Association of AKI with mortality and complications in hospitalized patients with cirrhosis.

UNLABELLED: Acute kidney injury (AKI) is a common and devastating complication in patients with cirrhosis. However, the definitions of AKI employed in studies involving patients with cirrhosis have not been standardized, lack sensitivity, and are often limited to narrow clinical settings. We conducted a multicenter, prospective observational cohort study of patients with cirrhosis and AKI, drawn from multiple hospital wards, utilizing the modern acute kidney injury network (AKIN) definition and assessed the association between AKI severity and progression with in-hospital mortality. Of the 192 patients who were enrolled and included in the study, 85 (44%) progressed to a higher AKIN stage after initially fulfilling AKI criteria. Patients achieved a peak severity of AKIN stage 1, 26%, stage 2, 24%, and stage 3, 49%. The incidence of mortality, general medical events (bacteremia, pneumonia, urinary tract infection), and cirrhosis-specific complications (ascites, encephalopathy, spontaneous bacterial peritonitis) increased with severity of AKI. Progression was significantly more common and peak AKI stage higher in nonsurvivors than survivors (P < 0.0001). After adjusting for baseline renal function, demographics, and critical hospital- and cirrhosis-associated variables, progression of AKI was independently associated with mortality (adjusted odds ratio = 3.8, 95% confidence interval 1.3-11.1). CONCLUSION: AKI, as defined by AKIN criteria, in patients with cirrhosis is frequently progressive and severe and is independently associated with mortality in a stage-dependent fashion. Methods for earlier diagnosis of AKI and its progression may result in improved outcomes by facilitating targeted and timely treatment of AKI.

Peer assessment of professional performance by hospitalist physicians.

BACKGROUND: The clinical collaborations among hospitalist physicians create opportunities for peer evaluation. We conducted this study to generate validity evidence for a scale that allows for peer assessment of professional performance. METHODS: All of the hospitalist physicians working for >1 year at our hospital were asked to assess each of their physician colleagues along eight domains and name three colleagues whom they would choose to care for a loved one needing hospitalization. A mean composite clinical performance score was generated for each provider. Statistical analyses using the Pearson coefficient were performed. RESULTS: The 22 hospitalist physician participants were confident in their ability to assess their peers' clinical skills. There were strong correlations between the domains of clinical excellence (r > 0.5, P < 0.05). Being selected as a doctor whom colleagues would choose to take care of their loved ones was highly correlated with high scores in the domains of humanism, diagnostic acumen, signouts/handoffs, and passion for clinical medicine, and higher composite clinical performance scores (all r > 0.5, P < 0.05). High scores on the Press Ganey questions correlated with peer assessment of humanism (r = .78, P = 0.06). CONCLUSIONS: The correlation among scale items, the composite clinical performance score, and the variable "a doctor whom you would choose to care for a loved one" provides validity evidence to our assessment scale. Such measurements may allow hospitalist groups to identify top performers who could be recognized, rewarded, and held up as role models and weaker performers who may need focused training or remediation.

Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis.

Transjugular intrahepatic portosystemic shunt (TIPS) decompresses the portal venous system. TIPS has been used to manage the complications of portal hypertension in cirrhosis, including variceal hemorrhage and refractory ascites. The uncoated TIPS stents are limited by stent stenosis; however, the introduction of coated stents has decreased this. With the introduction of coated stents, we must reevaluate the utility of TIPS in the management of complications of portal hypertension.

The molecular pathogenesis of cholestasis in sepsis.

Sepsis-induced cholestasis is a complication of infection. Infections cause systemic and intrahepatic increase in proinflammatory cytokines which result in impaired bile flow ie. cholestasis. Several other mediators of impairment in bile flow have been identified under conditions of sepsis such as increased nitric oxide production and decreased aquaporin channels. The development of cholestasis may also further worsen inflammation. The molecular basis of normal bile flow and mechanisms of impairment in sepsis are discussed.

Staging of liver disease: which option is right for my patient?

It is important to assess the stage of liver fibrosis in chronic hepatitis C to guide treatment decisions. Liver biopsy has limitations in staging fibrosis. Several blood tests, algorithms, and imaging tests have been studied as noninvasive markers to stage fibrosis in hepatitis C. In patients without suspicion for cirrhosis, 2 noninvasive methods can be used to predict presence of absence of significant liver fibrosis; however, liver biopsy remains the gold standard. It is imperative not to miss the diagnosis of cirrhosis, because this has further implications for screening of hepatocellular carcinoma and varices.