Hepatic Venous Pressure Gradient Predicts Long-Term Mortality in Patients with Decompensated Cirrhosis

PURPOSE: The present study aimed to investigate the role of hepatic venous pressure gradient (HVPG) for prediction of long-term mortality in patients with decompensated cirrhosis. MATERIALS AND METHODS: Clinical data from 97 non-critically-ill cirrhotic patients with HVPG measurements were retrospectively and consecutively collected between 2009 and 2012. Patients were classified according to clinical stages and presence of ascites. The prognostic accuracy of HVPG for death, survival curves, and hazard ratios were analyzed. RESULTS: During a median follow-up of 24 (interquartile range, 13-36) months, 22 patients (22.7%) died. The area under the receiver operating characteristics curves of HVPG for predicting 1-year, 2-year, and overall mortality were 0.801, 0.737, and 0.687, respectively (all p17 mm Hg, respectively (p=0.015). In the ascites group, the mortality rates at 1 and 2 years were 3.9% and 17.6% with HVPG 17 mm Hg, respectively (p=0.044). Regarding the risk factors for mortality, both HVPG and model for end-stage liver disease were positively related with long-term mortality in all patients. Particularly, for the patients with ascites, both prothrombin time and HVPG were independent risk factors for predicting poor outcomes. CONCLUSION: HVPG is useful for predicting the long-term mortality in patients with decompensated cirrhosis, especially in the presence of ascites.

In-hospital mortality risk factors in patients with ascites due to cirrhosis / Fatores de risco de mortalidade intra-hospitalar em pacientes com ascite por cirrose hepática

Introduction: ascites is one of the most common complications of cirrhosis associated with a high rate of mortality. Although several scores have been developed in order to assess the prognosis of the disease, they were designed for predicting liver transplantation requirements and mortality in the short term, but not while in hospital. The aim of this study was to weigh risk factors for in-hospital mortality in adult patients with ascites due to alcoholic cirrhosis. Material and methods: we performed a cross-sectional study in 180 adult patients with diagnosis of cirrhosis with portal hypertension associated with high alcohol intake. The diagnosis of cirrhosis was made by liver echography and portal hypertension was defined by clinical features plus serum-ascites albumin gradient. Sampled individuals were subjected to complete clinical examination. Child Pugh and the MELD scores were applied in all the patients. Results: nineteen patients died while in-hospital. Mortality was associated with increased levels of serum white blood cell, urea, creatinine, prolonged prothrombin time, aspartate aminotransferase and alanine aminotransferase. We conducted a multiple binary logistic to predict in-hospital mortality which yielded that serum urea, creatinine and prothrombin time made a significant contribution to prediction with an OR 14 (95% CI 12.8 - 16.7 p = 0.03), 2 (95% CI 0.5 - 3.47, p = 0.04), and 2 (95% CI 1.03 - 2.31, p = 0.01) linearly-related. Conclusions: our results suggest that acute renal failure and prolonged prothrombin time are predictors of in-hospital mortality in patients with portal hypertension due to alcoholic cirrhosis. .

Introdução: ascite é uma das complicações mais comuns de cirrose associadas a uma elevada taxa de mortalidade. Embora vários escores tenham sido desenvolvidos a fim de avaliar o prognóstico da doença, eles foram concebidos para prever requisitos de transplante de fígado e mortalidade a curto prazo, mas não durante a internação. O objetivo deste estudo foi o de pesar fatores de risco para a mortalidade intra-hospitalar em pacientes adultos com ascite decorrente de cirrose alcoólica. Material e métodos: foi realizado um estudo transversal em 180 pacientes adultos com diagnóstico de cirrose com hipertensão portal, associada à alta ingestão de álcool. O diagnóstico de cirrose foi feita por ecografia hepática e a hipertensão portal foi determinada por características clínicas e pelo gradiente de albumina soro-ascite. Indivíduos avaliados foram submetidos a exame clínico completo. A classificação de Child-Pugh e a escala MELD foram aplicadas em todos os pacientes. Resultados: dezenove pacientes morreram durante a internação. A mortalidade foi associada ao aumento dos níveis de glóbulos brancos, ureia, creatinina, aspartato aminotransferase, alanina aminotransferase e tempo de protrombina prolongado. Realizamos uma logística binária múltipla para prever a mortalidade intra-hospitalar, que confirmou que ureia, creatinina e tempo de protrombina contribuíram significativamente para a previsão, com uma OR = 14 (IC 95% 12,8-16,7 p = 0,03), 2 (IC 95% 0,5-3,47, p = 0,04), e 2 (IC 95% 1,03-2,31, p = 0,01), relacionada linearmente. Conclusões: nossos resultados sugerem que a insuficiência renal aguda e de tempo de protrombina prolongado são preditores de mortalidade intra-hospitalar em pacientes com hipertensão portal decorrente de cirrose alcoólica. .

Ascitis. Fisiopatología y tratamiento

Cirrhosis of the liver is the main cause of ascitis. Recent studies have shown in compensated cirrhotics a 40 percent chance to develop ascitis after five years of follow up. The presence of ascitis is usually associated with advanced liver disease, and higher mortality than patients with compensated cirrhosis. Many theories have been proposed to explain ascitis formation being the most important the presence of portal hypertension and sodium retention. Extravascular fluid accumulation depends directly of a balance between hydrostatic and colloid-osmotic pressure (Starling law). Hepatic sinusoids differ from splanchnic ones in regard to the presence of fenestrae, that allows albumin and other substances to flow freely from the sinusoid to the extravascular space. For these reasons the sinusoids lacks colloid-osmotic pressure, and the hydrostatic pressure regulates the flow of fluids passing through them. In cirrhosis, diffuse fibrosis and nodule formation cause functional obstruction to the hepatic blood flow, and a secondary increase in the sinusoidal pressure, that leads to exit of fluids from the sinusoids to the hepatic lymphatics and the thoracic duct. When the amount of fluid that leaves the sinusoids exceeds the capacity of the thoracic duct, fluids accumulate in the abdominal cvity (ascitis). A new theory about ascitis formation states that the first event is a diffuse peripheral arterial vasodilation that cause ineffective plasma volume that triggers the production of humoral factors directed to retain sodium in the kidney...

Prognostic value of preoperative tests in the surgical treatment of ascites with the implant of Le Veen shunts in cirrhotics

No período de janeiro de 1978 a outubro de 1982, 32 válvulas de Le Veen foram implantadas em 20 pacientes, dos quais 16 eram cirróticos alcoólicos e quatro pós-necróticos. No presente estudo foram correlacionados dados laboratoriais pré-operatórios destes pacientes com sua evoluçäo pós-operatória. Foram comparados os resultados clínicos dos pacientes que sobreviveram mais de 30 dias (13 pacientes = 65%), com os resultados daqueles que morreram dentro do mesmo período (sete pacientes = 35%). Foram realizadas 14 provas laboratoriais visando definir níveis séricos de hematócrito, hemoglobina, uréia, creatina, sódio, potássio, bilirrubina, aminotransferases, fosfatase alcalina, fibrinogênio, gamaglutamiltransferase e atividade de protrombina. Após análises estatísticas, observou-se que seis dos 14 testes realizados podem ser considerados de valor prognóstico, segundo ordem decrescente de importancia: fibrinogênio, fosfatase alcalina, uréia, gamaglutamiltransferase, bilirrubina e atividade de protrombina. Observou-se que todos os sete pacientes que prematuramente faleceram, tinham três ou mais destes alterados, quando comprados com valores padröes. Baseados nestes dados, conclui-se que estes säo fatores importantes em determinar o prognóstico da sobrevida imediata de cirróticos submetidos ao implante da válvula de Le Veen. Conclui-se, também, que quando três ou mias destes fatores estäo alterados, este procedimento cirúrgico dever ser contra-indicado