levels, were found in CCl₄ intoxicated rats. Heparin, silymarin and combination of drug (heparin and silymarin) treatment for 6 wk prevented a rise in SGOT, SGPT, ALP, total, direct and indirect bilirubin levels and improved fibrinogen levels. Deterioration in hepatic function determined by the fibrosis area was retarded, as evident from hepatic histopathology. Total protein levels were not changed in all groups.CONCLUSION: Heparin, a thrombin antagonist, preserved hepatic function and reduced severity of hepatic dysfunction/fibrogenesis. Combination of heparin and silymarin produced additional benefits on liver fibrosis.     

Diagnostic value of fibronectin discriminant score for predicting liver fibrosis stages in chronic hepatitis C virus patients

Background. Several noninvasive predictive models were developed to substitute liver biopsy for fibrosis assessment.Aim. To evaluate the diagnostic value of fibronectin which reflect extracellular matrix metabolism and standard liver functions tests which reflect alterations in hepatic functions.Material and methods. Chronic hepatitis C (CHC) patients (n = 145) were evaluated using ROC curves and stepwise multivariate discriminant analysis (MDA) and was validated in 180 additional patients. Liver biochemical profile including transaminases, bilirubin, alkaline phosphatase, albumin, complete blood count were estimated. Fibronectin concentration was determined using monoclonal antibody and ELISA.Results. A novel index named fibronectin discriminant score (FDS) based on fibronectin, APRI and albumin was developed. FDS produced areas under ROC curves (AUC) of 0.91 for significant fibrosis and 0.81 for advanced fibrosis. The FDS correctly classified 79% of the significant liver fibrosis patients (F2–F4) with 87% sensitivity and 75% specificity. The relative risk [odds ratio (OR)] of having significant liver fibrosis using the cut-off values determined by ROC curve analyses were 6.1 for fibronectin, 4.9 for APRI, and 4.2 for albumin. FDS predicted liver fibrosis with an OR of 16.8 for significant fibrosis and 8.6 for advanced fibrosis. The FDS had similar AUC and OR in the validation group to the estimation group without statistically significant difference. Conclusion. FDS predicted liver fibrosis with high degree of accuracy, potentially decreasing the number of liver biopsy required.     

Liver Affection in Iron Overload Studied with Serum Ferritin and Serum Aminotransferases

ABSTRACT Liver dysfunction as measured by S-ALAT activity was present in 72% of patients over 40 years of age with HLA-related iron overload, mainly detected by laboratory screening. Liver dysfunction was correlated to the amount of iron stored (r=0.54, p<0.001). When iron was removed by phlebotomy, liver function returned to normal. S-ALAT activity was closely correlated to serum ferritin concentration (r=0.73, p<0.001). Even a mild iron excess can affect hepatocytes and result in increased levels of ferritin and aminotransferases in serum. Patients with “transaminitis” should be investigated for iron overload.     

The nutritional status and factors contributing to malnutrition in children with chronic pancreatitis

Background/objectivesThe present study was undertaken to determine the prevalence of malnutrition among children with chronic pancreatitis (CP). Furthermore, we aimed to evaluate the relationship between etiological factors of CP, its clinical characteristics, and the severity of malnutrition.MethodsThe study included 208 children with CP (113 girls and 95 boys; mean age: 10.8 years, range: 1.6–18 years), hospitalized at our center between 1988 and 2012. The severity of malnutrition was graded on the basis of Cole's ratios, and its prevalence was analyzed according to the etiological factors of pancreatitis. Moreover, the analysis of discrimination was performed to identify the factors contributing to malnutrition among the following variables: age at CP onset, duration of CP, number of CP exacerbations, the number of ERCPs performed, the grade of pancreatic damage documented on imaging, co-occurrence of diabetes, and the results of 72-h fecal fat quantification.ResultsWe documented features of malnutrition in 52 (25%) children with CP, including 36 (17.3%) patients with moderate malnutrition, and 2 (0.96%) with severe malnutrition. There was no significant difference in the prevalence of malnutrition between groups of patients with various etiological factors of chronic pancreatitis. The age at CP onset showed the best discrimination ability of malnourished patients: the mean age at disease onset in a subgroup of malnourished children was significantly higher than in children with Cole's index >85%.ConclusionsA considerable percentage of children with CP can suffer from clinically significant malnutrition. Later age at CP onset predisposes to development of malnutrition.     

Laparoscopic evaluation of liver disease in chronic renal failure prior to renal transplantation

Background: Diagnostic laparoscopy with liver biopsy has been shown to be safe and effective in the evaluation of patients with chronic liver disease. Patients with end-stage renal disease may be more prone to bleeding complications secondary to liver biopsy as a result of multiple factors directly related to their underlying renal condition. Methods and patients: From January 1994 to June 1996, 16 patients with end-stage renal disease and hepatic dysfunction (6 women and 10 men) underwent diagnostic laparoscopy with liver biopsy prior to renal transplantation at the University of Miami School of Medicine. Laparoscopy was performed using a 5 mm video laparoscope with a left paramedian approach. The mean patient age was 46 years. Fourteen patients had chronic hepatitis C with a reactive anti-HCV by ELISA; one patient had chronic hepatitis B with reactive HBsAg, and one patient was co-infected with both hepatitis B and C viruses. Results: Two patients developed hypotension related to the procedure and one patient developed an intra-abdominal hemorrhage 5 days after laparoscopy that did not require surgical intervention. Biopsy findings were as follows: 13 patients had mild chronic hepatitis; 2 patients had chronic hepatitis with bridging fibrosis; and 1 patient was cirrhotic. Prior kidney transplantation or peritoneal dialysis did not preclude the performance of laparoscopy. Conclusion: Diagnostic laparoscopy can be safely performed in patients with end-stage renal disease with acceptable morbidity and mortality. (Gastrointest Endosc 1997;45:503-7.)