Successful Treatment of Refractory Chylous Ascites With Octreotide in a Patient With Decompensated Cirrhosis.

Chylous ascites is a rare manifestation of decompensated cirrhosis that is associated with increased short-term mortality. Exclusion of other etiologies must be performed to allow for appropriate management, which itself can be a challenge in the setting of decompensated cirrhosis. We report a case of chylous ascites in a patient with decompensated cirrhosis that was successfully managed with octreotide before liver transplantation.

Progression to cirrhosis is similar among all ages in nonalcoholic fatty liver disease, but liver-related events increase with age.

BACKGROUND: NAFLD is increasingly common among young people. Whether NAFLD carries a more benign course in younger adults is not known. We aimed to characterize genetic and metabolic risk factors for NAFLD and their effects on disease progression across age groups. METHODS: We conducted a retrospective study of adults with NAFLD seen within Michigan Medicine, a tertiary care center, between 2010 and 2021. NAFLD was defined by hepatic steatosis on imaging, biopsy, or transient elastography in the absence of other chronic liver diseases. Cirrhosis was determined by validated International Classification of Diseases-9/10 codes or imaging. Fine-Gray competing risk models were generated, with incident cirrhosis and liver-related events (LREs) as the primary outcomes and death without cirrhosis or LREs as a competing risk. The primary predictor was the age category. RESULTS: We included 31,505 patients with NAFLD, with 8,252 aged 18 to younger than 40, 15,035 aged 40 to younger than 60, and 8,218 aged 60 years or older years at diagnosis. Compared with older patients, young adults more often had obesity, higher ALT, and high-risk PNPLA3 alleles, and fewer had prevalent cirrhosis, hypertension, hyperlipidemia, and diabetes. The 10-year risk of incident cirrhosis was similar between ages (3.4% in age 18 to <40 vs 3.7% in age 40 to <60 vs 4.7% in age ≥60; p = 0.058). Predictors of LREs were advancing age and diabetes, with a significantly higher 10-year risk of LREs in the oldest age group (0.2% in age 18 to <40 vs 0.7% in age 40 to <60 vs 1.1% in age ≥60; p = 0.008). CONCLUSIONS: While the baseline prevalence of cirrhosis was higher among older adults, the rate of NAFLD progression to cirrhosis was similar in young and older adults. Older patients were more likely to have LREs.

Long-term weight changes are associated with initial weight changes after nonalcoholic fatty liver disease diagnosis.

OBJECTIVES: Weight loss is the mainstay of treatment of NAFLD, but longitudinal data on weight changes and their impact on liver disease are limited. We aimed to characterize weight trajectory up to 5 years of follow-up, effects of weight loss on liver enzyme levels, and predictors of weight loss in NAFLD. METHODS: This was a single-center retrospective study of consecutive patients with hepatic steatosis diagnosed on imaging, liver biopsy, or transient elastography between 2010 and 2020. The primary outcome was ≥5% weight change at 1-2 years. Secondary outcomes were weight change at 4-5 years and alanine aminotransferase level at 1-2 and 4-5 years. We conducted multivariable logistic regression to identify predictors of ≥5% weight loss at 1-2 years. RESULTS: We included 11,559 patients with NAFLD. At year 1-2, 27% had ≥5% weight loss, whereas 26% had ≥5% weight gain. Total 59% and 68% of patients with weight loss and gain, respectively, sustained their weight change by year 4-5. Patients with weight loss at year 1-2 had lower alanine aminotransferase levels at year 1-2 and 4-5. Predictors of ≥5% weight loss included female sex, severe obesity, diabetes, and consultation with a dietitian or pharmacist. CONCLUSIONS: Over half of patients with NAFLD had ≥5% weight loss or gain within 1-2 years, and these changes were usually sustained at 4-5 years. Intensive intervention early after NAFLD diagnosis may result in long-term weight loss and decreased NAFLD disease activity.

Hepatic decompensation is accelerated in patients with cirrhosis and alpha-1 antitrypsin Pi∗MZ genotype.

Background & Aims: Alpha-1 antitrypsin deficiency is caused by mutations in SERPINA1, most commonly homozygosity for the Pi∗Z variant, and can present as liver disease. While heterozygosity for Pi∗Z (Pi∗MZ) is linked to increased risk of cirrhosis, whether the Pi∗MZ genotype is associated with an increased rate of decompensation among patients who already have compensated cirrhosis is not known. Methods: This was a retrospective study of Michigan Genomics Initiative participants with baseline compensated cirrhosis. The primary predictors were Pi∗MZ or Pi∗MS genotype (vs. Pi∗MM). The primary outcomes were hepatic decompensation with ascites, hepatic encephalopathy, or variceal bleeding, or the combined endpoint of liver-related death or liver transplant, both modeled with Fine-Gray competing risk models. Results: We included 576 patients with baseline compensated cirrhosis who had undergone genotyping, of whom 474 had Pi∗MM, 49 had Pi∗MZ, and 52 had Pi∗MS genotypes. Compared to Pi∗MM genotype, Pi∗MZ was associated with increased rates of hepatic decompensation (hazard ratio 1.81; 95% CI 1.22-2.69; p = 0.003) and liver transplant or liver-related death (hazard ratio 2.07; 95% CI 1.21-3.52; p = 0.078). These associations remained significant after adjustment for severity of underlying liver disease, and were robust across subgroup analyses based on etiology, sex, obesity, and diabetes status. Pi∗MS was not associated with decompensation or death/transplantation. Conclusions: The SERPINA1 Pi∗MZ genotype is associated with an increased rate of hepatic decompensation and decreased transplant-free survival among patients with baseline compensated cirrhosis. Lay summary: There is a mutation in the gene SERPINA1 called Pi∗MZ which increases risk of liver scarring (cirrhosis); however, it is not known what effect Pi∗MZ has if someone already has cirrhosis. In this study, we found that people who had cirrhosis and Pi∗MZ developed complications from cirrhosis faster than those who did not have the mutation.

Accuracy of Non-invasive Indices for Diagnosing Hepatic Steatosis Compared to Imaging in a Real-World Cohort.

BACKGROUND & AIMS: Nonalcoholic fatty liver disease is common and under-diagnosed. This study evaluated the accuracy of several previously reported indices, including hepatic steatosis index, alanine aminotransferase (ALT) method, Framingham steatosis index, and Dallas steatosis index, to diagnose hepatic steatosis in a real-world cohort. METHODS: This study included 701 randomly selected adult patients seen in our integrated healthcare system between 2015 and 2020 with appropriate abdominal imaging and routine outpatient laboratory studies. Information on demographics, comorbidities and existing liver disease, anthropometrics, laboratory studies, and abdominal imaging was collected. The sensitivity, specificity, and C-statistic of each method in detecting hepatic steatosis based on abdominal imaging were determined. RESULTS: 202/701 patients (28.8%) had hepatic steatosis on abdominal imaging. These patients were more likely to have metabolic syndrome components and higher body mass index. All indices performed similarly with moderate accuracy in detecting hepatic steatosis based on the C-statistic (95% confidence interval): Hepatic steatosis index 0.76 (0.72-0.79), Framingham steatosis index 0.78 (0.74-0.82), and Dallas steatosis index 0.80 (0.76-0.83). ALT method had sensitivity 44.7% (36.9-52.7%) and specificity 88.6% (85.0-91.7%). Several sensitivity analyses were performed, which did not significantly alter the performance of any index. CONCLUSION: The findings support both the clinical utility of these indices in diagnosing hepatic steatosis in the absence of imaging in real-world settings and the research utility of these indices in generating reliable electronic medical record-based nonalcoholic fatty liver disease cohorts.

Accuracy of International Classification of Diseases-10 Codes for Cirrhosis and Portal Hypertensive Complications.

BACKGROUND AND AIMS: International Classification of Diseases (ICD)-10 codes may correspond to cirrhosis diagnosis. However, these codes have not been as well studied as ICD-9 codes. We aimed to evaluate the positive predictive value (PPV) and specificity of ICD-10 codes for cirrhosis. METHODS: We conducted a single-center retrospective study of patients in Michigan Medicine (Ann Arbor, MI, USA). We evaluated patients with at least one of 28 ICD-10 codes for cirrhosis and randomly selected controls for the presence of cirrhosis and/or portal hypertensive complications. RESULTS: Among 1317 patients with at least one ICD-10 code consistent with cirrhosis and/or portal hypertension, 796 had confirmed cirrhosis. After excluding ICD-10 codes found in < 10 patients, we evaluated the PPV of the 19 remaining codes. Of these, 15 had a high PPV for cirrhosis (> 80%), including codes for cirrhosis itself, gastroesophageal varices, hepatic encephalopathy, and other portal hypertensive complications. Specificity of ICD codes for cirrhosis for these 15 codes was high (> 94% for all). PPV and specificity were high across liver disease etiologies. Among patients without portal hypertension, PPVs of ICD-10 codes for cirrhosis were lower but still > 80% for the most common codes. PPVs of most codes for portal hypertensive complications were > 70%. Defining cirrhosis based on the presence of any of the 15 codes resulted in a PPV of 86% and by two different codes, a PPV 94%. CONCLUSIONS: ICD-10 codes for cirrhosis can accurately identify patients with cirrhosis with or without portal hypertensive complications.

Lateral lumbar interbody fusion: a systematic review of complication rates.

BACKGROUND CONTEXT: Lateral lumbar interbody fusion (LLIF) is a frequently used technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach. PURPOSE: To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF. STUDY DESIGN: Systematic review. PATIENT SAMPLE: 6,819 patients who underwent LLIF reported in clinical studies through June 2016. OUTCOME MEASURES: Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and spine (MSK) categories. METHODS: This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and MSK categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work. RESULTS: A total of 2,232 articles were identified. Following screening of title, abstract, and full-text availability, 63 articles were included in the review. A total of 6,819 patients had 11,325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval [CI]=1.00%-1.85%), cardiac (1.86%; CI=1.33%-2.52%), vascular (0.81%; CI=0.44%-1.36%), pulmonary (1.47; CI=0.95%-2.16%), gastrointestinal (1.38%; CI=1.00%-1.87%), urologic (0.93%; CI=0.55%-1.47%), transient neurologic (36.07%; CI=34.74%-37.41%), persistent neurologic (3.98%; CI=3.42%-4.60%), and MSK or spine (9.22%; CI=8.28%-10.23%). CONCLUSIONS: The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks to and expectations for patients following LLIF procedures.

The Utility of Routinely Obtaining Postoperative Laboratory Studies Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: This is a retrospective analysis. OBJECTIVE: To test the hypothesis that there is limited utility in routinely obtaining postoperative laboratory values following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). BACKGROUND DATA: At many institutions, it is routine to obtain a complete blood count and basic metabolic profile (BMP) following a MIS TLIF. However, the utility of this practice has not been well characterized. METHODS: A total of 332 consecutive patients who underwent a primary, 1-level MIS TLIF for degenerative spinal pathology between 2007 and 2013 were identified. Patients were stratified into low-risk and high-risk cohorts based upon risk for postoperative laboratory abnormalities. Inclusion criteria for the high-risk cohort were malignancy, complicated diabetes, renal failure, liver disease, hematologic disease, or significant intraoperative blood loss (>300 mL). Preoperative and postoperative hemoglobin (Hb), hematocrit, and BMP values were compared. Any interventions that were potentially related to laboratory values were identified. RESULTS: Totals of 270 low-risk and 62 high-risk patients were identified. Mean postoperative Hb, hematocrit, blood urea nitrogen, sodium, potassium, and calcium values were decreased compared with preoperative values (P<0.001 for each) in both cohorts. Similar changes from preoperative levels were demonstrated in each cohort. No patients received blood product transfusion. Eleven low-risk (4.1%) and 5 high-risk patients (8.1%) received oral potassium supplementation. All patients who received potassium supplementation were asymptomatic. Most patients who were given potassium replacement consumed medications known to decrease serum potassium levels. No other interventions were performed in either group. CONCLUSIONS: Despite a significant decrease in mean Hb concentration following surgery, no patients required a transfusion. In total, 16 patients received potassium supplementation likely related to medication-related potassium deficits. Overall, these findings suggest that the utility of routinely obtaining a complete blood count or BMP following uncomplicated MIS TLIF may be limited except in the setting of select preoperative comorbidities and/or perioperative risk factors or events. LEVEL OF EVIDENCE: Level III.