Complications Requiring Hospital Admission and Causes of In-Hospital Death over Time in Alcoholic and Nonalcoholic Cirrhosis Patients

BACKGROUND/AIMS: Data on the epidemiology of alcoholic cirrhosis, especially in Asian countries, are limited. We compared the temporal evolution of patterns of alcoholic and nonalcoholic cirrhosis over the last decade. METHODS: We retrospectively examined the inpatient datasets of five referral centers during 2002 and 2011. The study included patients who were admitted due to specific complications of liver cirrhosis. We compared the causes of hospital admissions and in-hospital deaths between patients with alcoholic and nonalcoholic cirrhosis. RESULTS: Among the included 2,799 hospitalizations (2,165 patients), 1,496 (1,143 patients) were from 2002, and 1,303 (1,022 patients) were from 2011. Over time, there was a reduction in the rate of hepatic encephalopathy (HE) as a cause of hospitalization and an increase in the rate of hepatocellular carcinoma. Deaths that were attributable to HE or spontaneous bacterial peritonitis (SBP) significantly decreased, whereas those due to hepatorenal syndrome (HRS) significantly increased over time in patients with alcoholic cirrhosis. However, in patients with nonalcoholic cirrhosis, hepatic failure and HRS remained the principal causes of in-hospital death during both time periods. CONCLUSIONS: The major causes of in-hospital deaths have evolved from acute cirrhotic complications, including HE or SBP to HRS in alcoholic cirrhosis, whereas those have remained unchanged in nonalcoholic cirrhosis during the last decade.

Síndrome hepatorrenal: abordaje clínico y estrategia terapéutica / Hepatorenal Syndrome: clinical approach and therapeutic strate

El síndrome hepatorrenal (SHR) se define como el desarrollo de injuria renalen un paciente cirrótico en ausencia de una causa identificable que la explique. De acuerdo con la velocidad de instalación y la severidad de la fallarenal, se describen 2 tipos (tipo I y tipo II). El SHR tipo I se caracteriza por un rápido y progresivo deterioro de la función renal con un pronóstico ominoso, mientras que en el SHR tipo II el desarrollo de la falla renal es de instalación más insidiosa y de menor gravedad, pero de todas formas con un mal pronóstico a corto plazo. La media de sobrevida global de esta entidad es deaproximadamente 3 meses (2 semanas para el SHR tipo I vs. 4 a 6 meses para el SHR tipo II), aunque la implementación de estrategias terapéuticas tiene un claro impacto en el pronóstico. Dado que no existen pruebas de laboratorio específicas para su diagnóstico, éste se basa en datos clínico-analíticos y en la exclusión de otras causas de injuria renal en este contexto. El tratamiento definitivo de esta entidad es el trasplante hepático, siendo los fármacos vasoconstrictores sistémicos análogos de la vasopresina en combinación con albúmina la terapéutica puente de elección a él

Hepatorenal syndrome (HRS) is defined as the onset of renal failure without an identifiable cause in a cirrhotic patient. According with the installation speed and the severity of the renal failure, two types are described: type I and type II. Type I is characterized by a rapid and progressive deterioration of renal function with an ominous prognosis. Type II, presents with an insidious and less severe development of renal failure, but always bears a poor short-term prognosis. Although the implementation of therapeutic strategies has a clear impact on the prognosis, the median overall survival of these patients is approximately 3 months (2 weeks for type I HRS vs. 4 to 6 months for type II HRS). Since there are no specific tests for the diagnosis, it is based on a combination of clinical and laboratory data as well as the exclusion of other kinds of renal injury. Systemic vasoconstrictors drugs analogues of vasopressin combined with albumin are the treatment of choice before liver transplantation, which constitutes the definitive treatment of this entity.

Current status of liver diseases in Korea: Liver cirrhosis / 대한간학회지

Liver cirrhosis represents the final common pathway of virtually all chronic liver diseases, and is characterized by an accumulation of extracellular matrix rich in fibrillar collagens. Patients with cirrhosis are at risk of developing many potential complications. The most common complication seen in patients with liver cirrhosis is ascites, and the most lethal one is bleeding varices. Other intermediate and late stage complications include spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. The mortality and morbidity attributable to liver disease in Korea have decreased continuously over the past decades, probably due to the implementation of universal vaccination and potent antiviral therapies. In addition, recent advances in the understanding of the pathophysiology of cirrhosis and in various management approaches to cirrhosis complications will contribute to the steady improvement in patient outcomes in this country. This review article outlines recent changes in etiologies and prognosis, and the advances in management of cirrhosis in Korea.

Current status of liver diseases in Korea: Liver cirrhosis / 대한간학회지

Liver cirrhosis represents the final common pathway of virtually all chronic liver diseases, and is characterized by an accumulation of extracellular matrix rich in fibrillar collagens. Patients with cirrhosis are at risk of developing many potential complications. The most common complication seen in patients with liver cirrhosis is ascites, and the most lethal one is bleeding varices. Other intermediate and late stage complications include spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. The mortality and morbidity attributable to liver disease in Korea have decreased continuously over the past decades, probably due to the implementation of universal vaccination and potent antiviral therapies. In addition, recent advances in the understanding of the pathophysiology of cirrhosis and in various management approaches to cirrhosis complications will contribute to the steady improvement in patient outcomes in this country. This review article outlines recent changes in etiologies and prognosis, and the advances in management of cirrhosis in Korea.

Hepatorenal syndrome: an update

Hepatorenal syndrome (HRS) is the development of renal failure in patients with chronic previous liver disease, without clinical or laboratory evidence of previous kidney disease. It affects up to 18 percent of cirrhotic patients with ascites during the first year of follow-up, reaching 39 percent in five years and presenting a survival of about two weeks after its establishment. HRS diagnosis is based on clinical and laboratory data. The occurrence of this syndrome is related to the mechanism for ascites development, involving vasoconstriction, low renal perfusion, water and sodium retention, increased plasma volume, and consequent overflow at the splanchnic level. Renal vasoactive mediators like endothelin 1, thromboxane A2, and leukotrienes are also involved in the genesis of this syndrome, which culminates in functional renal insufficiency. The treatment of choice can be pharmacological or surgical, although liver transplantation is the only permanent and effective treatment, with a four-year survival rate of up to 60 percent. Liver function recovery is usually followed by renal failure reversion. Early diagnosis and timely therapeutics can increase life expectancy for these patients while they are waiting for liver transplantation as a definitive treatment.

A síndrome hepatorrenal (SHR) é o desenvolvimento do quadro de insuficiência renal em pacientes com doença hepática crônica prévia sem evidências clínica ou laboratorial de nefropatia prévia. Atinge até 18 por cento dos pacientes cirróticos com ascite em um ano, chegando a 39 por cento em cinco anos, com uma sobrevida média em torno de duas semanas após estabelecido o quadro. O diagnóstico da SHR baseia-se em critérios clínicos e laboratoriais. Seu aparecimento está relacionado ao mecanismo de formação de ascite, que envolve vasoconstrição e hipofluxo renal, retenção de água e sódio, aumento do volume plasmático, e conseqüentemente hiperfluxo no território esplâncnico. Mediadores vasoativos renais e humorais, como a endotelina 1, tromboxano A2 e leucotrienos, estão ainda envolvidos na gênese desta síndrome que culmina com insuficiência renal funcional. O tratamento preconizado da SHR pode ser farmacológico ou cirúrgico, sendo o transplante de fígado o único efetivo e permanente, com sobrevida de até 60 por cento em quatro anos. Após melhora da função hepática, geralmente há a reversão da insuficiência renal. O diagnóstico precoce e a rápida terapêutica podem ampliar a expectativa de vida destes hepatopatas enquanto se aguarda o transplante hepático para seu tratamento definitivo.

Syndrome hepatorrenal / Hepatorenal syndrome

Alterações da função renal e do metabolismo hidrossalino são comuns em pacientes com doença hepática. As alterações renais variam de importância e abrangem desde condições leves até aquelas que colocam a vida em risco. Há várias síndromes azotêmicas em cirróticos; no entanto, a síndrome hepatorrenal é a que chama mais atenção nesse grupo de pacientes. O autor revisa esta síndrome de maneira clara, objetiva e atualizada

Frequency of hepatorenal syndrome among cirrhotics

To determine the frequency of hepatorenal syndrome in patients with chronic liver disease and ascites. A cross-sectional study. From July 2001 to March 2002 at Civil Hospital, Karachi. The study included 240 patients who were admitted in the Medical Wards of Civil Hospital, Karachi, during the study period. The subjects were diagnosed as having chronic liver disease and all of them had ascites. All the patients with renal dysfunction were identified and were worked up for hepatorenal syndrome and other causes of renal dysfunction. Of two hundred and forty [240] patients enrolled in the study, 148 were male [61.7%] and 92 were female [38.3%]. Seventy-six [76] patients [31.6%] were found to have renal impairment as diagnosed by serum creatinine level of 1.5 mEq/L or greater. Six [6] patients showed improvement in their serum creatinine level [below 1.5 mg/dL] after receiving 1.5 liter of normal saline infusion and diuretic withdrawal. Eleven [11] patients were diagnosed to have primary renal disease based on urine analysis, urinary protein excretion and ultrasound examination. Six [6] patients were diagnosed to have renal dysfunction secondary to analgesic nephropathy and in seventeen [17] patients renal dysfunction was secondary to spontaneous bacterial peritonitis. The remaining 36 [47.4%] patients with renal dysfunction were diagnosed as suffering from hepatorenal syndrome based on the diagnostic criteria. This represents the frequency of 15% among patients with chronic liver disease and ascites. Hepatorenal syndrome is common complication in patients with cirrhosis and ascites. It was the most common cause of renal impairment in this series followed by other causes like spontaneous bacterial peritonitis, primary renal disease, analgesic nephropathy and hypovolemia

Advances in treatment and prevention of hepatorenal syndrome.

Hepatorenal syndrome (HRS) remains one of the major therapeutic challenges in clinical medicine today. The pathogenesis is complex, but the final common pathway seems to be that sinusoidal portal hypertension, in the presence of severe hepatic decompensation, leads to splanchnic and systemic vasodilatation and decreased effective arterial blood volume. Renal vasoconstriction increases concomitantly, renal haemodynamics worsens, and renal failure occurs. About 15 years ago it was shown that the renal failure is potentially reversible after liver transplantation. This potential reversibility together with increased understanding of the pathogenesis has led to successful preliminary attempts to reverse HRS nonsurgically with combinations of splanchnic vasoconstrictors and colloid volume expansion, insertion of trans-jugular intrahepatic portovenous shunt radiologically, and improved forms of dialysis. The aim of this chapter is to discuss the advances in the therapy of patients with HRS

Cirrose hepática: parte 2 - exames laboratoriais, diagnóstico, tratamento, complicações e prognóstico / Hepatic cirrhosis: part 2 - laboratorial exams, diagnosis, treatment, complications and prognostic

No presente artigo são revisados os aspectos diagnósticos (exames complementares), terapêuticos e prognósticos (relacionados principalmente às complicações) da cirrose hepática, importante problema de saúde pública no mundo atual

Síndrome hepatorrenal / Hepatorenal Syndrome

Os autores fazem uma revisão bibliográfica sobre as definições, identificação e classificação da Síndrome Hepatorrenal. Através de uma base de dados atualizada, expõem-se as abordagens terapêuticas da patologia

TIPS--anastomose portossistêmica intra-hepática transjugular. Revisao / TIPS - Transjugular intrahepatic portosystemic shunt. A review

At the present time several therapeutic options are used for the treatment of bleeding esophageal varices in patients with portal hypertension. We will review the main medical publications on transjugular intrahepatic portosystemic shunt (TIPS), a procedure seldom used among us. TIPS works as a portocaval side-to-side shunt and decreases the risk of esophageal bleeding through lowering of the portal system pressure and a decrease of the portal hepatic pressure gradient. TIPS consists in the percutaneous insertion, through the internal jugular vein, of a metallic stent under fluoroscopic control in the hepatic parenchyma creating a true porta caval communication. There are several studies demonstrating the efficacy of TIPS, although only a few of them are randomized and control-matched to allow us to conclude that this procedure is safe, efficient and with a good cost benefit ratio. In this review, we search for the analysis of the TIPS utilization, its techniques, its major indications and complications. TIPS has been used in cases of gastroesophageal bleeding that has failed with pharmacologic or endoscopic treatment in patients Child-Pugh B and C. It can be used also as a bridge for liver transplantation. Others indications for TIPS are uncontrolled ascites, hepatic renal syndrome, and hepatic hydrothorax. The main early complications of TIPS using are related to the insertion site and hepatic encephalopathy and the stent occlusion is the chief late complication.

Reversäo da síndrome hepatorrenal após transplante de fígado. Consideraçöes sobre três pacientes / Reversal of the hepatorenal syndrome after liver transplantation. Considerations about 3 patients

A ocorrência de síndrome hepatorrenal em cirróticos com precária reserva funcional do parênquima hepático, é observada em cerca de 25 por cento destes pacientes, antes da realizaçäo do transplante de fígado. Nesta situaçäo, eles permanecem em períodos mais longos, em unidades de tratamento intensivo no pós-operatório, requerendo hemodiálise em alguns dos 67 por cento que evoluíam com esta complicaçäo no pós-operatório. Estes aspectos definem a gravidade do processo. Neste trabalho descrevem-se três pacientes com síndrome hepatorrenal reversível após o transplante de fígado. Define-se a forma de conduçäo dos mesmos no pós-operatório e estabelecem-se consideraçöes sobre a introduçäo da ciclosporina A, apenas 72 horas após a cirurgia, evitando-se o emprego de outros fármacos potencialmente nefrotóxicos como aminoglicosídios e anfotericina. Reforça-se a importância da inexistência de episódios de hipovolemia, hipotensäo arterial ou infecçäo no intra e pós-operatório, bem como a viabilidade do órgao transplantado para que ocorra reversäo do quadro.

Tratamento da ascite refratária e da síndrome hepatorrenal / Treating refractory ascites and hepatorenal syndrome

Após conceituar a ascite refratária, o autor entende fundamental que sejam excluidas causas de falsa refratariedade, chamando a atençäo para uma indevida ingestäo excessiva de sódio. Dentre as diversas opçöes terapêuticas, enfatiza o papel da paracentese total com reposiçäo de albumina...

Problemas renales de la cirrosis

Cirrhosis of the liver is a common entity frequently seen by the clinician only after initiation of edema or ascitis. Renal problems have been described for many years associated to all types of cirrhosis, and are responsible for many abnormalities of water and electrolytes seen in these patients. One of the most remarkable renal abnormalities is sodium retention, with urinary excretion (Una V) of less than 10 mEq/1. This fact explains the common appearance of edema and ascitis even in the early states of cirrhosis. For many years two main theories have been postulated in order to explain this avid sodium retention: 1) The "underfill theory" states that the initial event is a state of peripheral vasodilatation that causes ineffective plasma volume and sodium retention by the kidney, meaning that the sodium retention is a secondary event. 2) the "overflow theory" in contrast, emphasizes that the primary event is sodium retention by the kidney, with secondary expansion of plasma volume and associated sequestration of fluid in the abdomen due to portal hypertension and a reduction of the colloid-osmotic pressure. Recent evidence is suggestive that both theories play a significant role in the avid sodium retention of cirrhosis. In order to explain the sodium retention by the kidney the following humoral factors have been postulated: increased secretion and decreased degradation of aldosterone, decreased production of prostaglandin E, increased secretion of catecholamines, decreased response to the natriuretic atrial factor and abnormalities of the kalikrein-kinin system. Although some studies have shown abnormalities in the handling of water by the kidney, most of the evidence suggest that it is due to the sodium retention...