ABSTRACT
Background: Patients with decompensated cirrhosis and ascites are at risk for developing acute kidney injury (AKI), occurring in 20-49% of patients. Those with recurrent or refractory ascites requiring regular large volume paracentesis (LVPs) are at greater risk for AKI because of their advanced cirrhosis, abnormal hemodynamics and frequent fluid shifts from the LVPs. Aim(s): To assess the natural history of renal function in ascitic cirrhotic patients who require regular LVPs. Method(s): A single centre retrospective study including all ascitic cirrhotic patients who attended for outpatient regular LVPs from April 2020 to March 2021, excluding those with COVID infection, hepatocellular carcinoma exceeding Milan's criteria, or extensive non-liver malignancy. Data collected included demographics, paracentesis details, albumin infusions, renal function at baseline and during 3-month (M) follow-up, especially any AKI details, hospital admissions and survival. Result(s): 87 (M:57, F:30;62.0+/-11.3 yrs;MELD-Na: 17.6+/-4.8) mostly alcoholic (47%) and NASH (25%) patients who attended for regular LVPs were included. 14 patients had history of variceal bleed, 26 had a history of encephalopathy (HE). Ascites had been present for 17+/-24M at enrolment, and 12 patients had prior spontaneous bacterial peritonitis. LVP had started 9+/-11M earlier. The mean # of LVPs was 4.2+/-2.6/M with 7.3+/-2.6L of ascites removed/LVP, receiving 90.5+/-38gm/M albumin with the LVPs. The mean serum creatinine (sCr) at enrolment was 100.9+/-50.3mumol/L, with 12 patients fulfilling the KDIGO's criteria for chronic kidney disease (CKD), due to diabetes or hypertension or both. 23 patients were diagnosed to have AKI at enrolment, 3 with background CKD. 5 patients required hospital admission. Table shows the details of AKI at enrolment. During 3M follow-up, 15 episodes of AKI (stage 1: n=9, stage 2: n=6) recurred in 11 patients, with the final sCr at 3M at 113+/-90mumol/L. 17 patients had 26 admissions in 3M, mostly related to cirrhosis complications (AKI/ HRS: n=4, HE: n=4;ascites related: n=4, GI bleed: n=4;infection (n=6). There was 1 liver transplant and 7 liver related deaths. Conclusion(s): CKD is becoming common among ascitic cirrhotic patients requiring LVPs. Irrespective of CKD presence, such patients frequently develop AKI, although mostly stage 1, but recur often, leading to gradual worsening of renal function within 3 M. This subset of patients needs close monitoring and future strategies to prevent AKIs.
ABSTRACT
Aim: The covid-19 pandemic greatly impacted surgical and cancer services across the world. 1. Pressure on services and concerns surrounding transmission of covid-19 led to delays in the diagnosis and treatment of colorectal cancer. 2. We set out to assess the impact of covid-19 on the staging of colorectal cancer at our centre, a district general hospital (DGH) in the United Kingdom. Method(s): Patients diagnosed with colorectal cancer who underwent either elective or emergency operative management in the 4 month period between April 1st and July 31st in 2019 (pre-COVID-19), 2020 and 2021 (during the COVID-19 pandemic) were included in our analysis. Each patient's TNM classification was assessed. Result(s): 76 patients were treated for colorectal cancer in the 4 months examined in 2019, 35 in 2020 and 45 in 2021. Analysis of post operative TNM staging found a greater proportion of T4 cancers during the COVID-19 pandemic, vs pre-pandemic levels - 15.8% in 2019, 31.4% in 2020, 22.2% in 2021. There was an increase in nodal positivity, with 49% of patients with N1/N2 disease in 2020/2021, compared to 40% in 2019. Metastatic disease (M1 classification) increased in during the COVID-19 pandemic. 88% of patients in 2019 had M0 classification, 85% in 2020 and 84% in 2021. Conclusion(s): The data from our centre demonstrates an increase in the TNM staging of colorectal cancers diagnosed during the 2020 and 2021 COVID-19 pandemic vs the same period in 2019. We have also seen a reduction in patients undergoing operative management for colorectal cancer since the start of the pandemic. This may indicate late presentation, or delays in diagnosis - of note is that half (5/10) of the patients with T4 cancers in the 2021 cohort presented as emergencies. Ongoing monitoring and analysis will be necessary to establish whether long term outcomes will have been affected by the delays in diagnosis and management caused by the COVID-19 pandemic.