Management and outcomes of hepatorenal syndrome at an urban academic medical center: a retrospective study.

OBJECTIVES: This study is aimed to evaluate the management of acute kidney injury (AKI) in our inner city, American hospital. We intended to ascertain whether or not there is prompt recognition of AKI in cirrhosis according to International Club of Ascites and acute kidney injury network criteria as well how effective we are at distinguishing among different causes of AKI. We aimed to calculated the mortality of hepatorenal syndrome (HRS) in our hospital, and to evaluate the adequacy of the established treatment of AKI at each stage of its algorithm. PATIENTS AND METHODS: ICD diagnostic codes were used to identify patients with liver cirrhosis and acute renal failure. A total of 725 patients met the search criteria. We excluded the patients without clinical or imaging evidence of ascites, heart failure, on hemodialysis, baseline creatinine more than 1.5 mg/dl and patients who died within 48 h of developing acute renal failure. 291 patients met the inclusion criteria. All statistical analyses were performed using SPSS version 23.0 software with a two-sided significance level set at P value less than 0.05. RESULTS: Mean age was 55.7 ± 0.61 and baseline serum creatinine was 0.94 ± 0.14. 66.5% of patients were African American, 27.3%, Hispanic, and 4.3% White. The average rise in creatinine from baseline was 1.36 ± 0.08 mg/dl. 27.2% of patients met the diagnostic criteria of HRS. 92.3% of patients with HRS received intravenous fluids and 75.4% received intravenous albumin within 48 h of acute creatinine rise. The in-hospital mortality rate was 14.1, 23.3, and 41.5% for patients with pre-renal azotemia, ARF, and HRS, respectively (P < 0.01). CONCLUSION: This study demonstrates that with present tools, there is significantly higher mortality in HRS despite guideline-based treatment. Biomarkers for early diagnosis of HRS are necessary to avoid delays in initiation of HRS treatment while establishing the diagnosis. As well, worldwide standardization of the treatment of HRS will be important if the outcome is to be improved.

Impact of sustained virologic response on short-term clinical outcomes in hepatitis C-related cirrhosis.

BACKGROUND: Hepatitis C virus (HCV) is a common cause of cirrhosis, leading to increased morbidity and mortality. Treatment of the underlying etiology has been shown to improve fibrosis and cirrhosis. AIM: We sought to evaluate the impact of a sustained virologic response on liver chemistries, model for end stage liver disease (MELD) score, Child-Pugh-Turcotte score (CPT), and fibrosis 4 score (FIB4) in patients with liver cirrhosis secondary to HCV with portal hypertension, with or without decompensation. METHODS: Patients with HCV seen in our transplant clinic between June 2013 and September 2015 were identified using ICD-9 code 573.3. Charts were reviewed retrospectively. RESULTS: We collected data from 92 patients with a mean pretreatment MELD score of 9.16±2.98. The most common genotype was Ia, n=79 (86%). The mean duration of follow-up was 7.52±2.25 months. Transaminitis improved significantly at follow-up versus pretreatment [mean aspartate transaminase from 81.2±62.9 to 32.4±12.0 (P<0.0001); alanine transaminase 74.7±77.8 to 27.7±19.4 (P<0.0001)]. Albumin, bilirubin, and α-fetoprotein improved significantly. MELD scores improved in patients with pretreatment scores greater than 10 (P<0.0003), but not in patients with pretreatment scores less than 10 (P=0.501). The CPT score decreased from 6.1±0.9 to 5.8±0.9 (P<0.0024). The FIB4 score improved significantly in patients with baseline FIB4 more than 3.24, but not with higher baseline FIB4. CONCLUSION: Use of direct antivirals in patients with decompensated cirrhosis because of HCV leads to improved MELD, FIB4, and CPT scores.

Diabetics on Narcotics Are Less Likely to Achieve Excellent Bowel Preparation Than Are Patients with Either Condition.

BACKGROUND: Diabetes and chronic narcotic use negatively affect the quality of bowel preparation before colonoscopy. AIM: To investigate whether narcotic use and diabetes have an additive negative impact on bowel preparation. PATIENTS AND METHODS: We performed a retrospective study of 2841 patients (mean age 61 ± 10.2; 94% male) who received outpatient colonoscopies at our Veterans Affairs Medical Center between June 2012 and December 2014. We collected information related to demographics, body mass index, indications, and medical/surgical history (diabetes mellitus, stroke, cirrhosis, dementia, constipation, hypothyroidism, and use of narcotics or antidepressants/anxiolytics for more than three months). Patients were classified into four groups: (1) diabetics on narcotics, (2) diabetics only, (3) on narcotics only, and (4) neither diabetic nor using narcotics. Quality of the bowel preparation was scored using the Boston Bowel Preparation Scale (BBPS) and categorized as either excellent (BBPS ≥7, with no individual segment scoring <2) or not excellent (BBPS <7). Multivariate logistic regression analysis was performed to identify the combined impact of narcotic use and diabetes on bowel preparation. RESULTS: Bowel preparation quality was excellent in 49%. Thirty-eight percent of patients with diabetes who were using narcotics (adjusted OR 0.6, CI [0.4, 0.8]) achieved excellent bowel preparation compared with 44% (adjusted OR 0.7, CI [0.6, 0.9]) of patients on narcotics only, 48% (adjusted OR 0.8, CI [0.7, 0.9]) of diabetics only, and 54% of patients with neither condition. CONCLUSION: Concomitant narcotic use and diabetes have a compounding effect on the quality of bowel preparation prior to colonoscopy.

Effect of allopurinol on slowing allograft functional decline in kidney transplant recipients.

OBJECTIVES: Hyperuricemia may be a risk factor for graft loss in kidney transplant recipients. The purpose of this study was to evaluate the effects of allopurinol in kidney transplant recipients. MATERIALS AND METHODS: A single center retrospective case-control study was performed with kidney transplant recipients who were treated with allopurinol (54 patients) and a control group matched for time of transplant (± 3 months) and estimated glomerular filtration rate (54 patients). We evaluated the relation between allopurinol use and estimated glomerular filtration rate, graft survival, blood pressure, and number of anti-hypertensive drugs used. RESULTS: At the start of allopurinol therapy, mean serum uric acid level was greater in the allopurinol (476 ± 119 µmol/L) than control group (404 ± 125 µmol/L; P ≤ .001) and estimated glomerular filtration rate was similar between the 2 groups (allopurinol, 39 ± 16 mL/min; control, 38 ± 16 mL/min; not significant). At 1 year, mean estimated glomerular filtration rate was greater in the allopurinol than control group (allopurinol, 41 ± 15 mL/min; control, 36 ± 13 mL/min; P ≤ .04). At 2 years, mean serum uric acid level was significantly lower in the allopurinol (399 ± 101 µmol/L) than control group (452 ± 95 µmol/L; P ≤ .02). Graft survival, blood pressure, and antihypertensive requirements were similar between the groups. CONCLUSIONS: Allopurinol use is associated with preservation of estimated glomerular filtration rate in kidney transplant recipients. There may be potential benefit in treating asymptomatic hyperuricemia in kidney transplant recipients.

Lung volume abnormalities and its correlation to spirometric and demographic variables in adult asthma.

BACKGROUND: Presence of airflow obstruction in asthma has been based on a fixed FEV1(forced expiratory volume at 1 second)/FVC (forced vital capacity) ratio abnormality. The accuracy of FEV1/FVC ratio in diagnosing airflow obstruction remains controversial. Lung volume abnormalities have been observed in severe asthma. We utilized simultaneously measured spirometry and lung volume to determine the utility of residual volume (RV)/total lung capacity (TLC) ratio in diagnosing airflow obstruction and to identify predictors of abnormal RV in asthmatic subjects. METHODS: Data from physician-diagnosed asthmatics referred for lung function tests were collected retrospectively. Patient demographics and lung function data were analyzed using general linear modeling. RESULTS: Of the 321 subjects, 221 were female (69%). The ethnicity was Caucasian in 157 (49%), Hispanic in 131 (41%), and African-American in 33 (10%). The percentage of subjects with FEV(1)/FVC ratio <70%, FEV(1)-predicted <80%, and FEF25-75% <65% were 25%, 25%, and 38%, respectively. Fifty-two and fifty-seven percent of the patients had abnormal residual volume and abnormal RV/TLC ratio, respectively. A significant bronchodilator response was observed in 32% of the patients. A positive correlation was observed between RV to age (r = 0.4) and height (r = 0.3). A negative correlation was observed between RV to FEF25-75% (r = 0.5) and body weight (r = 0.07). There was no significant correlation between FEV1 reversibility and residual volume (r = 0.1). RV correlated significantly better with FEF25-75% (r(2) = 0.25) than FEV(1) (r(2) = 0.16). CONCLUSION: A significant proportion of asthmatic patients have elevated residual volume and abnormal RV/TLC ratio in the presence of normal FEV1/FVC ratio and absence of significant bronchodilator response. The clinical significance of these findings in asthma needs further prospective study.

COPD elicits remodeling of the diaphragm and vastus lateralis muscles in humans.

A profound remodeling of the diaphragm and vastus lateralis (VL) occurs in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). In this mini-review, we discuss the following costal diaphragm remodeling features noted in patients with moderate-to-severe COPD: 1) deletion of serial sarcomeres, 2) increased proportion of slow-twitch fibers, 3) fast-to-slow isoform shift in sarco(endo)plasmic reticulum Ca(2+)-ATPase, 4) increased capacity of oxidative metabolism, 5) oxidative stress, and 6) myofiber atrophy. We then present the sole feature of diaphragm remodeling noted in mild-to-moderate COPD under the heading "MyHC and contractile remodeling noted in mild-to-moderate COPD." The importance of VL remodeling in COPD patients as a prognostic indicator as well as a major determinant of the ability to carry out activities of daily living is well accepted. We present the remodeling of the VL noted in COPD patients under the following headings: 1) Decrease in proportion of slow-twitch fibers, 2) Decreased activity of oxidative pathways, 3) Oxidative and nitrosative stress, and 4) Myofiber atrophy. For each of the remodeling features noted in both the VL and costal diaphragm of COPD patients, we present mechanisms that are currently thought to mediate these changes as well as the pathophysiology of each remodeling feature. We hope that our mechanistic presentation stimulates research in this area that focuses on improving the ability of COPD patients to carry out increased activities of daily living.

Suppression of regrowth of normal skin flora under chlorhexidine gluconate dressings applied to chlorhexidine gluconate-prepped skin.

BACKGROUND: Catheter colonization and bloodstream infection during the first week after insertion of a central venous catheter have been shown to result from the patient's own skin flora. METHODS: The backs of 32 healthy subjects were prepped with a 2% chlorhexidine gluconate (CHG)/70% isopropyl alcohol antiseptic. Three dressings, 2 of which contained CHG, were placed on the prepped skin in a randomized design. Samples of aerobic bacteria were collected using the cup scrub method. Skin under the dressings was sampled by quadrant on days 1, 4, and 7. Relative suppression of regrowth was compared using an adjusted paired t test. RESULTS: Mean log counts were 3.2 log(10) colony-forming units (CFU)/cm(2) before antisepsis and 0.4 after antisepsis. Mean log counts obtained on days 1, 4, and 7 were 0.4, 0.3, and 0.5 log(10) CFU/cm(2) for the CHG gel; 0.4, 0.4, and 0.9 log(10) CFU/cm(2) for the CHG disk; and 0.9, 1.2, and 1.5 log(10) CFU/cm(2) for the Control, respectively. CONCLUSION: Skin flora was not completely eradicated during antisepsis, and bacterial regrowth occurred postantisepsis. The use of CHG dressings helped sustain a reduced bacterial count on the skin. The continuously releasing CHG gel maintained suppression to a greater extent than the CHG disk at 7 days (P = .01).