The management of renal failure in patients with liver disease. Experiences from a district general hospital.

AIM: To compare the pre-existing management of patients with Hepatorenal Syndrome (HRS) in the gastroenterology unit of the Royal Alexandra Hospital, Renfrewshire, with the published evidence based studies. METHOD: A retrospective, 6-month, case record review of patients diagnosed with HRS was performed. An evidence-based protocol for the diagnosis and management of HRS was introduced into the unit, to aid patient treatment prospectively. After 6 months, both compliance with the protocol, and patient outcomes were analysed. RESULTS: Eleven patients were identified in the first part of the audit cycle, all of whom died. Seven were identified in the second cycle. Two had their renal function successfully corrected and one was discharged from hospital. Renal impairment and staging of liver disease was equivalent in both groups. The second group received more appropriate and aggressive therapy. Alcohol was the causative aetiology of liver disease in all patients. CONCLUSIONS: Targetted therapy in patients with severe liver disease and HRS can improve renal parameters. Previous studies have shown this to be linked with improved patient outcomes.

Consultants workload due to alcohol related conditions in acute medical receiving gastroenterology and endocrinology.

A four-week survey was performed into the incidence of alcohol related problems in the acute medical receiving unit, and the prevalence of alcohol related cases in a ward shared between two gastroenterologists and an endocrinologist. Alcohol related conditions were the commonest reason for acute admission (19%). Gastroenterologists, in contrast to their colleagues have a substantial workload related to alcohol, especially chronic liver disease. These patients have longer lengths of stay with higher morbidity and mortality than those without alcohol related conditions. The reason for these differences and the implications for service planning are discussed.

Induction and role of NO synthase in hypotensive hepatic failure.

Nitric oxide (NO) plays an important role in the physiological and pathophysiological control of the vascular system. NO is synthesized by isoforms of the enzyme NO synthase (NOS). Hepatic failure is complicated by hypotension, low systemic vascular resistance, and resistance to vasoconstrictor drugs. The potential role of NO in these abnormalities was investigated by using in vitro pharmacological interventions on hepatic arteries obtained from both donor and recipient patients at the time of liver transplantation. The presence of NOS mRNA was investigated by reverse transcription polymerase chain reaction (RT-PCR) with primers designed from human endothelial NOS (eNOS) and inducible NOS (iNOS) cDNA sequences. Arteries from patients with hepatic failure had an impaired constrictor response to phenylephrine compared with those of donor arteries. The constrictor effect of phenylephrine was potentiated by NG-monomethyl-L-arginine, an inhibitor of NOS, which had no effect in donor control arteries. RT-PCR identified human eNOS mRNA in donor and recipient arteries and human iNOS mRNA in recipient arteries only. Induction of NOS in the vasculature with subsequent NO-induced vasodilatation may therefore contribute to the hemodynamic abnormalities observed in hepatic failure and potentially in other pathologies associated with endotoxemia. Whether selective inhibitors of iNOS will improve hemodynamic control or clinical outcome in these conditions requires further study.

Clinical course and survival after liver transplantation for hepatitis B virus infection complicated by hepatocellular carcinoma.

OBJECTIVES AND METHODS: The outcome after liver transplantation for HBsAg-positive liver disease complicated by hepatocellular carcinoma is not clearly defined, and in the present study we analyzed the clinical course in 39 patients transplanted for hepatitis B virus (HBV)-related liver disease (group 1) compared with 16 patients with chronic HBV and hepatocellular carcinoma (group 2) and 52 patients with primary hepatocellular carcinoma seronegative for HBsAg (group 3). RESULTS: Despite similar pretransplant viral serology, HBV recurred more often in patients with tumor (group 2) than in nontumor cases (group 1), with 1-yr actuarial cumulative reinfection rates of 85.4% versus 65.0%, respectively (p < 0.05). In group 2 cases, we observed a more aggressive pattern of HBV-related graft injury with a higher frequency of graft loss (56.3% vs. 12.8%, p < 0.001). Long-term outcome was worse in the group 2 cases, with 5-yr actuarial survival rates of 16.7% compared with 73.2% and 28.2% for groups 1 and 3, respectively. In group 2, recurrence of HBV in the graft, rather than tumor recurrence, was the principal cause of the high mortality observed (56.2% vs. 12.5%), which, in some cases, may have been potentiated by adjuvant chemotherapy. CONCLUSION: The poor outcome of patients transplanted for HBsAg-positive cirrhosis and hepatocellular carcinoma is due to HBV reinfection of the graft, rather than tumor recurrence. Antiviral agents in association with hepatitis B immunoglobulin would be the most promising approach to improving survival in this patient population.

Liver transplantation for primary hepatocellular carcinoma: tumor size and number determine outcome.

Liver transplantation for primary hepatocellular carcinoma (HCC) has in general been complicated by high recurrence rates. In the present study results from experience of 87 patients were analyzed [56 cirrhotic, 31 non-cirrhotic, 6 with the fibrolamellar (FL) variant] in relation to curative potential. Sixty-two survived > 90 days and form the study cohort. Fifty-six had non-fibrolamellar HCC and, of these, 39 had discrete lesions, measuring 0.8-21 cm (median 5.0 cm) including 4 in whom the diagnosis was made after examination of the explanted liver; 23 had multifocal lesions (> 2 tumor masses). There was no tumor recurrence in the group of 14 cases with single dominant lesions measuring < 4 cm, whereas in the 15 cases with lesions of 4-8 cm the recurrence rate was 40%, and 78% in those > 8 cm and the multifocal lesions (n = 27, P = 0.0001). Five-year actuarial survival figures were 57.1%, 44.4% and 11.1% (P < 0.003) respectively. The mean survival times in patients who died of recurrence were: 4-8 cm, 3.3 years (range 10 months to 6.3 years); > 8 cm or multifocal, 13 months (3-25 months). Reduction of serum alpha-fetoprotein (AFP) to normal levels does not exclude a later recurrence (7 of 17 cases) and this was documented after maintenance of normal AFP levels for up to 29 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatitis A causing a second episode of virus-associated haemophagocytic lymphohistiocytosis in a patient with Still's disease.

A 20-year-old female with Still's disease who had contracted hepatitis A became critically ill 2 weeks after the onset of jaundice with pancytopenia, coagulopathy, deteriorating liver function tests, and hepatomegaly. The diagnosis of virus-associated haemophagocytic lymphohistiocytosis was made, and she improved slowly after supportive treatment with parenteral steroids and immunoglobulin. Twelve years earlier, at the onset of her arthritis, she had suffered a similar episode of haemophagocytic lymphohistiocytosis in association with Epstein-Barr virus infection.