Low dose albumin for the prevention of renal impairment following large volume paracentesis in cirrhosis

Objectives: To evaluate the effect of low dose Albumin i.e. 4 grams per litre of ascitic fluid after large volume paracentesis [LVP] for the prevention of paracentesis induced circulatory dysfunction [PICD] related renal impairment in cirrhosis. Methods: Case records of all patients with cirrhosis who underwent LVP from January 12th, 2011 till December 29th, 2013 were reviewed. Patients were excluded if they had spontaneous bacterial peritonitis, creatinine >1.5 mg/dl, hepatoma or if volume of ascitic fluid removed was <5 litres. Data including age, gender, cause of cirrhosis, CTP score and volume of ascitic fluid drained were noted. In addition serum creatinine and serum sodium at baseline and one week post paracentesis were recorded. Results: Two hundred and fourteen patients with cirrhosis underwent LVP during the study period. One hundred and thirty nine patients met the inclusion criteria and were analyzed. Patients were divided into two groups based on the amount of albumin given. The amount of albumin given was 25 grams and 50 grams while the volume of ascitic fluid removed were 6.2+/-1 litres and 10.4+/-1.5 litres in groups A and B respectively. One hundred and eight patients were in group A while thirty one patients were in group B respectively. Both groups received albumin at a dose of 4 grams per litre of ascitic fluid removed. Mean age in both groups were 53 years. Hepatitis C was the commonest etiology in both the groups, followed by Hepatitis B. More than 70% patients in both the groups were in child class C. Serum creatinine at baseline and one week post LVP was 1.04+/-0.24 mg/dl and 1.07+/-0.35 mg/dl in GROUP A while 1.11+/-0.23 mg/dl and 1.41+/-0.94 mg/dl in GROUP B. [P value 0.35]. Similarly, serum sodium at baseline and one week post LVP was 130 +/-5.6 meq/lit and 129.6+/-5.9 meq/lit in GROUP A while 127.6+/-5.8 meq/lit and 128+/-6.2 meq/lit in GROUP B respectively. [P value 0.14] Conclusion: This study suggests that 4 grams of albumin per litre of ascitic fluid drained is effective in preventing the PICD related renal impairment following large volume paracentesis in cirrhosis

Varied presentation of celiac disease in Pakistani adults

The objective of this retrospective study was to evaluate presentation of celiac disease in adults. It included 77 patients, 41 [53.2%] males with median age 26 years and median body mass index of 18 [16 - 22] kg/m[2]. Typical presentation with gastrointestinal symptoms was seen in 76.6%. Atypical presentation with extra intestinal complaints in 7.8% and silent presentation in 15.6%. Major symptoms were diarrhea in 64.9%, weight loss 36.4%, abdominal pain 35.1%, vomiting 32.5%, pallor 24.7%, and weakness 13%. Iron deficiency was documented in 20.8%, B12 deficiency in 9.1%, folic acid deficiency in 6.5% and vitamin D deficiency in 10.4%. Half of the patients had haemoglobin less than 11 g/dl. Osteoporosis and osteomalacia, hypothyroidism, diabetes and atrophic gastritis were seen in 2.6% each. Raised alanine aminotransferase was documented in 23.4%. Duodenal biopsy, done in 39 patients, revealed increased intraepithelial lymphocytes in 11, along with crypt hyperplasia in 3, partial villous atrophy in 15 and sub-total villous atrophy in 10. In conclusion, celiac disease in adults should be looked for in patients with chronic diarrhea or irritable bowel syndrome like symptoms, underweight, anaemic, or having nutritional deficiencies

Perception and knowledge about dietary intake in patients with liver cirrhosis and its relationship with the level of education

To determine patients perception and knowledge regarding diet in cirrhosis and its relationship with the level of patients education. Cross-sectional observational study. This study was conducted at Gastroenterology Outpatient Clinics at the Aga Khan University Hospital, Karachi, the Aga Khan Health Services, Malir, Karachi and Hamdard University, Karachi, from January to December 2010. Consecutive adult patients with compensated cirrhosis were enrolled. Demographic data, level of education, type and reason of food restriction as well as the source of dietary information was asked. Baseline laboratory test were performed, and nutritional status was assessed by BMI normogram. Ninety patients, 58% male were enrolled. Mean age of the patient was 49 +/- 11 years. Overall 73% of the patients were restricting fat, meat, fish and eggs in their diet; 53% were in uneducated group and 47% were in educated group [CI, 0.24-1.62, p-0.34]. Twenty two patients [62.8%] in uneducated and 21 in educated group [68%] were restricting diet on the advice of their doctors, whereas 13 in uneducated group [37%] and 11 in educated group [32%] believed these dietary components to be harmful for the liver. Thirty two of uneducated patient [71.1%] and 28 of educated patients [62.2%] believed that vegetables, fruits and sugarcane had a beneficial effect on the liver. Main source of dietary information to the patients was the doctor. On sub-group analysis those who restricted diet irrespective of their educational level, had more patients with BMI less than 18.5 kg/m[2], [CI 0.01-0.94, p-0.001], haemoglobin less than 12 g/dl [CI 0- 0.03, p-0.001] and serum albumin less than 3 g/dl [CI 0.1- 03, p-0.001]. Both educated and uneducated classes of the patients have improper knowledge and perception of diet in cirrhosis. Patients with cirrhosis who restricted diet, had relatively low BMI, haemoglobin and albumin as compared to those who did not restrict. Main source of dietary information to cirrhotic patients were health care personnels

Model for end-stage liver disease [MELD] score as a useful prognostic marker in cirrhotic patients with infection

To determine the association of Model for End stage liver disease [MELD] score to the outcome of cirrhotic patients with bacterial infection and to compare it with Child-Turcott-Pugh [CTP] score. Descriptive study. The Aga Khan University Hospital, Karachi, from January 2005 to December 2007. Patients with diagnosis of liver cirrhosis and bacterial infection were included. Demographic features, laboratory data and type of infection were recorded. Multiple logistic regression assays were applied to determine the factors associated with poor outcome in cirrhotics with infection. Receiver-Operating Characteristics [ROC] were used to determine the cut-off values of CTP score and MELD score with the best sensitivity and specificity. A total of 530 patients, 313 male [59%] with a mean age of 53 +/- 13 years were analyzed. Spontaneous bacterial peritonitis was the predominant infection seen in 369 [69%] patients. One hundred and eighty six [35%] patients died. Factors associated with poor outcome were a CTP score of more than 11 [p=0.001], raised blood urea nitrogen [p=0.020], raised creatinine [p=0.004], shock [p=0.002], and MELD score > 22 [p=0.03]. An eight percent increase in mortality rate was noticed with every one point rise in MELD score above 22. ROC curve showed that the specificity of CTP and MELD score to predict poor outcome in these patients was 36% and 59% respectively. Child-Turcott-Pugh score more than 11, raised BUN and creatinine, shock and high MELD score were poor prognostic markers in cirrhotic patients with infection. MELD score had better specificity than CTP score in determining outcome