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Clinics ; 76: e2921, 2021. tab, graf
Article in English | LILACS | ID: biblio-1278928


OBJECTIVES: Acute variceal bleeding (AVB) results from rupture of esophageal or gastric varices. It is a life-threatening complication of portal hypertension. Nevertheless, it remains unclear how to predict adverse outcomes and identify high-risk patients. In variceal hemorrhage, high Child-Turcotte-Pugh (Child) and Model for End-stage Liver Disease (MELD) scores are associated with a worse prognosis. The Rockall system (Rockall), Glasgow-Blatchford (Blatchford), and AIMS65 scores have been validated for risk stratification for nonvariceal upper gastrointestinal bleeding; however, their use is controversial in AVB. The aim of this study was to compare the performance of Child, MELD, Rockall, Blatchford, and AIMS65 scores in risk stratification for rebleeding and/or mortality associated with AVB. METHODS: This retrospective study was conducted at a tertiary care hospital over 42 months. The outcomes were 6-week rebleeding and mortality. The AUROC was calculated for each score (1-0.9, 0.9-0.8, and 0.8-0.7, indicating excellent, good, and acceptable predictive power, respectively). RESULTS: In total, 222 patients were included. Six-week rebleeding and mortality rates were 14% and 18.5%, respectively. No score was useful for discriminating patients at a higher risk of rebleeding. The AUROCs were 0.59, 0.57, 0.61, 0.63, and 0.56 for Rockall, Blatchford, AIMS65, Child, and MELD scores, respectively. Prediction of 6-week mortality based on Rockall (AUROC 0.65), Blatchford (AUROC=0.60), and AIMS65 (AUROC=0.67) scores were also not considered acceptable. The AUROCs for predicting mortality were acceptable for Child and MELD scores (0.72 and 0.74, respectively). CONCLUSION: Rockall, Blatchford, and AIMS65 scores are not useful for predicting 6-week rebleeding or mortality in patients with AVB. Child and MELD scores can identify patients at higher risk for 6-week mortality but not for 6-week rebleeding.

Humans , Esophageal and Gastric Varices/diagnosis , Esophageal and Gastric Varices/etiology , End Stage Liver Disease , Prognosis , Severity of Illness Index , Retrospective Studies , ROC Curve , Hospital Mortality , Risk Assessment , Gastrointestinal Hemorrhage/diagnosis , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/therapy
Clinics ; 76: e2409, 2021. tab, graf
Article in English | LILACS | ID: biblio-1278910


This study aimed to perform a meta-analysis to determine the efficacy and safety of emricasan. Nine databases were searched for clinical trials investigating the efficacy of emricasan treatment in patients with liver cirrhosis or fibrosis. A manual search was conducted to identify the missing trials. The quality of the included studies was assessed using the revised Cochrane risk of bias tool. Efficacy of emricasan treatment was defined as a positive change in apoptosis-related parameters from baseline to the last follow-up visit. Overall, emricasan treatment is more effective in patients with liver cirrhosis or fibrosis than placebo (standardized mean difference [SMD] [95% confidence intervals (CI)]=0.28 [0.14; 0.41]). No significant change in model for end-stage liver disease (MELD) score between the emricasan and placebo groups was noted (SMD [95% CI]=0.18 [-0.01; 0.36]; p=0.058). A 50 mg dose of emricasan had the highest efficacy rate compared to placebo (SMD [95% CI]=0.28 [0.06; 0.50]; p=0.012), followed by the 5 mg dosing regimen (SMD [95% CI]=0.28 [0.06; 0.50]; p=0.012). Treatment with emricasan resulted in significant reductions in ALT (mean difference (MD) [95% CI]=-5.89 [-10.59; -1.20]; p=0.014) and caspase3/7 levels (MD [95%CI]=-1215.93 [-1238.53; -1193.33]; p<0.001), respectively. No significant increase in the rate of overall adverse events was noted (OR [95% CI]=1.52 [0.97; 2.37]; p=0.069). Treatment with emricasan is more effective in improving liver function and apoptosis parameters compared to placebo, with a well-tolerated safety profile. However, due to the poor quality of the analyzed studies, the small number of trials and patients, and the short follow-up periods, more robust trials are still warranted.

Humans , End Stage Liver Disease , Pentanoic Acids , Severity of Illness Index , Fibrosis , Liver Cirrhosis/drug therapy
Chinese Journal of Surgery ; (12): 179-191, 2021.
Article in Chinese | WPRIM | ID: wpr-878277


Pediatric liver transplantation (PLT) is an effective strategy of treating various acute or chronic end-stage liver diseases and inherited metabolic diseases in children.PLT has been applied in many transplant centers nationwide and has achieved satisfactory results.However,the development of transplant centers is uneven,and there is a lack of consensus and standards within the industry.In order to reduce post-operative complications,accelerate post-operative recovery,and improve the short-and long-term quality of life of children,the Enhanced Recovery After Surgery Committee of Chinese Research Hospital Association organized multidisciplinary experts to summarize the progress of domestic and international research,and formulated a perioperative consensus on PLT based on the principles of evidence-based medicine.The consensus provides recommendations for perioperative PLT from three aspects:preoperative assessment and preparation,intraoperative management and postoperative management,in order to provide reference guidelines for centers that are conducting or preparing to conduct PLT.

Child , Consensus , End Stage Liver Disease/therapy , Enhanced Recovery After Surgery/standards , Humans , Liver Transplantation/standards , Metabolism, Inborn Errors/therapy , Perioperative Care/standards , Practice Guidelines as Topic
Rev. Col. Bras. Cir ; 48: e20212997, 2021. tab, graf
Article in English | LILACS | ID: biblio-1360755


ABSTRACT Objective: to correlate clinical and epidemiological data with the pathological analysis of liver explants from patients undergoing liver transplantation for hetapocarcinoma in the UNICAMP HC and to verify whether the MELD and MELD-Na scores are reliable factors to predict a worse post-transplant prognosis. Methods: we studied liver transplants carried out between May 2010 and November 2017. After excluding 38 patients, we included 87, analyzing clinical and laboratory data for correlation with the outcome Microvascular Invasion (MVI). Subsequently, we computed the MELD and MELD-Na scores and performed a descriptive analysis of clinical and laboratory data and, finally, calculated ROC curves to assess the association between these laboratory parameters and mortality in these patients. Results: most patients were male (78.30%), with an average age of 58.53 years. Most liver diseases were caused by HCV (53.26%). We found no predictors for MVI among the laboratory parameters. The ROC curves for death identified the MELD score as the cutoff point with the highest combined sensitivity (90.91%) and specificity (37.50%), with a value of 10 points, whereas in the MELD-Na the cutoff point was 7 points, with a sensitivity of 90.91% and a specificity of 33.33%, both scores being significant. Conclusions: there were no reliable predictors of MVI between clinical, laboratory, and epidemiological variables. The MELD-Na score is more sensitive than the MELD one for predicting mortality in patients undergoing liver transplantation.

RESUMO Objetivo: correlacionar dados clínicos e epidemiológicos com a análise patológica dos explantes hepáticos dos pacientes submetidos ao transplante hepático por hetapocarcinoma no HC da UNICAMP e verificar se os scores MELD e MELD-Na apresentam diferenças estatísticas para predizer pior prognóstico pós-transplante. Métodos: considerando os transplantes hepáticos ocorridos entre maio/2010 e novembro/2017, após excluir 38, 87 pacientes foram incluídos, analisando-se dados clínicos e laboratoriais desses pacientes para verificar se há independência entre esses e desfecho Invasão Microvascular (IMV). Posteriormente, realizou-se o cálculo do MELD e MELD-Na, a análise descritiva dos dados clínicos e laboratoriais e, por fim, curvas ROC para avaliar a associação entre esses parâmetros laboratoriais e o desfecho óbito nestes pacientes. Resultados: a maior parte dos pacientes foi do sexo masculino (78,30%), com idade, em média, de 58,53 anos. A maior parte das hepatopatias foi causada pelo VHC (53,26%). Não foi encontrado preditores para o desfecho IMV entre os parâmetros laboratoriais. As curvas ROC para o desfecho óbito identificaram o score MELD como ponto de corte de maior sensibilidade (90,91%) e especificidade (37,50%) simultâneas com o valor de 10 pontos, ao passo que no MELD-Na o ponto de corte foi 7 pontos, com sensibilidade de 90,91% e especificidade de 33,33%, sendo ambas as escalas significativas. Conclusões: não foram encontrados preditores para IMV entre critérios clínicos, laboratoriais e epidemiológicos. O score MELD-Na é mais sensível que o MELD para predizer mortalidade nos pacientes submetidos a transplante hepático.

Liver Transplantation , End Stage Liver Disease/surgery , Liver Diseases , Prognosis , Severity of Illness Index , Retrospective Studies , ROC Curve , Middle Aged
Einstein (Säo Paulo) ; 18: eAO4039, 2020. tab, graf
Article in English | LILACS | ID: biblio-1056073


ABSTRACT Objective To evaluate the oxidative profile, nutritional status and food intake (caloric value; macronutrients; vitamins A, E and C; and zinc), and to correlate oxidative stress with nutritional status in patients who were candidates for liver transplant. Methods This is a cross-sectional, analytical, and descriptive study with 51 candidates for liver transplant. Sociodemographic and clinical data, anthropometric parameters, food consumption, and a 10mL blood sample were collected from each patient. Oxidative stress was analyzed by the thiobarbituric acid method. The consumption of macronutrients, caloric value and micronutrients (zinc, vitamins A, E and C) were qualitatively analyzed, and zinc was also quantitatively analyzed. Results The mean age was 49.17±8.17 years. The highest percentage of malnutrition was according to arm muscle circumference (56.86%), followed by arm circumference (52.94%), triceps skin fold (50.98%), and body mass index (1.96%). The mean malondialdehyde level was 14.80±8.72μM/L, presenting a negative correlation with the body mass index for patients with liver cirrhosis according to IMC-Campillo values (p=0.001; r=-0.430). Low energy, carbohydrate, protein, vitamin A and E consumption were observed in more than 50% of subjects. Conclusion This study showed an association of nutritional status through body mass index for patients with liver cirrhosis according to IMC-Campillo, with oxidative stress in patients with liver cirrhosis on a liver transplant waiting list.

RESUMO Objetivo Avaliar o perfil oxidativo, o estado nutricional e o consumo alimentar (valor calórico; macronutrientes; vitaminas A, E e C; e zinco), e correlacionar o estresse oxidativo com o estado nutricional em pacientes candidatos ao transplante hepático. Métodos Trata-se de estudo transversal, analítico e descritivo com 51 pacientes candidatos ao transplante hepático. Coletaram-se dados sociodemográficos e clínicos, parâmetros antropométricos, consumo alimentar e amostra de 10mL de sangue de cada paciente. O estresse oxidativo foi analisado por método do ácido tiobarbitúrico. O consumo de macronutrientes, do valor calórico e dos micronutrientes (zinco, vitaminas A, E e C) foi analisado qualitativamente, e o zinco também foi analisado quantitativamente. Resultados A média de idade foi de 49,17±8,17 anos. Maior percentual de desnutrição esteve de acordo com circunferência muscular do braço (56,86%), seguida de circunferência do braço (52,94%), dobra cutânea triciptal (50,98%) e índice de massa corporal (1,96%). A média do malondialdeído foi de 14,80±8,72µM/L, apresentando correlação negativa com os valores do índice de massa corporal para pacientes com cirrose hepática segundo IMC-Campillo (p=0,001; r=-0,430). Observou-se baixo consumo de energia, carboidrato, proteína, e vitaminas A e E em mais de 50% dos indivíduos. Conclusão Este estudo mostrou associação do estado nutricional, por meio do índice de massa corporal para pacientes com cirrose hepática segundo IMC-Campillo, com o estresse oxidativo em paciente com cirrose hepática em lista de transplante de fígado.

Humans , Male , Female , Adult , Nutritional Status/physiology , Liver Transplantation/statistics & numerical data , Oxidative Stress/physiology , End Stage Liver Disease/metabolism , Transplant Recipients/statistics & numerical data , Reference Values , Energy Intake , Nutrition Assessment , Anthropometry , Cross-Sectional Studies , Statistics, Nonparametric , Educational Status , Feeding Behavior/physiology , End Stage Liver Disease/surgery , Malondialdehyde/blood , Middle Aged
Rev. méd. Chile ; 147(9): 1099-1106, set. 2019. tab, graf
Article in Spanish | LILACS | ID: biblio-1058651


Background: Cirrhotic patients have an increased surgical risk due to potential intra and postoperative complications. Aim: To describe the clinical characteristics and surgical complications of cirrhotic patients undergoing surgery in a Chilean university hospital. Patients and Methods: Review of medical records of 102 cirrhotic patients aged 60 ± 11 years (52% males) who underwent elective or urgency surgery at an university hospital between 2010 and 2016. General, pre-surgical, and post-surgical complications were recorded. Results: The main etiologies of cirrhosis were non-alcoholic steatohepatitis (31%), and alcoholic cirrhosis (28%). Child-Pugh scores were A, B and C in 50, 28 and 22% of cases respectively. Median MELD (Model for End-stage Liver Disease) score was 11 (interquartile range: 10-15). The surgical procedure was elective in 71% of cases, with predominance of abdominal surgery (86%). The American Society of Anesthesiologists (ASA) score was three or more in 52% of patients. The frequency of any adverse outcome was 62%. The frequency increased along with the severity of cirrhosis and when surgery was urgent. The most common complications were acute renal failure (24%), increased ascites (23%) and encephalopathy (22%). Admission to intensive care unit occurred on 26% of patients, with six hospital deaths. Conclusions: In these patients, surgical complications were common, although with low mortality.

Humans , Male , Female , Middle Aged , Aged , End Stage Liver Disease , Severity of Illness Index , Chile/epidemiology , Elective Surgical Procedures , Liver Cirrhosis/surgery , Liver Cirrhosis/complications
Arq. gastroenterol ; 56(3): 252-255, July-Sept. 2019. tab
Article in English | LILACS | ID: biblio-1038715


ABSTRACT BACKGROUND: Fatigue is highly prevalent in end stage liver disease, the studies about its association with exercise capacity in cirrhotic patients before liver are scarse. OBJECTIVE: In this study, we evaluated fatigue in 95 in end stage liver disease patients awaiting transplantation, compared to healthy volunteers, and tested the association between exercise capacity and fatigue. METHODS: Cross-sectional study of patients with chronic liver disease treated at a referral center in Fortaleza, Brazil. Fatigue was quantified with the Fatigue Severity Scale. The patients were submitted to the 6-min walk test, the 6-min step test, the Hospital Anxiety and Depression Scale, C-reative protein measurement and hematocrit count, measurement of dyspnea among other tests. Fatigue data were obtained from healthy individuals for comparison with patients. RESULTS: The mean age of patients was 45.9±12.3 years, and 53.7% were male. Fatigue, anxiety and depression levels were higher among end stage liver disease patients than among controls. A negative correlation was observed between 6 min step test and Fatigue Severity Scale score (r= -0.2; P=0.02) and between hematocrit count and Fatigue Severity Scale score (r= -0.24; P=0.002). Dyspnea on the Borg scale and fatigue were positively correlated (r=31; P=0.002). In the multivariate analysis, low 6-min step test values and high levels of dyspnea were associated with fatigue. CONCLUSION: Fatigue was more prevalent and severe in end stage liver disease patients than in healthy controls. Low 6MST values and high levels of dyspnea were associated with fatigue in this scenario.

RESUMO CONTEXTO: A fadiga é uma queixa comum em indivíduos com doença hepática crônica candidatos a transplante hepático. Estudos sobre sua associação com capacidade do exercício são escassos. OBJETIVO: Avaliar a fadiga de pacientes com hepatopia crônica candidatos a transplante hepático comparando com um grupo de indivíduos saudáveis. Avaliar a associação da fadiga com capacidade de exercício. MÉTODOS: Este é um estudo transversal com pacientes hepatopatas crônicos num centro de referência em Fortaleza, Brasil. Foi utilizado o questionário de gravidade da fadiga. Os pacientes realizaram o teste da caminhada dos 6 min, teste do degrau 6 min, foi aplicada a escala de ansiedade e depressão, foram dosados proteína C reativa e hematócrito. RESULTADO: A idade média dos pacientes foi de 45,9±12,3 anos, sendo que 53,7% eram homens. Os níveis de fadiga e ansiedade e depressão eram maiores entre os pacientes hepatopatas crônicos quando comparados ao grupo controle. Uma correlação inversa foi observada entre fadiga e o teste do degrau (r= -0,2; P=0,02) também entre hematócrito e fadiga (r= -0,24; P=0,002). Houve uma correlação positiva entre dispneia, através da escala de Borg, e fadiga (r=31; P=0,002). Na análise multivariada um baixo desempenho no teste do degrau e um nível maior de dispneia mostraram uma associação com fadiga. CONCLUSÃO: A fadiga é mais frequente entre os pacientes hepatopatas crônicos quando comparados ao grupo controle. O baixo desempenho na capacidade de exercício e uma queixa maior de dispneia apresentaram uma associação com fadiga nestes pacientes.

Humans , Male , Female , Adult , Liver Transplantation/psychology , Exercise Tolerance/physiology , Fatigue/psychology , End Stage Liver Disease/psychology , Anxiety Disorders/psychology , Cross-Sectional Studies , Waiting Lists , Depressive Disorder/psychology , Fatigue/physiopathology , End Stage Liver Disease/physiopathology , Middle Aged
Arq. gastroenterol ; 56(3): 286-293, July-Sept. 2019. tab, graf
Article in English | LILACS | ID: biblio-1038711


ABSTRACT BACKGROUND: Variceal bleeding remains important cause of upper gastrointestinal bleed. Various risk scores are used in risk stratification for non-variceal bleed. Their utility in variceal bleeding patients is not clear. This study aims to compare probability of these scores in predicting various outcomes in same population. OBJECTIVE: This study aims to compare probability of these scores in predicting various outcomes in same population. To study characteristics and validate AIMS65, Rockall, Glasgow Blatchford score(GBS), Progetto Nazionale Emorragia Digestiva (PNED) score in variceal Upper Gastrointestinal Bleed (UGIB) patients for predicting various outcomes in our population. METHODS: Three hundred subjects with UGIB were screened prospectively. Of these 141 patients with variceal bleeding were assessed with clinical, blood investigations and endoscopy and risk scores were calculated and compared to non-variceal cases. All cases were followed up for 30 days for mortality, rebleeding, requirement of blood transfusion and need of radiological or surgical intervention. RESULTS: Variceal bleeding (141) was more common than non variceal (134) and 25 had negative endoscopy. In variceal group, cirrhosis (85%) was most common etiology. Distribution of age and sex were similar in both groups. Presence of coffee coloured vomitus (P=0.002), painless bleed (P=0.001), edema (P=0.001), ascites (P=0.001), hemoglobin <7.5 gms (P<0.001), pH<7.35 (P<0.001), serum bicarbonate level <17.6 mmol/L (P<0.001), serum albumin<2.75 gms% (P<0.001), platelet count <1.2 lacs/µL (P<0.001), high INR 1.35 (P<0.001), BUN >25mmol/L (P<0.001), and ASA status (P<0.001), high lactate >2.85 mmol/L (P=0.001) were significant. However, no factor was found significant on multivariate analysis. Rockall was found to be significant in predicting mortality and rebleed. AIMS65 was also significant in predicting mortality. GBS was significant in predicting blood transfusion and need of intervention. PNED score was significant in all events except mortality. CONCLUSION: All four scores had lower predictive potential in predicting events in variceal bleed. However, AIMS65 & Rockall score were significant in predicting mortality, while GBS in predicting need of transfusion and intervention. PNED score was significant in all events except mortality.

RESUMO CONTEXTO: O sangramento varicoso permanece como importante causa de sangramento gastrointestinal superior. Vários escores são utilizados na estratificação do risco para sangramento não varicoso. Sua utilidade em pacientes de sangramento varicoso não é clara. OBJETIVO: Este estudo tem como objetivo comparar a probabilidade desses escores em prever vários desfechos na mesma população. Estudar característica e validar o AIMS65, o Rockall, a Pontuação de Glasgow Blatchford (GBS), o escore Progetto Nazionale Emorragia Digestiva (PNED), na pontuação em hemorragia gastrointestinal varicosa superior (UGIB) em pacientes para prever vários resultados em nossa população. MÉTODOS: Um total de 300 indivíduos com UGIB foram rastreados prospectivamente. Destes, 141 pacientes com sangramento varicoso foram submetidos à avaliação clínica, hematológica e endoscopia tendo seus escores de risco calculados e comparados aos casos não-varicosos. Todos os casos foram acompanhados por 30 dias para mortalidade, necessidade de transfusão sanguínea por ressangramento ou de necessidade de intervenção radiológica ou cirúrgica. RESULTADOS: O sangramento varicoso (141) foi mais comum do que não varicoso (134) e em 25 teve endoscopia negativa. No grupo varicoso, a cirrose foi a etiologia mais comum (85%). A distribuição da idade e do sexo foi semelhante em ambos os grupos. Presença de vômito colorido em borra de café (P=0,002), sangramento indolor (P=0,001), edema (P=0,001), ascite (P=0,001), hemoglobina <7,5 GMS (P<0,001), pH <7,35 (P<0,001), nível de bicarbonato sérico <17,6 mmol/L (P<0,001), albumina sérica <2,75 GMS% (P<0,001), contagem plaquetária <1,2 Lacs/μL (P<0,001), INR elevada 1,35 (P<0,001), Bun >25 mmol/L (P<0,001) e estado ASA (P<0,001), lactato elevado >2,85 mmol/L (P=0,001) foram significativos. Entretanto, nenhum fator foi encontrado como significativo na análise multivariada. Rockall foi significativo em prever a mortalidade e ressangrar. O AIMS65 também foi significante na predição da mortalidade. O GBS foi significativo na predição de transfusão sanguínea e necessidade de intervenção. O escore de PNED foi significante em todos os eventos, exceto mortalidade. CONCLUSÃO: Todos os quatro escores apresentaram menor potencial preditivo na predição de eventos em sangramento varicoso. Entretanto, o AIMS65 e o escore de Rockall foram significantes na predição da mortalidade, enquanto o GBS na predição da necessidade de transfusão e intervenção. O escore de PNED foi significante em todos os eventos, exceto mortalidade.

Humans , Male , Female , Adult , Young Adult , Esophageal and Gastric Varices/complications , Gastrointestinal Hemorrhage/etiology , Blood Transfusion , ROC Curve , Risk Assessment , Lactic Acid/blood , Endoscopy , End Stage Liver Disease/etiology , End Stage Liver Disease/mortality , Gastrointestinal Hemorrhage/classification , Hospitalization , Liver Cirrhosis/complications , Liver Cirrhosis/mortality , Middle Aged
Rev. méd. Chile ; 147(8): 955-964, ago. 2019. tab, graf
Article in Spanish | LILACS | ID: biblio-1058630


Background: Liver transplantation (LT) is an option for people with liver failure who cannot be cured with other therapies and for some people with liver cancer. Aim: To describe, and analyze the first 300 LT clinical results, and to establish our learning curve. Material and Methods: Retrospective cohort study with data obtained from a prospectively collected LT Program database. We included all LT performed at a single center from March 1994 to September 2017. The database gathered demographics, diagnosis, indications for LT, surgical aspects and postoperative courses. We constructed a cumulative summation test for learning curve (LC-CUSUM) using 30-day post-LT mortality. Mortality at 30 days, and actuarial 1-, and 5-year survival rate were analyzed. Results: A total of 281 patients aged 54 (0-71) years (129 women) underwent 300 LT. Ten percent of patients were younger than 18 years old. The first, second and third indications for LT were non-alcoholic steatohepatitis, chronic autoimmune hepatitis and alcoholic liver cirrhosis, respectively. Acute liver failure was the LT indication in 51 cases (17%). The overall complication rate was 71%. Infectious and biliary complications were the most common of them (47 and 31% respectively). The LC-CUSUM curve shows that the first 30 patients corresponded to the learning curve. The peri-operative mortality was 8%. Actuarial 1 and 5-year survival rates were 82 and 71.4%, respectively. Conclusions: Outcome improvement of a LT program depends on the accumulation of experience after the first 30 transplants and the peri-operative mortality directly impacted long-term survival.

Humans , Male , Female , Adult , Middle Aged , Aged , Young Adult , Program Evaluation/standards , Liver Transplantation/standards , Learning Curve , Postoperative Complications/mortality , Time Factors , Survival Rate , Retrospective Studies , Liver Transplantation/methods , Liver Transplantation/mortality , Treatment Outcome , Statistics, Nonparametric , End Stage Liver Disease/surgery , End Stage Liver Disease/mortality
Rev. bras. anestesiol ; 69(3): 279-283, May-June 2019. tab, graf
Article in English | LILACS | ID: biblio-1013423


Abstract Background: Liver transplantation is the only curative therapeutic modality available for individuals at end-stage liver disease. There is no reliable method of predicting the early postoperative outcome of these patients. The Acute Physiology and Chronic Health Evaluation (APACHE) is a widely used model for predicting hospital survival and benchmarking in critically ill patients. This study evaluated the calibration and discrimination of APACHE IV in the postoperative period of elective liver transplantation in the southern Brazil. Methods: This was a clinical prospective and unicentric cohort study that included 371 adult patients in the immediate postoperative period of elective liver transplantation from January 1, 2012 to December 31, 2016. Results: In this study, liver transplant patients who evolved to hospital death had a significantly higher APACHE IV score (82.7 ± 5.1 vs. 51.0 ± 15.8; p < 0.001) and higher predicted mortality (6.5% [4.4-20.2%] vs. 2.3% [1.4-3.5%]; p < 0.001). The APACHE IV score showed an adequate calibration (Hosmer-Lemeshow - H-L = 11.37; p = 0.181) and good discrimination (Receiver Operator Curve - ROC of 0.797; Confidence Interval 95% - 95% CI 0.713-0.881; p < 0.0001), although Standardized Mortality Ratio (SMR = 2.63), (95% CI 1.66-4.27; p < 0.001) underestimate mortality. Conclusions: In summary, the APACHE IV score showed an acceptable performance for predicting a hospital outcome in the postoperative period of elective liver transplant recipients.

Resumo Introdução: O transplante de fígado é a única modalidade terapêutica curativa disponível para indivíduos com doença hepática terminal. Não há método confiável de prever o resultado pós-operatório imediato desses pacientes. A Avaliação da Gravidade da Doença Crônica e Aguda com bases Fisiológicas (APACHE) é um modelo amplamente usado para prever a sobrevida hospitalar e fazer a avaliação comparativa de pacientes criticamente enfermos. Este estudo avaliou a calibração e discriminação do APACHE IV no pós-operatório de transplante hepático eletivo no sul do Brasil. Métodos: Estudo clínico prospectivo de coorte em centro único que incluiu 371 pacientes adultos no pós-operatório imediato de transplante hepático eletivo de 1 de janeiro de 2012 a 31 de dezembro de 2016. Resultados: Neste estudo, pacientes com transplante hepático que evoluíram para óbito hospitalar obtiveram escore APACHE IV significativamente maior (82,7 ± 5,1 vs. 51,0 ± 15,8; p < 0,001) e mortalidade prevista mais alta (6,5% [4,4% -20,2%] vs 2,3% [1,4% -3,5%], p < 0,001). O escore APACHE IV mostrou uma calibração adequada (Hosmer-Lemeshow - H-L = 11,37; p = 0,181) e boa discriminação (Receiver Operator Curve - ROC de 0,797; intervalo de confiança de 95% - IC 95% 0,713-0,881; p < 0,0001), embora a taxa de mortalidade padronizada (Standardized Mortality Ratio - SMR = 2,63), (IC 95% 1,66-4,27; p < 0,001) subestime a mortalidade. Conclusões: Em resumo, o escore APACHE IV mostrou um desempenho aceitável para predizer um desfecho hospitalar no período pós-operatório de receptores eletivos de transplante hepático.

Humans , Aged , Liver Transplantation/methods , APACHE , End Stage Liver Disease/surgery , Postoperative Period , Brazil , Calibration , Prospective Studies , Cohort Studies , Liver Transplantation/mortality , Hospital Mortality , End Stage Liver Disease/mortality , Middle Aged
Chinese Journal of Hepatology ; (12): 330-342, 2019.
Article in Chinese | WPRIM | ID: wpr-773068


Malnutrition is common in patients with end-stage liver disease (ESLD) and is an independent risk factor for survival, therefore it should be treated as the same important guideline as ascites and hepatic encephalopathy. However, up to now, there is no clinical nutrition guideline for patients with ESLD in China. In order to standardize the nutrition treatment, Chinese Society of Hepatology (CSH) and Chinese Society of Gastroenterology (CSGE), Chinese Medical Association(CMA) co-organized and co-developed this guideline. Recommendations on nutritional screening and assessment as well as principles of intervention and management in patients with ESLD were provided to help clinicians make rational decisions on clinical malnutrition.

Ascites , China , End Stage Liver Disease , Enteral Nutrition , Reference Standards , Gastroenterology , Reference Standards , Hepatic Encephalopathy , Humans , Liver Cirrhosis , Malnutrition , Diet Therapy , Nutrition Assessment , Nutritional Status , Practice Guidelines as Topic
Yonsei Medical Journal ; : 944-951, 2019.
Article in English | WPRIM | ID: wpr-762038


PURPOSE: Hepatic hydrothorax is a complication of decompensated liver cirrhosis that is difficult and complex to manage. Data concerning the optimal treatment method, other than liver transplantation, are limited. This study aimed to compare the clinical features and outcomes of patients treated with various modalities, while focusing on surgical management and pigtail drainage. MATERIALS AND METHODS: Forty-one patients diagnosed with refractory hepatic hydrothorax between January 2013 and December 2017 were enrolled. RESULTS: The mean Child-Turcotte-Pugh and model for end stage liver disease scores of the enrolled patients were 10.1 and 19.7, respectively. The patients underwent four modalities: serial thoracentesis (n=11, 26.8%), pigtail drainage (n=16, 39.0%), surgery (n=10, 24.4%), and liver transplantation (n=4, 9.8%); 12-month mortality rate/median survival duration was 18.2%/868 days, 87.5%/79 days, 70%/179 days, and 0%/601.5 days, respectively. Regarding the management of refractory hepatic hydrothorax, surgery group required less frequent needle puncture (23.5 times in pigtail group vs. 9.3 times in surgery group), had a lower occurrence of hepatorenal syndrome (50% vs. 30%), and had a non-inferior cumulative overall survival (402.1 days vs. 221.7 days) compared to pigtail group. On multivariate analysis for poor survival, body mass index 10, and history of severe encephalopathy (grade >2) were associated with poor survival. CONCLUSION: Serial thoracentesis may be recommended for management of hepatic hydrothorax and surgical management can be a useful option in patients with refractory hepatic hydrothorax, alternative to pigtail drainage.

Body Mass Index , Brain Diseases , Drainage , End Stage Liver Disease , Fibrosis , Hepatorenal Syndrome , Humans , Hydrothorax , Liver Cirrhosis , Liver Transplantation , Methods , Mortality , Multivariate Analysis , Needles , Punctures , Thoracentesis
An. bras. dermatol ; 93(2): 277-278, Mar.-Apr. 2018. graf
Article in English | LILACS | ID: biblio-887187


Abstract: Crusted scabies is a less common variant of scabies that is highly contagious, difficult to treat and involves infestation by Sarcoptes scabiei var. hominis. The classical clinical presentation includes crusted, scaly and generally non-pruritic lesions usually located on the head, neck, palmar, plantar and periungual region. It was first described in Norway in 1848 in patients with leprosy who presented with crusted lesions. In this study, we report the case of a patient with crusted scabies with florid clinical manifestations and chronic liver disease due to hepatitis B and delta virus infection.

Humans , Male , Middle Aged , Scabies/pathology , Scabies/drug therapy , Hepatitis Delta Virus , Hepatitis B virus , End Stage Liver Disease/virology , Scabies/immunology , Treatment Outcome , End Stage Liver Disease/complications , Antiparasitic Agents/therapeutic use
Singapore medical journal ; : 628-633, 2018.
Article in English | WPRIM | ID: wpr-776975


Liver fibrosis is a slow, insidious process involving accumulation of extracellular matrix protein in the liver. The stage of liver fibrosis in chronic liver disease (CLD) determines overall morbidity and mortality; the higher the stage, the worse the prognosis. Noninvasive composite scores can be used to determine whether patients with CLD have significant or advanced fibrosis. Patients with low composite scores can be safely followed up in primary care with periodic reassessment. Those with higher scores should be referred to a specialist. As the epidemic of diabetes mellitus, obesity and non-alcoholic fatty liver diseases is rising, CLD is becoming more prevalent. Easy-to-use fibrosis assessment composite scores can identify patients with minimal or advanced fibrosis, and should be an integral part of decision-making. Patients with cirrhosis, high composite scores, chronic hepatitis B with elevated alanine aminotransferase and aspartate aminotransferase, or deranged liver panel of uncertain aetiology should be referred to a specialist.

Alanine Transaminase , Blood , Aspartate Aminotransferases , Blood , Decision Making , End Stage Liver Disease , Diagnosis , Therapeutics , Hepatitis B , Humans , Liver , Pathology , Liver Cirrhosis , Diagnosis , Therapeutics , Non-alcoholic Fatty Liver Disease , Diagnosis , Therapeutics , Prognosis , Referral and Consultation , Treatment Outcome
Article in Chinese | WPRIM | ID: wpr-771468


OBJECTIVE@#To establish a model for predicting the short-term prognosis of patients with HBV-related acute-onchronic liver failure (HBV-ACLF) based on red blood cell distribution width (RDW) and the model for end-stage liver disease (MELD) scores.@*METHODS@#A total of 245 patients with HBV-ACLF were retrospectively analyzed for their clinical data and results of routine hematological tests, liver function, renal function, coagulation test, HBV-DNA, and other indicators at admission. Univariate analysis and binary logistic regression analysis were used to test the short-term risk factors for death of the patients, and the MELD-RDW model was established. The accuracy of each index and the established model was verified using the ROC curve.@*RESULTS@#The surviving patients with HBV-ACLF had significantly decreased RDW (14.97 ± 1.38) and MELD score (23.54±4.35) compared with those in the patients dead within 90 days (17.05±2.92 and 28.95±5.99, respectively). Multivariate analysis indicated that RDW was a significant independent prognostic factor for mortality in patients with HBVACLF (OR=1.840, 95%CI: 1.47902.289, < 0.005). The risk assessment model was [logisticMELD-RDW]=-9.375+0.582×RDW- 0.091×ALB-0.05×PTA+0.186×MELD. The area under the ROC curve of MELD score combined with RDW was 0.878, which was higher than RDW (0.724) and MELD score (0.780) alone.@*CONCLUSIONS@#RDW is an independent prognostic indicator for mortality in patients with HBV-ACLF. Compared with MELD score, the risk assessment model based on MELD and RDW has a greater value in predicting the short-term prognosis of patients with HBV-ACLF.

Acute-On-Chronic Liver Failure , Blood , Mortality , Cell Size , End Stage Liver Disease , Blood , Mortality , Erythrocyte Volume , Erythrocytes , Cell Biology , Hepatitis B , Blood , Mortality , Humans , Prognosis , ROC Curve , Retrospective Studies
Chinese Medical Journal ; (24): 1314-1320, 2018.
Article in English | WPRIM | ID: wpr-688125


<p><b>Background</b>Contribution of model for end-stage liver disease incorporating with serum sodium (MELD-Na) score in predicting acute kidney injury (AKI) after orthotopic liver transplantation (OLT) is yet to be identified. This study assessed the prognostic value of MELD-Na score for the development of AKI following OLT.</p><p><b>Methods</b>Preoperative and surgery-related variables of 321 adult end-stage liver disease patients who underwent OLT in Fuzhou General Hospital were collected. Postoperative AKI was defined and staged in accordance with the clinical practice guidelines developed by Kidney Disease: Improving Global Outcomes. Univariate and multivariate analysis was performed to determine the risk factors for AKI following OLT. The discriminating power of MELD/MELD-Na score on AKI outcome was evaluated by receiver operating characteristic (ROC) curve. Spearman's correlation analysis was used for identifying the correlated relationship between MELD/MELD-Na score and the severity levels of AKI.</p><p><b>Results</b>The prevalence of AKI following OLT was in 206 out of 321 patients (64.2%). Three risk factors for AKI post-OLT were presented, preoperative calculated MELD score (odds ratio [OR] = 1.048, P = 0.021), intraoperative volume of red cell suspension transfusion (OR = 1.001, P = 0.002), and preoperative liver cirrhosis (OR = 2.015, P = 0.012). Two areas under ROC curve (AUCs) of MELD/MELD-Na score predicting AKI were 0.688 and 0.672, respectively; the difference between two AUCs was not significant (Z = 1.952, P = 0.051). The Spearman's correlation coefficients between MELD/MELD-Na score and the severity levels of AKI were 0.406 and 0.385 (P = 0.001, 0.001), respectively.</p><p><b>Conclusions</b>We demonstrated that preoperative MELD score, intraoperative volume of red cell suspension transfusion and preoperative liver cirrhosis were risk factors for AKI following OLT. Furthermore, we preliminarily validated that MELD score seemed to have a stronger power discriminating AKI post-OLT than that of novel MELD-Na score.</p>

Acute Kidney Injury , Blood , Pathology , Adult , End Stage Liver Disease , Blood , Pathology , Female , Humans , Liver Transplantation , Male , Middle Aged , Retrospective Studies , Sodium , Blood
Singapore medical journal ; : 224-227, 2018.
Article in English | WPRIM | ID: wpr-687885


We present five patients with vibrio necrotising fasciitis, a lethal and disabling disease. Two of these patients had a history of exposure to either warm seawater or raw/live seafood, three had underlying chronic liver disease, and four presented with hypotension and fever. There were three deaths and four patients required intensive care unit stays. Among the two survivors, one had high morbidity. Only one patient met the criteria of Laboratory Risk Indicator for Necrotising Fasciitis score > 6. A clinician should suspect possible vibrio necrotising fasciitis if the following are present: contact with fresh seafood/warm seawater, a known history of chronic liver disease and pain that is out of proportion to cutaneous signs. All patients must be managed via intensive care in high dependency units. We recommend a two-step surgical protocol for patient management involving an initial local debridement, followed by a second-stage radical debridement and skin grafting.

Aged , Aged, 80 and over , Debridement , End Stage Liver Disease , Fasciitis, Necrotizing , Diagnosis , Microbiology , General Surgery , Female , Fever , Hepatitis B , Humans , Hypotension , Male , Middle Aged , Retrospective Studies , Risk Factors , Seafood , Seawater , Severity of Illness Index , Singapore , Skin Transplantation , Vibrio , Vibrio Infections , Diagnosis , General Surgery
ABCD arq. bras. cir. dig ; 31(3): e1389, 2018. tab, graf
Article in English | LILACS | ID: biblio-949246


ABSTRACT Background: Liver transplant (LT) is the only effective and long-lasting option for patients with end-stage liver disease. Innovations and refinements in surgical techniques occurred with the advent of transplants with partial grafts and laparoscopy. Despite these modifications, the abdominal incision remains with only few changes. Aim: Demonstrate the experience with the upper midline incision in LT recipients with whole liver grafts from deceased donors. Methods: Retrospective study with patients submitted to LT. Data were collected from the recipients who performed the surgical procedure through the upper midline incision. Results: The upper midline incision was used in 20 LT, 19 of which were performed in adult recipients. The main cause was liver disease secondary to alcohol. Male, BMI>25 kg/m² and MELD greater than 20 were prevalent in the study. Biliary complications occurred in two patients. Hemoperitoneum was an indication for reoperation at one of the receptors. Complication of the surgical wound occurred in two patients, who presented superficial surgical site infection and evisceration (omental). Two re-transplant occurred in the first postoperative week due to severe graft dysfunction and hepatic artery thrombosis, which were performed with the same incision, without the need to increase surgical access. There were two deaths due to severe graft dysfunction after re-transplant in 72 h and respiratory sepsis with multiple organ dysfunction in the third week. Conclusion: The upper midline incision can be safely used in LT recipients with whole grafts from deceased donors. However, receptor characteristics and hepatic graft size should be considered in the option of abdominal surgical access.

RESUMO Racional: O transplante de fígado (TF) é a única opção eficaz e duradoura para os pacientes com doença hepática em estágio terminal. Inovações e refinamentos nas técnicas cirúrgicas ocorreram com o advento dos transplantes com enxertos parciais e da laparoscopia. Apesar dessas modificações, a incisão abdominal permanece sem grandes mudanças. Objetivo: Demonstrar a experiência com a incisão mediana superior nos receptores de TF com enxertos hepáticos inteiros provenientes de doadores falecidos. Método: É estudo retrospectivo entre os pacientes submetidos ao TF. Foram coletados os dados dos receptores que realizaram o procedimento cirúrgico através da incisão mediana superior . Resultados: Essa incisão foi utilizada em 20 TF, sendo 19 realizados em receptores adultos. A principal causa foi a doença hepática secundária ao álcool. O gênero masculino, IMC>25 kg/m² e o MELD superior a 20 foram prevalentes no estudo. Complicações biliares ocorreram em dois pacientes. Hemoperitônio foi indicação de reoperação em um dos receptores. Complicação da ferida cirúrgica ocorreu em dois pacientes, que apresentaram infecção de sítio cirúrgico superficial e evisceração (omental). Ocorreram dois re-transplantes na primeira semana de pós-operatório devido à disfunção grave do enxerto e à trombose da artéria hepática, sendo realizados com a mesma incisão, sem a necessidade de ampliar o acesso cirúrgico. Ocorreram dois óbitos por disfunção grave do enxerto após o re-transplante em 72 h e sepse respiratória com disfunção de múltiplos órgãos na terceira semana. Conclusão: A incisão mediana superior pode ser utilizada com segurança em receptores de TF com enxertos inteiros provenientes de doadores falecidos. Entretanto, características do receptor e tamanho do enxerto hepático devem ser considerados na opção do acesso cirúrgico abdominal.

Humans , Male , Female , Child , Adult , Liver Transplantation/methods , End Stage Liver Disease/surgery , Retrospective Studies , Abdomen/surgery