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1.
Liver Int ; 40(7): 1590-1593, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32369658

RESUMO

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious viral disease that predominantly causes respiratory symptoms. Elevated liver enzymes have been reported during the course of disease and appear to be common. We present a 56-year-old woman with a history of decompensated alcoholic cirrhosis who presented with abdominal pain, fever and diarrhoea and was found to have acute on chronic liver failure secondary to SARS-CoV-2 infection. The patient was treated with empiric antibiotic and supportive care with subsequent improvement.


Assuntos
Insuficiência Hepática Crônica Agudizada/virologia , Betacoronavirus/patogenicidade , Infecções por Coronavirus/virologia , Cirrose Hepática Alcoólica/complicações , Pneumonia Viral/virologia , Insuficiência Hepática Crônica Agudizada/diagnóstico , Insuficiência Hepática Crônica Agudizada/terapia , Antibacterianos/uso terapêutico , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Feminino , Hidratação , Interações Hospedeiro-Patógeno , Humanos , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/terapia , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Resultado do Tratamento
4.
Dig Liver Dis ; 52(1): 21-32, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31757596

RESUMO

Worldwide, the prevalence of alcohol use disorder (AUD) is 20-30% in men and 10-15% in women, and cirrhosis due to alcohol-related liver disease (ALD) is responsible for 0.9% of global deaths and 47.9% of cirrhosis-related deaths. End-stage ALD (ESALD) is the final condition of alcohol-related cirrhosis, and severe acute alcohol-related hepatitis (SAAH) is a distinct clinical syndrome associated with the consumption of large amounts of alcohol. In some cases, ESALD, and SAAH may need liver transplantation (LT). Thus, the management of ESALD and SAAH in patients affected by AUD may be an essential part of the clinical skills for hepatologists. For these reasons, the national board of the Italian Society on Alcohol have reviewed the most recent data on the management of ESALD, SAAH and LT for ALD in patients with AUD, formulating a position paper with related recommendations regarding four issues of specific clinical interest in this field: (a) the management of hepatic encephalopathy in patients with AUD, and LT in patients with ESALD; (b) the management of SAAH; (c) the management of AUD in patients with ESALD and SAAH; (d) special populations: polydrug addicts.


Assuntos
Alcoolismo/complicações , Doença Hepática Terminal/cirurgia , Hepatite Alcoólica/terapia , Cirrose Hepática Alcoólica/terapia , Transplante de Fígado , Abstinência de Álcool , Alcoolismo/terapia , Doença Hepática Terminal/etiologia , Hepatite Alcoólica/etiologia , Humanos , Itália , Cirrose Hepática Alcoólica/etiologia , Sociedades Médicas
5.
Alcohol Clin Exp Res ; 43(2): 334-341, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30667521

RESUMO

BACKGROUND: The burden of alcohol-associated cirrhosis (AC) is high, and though alcohol cessation improves mortality, many patients fail to engage in alcohol use disorder (AUD) treatment and continue drinking. Our aim was to determine rates, predictors, and outcomes of AUD treatment utilization in AC patients with private insurance. METHODS: We collected data from persons with AC (diagnosed by ICD-9/ICD-10 codes), aged 18 to 64 years, enrolled in the Truven MarketScan Commercial Claims and Encounters database (2009 to 2016). We determined rates and predictors of substance abuse treatment visits as well as rates of alcohol relapse prevention medication prescriptions, weighted to the national employer-sponsored insured population. Effects of AUD treatment utilization on decompensation rates were calculated using proportional hazards regression with propensity score adjustment. RESULTS: A total of 66,053 AC patients were identified, 32% were female, and mean age at diagnosis was 54.5 years. About 72% had insurance coverage for substance abuse treatment. Overall, AUD treatment utilization rates were low, with only 10% receiving a face-to-face mental health or substance abuse visit and only 0.8% receiving a Food and Drug Administration (FDA)-approved relapse prevention medication within 1 year of index diagnosis. Women were less likely to receive a face-to-face visit (hazard ratio [HR] 0.84, p < 0.001) or an FDA-approved relapse prevention medication (0.89, p = 0.05) than men. AC patients who had a clinic visit for AUD treatment or used FDA-approved relapse medication showed decreased risk of decompensation at 1 year (HR 0.85, p < 0.001 for either). CONCLUSIONS: AUD treatment utilization is associated with lower decompensation rates among privately insured patients with AC. Women were less likely to utilize AUD treatment visits. Efforts to reduce gender-specific barriers to treatment are urgently needed to improve outcomes.


Assuntos
Seguro Saúde/estatística & dados numéricos , Cirrose Hepática Alcoólica/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Cirrose Hepática Alcoólica/complicações , Cirrose Hepática Alcoólica/prevenção & controle , Cirrose Hepática Alcoólica/terapia , Masculino , Pessoa de Meia-Idade , Prevenção Secundária/estatística & dados numéricos , Fatores Sexuais , Adulto Jovem
6.
Dig Dis Sci ; 64(6): 1460-1469, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30673984

RESUMO

BACKGROUND: Inpatient charges for patients with cirrhosis are substantial. We aimed to examine trends in inpatient charges among patients with cirrhosis to determine the drivers of healthcare expenditures. We hypothesized that alcoholic cirrhosis (AC) was a significant contributor to overall expense. METHODS: We performed a retrospective analysis of the Health Care Utilization Project Nationwide Inpatient Sample Database 2002-2014 (annual cross-sectional data) and New York and Florida State Inpatient Databases 2010-2012 (longitudinal data). Adult patients with cirrhosis of the liver were categorized as AC versus all other etiologies of cirrhosis combined. Patient characteristics were analyzed using ordinary least squares regression modeling. A random effects model was used to evaluate 30-day readmissions. RESULTS: In total, 1,240,152 patients with cirrhosis were admitted between 2002 and 2014. Of these, 567,510 (45.8%) had a diagnosis of AC. Total charges for AC increased by 95.7% over the time period, accounting for 59.9% of all inpatient cirrhosis-related charges in 2014. Total aggregate charges for AC admissions were $28 billion and increased from $1.4B in 2002 to $2.8B by 2014. In the NIS and SID, patients with AC were younger, white and male. Readmission rates at 30, 60, and 90 days were all higher among AC patients. CONCLUSIONS: Inpatient charges for cirrhosis care are high and increasing. Alcohol-related liver disease accounts for more than half of these charges and is driven by sheer volume of admissions and readmissions of the same patients. Effective alcohol addictions therapy may be the most cost-effective way to substantially reduce inpatient cirrhosis care expenditures.


Assuntos
Preços Hospitalares/tendências , Hospitalização/economia , Hospitalização/tendências , Pacientes Internados , Cirrose Hepática Alcoólica/economia , Cirrose Hepática Alcoólica/terapia , Cirrose Hepática/economia , Cirrose Hepática/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Gastos em Saúde/tendências , Custos Hospitalares/tendências , Humanos , Cirrose Hepática/epidemiologia , Cirrose Hepática Alcoólica/epidemiologia , Estudos Longitudinais , Pessoa de Meia-Idade , Admissão do Paciente/economia , Admissão do Paciente/tendências , Readmissão do Paciente/economia , Readmissão do Paciente/tendências , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
7.
Clin Liver Dis ; 23(1): 115-126, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30454826

RESUMO

Alcohol-associated cirrhosis (AC) contributes up to 50% of the overall cirrhosis burden in the United States. AC is typically a comorbid condition in association with alcohol-use disorder. AC is often coexistent with other conditions. Several noninvasive methods are available to assist in recognizing the presence of AC. The natural history of AC is governed by the patients continued drinking or abstinence. All treatment starts with abstinence. After decompensation, the progression to acute-on-chronic liver failure heralds death. When patients who have deteriorated are declined liver transplant, palliative care should be considered.


Assuntos
Cirrose Hepática Alcoólica , Abstinência de Álcool , Alcoolismo/epidemiologia , Carcinoma Hepatocelular , Causas de Morte , Fumar Cigarros/epidemiologia , Comorbidade , Gerenciamento Clínico , Progressão da Doença , Hemocromatose/epidemiologia , Hepatite B Crônica/epidemiologia , Hepatite C Crônica/epidemiologia , Humanos , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/epidemiologia , Cirrose Hepática Alcoólica/metabolismo , Cirrose Hepática Alcoólica/terapia , Neoplasias Hepáticas , Transplante de Fígado , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Cuidados Paliativos
8.
A A Pract ; 12(1): 15-18, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29985842

RESUMO

A 46-year-old woman with alcoholic cirrhosis and hepatorenal syndrome requiring hemodialysis presented with hyperkalemia (5.5 mEq/L) immediately before liver transplantation. For correction of hyperkalemia, an exchange transfusion began by removing her blood into an autotransfusion system to wash out noncellular components while maintaining normovolemia. Additionally, she received washed homologous red blood cells, insulin, and glucose to minimize or reduce the degree of hyperkalemia. Serum potassium level decreased to 4.0 mEq/L within 3 hours and was 5.0 mEq/L 30 seconds after reperfusion of the grafted liver. Postreperfusion syndrome was not observed. In summary, exchange transfusion was used successfully for rapid correction of hyperkalemia, showing the value of its application in liver transplantation.


Assuntos
Transfusão de Sangue Autóloga/métodos , Glucose/administração & dosagem , Hiperpotassemia/terapia , Insulina/administração & dosagem , Terapia Combinada , Feminino , Síndrome Hepatorrenal/complicações , Síndrome Hepatorrenal/terapia , Humanos , Hiperpotassemia/etiologia , Cirrose Hepática Alcoólica/complicações , Cirrose Hepática Alcoólica/terapia , Transplante de Fígado , Pessoa de Meia-Idade , Resultado do Tratamento
9.
Nihon Shokakibyo Gakkai Zasshi ; 115(12): 1087-1093, 2018.
Artigo em Japonês | MEDLINE | ID: mdl-30531115

RESUMO

A 59-year-old man had been admitted to our hospital because of general malaise and abdominal fullness caused by massive ascites. He was diagnosed with alcoholic liver cirrhosis. Following the removal of ascites, he was referred to our department because of hematochezia. Emergent colonoscopy revealed the rupture of ascending colonic varices. Endoscopic variceal sclerotherapy using topical skin adhesive (75% Histoacryl) was performed to treat the colonic varices, which proved to be an effective treatment. Enhanced computerized tomography performed 5 days after the treatment of ascending colonic varices showed complete obstruction of the ileocolic varices without complication. It is important to consider the possibility of ectopic varices when a patient with liver cirrhosis reports bloody stool.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Cirrose Hepática Alcoólica/terapia , Escleroterapia , Adesivos , Varizes Esofágicas e Gástricas/complicações , Hemorragia Gastrointestinal/complicações , Hemorragia Gastrointestinal/terapia , Humanos , Masculino , Pessoa de Meia-Idade
10.
Minerva Med ; 109(6): 457-471, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30221911

RESUMO

Alcohol consumption is one of the main risks to public health. Alcohol use disorders (AUDs) cause 80% of hepatotoxic deaths, and approximately 50% of cirrhosis is alcohol-related. The acceptable daily intake (ADI) for ethanol is 2.6 g/day, deduced from morbidity and mortality rates due to liver fibrosis. The relative risk of cirrhosis increases significantly for doses above 60 g/day for men and 20 g/day for women over a period of around 10 years. Twenty to 40% of steatosis cases will evolve into steatohepatitis/steatofibrosis, and 8 to 20% will evolve directly into liver cirrhosis. About 20 to 40% of steatohepatitis cases will evolve into cirrhosis, and 4 to 5% into hepatocellular carcinoma. This cascade of events evolves in 5 to 40 years, with the temporal variability caused by the subjects' genetic patterns and associated risk/comorbidity factors. Steatohepatitis should be considered "the rate limiting step:" usually, it can be resolved through abstinence, although for some patients, once this situation develops, it is not substantially modified by abstention and there is a risk of fibrotic evolution. Early detection of fibrosis, obtained by hepatic elastography, is a crucial step in patients with AUDs. Such strategy allows patients to be included in a detoxification program in order to achieve abstention. Drugs such as silybin, metadoxine, and adenosylmethionine can be used. Other drugs, with promising antifibrotic effects, are currently under study. In this review, we discuss clinical and pathogenetic aspects of alcohol-related liver fibrosis and present and future strategies to prevent cirrhosis.


Assuntos
Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/terapia , Ensaios Clínicos como Assunto , Feminino , Hepatite C Crônica/complicações , Humanos , Cirrose Hepática Alcoólica/complicações , Cirrose Hepática Alcoólica/etiologia , Masculino
12.
J Subst Abuse Treat ; 91: 20-27, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29910011

RESUMO

BACKGROUND: While alcohol cessation improves mortality in alcoholic liver disease (ALD), many patients struggle to achieve abstinence. Our aim was to characterize ALD patients' preferences, misconceptions, and barriers to alcohol use treatment options. METHODS: This mixed-methods study included outpatients with a history of alcohol-related cirrhosis or alcoholic hepatitis recruited from a hepatology clinic for a survey or an in-depth semi-structured interview. We purposefully sampled men and women, compensated and decompensated patients to ensure adequate representation of gender and severity of liver disease for the qualitative interviews. RESULTS: 123 patients completed surveys among which 50% reported having at least one drink within the past year while only 20 patients were in any form of current alcohol treatment. Of the 23 patients reporting drinking within 3 months, only 3 were in AUD treatment currently. 17% had at least one misconception about alcohol use or treatment. An additional 22 ALD patients (10 women, 12 men) completed phone interviews of which two-third self-reported alcohol abstinence. All 22 interview participants had awareness of some form of alcohol treatment, but 13 felt that they did not need treatment with several characterizing it as ineffective or a "waste of time." Misconceptions included inaccurate perceptions of relapse medication side effects, beliefs that the presence of advanced liver disease symptoms means it is too late to treat alcohol use, and a lack of understanding about the chronicity of alcohol use disorders. The most common barriers to treatment included unwillingness to be in treatment, financial/insurance and transportation barriers. CONCLUSIONS: Alcohol use treatment was underutilized in many ALD patients, despite active drinking in many. Tailored education and preference sensitive treatment engagement may overcome barriers to alcohol use treatment and promote abstinence.


Assuntos
Abstinência de Álcool/estatística & dados numéricos , Consumo de Bebidas Alcoólicas/epidemiologia , Alcoolismo/reabilitação , Cirrose Hepática Alcoólica/terapia , Adulto , Idoso , Abstinência de Álcool/psicologia , Consumo de Bebidas Alcoólicas/psicologia , Alcoolismo/psicologia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Recidiva , Inquéritos e Questionários
13.
Ann Hepatol ; 17(3): 470-475, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29735785

RESUMO

INTRODUCTION AND AIM: Excessive alcohol consumption is a public health concern worldwide and has been associated with high mortality rates. This study aimed to determine the prevalence of alcohol consumption and its influence on the prognosis of hospitalized cirrhotic patients in a tertiary care hospital. MATERIAL AND METHODS: We reviewed the medical records of all patients with hepatic cirrosis admitted between January 2009 and December 2014, in a referral center for liver disease in southern Brazil. Data on clinical outcomes, associated conditions, infections, and mortality were collected and compared between alcoholic and nonalcoholic patients. RESULTS: The sample consisted of 388 patients; 259 (66.7%) were men. One hundred fifty-two (39.2%) were classified as heavy use of alcohol. Most alcoholic patients were men (n = 144; 94.7%). Mean age was 55.6 ± 8.9 years. Hepatic decompensations and infections were more prevalent in alcoholic patient. Spontaneous bacterial peritonitis and respiratory tract infection accounted for most of the infections. Excessive alcohol consumption was associated with mortality (P = 0.009) in multivariate analysis. CONCLUSION: On the present study, the prevalence of heavy use of alcohol was high and associated with a poorer prognosis in hospitalized cirrhotic patients, increasing the risk of infection and death.


Assuntos
Consumo de Bebidas Alcoólicas/efeitos adversos , Consumo de Bebidas Alcoólicas/epidemiologia , Cirrose Hepática Alcoólica/epidemiologia , Encaminhamento e Consulta , Centros de Atenção Terciária , Idoso , Consumo de Bebidas Alcoólicas/mortalidade , Brasil/epidemiologia , Estudos Transversais , Feminino , Mortalidade Hospitalar , Humanos , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/mortalidade , Cirrose Hepática Alcoólica/terapia , Masculino , Registros Médicos , Pessoa de Meia-Idade , Admissão do Paciente , Prevalência , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
14.
Hepatology ; 68(3): 872-882, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29579356

RESUMO

Alcoholic cirrhosis (AC) is a major cause of liver-related morbidity and mortality in the United States. Rising rates of alcohol use disorders in the United States will likely result in more alcoholic liver disease. Our aim was to determine the prevalence, health care use, and costs of AC among privately insured persons in the United States. We collected data from persons aged 18-64 with AC (identified by codes from the International Classification of Diseases, Ninth and Tenth Revisions) enrolled in the Truven MarketScan Commercial Claims and Encounters database (2009-2015). We determined yearly prevalence, weighted to the national employer-sponsored, privately insured population. Using competing risk analysis, we estimated event rates for portal hypertensive complications and estimated the association between AC and costs as well as admissions and readmissions. In 2015, 294,215 people had cirrhosis and 105,871 (36%) had AC. Mean age at AC diagnosis was 53.5 years, and 32% were women. Over the 7 years queried, estimated national cirrhosis prevalence rose from 0.19% to 0.27% (P < 0.001) and for AC from 0.07% to 0.10% (P < 0.001). Compared to non-AC, AC enrollees were significantly more likely to have portal hypertensive complications at diagnosis and higher yearly cirrhosis and alcohol-related admissions (25 excess cirrhosis admissions and 6.3 excess alcohol-related admissions per 100 enrollees) as well as all-cause readmissions. Per-person costs in the first year after diagnosis nearly doubled for AC versus non-AC persons (US$ 44,835 versus 23,319). CONCLUSION: In a nationally representative cohort of privately insured persons, AC enrollees were disproportionately sicker at presentation, were admitted and readmitted more often, and incurred nearly double the per-person health care costs compared to those with non-AC. (Hepatology 2018).


Assuntos
Efeitos Psicossociais da Doença , Seguro Saúde , Cirrose Hepática Alcoólica/economia , Cirrose Hepática Alcoólica/epidemiologia , Adulto , Feminino , Humanos , Cirrose Hepática Alcoólica/terapia , Masculino , Pessoa de Meia-Idade , Prevalência , Estados Unidos/epidemiologia , Adulto Jovem
15.
Gastroenterology ; 154(5): 1369-1379, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29317276

RESUMO

BACKGROUND & AIMS: Alcohol is the leading cause of cirrhosis and liver-related mortality, but we lack serum markers to detect compensated disease. We compared the accuracy of the Enhanced Liver Fibrosis test (ELF), the FibroTest, liver stiffness measurements (made by transient elastography and 2-dimensional shear-wave elastography), and 6 indirect marker tests in detection of advanced liver fibrosis (Kleiner stage ≥F3). METHODS: We performed a prospective study of 10 liver fibrosis markers (patented and not), all performed on the same day. Patients were recruited from primary centers (municipal alcohol rehabilitation, n = 128; 6% with advanced fibrosis) and secondary health care centers (hospital outpatient clinics, n = 161; 36% with advanced fibrosis) in the Region of Southern Denmark from 2013 through 2016. Biopsy-verified fibrosis stage was used as the reference standard. The primary aim was to validate ELF in detection of advanced fibrosis in patients with alcoholic liver disease recruited from primary and secondary health care centers, using the literature-based cutoff value of 10.5. Secondary aims were to assess the diagnostic accuracy of ELF for significant fibrosis and cirrhosis and to determine whether combinations of fibrosis markers increase diagnostic yield. RESULTS: The ELF identified patients with advanced liver fibrosis with an area under the receiver operating characteristic curve (AUROC) of 0.92 (95% confidence interval 0.89-0.96); findings did not differ significantly between patients from primary vs secondary care (P = .917). ELF more accurately identified patients with advanced liver fibrosis than indirect marker tests, but ELF and FibroTest had comparable diagnostic accuracies (AUROC of FibroTest, 0.90) (P = .209 for comparison with ELF). Results from the ELF and FibroTest did not differ significantly from those of liver stiffness measurement in intention-to-diagnose analyses (AUROC for transient elastography, 0.90), but did differ in the per-protocol analysis (AUROC for transient elastography, 0.97) (P = .521 and .004 for comparison with ELF). Adding a serum marker to transient elastography analysis did not increase accuracy. For patients in primary care, ELF values below 10.5 and FibroTest values below 0.58 had negative predictive values for advanced liver fibrosis of 98% and 94%, respectively. CONCLUSION: In a prospective, direct comparison of tests, ELF and FibroTest identified advanced liver fibrosis in alcoholic patients from primary and secondary care with high diagnostic accuracy (AUROC values of 0.90 or higher using biopsy as reference). Advanced fibrosis can be ruled out in primary health care patients based on an ELF value below 10.5 or a FibroTest value below 0.58.


Assuntos
Técnicas de Apoio para a Decisão , Técnicas de Imagem por Elasticidade , Cirrose Hepática Alcoólica/sangue , Cirrose Hepática Alcoólica/diagnóstico por imagem , Testes de Função Hepática , Fígado/diagnóstico por imagem , Fígado/metabolismo , Adolescente , Adulto , Idoso , Área Sob a Curva , Biomarcadores/sangue , Biópsia , Tomada de Decisão Clínica , Dinamarca , Feminino , Humanos , Fígado/patologia , Cirrose Hepática Alcoólica/patologia , Cirrose Hepática Alcoólica/terapia , Masculino , Pessoa de Meia-Idade , Contagem de Plaquetas , Valor Preditivo dos Testes , Atenção Primária à Saúde , Prognóstico , Estudos Prospectivos , Curva ROC , Reprodutibilidade dos Testes , Atenção Secundária à Saúde , Adulto Jovem
16.
Crit Care Med ; 46(5): 705-712, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29309369

RESUMO

OBJECTIVE: To assess the epidemiology and outcome of patients with cirrhosis following critical care unit admission. DESIGN: Retrospective cohort study. SETTING: Critical care units in England, Wales, and Northern Ireland participating in the U.K. Intensive Care National Audit and Research Centre Case Mix Programme. PATIENTS: Thirty-one thousand three hundred sixty-three patients with cirrhosis identified of 1,168,650 total critical care unit admissions (2.7%) admitted to U.K. critical care units between 1998 and 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ten thousand nine hundred thirty-six patients had alcohol-related liver disease (35%). In total, 1.6% of critical care unit admissions in 1998 had cirrhosis rising to 3.1% in 2012. The crude critical care unit mortality of patients with cirrhosis was 41% in 1998 falling to 31% in 2012 (p < 0.001). Crude hospital mortality fell from 58% to 46% over the study period (p < 0.001). Mean(SD) Acute Physiology and Chronic Health Evaluation II score in 1998 was 20.3 (8.5) and 19.5 (7.1) in 2012. Mean Acute Physiology and Chronic Health Evaluation II score for patients with alcohol-related liver disease in 2012 was 20.6 (7.0) and 19.0 (7.2) for non-alcohol-related liver disease (p < 0.001). In adjusted analysis, alcohol-related liver disease was associated with increased risk of death (odds ratio, 1.51 [95% CI, 1.42-1.62; p < 0.001]) with a year-on-year reduction in hospital mortality (adjusted odds ratio, 0.95/yr, [0.94-0.96, p < 0.001]). CONCLUSIONS: More patients with cirrhosis are being admitted to critical care units but with increasing survival rates. Patients with alcohol-related liver disease have reduced survival rates partly explained by higher levels of organ failure at admission. Patients with cirrhosis and organ failure warrant a trial of organ support and universal prognostic pessimism is not justified.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Cirrose Hepática/epidemiologia , APACHE , Grupos Diagnósticos Relacionados , Feminino , Humanos , Incidência , Cirrose Hepática/etiologia , Cirrose Hepática/mortalidade , Cirrose Hepática/terapia , Cirrose Hepática Alcoólica/epidemiologia , Cirrose Hepática Alcoólica/mortalidade , Cirrose Hepática Alcoólica/terapia , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Reino Unido/epidemiologia
17.
Am J Kidney Dis ; 71(3): 436-440, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29277507

RESUMO

Osmotic demyelination unrelated to hyponatremia is rarely reported. We present a case of osmotic demyelination in a patient with hypernatremia in the absence of preceding hyponatremia and review previously reported cases of osmotic demyelination in nonhyponatremic patients. We conclude that a rapid increase in serum sodium concentration and plasma tonicity even in the absence of preceding hyponatremia may surpass the brain's capacity for adaptation to hypertonicity and lead to osmotic demyelination in predisposed individuals. Risk factors for osmotic demyelination in patients with chronic hyponatremia and without hyponatremia are probably similar and are usually associated with states of limited brain osmolyte response, such as alcoholism, liver disease (including those undergoing orthotopic liver transplantation), malnutrition, malignancy, pregnancy/postpartum state, severe illness/sepsis, adrenal insufficiency, and metabolic derangements. Clinicians should be vigilant in identifying individuals who may, even in the absence of hyponatremia, have increased susceptibility to osmotic demyelination and avoid rapid fluctuations in serum sodium concentrations in such patients.


Assuntos
Encefalopatia Hepática/etiologia , Hipernatremia/diagnóstico , Imagem por Ressonância Magnética/métodos , Multimorbidade , Mielinólise Central da Ponte/etiologia , Análise Química do Sangue , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Progressão da Doença , Encefalopatia Hepática/diagnóstico por imagem , Encefalopatia Hepática/terapia , Cuidados Paliativos na Terminalidade da Vida , Humanos , Hipernatremia/complicações , Cirrose Hepática Alcoólica/complicações , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/terapia , Masculino , Pessoa de Meia-Idade , Mielinólise Central da Ponte/diagnóstico por imagem , Prognóstico , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia , Medição de Risco
18.
BMJ Case Rep ; 20172017 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-28500122

RESUMO

Severely decompensated cirrhosis presents major challenges in terms of balancing the benefits and burdens of life-extending treatment. Using accounts and interviews with a patient, her mother, consultant hepatologists and a consultant intensivist, this article explores the decision making around a 43-year-old woman with alcoholic liver disease who died after 100 days in a hospital. Particular focus is given to decisions on escalation, recognition of futility, distress associated with therapy and how messages given during end-of-life discussions are processed. Without suggesting that the case is an example of ideal practice, the importance of frequent multidisciplinary discussion, clinical re-evaluation and continuity of care is emphasised.


Assuntos
Tomada de Decisões , Cirrose Hepática Alcoólica/terapia , Adulto , Diagnóstico Diferencial , Tratamento de Emergência , Evolução Fatal , Feminino , Humanos , Futilidade Médica , Assistência Terminal
20.
Gut Liver ; 11(2): 173-188, 2017 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-28274107

RESUMO

Alcoholic liver disease (ALD) is a leading cause of cirrhosis, liver cancer, and acute and chronic liver failure and as such causes significant morbidity and mortality. While alcohol consumption is slightly decreasing in several European countries, it is rising in others and remains high in many countries around the world. The pathophysiology of ALD is still incompletely understood but relates largely to the direct toxic effects of alcohol and its main intermediate, acetaldehyde. Recently, novel putative mechanisms have been identified in systematic scans covering the entire human genome and raise new hypotheses on previously unknown pathways. The latter also identify host genetic risk factors for significant liver injury, which may help design prognostic risk scores. The diagnosis of ALD is relatively easy with a panel of well-evaluated tests and only rarely requires a liver biopsy. Treatment of ALD is difficult and grounded in abstinence as the pivotal therapeutic goal; once cirrhosis is established, treatment largely resembles that of other etiologies of advanced liver damage. Liver transplantation is a sound option for carefully selected patients with cirrhosis and alcoholic hepatitis because relapse rates are low and prognosis is comparable to other etiologies. Still, many countries are restrictive in allocating donor livers for ALD patients. Overall, few therapeutic options exist for severe ALD. However, there is good evidence of benefit for only corticosteroids in severe alcoholic hepatitis, while most other efforts are of limited efficacy. Considering the immense burden of ALD worldwide, efforts of medical professionals and industry partners to develop targeted therapies in ALF has been disappointingly low.


Assuntos
Gerenciamento Clínico , Cirrose Hepática Alcoólica/terapia , Hepatopatias Alcoólicas/terapia , Corticosteroides/uso terapêutico , Consumo de Bebidas Alcoólicas/efeitos adversos , Europa (Continente) , Humanos , Cirrose Hepática Alcoólica/etiologia , Cirrose Hepática Alcoólica/fisiopatologia , Hepatopatias Alcoólicas/complicações , Hepatopatias Alcoólicas/etiologia , Hepatopatias Alcoólicas/fisiopatologia , Transplante de Fígado
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