Large volume abdominal paracentesis effect on some humoral factors and cardiac performance in patients with liver cirrhosis and tense ascitses

Tense ascites is one of the most disabling and distressing manifestation of liver cirrhosis. In the presence of ascites alteration in ventricular function is marked. Renin-angiotensin-aldosterone and sympathetic nervous system, whose activation is marked when tense ascites develops, could be involved as pathogenic factors causing increased left ventricular wall thickness. Large volume para-centesis [LVP] is an old but safe and effective procedure to mobilize ascitic fluid in cirrhotic patients The study evaluated the left ventricular function in patients with liver cirrhosis and tense ascites and determine the effect of total abdominal paracentesis on cardiac performance and correlated between cardiac performance and some humoral factors [renin, aldosterone, nor-epinephrine and epineph-rine] in cirrhotic patients with ascites. Fifty cirrhotic patients with tense ascites, besides 20 normal persons matched with patients in age and gender as a control group were included in our study. All patients were hospitalized and, submitted to a 4 days bed rest, low sodium diet and subjected to full investigations clinically and laboratory. Abdominal paracentesis was done to all patients [mean volume 7.5+11.7 L] with dexran-70 infusion. Blood samples were taken before and immediately after paracentesis for neurohormonal assay [plasma rennin activity PRA, plasma aldosterone PA, plasma nor-epinephrine and epinephrine]. The plasma renin activity, plasma aldosterone, plasma epinephrine, and plasma nor epinephrine was significantly higher than control. They showed significant reduction after paracentesis but still significantly higher than control levels. The results showed that sudden abdominal decompression could play a role in the post paracentesis systemic haemodynamic changes through mechanical decompression of the splanchinic vascular bed. Total paracentesis with albumin infusion causes immediate favorable effects; increasing cardiac output, suppressing plasma renin activity and plasma aldosterone, decreasing serum creatinine and blood urea nitrogen and reducing portal pressure and Porto collateral blood flow

Denver peritoneovenous shunt in the management of refractory ascites due to chronic liver diseases: impact of patients selection on its outcome

Forty four patients with refractory ascites due to chronic liver diseases that fulfilling the inclusion criteria of selection were divided into 2 groups. The first group [G1, n=24] was subdivided into 2 subgroups according to degree of liver condition; GIa [n=11] with Child-Pugh class B and GIb [n=13] with early class C. The patients were subjected to P-V shunt [Denver group]. Similarly, patients in the second group [GII, n=20] were divided into 2 subgroups GIIa [n=10] and GIIb [n=10] respectively and treated by the repeated tapping and albumin infusion [control group]. Postoperative results revealed a significant increase in urine output [P

Role of inflammatory cytokines [TNF- alpha and IL-6] in evaluation of anemia in CRF patients

Anemia is an early sign of chronic renal failure [CRF]. It is nearly universal in all patients with CRF and is associated with worse outcome. In recent years, evidence has accumulated for the roles of inflammatory cytokines in the inhibition of erythropoiesis in CKD-related anemia. The aim of our study is to investigate serum levels of some anemia markers and to evaluate the role of inflammatory cytokines 1L6 and TNF-alpha in patients with chronic renal failure. Sixty patients diagnosed as chronic renal failure and subjected to haemodialysis for at least 2 years, besides, 20 healthy volunteers were selected for our study. All were subjected to full clinical examination and hematological and biochemical investigation. In addition to estimation of anemia markers [serum levels of iron, TIBC, ferritin, folic acid and vitamin B12] and estimation of serum levels of inflammatory cytokines [lL-6 and TNF-alpha]. There were significant reduction in blood Hb concentration and hematocrite value [p< 0.00 1]. There also were significant reduction in serum iron, folic acid and vitamin B12 [p<0.01] whereas there was significant elevation in ferritin and TIBC levels [p<0.01]. Inflammatory cytokines, IL-6 and TNF-alpha showed highly significant elevation [p<0.001] when compared to the reference group. There were strong direct correlation [p<0.01] between serum TNF-alpha and serum iron level, while there were indirect correlation [p<0.01] between serum TNF-alpha and both of TIBC and ferritin. We can conclude that anemia could be a risk factor for progression of chronic renal dysfunction to end-stage renal disease and inflammation is a predictable event in its pathophysiology due to inhibition of erythropoiesis and also anemia correlates with the level of serum inflammatory markers [IL-6 and, TNF-alpha]. Furthermore, partial correction of anemia in patients with ESRD and CKD improves physiologic and clinical parameters and quality of life. Ongoing studies are also recommended to investigate the use of anti-cytokine treatment as anti-[TNF-alpha] antibodies in treatment of erythropoietin resistant anemia

Role of cytokines [IL1-beta, IL2, IL6 and IL8] in some extrahepatic manifestations of chronic HCV patients, Sjogren syndrome

Several extrahepatic diseases have been associated with chronic HCV infection. Cytokines are peptides produced by the cells and play an important role in the defence against viral infections. The aim of our research is to investigate serum level of cytokines [IL1-beta, IL2, IL6 and IL8] in chronic HCV infected patients and find out the prevalence of primary Sjogren Syndrome [SS] and the relationship between disease severity and serum levels of these cytokines. This study included 60 patients [34 males and 26 females] with chronic virus C hepatitis, with mean age of 45 +/- 10.2 years and 20 healthy subjects [12 males and 8 females] with mean age 47 +/- 8.5 years as a control group. Biochemical assessment of hepatic condition and viral markers for hepatitis C virus [anti-HCV] and hepatitis B virus [HBs Ag and anti-HBc Ab], and serum levels of cytokines [IL1-beta, IL2, IL6 and IL8] were conducted to all patients. According to modified Child's criteria, the degree of liver affection was assessed for patients with chronic hepatitis. Liver biopsy was performed to confirm chronic liver hepatitis. Patients diagnosed having Sjogren Syndrome [SS] would further subjected to chest and hand X-ray, thyroid function tests and immunological study [anti-Ro, anti-La antibodies and Rhematoid factor]. There was highly significant elevation [p<0.0l] of interleukins 1, 2, 6 and 8, and ALT between patient and control groups. There were positive correlation between serum cytokines levels [IL1-beta, IL2, IL6] and liver function test ALT [p<0.05] and strong positive correlation between IL8 and ALT [p<0.0l]. Ten of sixty patients [16.6%] were diagnosed of having SS, 60% were males with mean age of 48 +/- 4.5 years. A highly significant direct correlation was found as regards number of swollen joints, duration of morning stiffness and serum levels of cytokines [IL1- beta, IL-2, 6 and IL-8]. High liters of anti Ro and anti La antibodies were associated with higher levels of interleukin 6. Eight patients showed evidence of hypothyroidism and four patients showed evidence of peripheral neuropathy. Cytokines and free radicals are thought to be responsible for the pathologic changes, but the precise mechanisms are not clear. The significant correlations between the severity of different clinical and laboratory parameters of SS and serum levels of cytokines can be explained by the assumption that proinflammatory cytokines inhibit neurally mediated lacrimal gland secretion as well as, in glandular epithelial cells the local production of cytokines by both mononuclear and epithelial cells may be involved in the immune-mediated destruction of exocrine glands in patients with primary SS. It is concluded that in chronic hepatitis C infection there is significant elevation of serum cytokines [IL1-beta, IL2, IL6 and IL8], and there is high prevalence rate of primary Sjogren Syndrome, specially in males of old age. The severity of SS clinical picture and laboratory diagnostic markers is directly correlated to the serum levels of those cytokines

Role of non invasive biomarkers in the assessment of liver condition in chronic hepatitis C Egyptian patients and if they correlate with the severity of liver affection

Hepatitis C virus [HCV] is considered the most common etiology of chronic liver disease in Egypt. Anti-HCV-positive patients are more likely to have elevated liver enzymes, liver cirrhosis, portal hypertension and spleen enlargement. Schistosomal liver disease in Egypt is commonly associated with HCV infection. Concurrent infection results in much more severe liver affection than that seen in either disease alone. Chronic hepatitis C is a slowly progressive inflammatory disease that can lead to cirrhosis with all its complications. Thus, repeated assessment of liver condition is always required. Assessment of liver damage has been primarily done by liver function tests as well as by histological evaluation. Meanwhile, assessment of liver affection is mainly done by liver biopsy with histological analysis which always remains the "reference standard" used by physicians to assess the presence as well as the degree of liver fibrosis in patients with chronic liver diseases and also to determine the appropriate management. However, many physicians are cautious to perform liver biopsy because of the relative risks associated with this procedure, particularly in patients with coagulation abnormalities. Among the possible alternatives, imaging is informative mainly for cirrhosis but not for lesser stages of fibrosis. In addition, it is nonquantitative and thus cannot track progression. Unfortunately, there are few reliable noninvasive methods for detecting liver fibrosis and its progression. Thus, a noninvasive test detecting hepatic fibrosis has become a priority in the context of hepatitis C evaluation and treatment. Therefore, identifying hepatic biomarkers that correlate with the severity of the liver pathology is an important issue in the follow up of such cases. Few serum markers such as hyaluronic acid, ferritin, and soluble interleukin-2 receptor [sIL-2R] have been reported to be useful in detecting fibrosis in liver disease. The aim of this study is to clarify the diagnostic value of serum hyaluronic acid, ferritin, and soluble interleukin-2 receptor levels as non-invasive biomarkers in the assessment of the liver condition in chronic hepatitis C Egyptian patients with and without concurrent Bilharzial affection and moreover, to evaluate whether their serum levels correlate with the histological severity of the related liver injury. One hundred and twenty Egyptian subjects were included in this study. They were divided into three main groups. Group A [n=30] included patients with chronic hepatitis C and with liver fibrosis as assessed by abdominal ultrasonography, Group B [n = 60] included patients with chronic hepatitis C and with liver cirrhosis and/or history of antibilharzial treatment and positive rectal snips for bilharzial ova, and Group C [n = 30] included apparently normal age and sex-matched subjects taken as a control group. Group B was further subdivided into two subgroups according to liver cirrhosis staging as performed by abdominal ultrasonography, where Subgroup B1 [n = 30] included patients with early cirrhotic changes while Subgroup B2 [n = 30] included patients with advanced cirrhotic changes. Patients were diagnosed as having hepatitis C by detecting HCV antibodies using a third generation enzyme immunoassay, ELISA. Biochemical blood tests were carried out to evaluate liver functions in the form of serum transaminases [AST and ALT], alkaline phosphatase [ALP], gamma glutamate [GGT], total bilirubin, as well as serum albumin. In addition, serum hyaluronic acid, ferritin, as well as sIL-2R levels were measured by EL1SA. Our study detected impaired liver functions in all patient groups compared to the controls. Liver functions were also detected to be more impaired in each of subgroup B1 early cirrhosis as well as in B2 advanced cirrhosis patients compared to group A fibrosis patients and this was statistically significant. Meanwhile, our study also demonstrated statistically significant difference on comparing both subgroups B1 and B2 together showing more impairment in subgroup. B2 advanced cirrhosis patients. The above findings denote that as the liver condition progresses from fibrosis to early then to advanced cirrhosis, the liver enzymes as well as the bilirubin concentrations increase progressively and the serum albumin concentrations decrease progressively, thus indicating more deterioration in liver functions and more liver injury. Not only this, but also our study detected more deterioration in liver functions occurring in the presence of bilharzial infection concurrent with hepatitis C infection than without it. This was shown clearly from comparing group B patients, whether subgroup B1 or B2, with history of bilharziasis to group A patients without, denoting that concurrent bilharzial infection adds more to the liver affection. As regarding the hepatic biomarkers, namely, serum hyaluronic acid, ferritin, and sIL-2R, our study detected statistically increased serum levels in each of the patient groups compared to the controls. A progressive increase in their serum levels was detected as the liver condition progressively deteriorates. Meanwhile, more serum level elevations occurred with the presence of bilharzial infection concurrent with hepatitis C infection than without it. In addition, our study reported that in advanced cirrhosis subgroup B2 patients; there was a significant positive correlation detected between each of serum hyaluronic acid, ferritin, and sIL-2R and each of ALT and GGT serum levels. A positive correlation was also detected between serum hyaluronic acid and ALP. Meanwhile, a significant negative correlation was detected between each of the above three biomarkers and serum albumin level. In conclusion, our study reported that in chronic hepatitis C Egyptian patients, as the liver affection progresses, the liver functions deteriorate progressively, thus indicating more liver injury. Not only this, but also more deterioration in liver functions was detected in the presence of concurrent bilharzial infection than without it. As regarding the serum biomarkers: serum hyaluronic acid, ferritin, and sIL-2R, a progressive increase in their serum levels was detected as the liver condition progressively deteriorates. In addition, more elevations occurred in the presence of concurrent bilharzial infection. Moreover, our study detected that in advanced cirrhosis, these biomarkers correlate significantly with the liver functions denoting not only their diagnostic value as non-invasive biomarkers in the assessment of the liver condition, but also that their levels correlate with the histological severity of the related liver injury, and thus can be used in the prognostic follow up to assess the degree of liver pathological progression especially when liver biopsy is contraindicated, thus, protecting the patient from its hazards especially in cases of hepatic coagulopathy which is well known to occur in this category of patients

Hyperhomocysteinemia in end stage renal disease: a risk factor for atherosclerotic and/or thromboembolic complications?

To clarify the association of hyperhomocysteinemia with the increased risk of atherosclerotic and thromboembolic vascular complications in patients with end stage renal disease [ESRD] independent of other traditional risk factors, this study was performed. It included 150 patients with established ESRD scheduled on chronic ambulatory peritoneal dialysis [CAPD] or regular hemodialysis using high-flux membrane. All patients were supplemented with multivitamins including B12, B6 and folic acid. These patients were divided into two groups: Group A included 26 patients with clinically documented peripheral vascular events [ten with deep venous thrombosis and 16 with peripheral arterial disease] and group B included 124 patients without any clinically or laboratory documented vascular disease. In addition, 30 apparently healthy individuals were included as a control group. Total fasting plasma homocysteine as well as other risk factors were determined including hypertension, obesity, smoking, diabetes mellitus, hyperuricemia, dyslipidemia, prolonged recumbency and recent operations or trauma. Biochemical analyses were done including blood glucose levels [fasting and 2-hour postprandial], lipid profile [total cholesterol, triglycerides, HDL, LDL], serum uric acid, BUN and creatinine. Hematological analyses were also done including complete blood count, prothrombin time and concentration, aPTT, protein C, protein S, antithrombin III as well as fibrinogen. Imaging was also performed in the form of duplex ultrasound for peripheral arterial and/or venous systems and/or angiography in the selected cases. It was concluded that hyperhomocysteinemia is frequently seen in ESRD patients and it represents an independent risk factor for the atherosclerotic and thrombotic vascular disorders which occur frequently in these patients. It is higher in hemodialysis patients than in those on chronic ambulatory peritoneal dialysis [CAPD]