Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage: Retrospective cohort study.

BACKGROUND: Acute esophageal variceal hemorrhage (AEVH) is a common complication of cirrhosis and might precipitate multi-organ failure, causing acute-on-chronic liver failure (ACLF). AIM: To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) is able to predict mortality in cirrhotic patients presenting AEVH. METHODS: Retrospective cohort study executed in Hospital Geral de Caxias do Sul. Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin. Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH, including 97 patients. Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis. RESULTS: All- cause mortality for AEVH patients was 36%, 40.2% and 49.4% for 30-, 90- and 365-day, respectively. The prevalence of ACLF was 41.3%. Of these, 35% grade 1, 50% grade 2 and 15% grade 3. In multivariate analysis, the non-use of non-selective beta-blockers, presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period. CONCLUSION: Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30- and 90-day mortality in cirrhotic patients admitted due to AEVH.

Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality / El protocolo basado en la evidencia para el diagnóstico y tratamiento del síndrome hepatorrenal se asocia de forma independiente con una menor mortalidad

Background: Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients.Methods: An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis.Results: The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality.Conclusion: The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.

Antecedentes: El síndrome hepatorrenal (SHR) es la complicación más mortal de la cirrosis. El objetivo de este estudio es analizar si el uso de un protocolo para el SHR se asocia a una mayor supervivencia en estos pacientes.Métodos: En 2013 se instituyó un protocolo basado en la evidencia para el diagnóstico y tratamiento del SHR. Los datos de los registros médicos del 2010 al 2016 se obtuvieron mediante la búsqueda en la base de datos del hospital de pacientes que recibieron terlipresina, 3 años antes y después de la institución del protocolo. Se revisaron los datos para confirmar el diagnóstico de SHR y se recopilaron múltiples variables. Se calcularon las puntuaciones específicas del hígado y se utilizó un enfoque gradual de la regresión de Cox para el análisis univariado y multivariado.Resultados: Se incluyó a 46 pacientes, 20 del período preprotocolo y 26 posprotocolo. Respectivamente, la mortalidad a los 30, 90 y 365 días fue del 75, el 75 y el 90%, respectivamente, para el período previo al protocolo y del61, el 69 y el 80%, respectivamente, para el posterior al protocolo. En el análisis multivariado, aspartato aminotransferasa (AST) <40 U/l, el período preprotocolo y las puntuaciones más altas de Child-Turcotte-Pugh se asociaron con una mayor mortalidad a los 30 y 90 días. Las dosis media total de terlipresina y albúmina humana utilizada por paciente se redujo de 27 a 22mg de terlipresina y de 236 a 144g de albúmina humana después de la institución del protocolo. Esto no se asoció con una mayor mortalidad.Conclusión: El uso de un protocolo basado en la evidencia para el tratamiento del SHR se tradujo en una mayor supervivencia. Los autores sugieren que el uso de protocolos basados en la evidencia para el diagnóstico y tratamiento del SHR podría reducir el costo y la mortalidad en los hospitales de tercer nivel.

Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality.

BACKGROUND: Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients. METHODS: An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis. RESULTS: The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality. CONCLUSION: The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.