Prevalence,risk factors,and short-term outcomes of postparacentesis acute kidney injury using revised criteria of the international club of ascites

Acute kidney injury (AKI) can become complicated after paracentesis due to extrarenal fluid loss and inadequate blood flow to the kidneys. The objective of this study was to explore the incidence and clinical implications of postparacentesis AKI.A retrospective cohort of 137 liver cirrhosis patients (mean age: 61.3 ± 11.8 years, male: 100 [73.0%], viral hepatitis: 93 [67.9%]) who underwent paracentesis was analyzed. The incidence of AKI as defined by the international club of ascites (ICA) criteria, the risk factors, and its impact on early mortality were all assessed.Thirty two patients (23.4%) developed AKI after paracentesis. In multivariate analysis, the Model for end-stage liver disease (MELD)-Na score was an independent factor associated with AKI development (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.07–1.23) after paracentesis. The incidence of early mortality was significantly higher for those with AKI than without AKI (71.9% [23/32 patients] vs 11.4% [12/105 patients], P < .001). AKI (hazard ratio [HR], 7.56; 95% CI, 3.40–16.8) and MELD-Na score (HR, 1.08; 95% CI, 1.02–1.14) were independent factors associated with early mortality. In subgroup analysis, AKI after paracentesis was associated with significantly higher early mortality in both MELD-Na groups, that is, patients with a MELD-Na score >26 (87.5% vs 22.2%, P < .001) and those with a MELD-Na score ≤26 (56.3% vs 9.2%, P < .001).Postparacentesis AKI occurred frequently in cirrhotic patients. Furthermore, it was associated with early mortality. Baseline MELD-Na score was associated with AKI, indicating that careful attention is required for those with a higher MELD-Na score who are being considered for therapeutic paracentesis.     

Association between admission time and in-hospital mortality in acute aortic dissection patients: A retrospective cohort study

PurposeThis study aimed to evaluate the relationship between admission time and in-hospital mortality in acute aortic dissection (AAD) patients.MethodsThe risk factors of in-hospital clinical outcomes were retrospectively evaluated in patients with AAD. All the patients were enrolled from January to December 2017 and were divided into two groups depending on the time of admission: daytime admissions were conducted from 8: 00 to 17: 30 hours whereas, nighttime admissions were from 17: 30 to 8: 00 hours. The primary endpoints were in-hospital mortality. Univariate and multivariable cox analyses were used to test the association between admission time and in-hospital mortality.ResultsThe average age of the 363 participants in the present study was 52.25 ± 11.77 years, of which 81.6% were male. A total of 183 (50.4%) of these patients were admitted during nighttime. In-hospital mortality rate was higher in the nighttime admission group than in the daytime admission group (HR=1.86; 95%CI, 1.13 to 3.06, P=0.015). After adjusting for age, sex, and other risk factors, nighttime admission suggested as an independent risk factor for in-hospital mortality (HR=2.67, 95%CI, 1.30 to 5.46; P=0.007). Further subgroup analysis showed that none of the variables had a significant effect on the association between nighttime admission and in-hospital mortality.ConclusionNighttime admission for type A acute aortic dissection is associated with a higher risk of in-hospital mortality. Therefore, health care systems should focus on managing the increased risk of in-hospital mortality among patients admitted at night, regardless of the cause.     

氢化可的松联合维生素C、维生素B1治疗脓毒症疗效的Meta分析

背景维生素C与维生素B₁具有抗氧化作用,推测其与氢化可的松联合使用能产生协同效应,从而起到改善脓毒症或脓毒性休克患者免疫功能和减轻氧化应激的作用。有研究者基于此假设通过回顾性对照研究发现,此三联疗法能明显降低脓毒症患者病死率,但其后多篇随机对照研究对此治疗方案提出质疑。目的采用Meta分析评价氢化可的松联合维生素C、维生素B₁(HAT)治疗脓毒症的疗效。方法检索PubMed、Embase、Cochrane Library、Web of Science、中国知网、万方数据知识服务平台、中国生物医学文献服务系统及维普网自建库至2021-08-01发表的HAT治疗脓毒症的随机对照试验。对照组采用脓毒症集束化基础治疗,试验组在对照组基础上采用HAT治疗。主要观察指标为院内病死率,次要观察指标为72 h序贯器官衰竭估计评分变化值(72 hΔSOFA)、血管活性药物使用时间、急性肾损伤(AKI)发生率。由2名研究者独立进行文献筛选、资料提取,并采用Cochrane偏倚风险评估工具对纳入文献进行方法学质量评价。应用RevMan 5.3软件评估纳入文献的偏倚风险,应用R 3.6.2软件Meta包进行Meta分析。根据疾病类型将患者分为脓毒症、脓毒症和脓毒性休克、脓毒性休克3类,进行亚组分析。应用漏斗图和Egger检验评估纳入文献的发表偏倚。结果最终纳入文献10篇,共包含1611例患者,其中试验组805例、对照组806例。在随机序列产生、分配隐藏方面,7篇文献为低偏倚风险,2篇文献为高偏倚风险,1篇文献的偏倚风险不清楚;在对受试者、试验人员施盲及对结局评估员施盲、结果数据不完整、选择性报告研究结果、其他偏倚来源方面,10篇文献均为低偏倚风险。Meta分析结果显示:试验组与对照组院内病死率〔相对危险度(RR)=1.03,95%可信区间(CI)(0.92,1.15),P=0.65〕、AKI发生率〔RR=1.04,95%CI(0.89,1.21),P=0.70〕比较,差异无统计学意义;试验组72 hΔSOFA高于对照组〔标准均数差(SMD)=0.58,95%CI(0.09,1.07),P=0.02〕;试验组血管活性药物使用时间短于对照组〔SMD=-0.66,95%CI(-0.84,-0.47),P<0.0001〕。亚组分析结果显示:在脓毒症患者中,试验组院内病死率〔RR=0.27,95%CI(0.12,0.63),P=0.01〕、72 hΔSOFA〔SMD=0.95,95%CI(0.64,1.27),P=0.04〕、AKI发生率〔RR=0.32,95%CI(0.15,0.66),P<0.01〕低于对照组。在脓毒症和脓毒性休克患者中,试验组与对照组院内病死率〔RR=1.02,95%CI(0.89,1.18),P=0.09〕、72 hΔSOFA〔SMD=0.22,95%CI(-0.09,0.53),P=0.05〕、AKI发生率〔RR=1.05,95%CI(0.88,1.26),P=0.73〕比较,差异无统计学意义。在脓毒性休克患者中,试验组与对照组院内病死率〔RR=1.12,95%CI(0.91,1.38),P=0.31〕、72 hΔSOFA〔SMD=0.66,95%CI(-0.58,1.90),P=0.30〕、AKI发生率〔RR=1.25,95%CI(0.91,1.71),P=0.16〕比较,差异无统计学意义。漏斗图分析结果显示,HAT治疗脓毒症患者的院内病死率文献的漏斗图分布不对称。Egger检验结果显示,HAT治疗脓毒症患者的院内病死率文献存在发表偏倚(P=0.02),进一步利用剪补法进行矫正后结果显示,试验组与对照组院内病死率比较,差异无统计学意义〔RR=1.07,95%CI(0.84,1.38),P=0.57〕,提示文献原结果具有真实性。结论HAT可降低早期脓毒症患者的院内病死率及AKI发生率,缩短血管活性药物使用时间,改善其预后,但对于脓毒性休克患者的治疗效果有限。     

Extensively drug-resistant bacteria are an independent predictive factor of mortality in 130 patients with spontaneous bacterial peritonitis or spontaneous bacteremia

AIM: To evaluate the epidemiology and outcomes of culture-positive spontaneous bacterial peritonitis (SBP) and spontaneous bacteremia (SB) in decompensated cirrhosis.METHODS: We prospectively collected clinical, laboratory characteristics, type of administered antibiotic, susceptibility and resistance of bacteria to antibiotics in one hundred thirty cases (68.5% males) with positive ascitic fluid and/or blood cultures during the period from January 1, 2012 to May 30, 2014. All patients with SBP had polymorphonuclear cell count in ascitic fluid > 250/mm³. In patients with SB a thorough study did not reveal any other cause of bacteremia. The patients were followed-up for a 30-d period following diagnosis of the infection. The final outcome of the patients was recorded in the end of follow-up and comparison among 3 groups of patients according to the pattern of drug resistance was performed.RESULTS: Gram-positive-cocci (GPC) were found in half of the cases. The most prevalent organisms in a descending order were Escherichia coli (33), Enterococcus spp (30), Streptococcus spp (25), Klebsiella pneumonia (16), S. aureus (8), Pseudomanas aeruginosa (5), other Gram-negative-bacteria (GNB) (11) and anaerobes (2). Overall, 20.8% of isolates were multidrug-resistant (MDR) and 10% extensively drug-resistant (XDR). Health-care-associated (HCA) and/or nosocomial infections were present in 100% of MDR/XDR and in 65.5% of non-DR cases. Meropenem was the empirically prescribed antibiotic in HCA/nosocomial infections showing a drug-resistance rate of 30.7% while third generation cephalosporins of 43.8%. Meropenem was ineffective on both XDR bacteria and Enterococcus faecium (E. faecium). All but one XDR were susceptible to colistin while all GPC (including E. faecium) and the 86% of GNB to tigecycline. Overall 30-d mortality was 37.7% (69.2% for XDR and 34.2% for the rest of the patients) (log rank, P = 0.015). In multivariate analysis, factors adversely affecting outcome included XDR infection (HR = 2.263, 95%CI: 1.005-5.095, P = 0.049), creatinine (HR = 1.125, 95%CI: 1.024-1.236, P = 0.015) and INR (HR =1.553, 95%CI: 1.106-2.180, P = 0.011).CONCLUSION: XDR bacteria are an independent life-threatening factor in SBP/SB. Strategies aiming at restricting antibiotic overuse and rapid identification of the responsible bacteria could help improve survival.     

Acute kidney injury is associated with increased levels of circulating microvesicles in patients with decompensated cirrhosis

BackgroundMicrovesicles (MVs) play a role in inflammation, coagulation, and vascular homeostasis in liver disease.AimTo characterize circulating plasma MVs profile in patients with decompensated cirrhosis and acute kidney injury (AKI).MethodsWe measured the levels of total, endothelial, platelet, tissue factor (TF)+, leukocyte and hepatocyte MVs by new generation flow-cytometry in a prospective cohort of patients with decompensated cirrhosis with and without AKI.ResultsEighty patients with decompensated cirrhosis were recruited (40 each with and without AKI). Patients with cirrhosis with AKI had significantly higher calcein+ (total), endothelial, and platelet-MVs. Conversely, TF+, leukocyte, and hepatocyte-MVs were comparable between groups. Resolution of AKI was associated with significantly decreased total and endothelial-MVs that became comparable with those in patients without AKI. Platelet MVs significantly decreased but remained higher compared to patients without AKI. TF+MVs significantly decreased and became lower than patients without AKI. Leukocyte and hepatocyte-MVs remained unchanged. Creatinine (OR 4.3 [95%CI 1.8–10.7]), MELD (OR 1.13 [95%CI 1.02–1.27]), any bleeding (OR 9.07 [95%CI 2.02–40.6]), and hepatocyte-MVs (OR 1.04 [95%CI 1.02–1.07]) were independently associated with 30-day mortality.ConclusionAKI worsened vascular and cellular homeostasis in patients with cirrhosis, particularly by inducing endothelial dysfunction and platelet activation. AKI did not worsen systemic inflammation and hepatocytes activation.     

Risk factors for acute kidney injury and 30-day mortality after liver transplantation

Introduction. The aim of this study is to evaluate the risk factors for acute kidney injury (AKI) and 30-day mortality after liver transplantation.Material and methods. This is a retrospective cohort of consecutive adults undergoing orthotopic liver transplantation (OLT) at a referral hospital in Brazil, from January 2013 to January 2014. Risk factors for AKI and death were investigated.Results. A total 134 patients were included, with median age of 56 years. AKI was found in 46.7% of patients in the first 72 h after OLT. Risk factors for AKI were: viral hepatitis (OR 2.9, 95% CI = 1.2-7), warm ischemia time (OR 1.1, 95% CI = 1.01-1.2) and serum lactate (OR 1.3, 95%CI = 1.02-1.89). The length of intensive care unit (ICU) stay was longer in AKI group: 4 (3-7) days vs. 3 (2-4) days (p = 0.001), as well as overall hospitalization stay: 16 (9-26) days vs. 10 (8-14) days (p = 0.001). The 30-day mortality was 15%. AKI was an independent risk factor for mortality (OR 4.3, 95% CI = 1.3-14.6). MELD-Na ≥ 22 was a predictor for hemodialysis need (OR 8.4, 95%CI = 1.5-46.5). Chronic kidney disease (CKD) was found in 36 patients (56.2% of AKI patients).Conclusions. Viral hepatitis, longer warm ischemia time and high levels of serum lactate are risk factors for AKI after OLT. AKI is a risk factor for death and can lead to CKD in a high percentage of patients after OLT. A high MELD-Na score is a predictor for hemodialysis need.     

Social Support Does Not Modify the Risk of Readmission for Patients with Decompensated Cirrhosis

Background

Patients with decompensated cirrhosis are at high risk of frequent hospitalizations. Whether the level of perceived social support impacts this risk is unknown. We sought to determine the relationship between social support and burden of hospitalization in patients with decompensated cirrhosis.

Methods

A total of 73 patients, all with decompensated cirrhosis and an index cirrhosis-related admission between 7/1/2017 and 7/1/2019, completed the modified medical outcomes study social support (mMOS-SS) survey. We retrospectively assessed the relationship between mMOS-SS scores and probability of readmission 90-days after the index admission. Additionally, we prospectively analyzed the association between mMOS-SS scores at enrollment and risk of 90-day hospitalization.

Results

At enrollment, 50.7% were female, median age 61 years, and median mMOS-SS score was 87.5. Median model for end-stage liver disease sodium (MELD-Na) at the time of the index admission was 15 and was 13 at the time of enrollment. The mMOS-SS score did not modify the rate of readmission 90 days after the index admission date (adjusted HR 1.01, 95%CI 0.98-1.03) nor was it associated with the rate of admission 90 days after enrollment prospectively (adjusted HR 0.99, 95%CI 0.96–1.02). The MELD-Na score at enrollment was the only significant predictor of hospitalization during prospective follow-up (adjusted HR 1.18, 95%CI 1.09–1.27).

Conclusions

Social support, as measured by the mMOS-SS survey, in patients with decompensated cirrhosis was high. However, this did not modify the risk of cirrhosis-related hospitalizations. Future investigation to define the specific components of social support that could modify readmission risk is needed.

     

Appropriate empirical antibiotic use and 30-d mortality in cirrhotic patients with bacteremia

AIM: To analyze whether prompt and appropriate empirical antibiotic(AEA) use is associated with mortality in cirrhotic patients with bacteremia. METHODS: A total of 102 episodes of bacteremia in 72 patients with cirrhosis were analyzed. AEA was defined as a using or starting an antibiotic appropriate to the isolated pathogen at the time of bacteremia. The primary endpoint was 30-d mortality. RESULTS: The mortality rate at 30 d was 30.4%(31/102 episodes). Use of AEA was associated with better survival at 30 d(76.5% vs 46.9%, P = 0.05), and inappropriate empirical antibiotic(IEA) use was an independent factor associated with increased mortality(OR = 3.24; 95%CI: 1.50-7.00; P = 0.003, adjusted for age, sex, ChildPugh Class, gastrointestinal bleeding, presence of septic shock). IEA use was more frequent when the isolated pathogen was a multiresistant pathogen, and when infection was healthcare-related or hospital-acquired. CONCLUSION: AEA use was associated with increased survival of cirrhotic patients who developed bacteremia. Strategies for AEA use, tailored according to the local epidemiological patterns, are needed to improve survival of cirrhotic patients with bacteremia.     

Impact of Acute Kidney Injury on Short- and Long-term Outcomes After Transcatheter Aortic Valve Implantation

Introduction and objectives

Acute kidney injury (AKI) is frequently observed after transcatheter aortic valve implantation (TAVI) and is associated with higher mortality. However, the impact of AKI on long-term outcomes remains controversial. Therefore, we sought to evaluate the impact of AKI on short- and long-term outcomes following TAVI using the Valve Academic Research Consortium 2 criteria.

Impact of pre-hospital renal function on the detection of acute kidney injury in acute decompensated heart failure

BackgroundAcute kidney injury (AKI) is a serious complication in patients hospitalized for decompensated heart failure (HF). Currently, AKI definitions consider creatinine levels at admission as reference of baseline renal function (RF). However, renal impairment may already be present at admission. We aimed to study the impact on AKI detection of considering outpatient RF as reference.MethodsIn a cohort of 458 patients hospitalized for decompensated HF, we studied the occurrence of AKI using the standardized KDIGO criteria and grading (stages: 1, 2, 3), and considering two different definitions according to the RF used as reference or baseline: the latest outpatient measurement prior to admission vs. the first measurement at admission. We compared the prevalence, timing and prognostic value for both AKI definitions.ResultsThe definition based on outpatient RF was associated with an increase in overall AKI detection from 20.1% to 33.8% (p < 0.001), and from 3.1% to 5.0% for advanced stages (2–3) (p < 0.001); additionally, 12.5% of patients already had criteria of AKI at admission (36.8% of AKI cases). Both definitions were associated with longer hospital stay. However, only AKI already present at admission, as based on pre-hospital creatinine, was independently associated with all-cause death, in-hospital and after discharge, and death or HF readmission in the follow-up: 1 stage (HR 2.72, 95%CI 1.83–4.06, p < 0.001) and 2–3 stage (HR 7.29, 95%CI, 3.02–17.64, p < 0.001).ConclusionsEvaluation of AKI in patients admitted with HF should consider pre-hospital RF, since it improves early identification of AKI and has implications for risk assessment.     

Vasopressin use in critically ill cirrhosis patients with catecholamine-resistant septic shock: The CVICU cohort

AIM To examine patient-centered outcomes with vasopressin(AVP) use in patients with cirrhosis with catecholaminerefractory septic shock. METHODS We conducted a single center, retrospective cohort study enrolling adult patients with cirrhosis treated for catecholamine-resistant septic shock in the intensive care unit(ICU) from March 2011 through December 2013. Other etiologies of shock were excluded. Multivariable regression models were constructed for seven and 28-d mortality comparing AVP as a second-line therapy to a group of all other vasoactive agents. RESULTS Forty-five consecutive patients with cirrhosis were treated for catecholamine-resistant septic shock; 21 received AVP while the remaining 24 received another agent [phenylephrine(10), dopamine(6), norepinephrine(4), dobutamine(2), milrinone(2)]. In general,no significant differences in baseline demographics, etiology of cirrhosis, laboratory values, vital signs or ICU mortality/severity of illness scores were observed with the exception of higher MELD scores in the AVP group(32.4, 95%CI: 28.6-36.2 vs 27.1, 95%CI: 23.6-30.6, P = 0.041). No statistically significant difference was observed in unadjusted 7-d(52.4% AVP vs 58.3% and P = 0.408) or 28-d mortality(81.0% AVP vs 87.5% non-AVP, P = 0.371). Corticosteroid administration was associated with lower 28-d mortality(HR = 0.37, 95%CI: 0.16-0.86, P = 0.021) independent of AVP use. CONCLUSION AVP is similar in terms of patient centered outcomes of seven and 28-d mortality, in comparison to all other vasopressors when used as a second line vasoactive agent in catecholamine resistant septic shock. Large-scale prospective study would help to refine current consensus standards and provide further support to our findings.     

Acute kidney injury in patients with cirrhosis of liver: Clinical profile and predictors of outcome

Background

Acute kidney injury (AKI) is a common complication of liver cirrhosis and is associated with poor survival. We studied the clinical profile and predictors of in-hospital mortality in patients with cirrhosis of the liver with AKI.

Methods

This retrospective cohort study examined patients at a tertiary care hospital. AKI staging was done based on the new 2015 Ascites Club Criteria. Patients were grouped into three types of AKI: pre-renal azotemia (PRA), hepatorenal syndrome (HRS), and acute tubular necrosis (ATN).

Results

Data of 123 patients with cirrhosis and AKI were analyzed. Most patients had AKI stage 3 (57.7%). ATN (42.3%) and HRS (43.9) were the predominant types of AKI followed by PRA (13.8%). The overall in-hospital mortality in our study was 44.7%. The mortality increased with increasing severity of AKI (p?=?0.0001) and was the highest in AKI stage 3 (p?=?0.001) and those who required hemodialysis (p?=?0.001). There was a significant in-hospital mortality in patients with ATN and HRS in comparison to PRA (p?=?0.001). On multivariate analysis, the factors predicting in-hospital mortality were AKI stage 3, and oliguria (p?=?0.0001).

Conclusions

Acute kidney injury in cirrhosis of liver carries high in-hospital mortality. Pre-renal AKI has a better survival compared to ATN and HRS. The higher stage of AKI at presentation and the presence of oliguria are two important predictors of in-hospital mortality.

     

The performance of prognostic models as predictors of mortality in patients with acute decompensation of cirrhosis

Background. Although several prognostic models have been proposed for cirrhotic patients listed for transplantation, the performance of these scores as predictors of mortality in patients admitted for acute decompensation of cirrhosis has not been satisfactorily investigated.Aims. To study MELD, MELD-Na, MESO, iMELD, Refit-MELD and Refit MELD-Na models as prognostic predictors in cirrhotic patients admitted for acute decompensation, and to compare their performance between admission and 48 hours of hospitalization to predict in-hospital mortality.Material and methods. This cohort study included cirrhotic patients admitted to hospital due to complications of the disease. Individuals were evaluated on admission and after 48 h of hospitalization, and mortality was evaluated during the present admission.Results. One hundred and twenty-three subjects with a mean age of 54.26 ± 10.79 years were included; 76.4% were male. Mean MELD score was 16.43 ± 7.08 and 52.0% of patients were Child-Pugh C. Twenty-seven patients (22.0%) died during hospitalization. Similar areas under the curve (AUROCs) for prognosis of mortality were observed when different models were compared on admission (P > 0.05) and after 48 h of hospitalization (P > 0.05). When models executed after 48 h of hospitalization were compared to their corresponding model calculated on admission, significantly higher AUROCs were obtained for all models (P < 0.05), except for MELD-Na (P = 0.075) and iMELD (P = 0.119).Conclusion. The studied models showed similar accuracy as predictors of in-hospital mortality in cirrhotic patients admitted for acute decompensation. However, the performance of these models was significantly better when applied 48 h after admission when compared to their calculation on admission.     

Are presepsin and resistin better markers for bacterial infection in patients with decompensated liver cirrhosis?

BackgroundBacterial infections impair prognosis in patients with cirrhosis. Presepsin and, more recently, resistin are promising markers of infection and sepsis in patients without cirrhosis.AimsThe aim of our study was to assess the performance of presepsin and resistin as early markers of infection compared with C reactive protein (CRP) and procalcitonin (PCT), and their prognostic relevance in patients with decompensated cirrhosis.MethodsOne hundred and fourteen consecutive patients with decompensated cirrhosis were enrolled and followed-up for 28 days. Diagnostic performances of CRP, PCT, presepsin and resistin were assessed.ResultsFifty-three (46.5%) patients had bacterial infections of which 30 (56%) had sepsis. Presepsin and resistin had similar performance as CRP and PCT for the diagnosis of infection (best cut-off of 1444 pg/ml and 20 ng/ml, respectively) and sepsis. Presepsin (HR = 5.5; 95%CI: 2.36–13.21, p < 0.0001) and the ≥500 pg/ml increase of presepsin at 48 h (HR = 9.24; 95%CI: 3.66–23.27, p < 0.008) were independently associated with 28-day mortality.ConclusionsPresepsin and resistin have similar diagnostic performances to CRP and PCT for bacterial infection in decompensated cirrhosis. Presepsin and Δ presepsin ≥500 pg/ml have also a prognostic relevance for 28-day mortality.     

Risk factors and surgical outcomes for spontaneous rupture of BCLC stages A and B hepatocellular carcinoma: A case-control study

AIM: To investigate the risk factors and surgical outcomes for spontaneous rupture of Barcelona Clinic Liver Cancer (BCLC) stages A and B hepatocellular carcinoma (HCC).METHODS: From April 2002 to November 2006, 92 consecutive patients with spontaneous rupture of BCLC stage A or B HCC undergoing hepatic resection were included in a case group. A control arm of 184 cases (1:2 ratio) was chosen by matching the age, sex, BCLC stage and time of admission among the 2904 consecutive patients with non-ruptured HCC undergoing hepatic resection. Histological confirmation of HCC was available for all patients and ruptured HCC was confirmed by focal discontinuity of the tumor with surrounding perihepatic hematoma observed intraoperatively. Patients with microvascular thrombus in the hepatic vein branches were excluded from the study. Clinical data and survival time were collected and analysed.RESULTS: Sixteen patients were excluded from the study based on exclusion criteria, of whom 3 were in the case group and 13 in the control group. Compared with the control group, more patients in the case group had underlying diseases of hypertension (10.1% vs 3.5%, P = 0.030) and liver cirrhosis (82.0% vs 57.9%, P < 0.001). Tumors in 67 (75.3%) patients in the case group were located in segments II, III and VI, and the figure in the control group was also 67 (39.7%) (P < 0.001). On multivariate analysis, hypertension (HR = 7.38, 95%CI: 1.91-28.58, P = 0.004), liver cirrhosis (HR = 6.04, 95%CI: 2.83-12.88, P < 0.001) and tumor location in segments II, III and VI (HR = 5.03, 95%CI: 2.70-6.37, P < 0.001) were predictive for spontaneous rupture of HCC. In the case group, the median survival time and median disease-free survival time were 12 mo (range: 1-78 mo) and 4 mo (range: 0-78 mo), respectively. The 1-, 3- and 5-year overall survival rates and disease-free survival rates were 66.3%, 23.4% and 10.1%, and 57.0%, 16.8% and 4.5%, respectively. Only radical resection remained predictive for overall survival (HR = 0.32, 95%CI: 0.08-0.61, P = 0.015) and disease-free survival (HR = 0.12, 95%CI: 0.01-0.73, P = 0.002).CONCLUSION: Tumor location, hypertension and liver cirrhosis are associated with spontaneous rupture of HCC. One-stage hepatectomy should be recommended to patients with BCLC stages A and B disease.     

Evaluation of the criteria of hepatorenal syndrome type of acute kidney injury in patients with cirrhosis admitted to ICU

Introduction: Acute kidney injury (AKI) is a common and devastating complication in patients with cirrhosis. In 2015, the International Club of Ascites (ICA) proposed the definition of hepatorenal syndrome (HRS) type of AKI (HRS-AKI) in patients with cirrhosis. This study aims to evaluate the criteria of HRS-AKI in patients with cirrhosis admitted to ICU with regard to the prognosis.

Methods: A total of 349 cirrhotic patients consecutively admitted to intensive care unit (ICU) from 2010 to 2017 were retrospectively analyzed. Demographic parameters and clinical variables were collected with case report forms. The occurrence of AKI was determined according to ICA-AKI criteria. The phenotypes of AKI comprised pre-renal azotemia (PRA), acute tubular necrosis (ATN) and HRS. In our study, patients with PRA or ATN were classified to the non-HRS-AKI group.

Results: The incidence of AKI was 73.0%, comprising PRA (18.6%), ATN (16.3%) and HRS (38.1%). The overall hospital mortality was 64.5%. Patients with AKI had a significantly higher in-hospital (76.1%) and 180-d (86.7%) mortality. AKI type was an independent risk factor for in-hospital mortality by a multivariate logistic regression. The in-hospital and 180-d mortality rates were of no significant difference among patients with HRS-AKI stages 1–3.

Conclusions: AKI is common in patients with cirrhosis admitted to ICU, associated with significant in-hospital mortality. HRS-AKI was the most common and severe type of AKI in patients with cirrhosis admitted to ICU. The current staging system may not be applicable for HRS-AKI in patients with cirrhosis admitted to ICU.     

Comparison of the model for end-stage liver disease (MELD), MELD-Na and MELDNa for outcome prediction in patients with acute decompensated hepatitis

Background and aimThe model for end-stage liver disease (MELD) is used to predict the outcome of patients with cirrhosis. Incorporation of serum sodium (Na) into MELD may further increase its prognostic ability. Two Na-containing MELD models, MELD-Na and MELDNa, were proposed to enhance the prognostic ability. This study compared the predictive accuracy of these models for acute decompensated hepatitis.MethodsWe investigated the outcome of 182 patients with acute decompensated hepatitis.ResultsTwenty (11%) patients died at 3 months. The MELD-Na and MELDNa both had significantly higher area under the receiver operating characteristic curve (AUC) in comparison to MELD (MELD-Na: 0.908, MELDNa: 0.895, MELD: 0.823, p = 0.004 and 0.001, respectively). Among 96 patients without specific antiviral treatment, the MELD-Na and MELDNa consistently had significantly higher AUC than the MELD (MELD-Na: 0.901, MELDNa: 0.882, MELD: 0.810, p = 0.008 and 0.004, respectively). Three independent indicators, pre-existing cirrhosis (odds ratio [OR]: 5.67, 95% confidence interval [CI]: 1.72–18.7), serum albumin <3.7 g/dL (OR: 5.68, 95% CI: 1.18–27.03) and serum sodium (Na) < 138 mequiv./L (OR: 10.0, 95% CI: 2.08–47.62), were associated with 3-month mortality.ConclusionMELD-Na and MELDNa provide better prognostic accuracy than the MELD for patients with acute decompensated hepatitis. The adequacy of liver reserve determines the outcome of these patients.     

Indicators of sorafenib efficacy in patients with advanced hepatocellular carcinoma

AIM: To determine significant indicators for the efficacy of sorafenib in patients with advanced hepatocellular carcinoma (HCC).METHODS: A total of 46 patients with Barcelona Clinic Liver Cancer stage C who received sorafenib for more than 30 d at the Iizuka Hospital from June 2009 to December 2012 were enrolled in this study. Multivariate and univariate analyses were performed to evaluate the associations of hepatic function according to Child-Pugh grade, location and size of the largest tumor and adverse events of sorafenib treatment, such as hand-foot syndrome (HFS), hypertension, diarrhea, and alopecia, with the efficacy of treatment, as measured by overall survival (OS) and time to progression (TTP).RESULTS: Patients included 39 men and 7 women whose ages ranged from 48 to 85 years (70.6 ± 9.6 years). HCC was classified according to etiology as follows: hepatitis C virus (n = 26), hepatitis B virus (n = 9), and other (n = 11). Liver function in patients was categorized as Child-Pugh grade A (n = 30) or B (n = 16). Tumors were categorized by size [< 5 cm (n = 33) or >5 cm (n = 13)] and the location of the largest tumor was used to categorize patients with intrahepatic (n = 28) or extrahepatic (n = 18) HCC. HFS, hypertension, diarrhea, and alopecia were present in 22 (47.8%), 19 (41.3%), 15 (32.6%) and 7 patients (15.2%), respectively. The median OS of all patients was 373 d and the median TTP was 112 d. The etiology of HCC did not correlate with the median OS and TPP. The median OS of patients with tumors < 5 cm was significantly longer than those with larger tumors (496 vs 245 d; HR = 0.19, 95%CI: 0.07-0.48; P < 0.01). According to the results of a multivariate analysis, the size of the largest tumor affected OS (HR = 0.22, 95%CI: 0.08-0.59; P < 0.01). The median TTP was significantly longer in patients with extrahepatic compared to intrahepatic major HCC (224 vs 98 d; HR = 0.32; 95%CI: 0.14-0.67; P < 0.01). The median TTP of patients with HFS was significantly longer than those without it (195 d vs 83 d; HR = 0.41, 95%CI: 0.20-0.82; P < 0.05), and the median TTP was significantly longer in patients with hypertension (195 d vs 84 d; HR = 0.43, 95%CI: 0.21-0.84; P < 0.05). According to the results of the multivariate analysis, extrahepatic major HCC (HR = 0.36, P < 0.01) and HFS (HR = 0.44, P < 0.05) prolonged TTP.CONCLUSION: Extrahepatic major HCC and HFS are associated with prolonged TTP and are useful indicators for judging the efficacy of sorafenib treatment.     

Transient vs In-Hospital Persistent Acute Kidney Injury in Patients With Acute Coronary Syndrome

BackgroundThe occurrence of acute kidney injury (AKI) among patients with acute coronary syndrome (ACS) undergoing invasive management is associated with worse outcomes. However, the prognostic implications of transient or in-hospital persistent AKI may differ.ObjectivesThe aim of this study was to evaluate the prognostic implications of transient or in-hospital persistent AKI in patients with ACS.MethodsIn the MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial, 203 subjects were excluded because of incomplete information or end-stage renal disease, with a study population of 8,201 patients. Transient and persistent AKI were defined as renal dysfunction no longer or still fulfilling the AKI criteria (>0.5 mg/dL or a relative >25% increase in creatinine) at discharge, respectively. Thirty-day coprimary outcomes were the out-of-hospital composite of death, myocardial infarction, or stroke (major adverse cardiovascular events [MACE]) and net adverse cardiovascular events (NACE), defined as the composite of MACE or Bleeding Academic Research Consortium type 3 or 5 bleeding.ResultsPersistent and transient AKI occurred in 750 (9.1%) and 587 (7.2%) subjects, respectively. After multivariable adjustment, compared with patients without AKI, the risk for 30-day coprimary outcomes was higher in patients with persistent AKI (MACE: adjusted HR: 2.32; 95% CI: 1.48-3.64; P < 0.001; NACE: adjusted HR: 2.29; 95% CI: 1.48-3.52; P < 0.001), driven mainly by all-cause mortality (adjusted HR: 3.43; 95% CI: 2.03-5.82; P < 0.001), whereas transient AKI was not associated with higher rates of MACE or NACE. Results remained consistent when implementing the KDIGO (Kidney Disease Improving Global Outcomes) criteria.ConclusionsAmong patients with ACS undergoing invasive management, in-hospital persistent but not transient AKI was associated with higher risk for 30-day MACE and NACE. (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox [MATRIX]; NCT01433627)