Ascites in patients on maintenance hemodialysis: causes, characteristics and predicting factors

Objective: To describe the causes, characteristics and factors associated with ascites in patients on maintenance hemodialysis

Study Design: Observational study

Place and Duration of Study: Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, from November 2007 to November 2014

Methodology: All patients on maintenance hemodialysis and age > 16 years with ascites were included. Frequencies and percentages were computed for different categorical variables. Chi-square or Fischer exact test were used to identify factors associated with ascites like frequency of hemodialysis, serum albumin and cardiac ejection fraction [EF]. Odds ratios were calculated for associated factors

Results: Ninety patients were included in this study; 55.5% were males. Median age was 33 years. Cause of ascites was nephrogenic in 77.8%, cardiac failure in 16.7%, hypothyroidism in 6.67%, liver cirrhosis in 4.4%, abdominal tuberculosis in 2.2%, and peritoneal carcinomatosis in 1.1% patients. The ascites was severe in 53.3% patients and severity was associated with serum albumin < 2.8 gm/dL [p=0.007] and cardiac EF < 40% [p=0.028]. The ascites was low serum ascites albumin gradient [SAAG], high protein type [LSHP] in 60% patients and associated with hemorrhage [p=0.040]. High SAAG, high protein [HSHP] ascites, found in 33.3%, was associated with cardiac EF < 40% [p=0.005] and portal hypertension [p=0.048]. High SAAG, low protein [HSLP] ascites, seen in 6.7%, was associated with portal hypertension [p=0.006]

Conclusion: The commonest cause of ascites in hemodialysis dependent patients is nephrogenic followed by cardiac failure. Low serum albumin and low cardiac EF predispose to severe forms of ascites

Clinical presentation and predictors of survival in patients with Budd Chiari syndrome: experience from a tertiary care hospital in Pakistan

To determine aetiology, clinical presentation and predictors of survival in Budd Chiari Syndrome patients. The prospective observational study based on non-probability convenient sampling was conducted at the Sindh Institute of Urology and Transplantation [SIUT], Karachi, and comprised Budd Chiari Syndrome patients between January 2004 and December 2013. The patients were evaluated for onset of symptoms, causes, mode of presentation and predictors of survival. SPSS 20 was used for statistical analysis. Of the 25 patients, 16[64%] were males, and 16[64%] belonged to the paediatric age group. Overall age range was 2-50 years with a mean of 14.7 +/- 12.41 years. Presentation was chronic in 14[56%] patients, acute in 10[40%] and acute on chronic in 1[4%]. Commonest morphological abnormality involved was hepatic veins alone in 14[56%]. Probable aetiologies were hypercoagulable states in 21[84%] patients, infections in 2[8%] and malignancy in 1[4%]. Among hypercoagulable states, protein C deficiency was the commonest, affecting 9[36%] patients. Seven [28%] patients died; acute 4[16%] and chronic 3[12%]. Causes of death included sepsis 4[16%], fulminant hepatic failure 1[4%], gastrointestinal bleeding 1[4%], and bleeding from liver biopsy site 1[4%]. Poor survival was associated with bilirubin >5mg/dl [p<0.031], serum alanine transaminase >40U/L [p<0.005], serum albumin <2.8 g/dl [p<0.008], Child-Turcotte-Pugh score >10 [p<0.001] and absence of varices [p<0.025]. Cox regression analysis failed to show any significant independent predictors of survival. Budd Chiari Syndrome affected young patients more frequently and was associated with high mortality. The commonest aetiology was hypercoagulable state. Survival was poor in patients with decompensated liver disease and those with an acute clinical presentation