Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 223
Filtrar
1.
BMC Infect Dis ; 21(1): 29, 2021 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-33413185

RESUMO

BACKGROUND: Serum levels of procalcitonin (PCT) are considered a useful biomarker for the diagnosis of bacterial infection or inflammation. There are few reports of high PCT levels in end-stage liver disease regardless of bacterial infection. Here, we present a case of extremely high PCT levels (> 100 ng/mL) in a patient with severe cirrhosis combined with hepatic carcinoma. CASE PRESENTATION: A 65-year-old man developed end-stage cirrhosis with hepatic carcinoma. Radiographic imaging showed a massive hepatocellular carcinoma with multiple loci lack of indications of resection. Hence, transcatheter hepatic arterial chemoembolization was performed three times over a period of 4 months. Before and after interventional therapies, the biochemistry laboratory results were only slightly abnormal except for persistently high PCT concentrations (> 100 ng/mL), irrespective of the evidence for bacterial infection or sepsis. CONCLUSIONS: This case suggests that continuously high levels of PCT (> 100 ng/mL) may be present in advanced liver disease, particularly in complex situations such as decompensated cirrhosis and liver cancer, in the absence of severe infection or sepsis. This knowledge could expand the significance of PCT in liver disease.


Assuntos
Biomarcadores/sangue , Carcinoma Hepatocelular/sangue , Cirrose Hepática/sangue , Neoplasias Hepáticas/sangue , Pró-Calcitonina/sangue , Idoso , Infecções Bacterianas/diagnóstico , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/terapia , Quimioembolização Terapêutica , Doença Hepática Terminal/sangue , Doença Hepática Terminal/patologia , Doença Hepática Terminal/terapia , Humanos , Cirrose Hepática/patologia , Cirrose Hepática/terapia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/terapia , Masculino , Sepse/diagnóstico
2.
BMC Gastroenterol ; 20(1): 428, 2020 Dec 26.
Artigo em Inglês | MEDLINE | ID: mdl-33357229

RESUMO

BACKGROUND: End-stage liver disease (ESLD) is a major burden on public health, particularly in sub-Saharan Africa, where hepatitis B virus (HBV) is an important risk factor. We aimed to describe clinical characteristics of ESLD from cirrhosis or hepatocellular carcinoma (HCC) and the performance of aspartate aminotransferase (AST)-platelet ratio index (APRI) and alpha fetoprotein (AFP) in Ghana. METHODS: We performed an observational cross-sectional study in outpatient hepatology clinics at three teaching hospitals in Ghana, West Africa. One hundred and forty-one HCC, 216 cirrhosis and 218 chronic HBV patients were recruited by convenience sampling. Sociodemographic, history and examination, laboratory, and disease staging information were shown using descriptive statistics. Performance of the APRI score in diagnosis of cirrhosis and AFP in the diagnosis of HCC was determined using AUROC analysis. RESULTS: Median age at presentation was 44 years for HCC and 46 years for cirrhosis. HBV was found in 69.5% of HCC and 47.2% of cirrhosis cases, and HCV in 6.4% and 3.7% respectively. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in diagnosis of cirrhosis, and cut-off of 1 had sensitivity of 75.9% and specificity of 89%. AUC of AFP was 0.88 (95% CI 0.81-0.94) in diagnosis of HCC. Low monthly income was associated with lower odds of undertaking AFP. Thirty one percent of cirrhotic persons were Child-Pugh C, and 67.9% of HCC patients had advanced or terminal disease at presentation. CONCLUSIONS: Our findings emphasize the young age of ESLD patients in Ghana and the advanced nature at presentation. It highlights shortcomings in surveillance and the need for policies to address the burden and improve outcomes in Ghana.


Assuntos
Aspartato Aminotransferases/sangue , Biomarcadores/sangue , Carcinoma Hepatocelular/patologia , Doença Hepática Terminal/sangue , Hepatite C Crônica/sangue , Hepatite C Crônica/complicações , Neoplasias Hepáticas/patologia , alfa-Fetoproteínas/metabolismo , Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/virologia , Estudos Transversais , Doença Hepática Terminal/epidemiologia , Doença Hepática Terminal/virologia , Feminino , Gana/epidemiologia , Hepatite B Crônica , Hepatite C Crônica/diagnóstico , Humanos , Cirrose Hepática/sangue , Cirrose Hepática/diagnóstico , Cirrose Hepática/epidemiologia , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/virologia , Masculino , Contagem de Plaquetas
3.
J Surg Res ; 255: 99-105, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32543385

RESUMO

BACKGROUND: Patients undergoing liver transplantation (LT) frequently receive platelet transfusion (PLT) to minimize their risk of hemorrhage. Alloimmunization to platelets may lead to refractoriness to PLT. Data on the implications of platelet alloimmunization in patients undergoing LT remain limited. We examined the effect of human leukocyte antigen class I (HLA-I) antibodies on PLT refractoriness and short-term outcomes after LT. METHODS: Peritransplant clinical and PLT factors were reviewed for all adult liver or simultaneous liver-kidney transplantations from 2012 to 2017. Sensitized patients (SE) with pretransplant HLA-I calculated panel-reactive antibody ≥20% were compared with unsensitized patients (US) with calculated panel-reactive antibody <20%. The mean follow-up was 21.4 mo. RESULTS: Alloimmunization was observed in 39% of the study cohort. SE (n = 28) received 272 PLTs, and US (n = 44) received 246 PLTs. History of pregnancy was higher among SE than US (P < 0.01); otherwise, both groups had similar clinical characteristics. SE had higher rates of PLT refractoriness (66% versus 47%; P < 0.01) than US. The mean platelet corrected count increment was lower among SE compared with US up to 100 min after PLT (P < 0.05). Alloimmunization and simultaneous liver-kidney transplantation independently predicted refractoriness on multivariate logistic regression (P < 0.05). Early allograft rejection and patient survival rates were comparable for both groups. CONCLUSIONS: LT patients experienced high rates of HLA-I alloimmunization and PLT refractoriness. SE had higher rates of refractoriness and lower mean corrected count increment after transfusion compared with US. Our study suggests that further research to evaluate the utility of HLA-matched PLTs in HLA-I alloimmunized LT patients is warranted.


Assuntos
Antígenos HLA/imunologia , Isoanticorpos/imunologia , Transplante de Fígado/efeitos adversos , Transfusão de Plaquetas/efeitos adversos , Trombocitopenia/terapia , Perda Sanguínea Cirúrgica/prevenção & controle , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Doença Hepática Terminal/cirurgia , Feminino , Antígenos HLA/sangue , Teste de Histocompatibilidade , Humanos , Isoanticorpos/sangue , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/prevenção & controle , Estudos Prospectivos , Estudos Retrospectivos , Trombocitopenia/sangue , Trombocitopenia/etiologia , Resultado do Tratamento
4.
Aliment Pharmacol Ther ; 52(1): 107-122, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32478917

RESUMO

BACKGROUND: Palliative care remains suboptimal in end-stage liver disease. AIM: To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison. METHODS: A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion. RESULTS: Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (µmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway. CONCLUSIONS: The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation. TRIAL REGISTRATION: ISRCTN30697116, date assigned: 07/10/2015.


Assuntos
Ascite/terapia , Drenagem , Doença Hepática Terminal/terapia , Cirrose Hepática/terapia , Idoso , Ascite/sangue , Ascite/etiologia , Creatinina/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Feminino , Humanos , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos , Albumina Sérica
5.
Transplantation ; 104(7): e188-e198, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32150034

RESUMO

BACKGROUND: Cystatin C (CysC) is an early biomarker of renal dysfunction scarcely studied in patients awaiting liver transplantation (LT). Sarcopenia is frequent in cirrhosis and impacts prognosis. We aimed to assess the capability of these factors to predict survival and acute-on-chronic liver failure (ACLF) in patients awaiting LT, as well as early post-LT outcomes. METHODS: Single-center study that included all cirrhotic patients listed for LT between 2014 and 2017. Competing risk regression analysis was used to evaluate the capability of liver-, kidney-, and global status-related variables at waitlist (WL) inclusion to predict WL mortality and ACLF. Variables associated with post-LT outcomes were evaluated with logistic regression analysis. RESULTS: One-hundred-and-eighty patients were included. Fifty-six (31%) patients developed ACLF, 54 (30%) underwent LT and 35 (19%) died. In the adjusted competing risk regression analysis, CysC ≥ 1.5 mg/L, sarcopenia and MELD-Na were independent predictors of ACLF in the WL, while CysC ≥ 1.5 mg/L, sarcopenia and albumin were independent predictors of mortality. The cumulative incidence of ACLF and mortality at 12 months were 50% and 34% in patients with sarcopenia and CysC ≥1.5 mg/L. An estimated glomerular filtration rate by chronic kidney disease (CKD)-EPI-CysC-creatinine <60 mL/min/1.73 m at WL inclusion was an independent predictor of the need for renal replacement therapy (RRT) in the first month post-LT. CONCLUSIONS: Higher levels of CysC and sarcopenia are strongly associated with the ACLF and mortality in WL. The assessment of both risk factors may improve the prognostic evaluation and allow identifying a group of patients with a very high risk of poor outcomes while awaiting LT.


Assuntos
Insuficiência Hepática Crônica Agudizada/diagnóstico , Cistatina C/sangue , Doença Hepática Terminal/mortalidade , Cirrose Hepática/mortalidade , Transplante de Fígado/efeitos adversos , Sarcopenia/embriologia , Lesão Renal Aguda/sangue , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Insuficiência Hepática Crônica Agudizada/epidemiologia , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Idoso , Biomarcadores/sangue , Creatinina/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/etiologia , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sarcopenia/sangue , Sarcopenia/etiologia , Índice de Gravidade de Doença , Listas de Espera/mortalidade
6.
Clin Chim Acta ; 505: 141-147, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32119835

RESUMO

BACKGROUND: Previous studies have used a modified version of the Child-Turcotte-Pugh (CTP) score to include insulin-like growth factor 1 (IGF-1) concentrations, denoted the Insulin-like Growth Factor 1-Child-Turcotte-Pugh (IGF-CTP) system. We evaluated the predictive power of IGF-CTP for 1-year mortality in patients with decompensated cirrhosis (DC). METHODS: A total of 386 patients with DC were retrospectively analyzed. Comparison of distribution of patients with decompensated cirrhosis according to Insulin-like Growth Factor-1-Child-Turcotte-Pugh and Child-Turcotte-Pugh scores were performed. Area under the receiver operating characteristic curves (AUROCs) for IGF-CTP, CTP and the Model for End-stage Liver Disease (MELD) scores were evaluated to compare predictive value. Univariate and multivariate analyses were carried out to determine potential risk factors for 1-y mortality. RESULTS: During the 1-y follow-up, 94 patients died. Significantly more patients (both surviving and non-surviving) were classified as IGF-CTP stage C than CTP stage C. The AUROC of IGF-CTP was significantly higher than that of CTP and MELD in the training and validation cohorts. Multivariate analysis indicated IGF-CTP score and IGF-1 to be independently associated with mortality. CONCLUSION: The IGF-CTP score is independently associated with mortality for patients with DC, and offers more accurate prediction of 1-y mortality than either CTP or MELD score for these patients.


Assuntos
Algoritmos , Fibrose/sangue , Fator de Crescimento Insulin-Like I/análise , Adulto , Idoso , Área Sob a Curva , Estudos de Coortes , Doença Hepática Terminal/sangue , Feminino , Fibrose/mortalidade , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida
7.
J Surg Res ; 250: 45-52, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32018142

RESUMO

BACKGROUND: The Model for End-Stage Liver Disease Sodium (MELD-Na) incorporates hyponatremia into the MELD score and has been shown to correlate with surgical outcomes. The pathophysiology of hyponatremia parallels that of ascites, which purports greater surgical risk. This study investigates whether MELD-Na accurately predicts morbidity and mortality in patients with ascites undergoing general surgery procedures. MATERIALS AND METHODS: We used the National Surgical Quality Improvement Program database (2005-2014) to examine the adjusted risk of morbidity and mortality of cirrhotic patients with and without ascites undergoing inguinal or ventral hernia repair, cholecystectomy, and lysis of adhesions for bowel obstruction. Patients were stratified by the MELD-Na score and ascites. Outcomes were compared between patients with and without ascites for each stratum using low MELD-Na and no ascites group as a reference. RESULTS: A total of 30,391 patients were analyzed. Within each MELD-Na stratum, patients with ascites had an increased risk of complications compared with the reference group (low MELD-Na and no ascites): low MELD-Na with ascites odds ratio (OR) 4.33 (95% confidence interval [CI] 1.96-9.59), moderate MELD-Na no ascites OR 1.70 (95% CI 1.52-1.9), moderate MELD-Na with ascites OR 3.69 (95% CI 2.49-5.46), high MELD-Na no ascites OR 3.51 (95% CI 3.07-4.01), and high MELD-Na ascites OR 7.18 (95% CI 5.33-9.67). Similarly, mortality risk was increased in patients with ascites compared with the reference: moderate MELD-Na no ascites OR 3.55 (95% CI 2.22-5.67), moderate MELD-Na ascites OR 13.80 (95% CI 5.65-33.71), high MELD-Na no ascites OR 8.34 (95% CI 5.15-13.51), and high MELD-Na ascites OR 43.97 (95% CI 23.76-81.39). CONCLUSIONS: MELD-Na underestimates morbidity and mortality risk for general surgery patients with ascites.


Assuntos
Ascite/cirurgia , Doença Hepática Terminal/diagnóstico , Hiponatremia/diagnóstico , Cirrose Hepática/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Índice de Gravidade de Doença , Adulto , Idoso , Ascite/sangue , Ascite/etiologia , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Feminino , Mortalidade Hospitalar , Humanos , Hiponatremia/sangue , Hiponatremia/etiologia , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sódio/sangue , Resultado do Tratamento
8.
Sci Rep ; 10(1): 822, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31964979

RESUMO

Increased concentrations of the vasodilator histamine have been observed in patients undergoing abdominal surgery. The role of histamine during orthotopic liver transplantation (OLT) has only been studied in animals. The aim of this study was to measure plasma concentrations of histamine and its degrading enzyme diamine oxidase (DAO) in patients undergoing orthotopic liver transplantation, and assess whether histamine or DAO correlate with intraoperative noradrenaline requirements. Histamine and DAO concentrations were measured in 22 adults undergoing liver transplantation and 22 healthy adults. Furthermore, norepinephrine requirements during liver transplantation were recorded. Baseline concentrations of histamine and DAO were greater in patients, who underwent liver transplantation, than in healthy individuals (Histamine: 6.4 nM, IQR[2.9-11.7] versus 4.3 nM, IQR[3.7-7.1], p = 0.029; DAO: 2.0 ng/mL, IQR[1.5-4.1] versus <0,5 ng/mL, IQR[<0.5-1.1], p < 0.001). During liver transplantation, histamine concentrations decreased to 1.8 nM, IQR[0.5-4.9] in the anhepatic phase (p < 0.0001 versus baseline), and to 1.5 nM, IQR[0.5-2.9] after reperfusion (p < 0.0001 versus baseline). In contrast, DAO concentrations increased to 35.5 ng/ml, IQR[20-50] in the anhepatic phase (p = 0.001 versus baseline) and to 39.5 ng/ml, IQR[23-64] after reperfusion (p = 0.001 versus baseline), correlating inversely with histamine. Norepinephrine requirements during human liver transplantation correlated significantly with DAO concentrations in the anhepatic phase (r = 0.58, p = 0.011) and after reperfusion (r = 0.56; p = 0.022). In patients undergoing orthotopic liver transplantation, histamine concentrations decrease whereas DAO concentrations increase manifold. Diamine oxidase correlates with intraoperative norepinephrine requirements in patients undergoing OLT.


Assuntos
Amina Oxidase (contendo Cobre)/sangue , Doença Hepática Terminal/cirurgia , Histamina/sangue , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Transplante de Fígado/efeitos adversos , Transplante de Fígado/métodos , Idoso , Biomarcadores/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/fisiopatologia , Feminino , Hemodinâmica , Humanos , Hipotensão/diagnóstico por imagem , Hipotensão/etiologia , Cuidados Intraoperatórios , Complicações Intraoperatórias/tratamento farmacológico , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem
9.
Am J Emerg Med ; 38(7): 1408-1413, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31839522

RESUMO

BACKGROUND: Patients with end stage liver disease (ESLD) are particularly vulnerable to sepsis. ESLD patients are often excluded from controlled sepsis trials and more data are needed to guide the management of this population. OBJECTIVE: To describe the clinical factors and outcomes of patients with ESLD presenting to the emergency department (ED) with septic shock. METHODS: We performed a retrospective review of patients registered in our dedicated ED adult septic shock pathway. All patients registered between January 2014 and May 2016 were included. Clinical and treatment variables for ESLD patients were compared with non-ESLD patients. A second analysis assessed ESLD survivors compared to non-survivors. RESULTS: 2,584 septic shock patients were enrolled. ESLD was present in 6.2% (n = 161) of patients. Patients with ESLD had higher mortality compared to patients without ESLD 36.6% vs 21.2% (p < 0.001). ESLD patients were more likely to be younger, female, obese, and have other comorbidities. ESLD patients exhibited lower temperature, higher lactate, and higher incidence of acute kidney injury. There was no difference in antibiotics or fluid resuscitation between groups. ESLD patients received more ED vasopressor support. Among ESLD septic shock patients, maximum lactate and presence of pneumonia were independently associated with death. CONCLUSIONS: Patients with ESLD comprise a small but important subgroup of patients with ED septic shock that experience high mortality compared to patients without ESLD. Maximum ED lactate and pneumonia as the source of sepsis are independently associated with adverse outcome and may be used for early recognition of high-risk ESLD sepsis patients.


Assuntos
Doença Hepática Terminal/epidemiologia , Choque Séptico/epidemiologia , APACHE , Lesão Renal Aguda , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Temperatura Corporal , Comorbidade , Procedimentos Clínicos , Serviço Hospitalar de Emergência , Doença Hepática Terminal/sangue , Doença Hepática Terminal/terapia , Feminino , Hidratação , Humanos , Ácido Láctico/sangue , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Pneumonia/mortalidade , Estudos Retrospectivos , Albumina Sérica/análise , Distribuição por Sexo , Choque Séptico/sangue , Choque Séptico/terapia , Análise de Sobrevida , Vasoconstritores/uso terapêutico , Adulto Jovem
10.
Transplantation ; 104(7): 1413-1418, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31644488

RESUMO

BACKGROUND: The vast majority of patients with cirrhosis have low Model for End-Stage Liver Disease-Sodium (MELD-Na) scores; however, the ability for the MELD-Na score to predict patient outcomes at low scores is unclear. METHODS: Adult patients in a multicenter, Chicago-wide database of medical records with International Classification of Disease, Ninth Edition codes of cirrhosis and without a history of hepatocellular carcinoma were included. Records were linked with the state death registry, and death certificates were manually reviewed. Deaths were classified as "liver-related," "non-liver-related," and "non-descript" as adjudicated by a panel comprised of a transplant surgeon, a hepatologist, and an internist. A sensitivity analysis was performed where patients with hepatocellular carcinoma were included. RESULTS: Among 7922 identified patients, 3999 patients had MELD-Na scores that were never higher than 15. In total, 2137 (27%) patients died during the study period with higher mortality rates for the patients in the high MELD-Na group (19.4 (41.6%) versus 4.1 (12.6%) per 100 person-y, P < 0.001). The high MELD-Na group died of a liver-related cause in 1142 out of 1632 (70%) as compared to 240 out of 505 (47.5%) deaths in the low MELD-Na group. There was no difference in the distribution of subcategory of liver-related death between low and high MELD-Na groups. Among subclassification of liver-related deaths, the most common cause of death was "Infectious" in both groups. CONCLUSIONS: Despite persistently low MELD-Na scores, patients with cirrhosis still experience high rates of liver-related mortality.


Assuntos
Doença Hepática Terminal/mortalidade , Cirrose Hepática/mortalidade , Índice de Gravidade de Doença , Sódio/sangue , Listas de Espera/mortalidade , Adulto , Idoso , Causas de Morte , Chicago/epidemiologia , Atestado de Óbito , Progressão da Doença , Doença Hepática Terminal/sangue , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/patologia , Feminino , Humanos , Cirrose Hepática/sangue , Cirrose Hepática/diagnóstico , Cirrose Hepática/patologia , Transplante de Fígado/normas , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Medição de Risco/estatística & dados numéricos , Fatores de Tempo
11.
Transplantation ; 104(7): 1396-1402, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31651793

RESUMO

BACKGROUND: Model for End-Stage Liver Disease (MELD) score-based liver transplant allocation was implemented as a fair and objective measure to prioritize patients based upon disease severity. Accuracy and reproducibility of MELD is an essential assumption to ensure fairness in organ access. We hypothesized that variability in laboratory methodology between centers could impact allocation scores for individuals on the transplant waiting list. METHODS: Aliquots of 30 patient serum samples were analyzed for creatinine, bilirubin, and sodium in all transplant centers within United Network for Organ Sharing (UNOS) region 9. Descriptive statistics, intraclass correlation coefficients (ICCs), and linear mixed-effects regression were used to determine the relationship between center, bilirubin, and calculated MELD-sodium (MELD-Na) score. RESULTS: The mean MELD-Na score per sample ranged from 14 to 38. The mean range in MELD-Na per sample was 3 points, but 30% of samples had a range of 4-6 points. Correlation plots and intraclass correlation coefficient analysis confirmed bilirubin interfered with creatinine, with worsening agreement in creatinine at high bilirubin levels. Center and bilirubin were independently associated with creatinine reported in mixed-effects models. Unbiased hierarchical clustering suggested that samples from specific centers have consistently higher creatinine and MELD-Na values. CONCLUSIONS: Despite implementation of creatinine standardization, centers within a single UNOS region report clinically significant differences in MELD-Na on an identical sample, with differences of up to 6 points in high MELD-Na patients. The bias in MELD-Na scores based upon center choice within a region should be addressed in the current efforts to eliminate disparities in liver transplant access.


Assuntos
Doença Hepática Terminal/diagnóstico , Transplante de Fígado/normas , Alocação de Recursos/normas , Índice de Gravidade de Doença , Centros de Atenção Terciária/normas , Aloenxertos/provisão & distribução , Bilirrubina/sangue , Serviços de Laboratório Clínico/normas , Creatinina/sangue , Definição da Elegibilidade/normas , Doença Hepática Terminal/sangue , Humanos , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Padrões de Referência , Reprodutibilidade dos Testes , Sódio/sangue , Estados Unidos , Listas de Espera
12.
Dig Dis Sci ; 65(2): 524-533, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31407130

RESUMO

BACKGROUND: Thrombocytopenia is a hallmark of advanced liver disease. Platelets, growth factors (GFs), and vascular integrity are closely linked factors in disease pathogenesis, and their relationship, particularly in early disease stages, is not entirely understood. The aim was to compare circulating platelets, growth factors, and vascular injury markers (VIMs) in hepatitis C-infected (HCV) patients with early fibrosis and cirrhosis. METHODS: Retrospective evaluation of serum GFs and VIMs by ELISA were evaluated from twenty-six HCV patients. Analytes from an earlier time-point were correlated with MELD at a later time-point. RESULTS: Platelets and GFs decreased, and VIMs increased with fibrosis. Platelets correlated positively with PDGF-AA, PDGF-BB, TGFB1, EGF, and P-selectin, and negatively with ICAM-3 and VCAM-1. P-selectin showed no correlations with VIMs but positively correlated with PDGF-AA, PDGF-BB, TGFB1, and EGF. Soluble VCAM-1 and ICAM-3 were linked to increasing fibrosis, liver enzymes, and synthetic dysfunction. Higher VCAM-1 and ICAM-3 and lower P-selectin at an earlier time-point were linked to higher MELD score at a later time-point. CONCLUSION: In chronic HCV, progressive decline in platelets and growth factors with fibrosis and their associations suggest that platelets are an important source of circulating GFs and influence GF decline with fibrosis. Enhanced markers of vascular injury in patients with early fibrosis suggest an earlier onset of endothelial dysfunction preceding cirrhosis. Associations of VIMs with platelets suggest a critical link between platelets and vascular homeostasis. Circulating markers of vascular injury may not only have prognostic importance but emphasize the role of vascular dysfunction in liver disease pathogenesis (NCT00001971).


Assuntos
Endotélio Vascular/fisiopatologia , Hepatite C Crônica/sangue , Cirrose Hepática/sangue , Trombocitopenia/sangue , Adulto , Antígenos CD/sangue , Becaplermina/sangue , Biomarcadores , Moléculas de Adesão Celular/sangue , Progressão da Doença , Doença Hepática Terminal/sangue , Doença Hepática Terminal/metabolismo , Fatores de Crescimento Endotelial/sangue , Endotélio Vascular/metabolismo , Ensaio de Imunoadsorção Enzimática , Feminino , Hepatite C Crônica/complicações , Hepatite C Crônica/metabolismo , Homeostase , Humanos , Cirrose Hepática/etiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Selectina-P/sangue , Contagem de Plaquetas , Fator de Crescimento Derivado de Plaquetas/metabolismo , Estudos Retrospectivos , Índice de Gravidade de Doença , Trombocitopenia/etiologia , Trombocitopenia/metabolismo , Fator de Crescimento Transformador beta1/sangue , Molécula 1 de Adesão de Célula Vascular/sangue
13.
Transplantation ; 104(1): 72-78, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31283668

RESUMO

BACKGROUND: Destruction of the endothelial glycocalyx has been observed within lung and kidney grafts during ischemic organ preservation. We aimed to quantify glycocalyx damage within human liver grafts after organ preservation and correlate the results with graft injury and postoperative graft function in patients undergoing orthotopic liver transplantation (OLT). METHODS: Syndecan-1 (Sdc-1) was measured as indicator of glycocalyx degradation in effluents of 38 liver grafts and serum of patients undergoing OLT. Effluent Sdc-1 concentrations were correlated with hepatic injury markers from the effluent. Furthermore, we assessed the association of Sdc-1 with early allograft dysfunction (EAD), 1-year graft survival, and 1-year patient survival. RESULTS: Effluent Sdc-1 concentrations correlated with effluent concentrations of hepatocellular injury markers, including alkaline phosphatase (R = 0.543, P = 0.003), aspartate aminotransferase (R = 0.420, P = 0.029), and lactate (R = 0.574, P = 0.002). Sdc-1 effluent concentrations were greater in patients who developed EAD compared with those without EAD (4720 [4374-5133] vs 3838 [3202-4240] ng/mL, P = 0.015). Furthermore, receiver operating characteristics analyses revealed that effluent Sdc-1 concentrations (AUC = 0.82, P = 0.017) and serum Sdc-1 concentrations (AUC = 0.84, P = 0.006) were associated with the development of EAD. These results were confirmed by regression analyses. No association was found between Sdc-1 and 1-year graft survival or 1-year patient survival. CONCLUSIONS: Our data suggest that the glycocalyx is damaged within human liver grafts during preservation and the extent of glycocalyx damage correlates with the severity of hepatocellular injury. Recipients of livers grafts with greater glycocalyx damage might be at higher risk for development of EAD after OLT.


Assuntos
Doença Hepática Terminal/cirurgia , Glicocálix/patologia , Transplante de Fígado/efeitos adversos , Fígado/patologia , Preservação de Órgãos/efeitos adversos , Idoso , Doença Hepática Terminal/sangue , Doença Hepática Terminal/mortalidade , Células Endoteliais/citologia , Células Endoteliais/patologia , Feminino , Glicocálix/metabolismo , Sobrevivência de Enxerto , Humanos , Fígado/citologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Período Pós-Operatório , Estudos Prospectivos , Fatores de Risco , Sindecana-1/sangue , Sindecana-1/metabolismo
14.
Arq Bras Cir Dig ; 32(3): e1460, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31826087

RESUMO

BACKGROUND: Serum sodium was incorporated to MELD score for the allocation of liver transplantation In the USA in 2016. Hyponatremia significantly increased the efficacy of the score to predict mortality on the waiting list. Such modification was not adopted in Brazil. AIM: To carry out a simulation using MELD-Na as waiting list ordering criteria in the state of Paraná and to compare to the list ordered according to MELD score. METHODS: The study used data of 122 patients waiting for hepatic transplantation and listed at Parana´s Transplantation Central. Two classificatory lists were set up, one with MELD, the current qualifying criteria, and another with MELD-Na. We analyzed the changes on classification comparing these two lists. RESULTS: Among all patients, 95.1% of the participants changed position, 30.3% showed improvement, 64.8% presented worsening and 4.9% maintained their position. There were 19 patients with hyponatremia, of whom 94.7% presented a change of position, and in all of them there was an improvement of position. One hundred and one patients presented sodium within the normal range and 95% of them presented a change of position: Improved placement was observed in 18.8%, and worsened placement in 76.2%. Two patients presented hypernatremia and changed their position, both worsening the placement. There was a significant different behavior on waiting list according to sodium serum level when MELD-Na was applied. CONCLUSION: The inclusion of serum sodium caused a great impact in the classification, bringing benefit to patients with hyponatremia.


Assuntos
Doença Hepática Terminal/sangue , Transplante de Fígado , Sódio/sangue , Listas de Espera , Adolescente , Adulto , Idoso , Doença Hepática Terminal/enzimologia , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Fatores de Tempo , Adulto Jovem
15.
Biomed Res Int ; 2019: 7284040, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31737675

RESUMO

Inflammatory markers have been studied in cancers and chronic states of inflammation. They are thought to correlate with tumor pathology through disruption of normal homeostasis. Markers such as neutrophil to lymphocyte ratio (NLR) among others have shown promise as prognostic tools in various cancers. In this study, we evaluate complete blood count based inflammatory markers in hepatocellular carcinoma (HCC) to predict overall and recurrence-free survival of patients after liver transplant. Between 2001 and 2017, all HCC indicated liver transplants were retrospectively reviewed. Inclusion criteria included presence of complete blood cell counts with differential within three months prior to transplantation. Exclusion criteria included retransplantation and inadequate posttransplant followup. A total of 160 patients with HCC were included in the study. Of those, 74.4% had hepatitis C virus as the underlying cause of HCC. Calculated Model for End stage Liver Disease (MELD) scores were statistically worse in patients with elevated NLR (≥5), derived NLR (≥3), and low lymphocyte to monocyte ratio (LMR) (<3.45), whereas elevated platelet to lymphocyte ratio (PLR) (≥150) did not correlate with MELD. Of the tumor characteristics, low LMR was associated with tumor presence and microvascular invasion on explant. Though overall survival trended towards better outcomes with low NLR and dNLR and high LMR, these did not reach statistical significance. High LMR also trended towards better recurrence-free survival without statistical significance. Low PLR was associated with statistically significant overall and recurrence-free survival. In conclusion, while prior studies in HCC have identified NLR as surrogate for tumor burden and survival, in this study we highlight that PLR is a good surrogate of mortality and recurrence-free survival in HCC transplant patients. Further, future study of PLR, NLR, and LMR in larger HCC populations before and after interventions may help clarify their clinical utility as a simple and noninvasive clinical tool as prognostic markers.


Assuntos
Carcinoma Hepatocelular/sangue , Inflamação/sangue , Neoplasias Hepáticas/sangue , Transplante de Fígado/efeitos adversos , Biomarcadores Tumorais/sangue , Contagem de Células Sanguíneas , Plaquetas/metabolismo , Carcinoma Hepatocelular/patologia , Intervalo Livre de Doença , Doença Hepática Terminal/sangue , Doença Hepática Terminal/patologia , Feminino , Hepacivirus/patogenicidade , Humanos , Inflamação/etiologia , Inflamação/patologia , Fígado/patologia , Neoplasias Hepáticas/patologia , Linfócitos/citologia , Masculino , Pessoa de Meia-Idade , Monócitos/citologia , Recidiva Local de Neoplasia/sangue , Recidiva Local de Neoplasia/patologia , Neutrófilos/citologia , Contagem de Plaquetas
16.
Medicine (Baltimore) ; 98(45): e17862, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702650

RESUMO

Since the progression of cirrhosis is accelerated each time a complication recurs, the management and treatment of the complication is critical in enhancement of the quality of life and expectation of life in patients. The use of model for end-stage liver disease with incorporation of serum-sodium (MELD-Na) with physiological indicators can be used to assess severity and differentiate therapeutic interventions.This study is aimed to determine the mean survival period and cumulative survival rate by classifying patients into high-risk and low-risk groups based on MELD-Na, a predictor of mortality in liver disease, and to investigate the mortality prognostic factors.A retrospective cohort study, which follows the STROBE checklist, was performed. 263 patients who were diagnosed with liver cirrhosis complications for the first time and hospitalized were selected as the subjects of this study. The collected data were analyzed based on the survival package provided by the statistical program R version 3.4.2.Subjects were classified into high-risk and low-risk groups using MELD-Na 14 points where sensitivity and specificity crossed the cut-off point. Gender, age, and primary caregiver were significant variables in the mortality high-risk group, and AST, albumin, and primary caregiver were significant variables in the mortality low-risk group. Based on these mortality prognostic factors, it is possible to present the factors affecting mortality in patients who were diagnosed with liver cirrhosis complications for the first time. The classification of patients by risk level could be the foundation to provide accurate guidelines for management and it is necessary to modify prognostic factors and apply nursing interventions to manage complications.


Assuntos
Doença Hepática Terminal/mortalidade , Cirrose Hepática/mortalidade , Índice de Gravidade de Doença , Sódio/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Progressão da Doença , Doença Hepática Terminal/sangue , Doença Hepática Terminal/etiologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos
17.
Dis Markers ; 2019: 3862024, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31636735

RESUMO

Background and Aim: Serum Golgi protein 73 (GP73) is a promising alternative biomarker of chronic liver diseases, but most data are from patients with HBV infection rather than HCV. Materials and Methods: Two independent cohorts of chronic hepatitis C (CHC) patients from the 5th Medical Centre of the Chinese PLA General Hospital (n = 174) and Beijing Youan Hospital (n = 120) with different histories of HCV infection were enrolled. The correlations between serum GP73 and other biochemical indices, as well as its correlations with different stages of liver disease progression, were investigated. The receiver operating characteristic (ROC) curve was employed to evaluate the diagnostic potential of serum GP73 for liver necroinflammation and fibrosis, and comparisons of the diagnostic efficiency with traditional indices of hepatic liver injuries were further investigated. Results: Levels of serum GP73 were found significantly elevated in patients with moderate to severe inflammatory grade (G ≥ 2) and/or with advanced fibrotic stages (F ≥ 3) in both cohorts (P < 0.05, respectively), as compared to those with a normal or mild liver lesion. Further ROC analysis demonstrated that serum GP73 was comparable to serum ALT and AST in diagnosing the liver necroinflammation grade at G ≥ 2, but its diagnostic values for advanced fibrosis (F ≥ 3) and cirrhosis (F = 4) were limited when compared to APRI and FIB-4, and FIB-4 exhibited the best performance. Notably, an obvious elevation of serum GP73 was observed after patients received PEG-IFN and ribavirin treatment. Conclusions: Serum GP73 is an important biomarker in evaluating and monitoring the disease progression including liver necroinflammation and fibrosis in patients with chronic HCV infection, but the value is limited for diagnosing advanced fibrosis and cirrhosis in comparison with APRI and FIB-4.


Assuntos
Doença Hepática Terminal/sangue , Hepatite C Crônica/sangue , Cirrose Hepática/sangue , Proteínas de Membrana/sangue , Adulto , Biomarcadores/sangue , Progressão da Doença , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/tratamento farmacológico , Feminino , Hepatite C Crônica/diagnóstico , Hepatite C Crônica/tratamento farmacológico , Humanos , Inflamação , Interferon-alfa/uso terapêutico , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Polietilenoglicóis , Curva ROC , Ribavirina/uso terapêutico , Resultado do Tratamento
18.
Am Surg ; 85(10): 1184-1188, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657321

RESUMO

Guidelines suggest targeting a preoperative international normalized ratio (INR) < 1.5. We examined and compared the predictive value of INR relative to the Model for End-Stage Liver Disease (MELD). We reviewed the American College of Surgeons NSQIP from 2005 to 2016 for adult patients undergoing open or laparoscopic cholecystectomy. Patients with a preoperative INR were stratified into groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2. Thirty day postoperative mortality was the primary outcome. Multivariable logistic regressions controlled for baseline differences. Of 58,177 cholecystectomy patients, 15.2 per cent had INR ≤ 1, 80.4 per cent had INR > 1 to ≤1.5, 3.7 per cent had INR > 1.5 to ≤2, and 0.7 per cent had INR > 2. Patients with INR > 2 were older and more likely to have diabetes and hypertension (P < 0.001). Multivariable regression demonstrated a stepwise increase in mortality for INR > 1 to ≤1.5 (odds ratio (OR) = 1.50 [1.10-2.05]), INR > 1.5 to ≤2 (OR = 2.96 [1.97-4.45]), and INR > 2 (OR = 3.21 [1.64-6.31]) relative to INR ≤ 1. C-statistic for INR (0.910) and MELD (0.906) models indicated a similar value in predicting mortality. INR groups also faced an incremental, increased risk of bleeding. Although unable to track preoperative correction of INR, this analysis identifies that INR remains an excellent predictor of postoperative mortality and bleeding after both open and laparoscopic cholecystectomies and is comparable to MELD.


Assuntos
Colecistectomia/mortalidade , Doença Hepática Terminal/sangue , Doença Hepática Terminal/mortalidade , Coeficiente Internacional Normatizado/mortalidade , Adulto , Fatores Etários , Análise de Variância , Colecistectomia Laparoscópica/mortalidade , Diabetes Mellitus/tratamento farmacológico , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Hipertensão/tratamento farmacológico , Coeficiente Internacional Normatizado/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/mortalidade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco
19.
PLoS One ; 14(10): e0223053, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31581270

RESUMO

The Model for End-Stage Liver Disease (MELD) score has been successfully used to prioritize patients on the United States liver transplant waiting list since its adoption in 2002. The United Network for Organ Sharing (UNOS)/Organ Procurement Transplantation Network (OPTN) allocation policy has evolved over the years, and notable recent changes include Share 35, inclusion of serum sodium in the MELD score, and a 'delay and cap' policy for hepatocellular carcinoma (HCC) patients. We explored the potential of a registrant's change in 30-day MELD scores (ΔMELD30) to improve allocation both before and after these policy changes. Current MELD and ΔMELD30 were evaluated using cause-specific hazards models for waitlist dropout based on US liver transplant registrants added to the waitlist between 06/30/2003 and 6/30/2013. Two composite scores were constructed and then evaluated on UNOS data spanning the current policy era (01/02/2016 to 09/07/2018). Predictive accuracy was evaluated using the C-index for model discrimination and by comparing observed and predicted waitlist dropout probabilities for model calibration. After the change to MELD-Na, increased dropout associated with ΔMELD30 jumps is no longer evident at MELD scores below 30. However, the adoption of Share 35 has potentially resulted in discrepancies in waitlist dropout for patients with sharp MELD increases at higher MELD scores. Use of the ΔMELD30 to add additional points or serve as a potential tiebreaker for patients with rapid deterioration may extend the benefit of Share 35 to better include those in most critical need.


Assuntos
Doença Hepática Terminal/sangue , Transplante de Fígado , Modelos Teóricos , Sistema de Registros , Sódio/sangue , Obtenção de Tecidos e Órgãos , Adulto , Humanos , Incidência , Análise Multivariada , Pacientes Desistentes do Tratamento , Listas de Espera
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...