Factors affecting the outcome of hospitalization among liver cirrhosis patients.

OBJECTIVES: To determine the factors affecting the outcome of hospitalization in patients suffering liver cirrhosis hospitalized to tertiary care hospital, Gujranwala, Pakistan. METHODS: After informed consent, the data of liver cirrhosis patients with age >12 years hospitalized from June 2016 to May 2017 was collected by purposive sampling. The outcome of the hospitalization in term of 'death' and 'no death' was noted. Statistical analysis was done using SPSS version 25. Bivariate analysis as well binary logistic regression was performed to ascertain the effect of different predictors like gender, age, history of diabetes mellitus, etiology of cirrhosis, presence of hepatic encephalopathy at presentation, presence of upper GI bleed, and tracheobronchial aspiration on the likelihood that death would be the outcome in liver cirrhosis patients. RESULTS: Amongst total of 1304 patients, 15.7% died during hospitalization. The mean age of those who died was 58.08 + 14.49 years. Bivariate analysis suggested that mortality was significantly higher in group of patients who had hepatic encephalopathy at presentation (p<0.01), no upper gi bleed (p<0.01), and who got tracheobronchial aspiration during hospitalization (p<0.01). It did not differ significantly in male/female gender (p=0.504), diabetic/non-diabetic groups (p=0.652), with viral/non-viral etiology of cirrhosis (p=0.918). Binary logistic regression revealed that patients who had tracheobronchial aspiration were 12.392 times more likely to die than who had no tracheobronchial aspiration. Similarly, patients who presented in hepatic encephalopathy were 7.862 times more likely to die than who presented without hepatic encephalopathy. CONCLUSION: The inpatient mortality rate amongst cirrhotic patients was high. Age, gender, history of diabetes, viral etiology of cirrhosis did not significantly contribute in the mortality of these patients. The patients who presented in hepatic encephalopathy, and who suffered tracheobronchial aspiration during hospitalization were more likely to die. Excellence in hepatic encephalopathy management and prevention from aspiration can effectively reduce the mortality rate of cirrhotic patients in our hospitals.

Diagnosis, Management And Prevention Of Hepatitis C In Pakistan 2017.

AIMS AND OBJECTIVES: Since the advent of direct acting antiviral agents, there is a revolutionary change in the management of HCV infection. Newer drugs with different mechanism of action are being introduced and are expected to be available in coming few months in Pakistan as well. The main purpose of the guideline is to review and induct the latest research in field of HCV infection in Pakistani perspective so that our healthcare professionals can apply the new recommendations in timely and judicial manner. Target groups of guidelines are general physicians treating hepatitis C, hepatologists and gastroenterologists. Other beneficiaries of these guidelines are public health institutions of Pakistan, which provide free treatment to deserving patients under National Hepatitis Prevention and Control Program and Pakistan Bait-ul- Mal Program. METHODOLOGY: These guidelines are based on the review of National consensus practice guidelines: Diagnosis, Management and Prevention of Hepatitis C Pakistan 2009. Published data in National and International Journals searched with the help of Google search and pub med, and 2015-16 guidelines of HCV by AASLD, EASL, APASL and WHO. Local studies are preferably added with references to enhance the Pakistani perspective. Evidence was also taken from published studies. Recommendations have been based upon evidence from national publications on the subject and scientific presentations at national liver meeting as well from experts' personal experience and opinion.

Eltrombopag before procedures in patients with cirrhosis and thrombocytopenia.

BACKGROUND: Eltrombopag is an oral thrombopoietin-receptor agonist. This study evaluated the efficacy of eltrombopag for increasing platelet counts and reducing the need for platelet transfusions in patients with thrombocytopenia and chronic liver disease who are undergoing an elective invasive procedure. METHODS: We randomly assigned 292 patients with chronic liver disease of diverse causes and platelet counts of less than 50,000 per cubic millimeter to receive eltrombopag, at a dose of 75 mg daily, or placebo for 14 days before a planned elective invasive procedure that was performed within 5 days after the last dose. The primary end point was the avoidance of a platelet transfusion before, during, and up to 7 days after the procedure. A key secondary end point was the occurrence of bleeding (World Health Organization [WHO] grade 2 or higher) during this period. RESULTS: A platelet transfusion was avoided in 104 of 145 patients who received eltrombopag (72%) and in 28 of 147 who received placebo (19%) (P<0.001). No significant difference between the eltrombopag and placebo groups was observed in bleeding episodes of WHO grade 2 or higher, which were reported in 17% and 23% of patients, respectively. Thrombotic events of the portal venous system were observed in 6 patients who received eltrombopag, as compared with 1 who received placebo, resulting in the early termination of the study. The incidence and severity of other adverse events were similar in the eltrombopag and placebo groups. CONCLUSIONS: Eltrombopag reduced the need for platelet transfusions in patients with chronic liver disease who were undergoing elective invasive procedures, but it was associated with an increased incidence of portal-vein thrombosis, as compared with placebo. (Funded by GlaxoSmithKline; ELEVATE ClinicalTrials.gov number, NCT00678587.).

Eltrombopag increases platelet numbers in thrombocytopenic patients with HCV infection and cirrhosis, allowing for effective antiviral therapy.

BACKGROUND & AIMS: Thrombocytopenia is common among patients with hepatitis C virus (HCV) infection and advanced fibrosis or cirrhosis, limiting initiation and dose of peginterferon-alfa (PEG) and ribavirin (RBV) therapy. The phase 3 randomized, controlled studies, Eltrombopag to Initiate and Maintain Interferon Antiviral Treatment to Benefit Subjects with Hepatitis C-Related Liver Disease (ENABLE)-1 and ENABLE-2, investigated the ability of eltrombopag to increase the number of platelets in patients, thereby allowing them to receive initiation or maintenance therapy with PEG and RBV. METHODS: Patients with HCV infection and thrombocytopenia (platelet count <75,000/µL) who participated in ENABLE-1 (n = 715) or ENABLE-2 (n = 805), from approximately 150 centers in 23 countries, received open-label eltrombopag (25-100 mg/day) for 9 weeks or fewer. Patients whose platelet counts reached the predefined minimal threshold for the initiation of PEG and RBV therapy (95% from ENABLE-1 and 94% from ENABLE-2) entered the antiviral treatment phase, and were assigned randomly (2:1) to groups that received eltrombopag or placebo along with antiviral therapy (24 or 48 weeks, depending on HCV genotype). The primary end point was sustained virologic response (SVR) 24 weeks after completion of antiviral therapy. RESULTS: More patients who received eltrombopag than placebo achieved SVRs (ENABLE-1: eltrombopag, 23%; placebo, 14%; P = .0064; ENABLE-2: eltrombopag, 19%; placebo, 13%; P = .0202). PEG was administered at higher doses, with fewer dose reductions, in the eltrombopag groups of each study compared with the placebo groups. More patients who received eltrombopag than placebo maintained platelet counts of 50,000/µL or higher throughout antiviral treatment (ENABLE-1, 69% vs 15%; ENABLE-2, 81% vs 23%). Adverse events were similar between groups, with the exception of hepatic decompensation (both studies: eltrombopag, 10%; placebo, 5%) and thromboembolic events, which were more common in the eltrombopag group of ENABLE-2. CONCLUSIONS: Eltrombopag increases platelet numbers in thrombocytopenic patients with HCV and advanced fibrosis and cirrhosis, allowing otherwise ineligible or marginal patients to begin and maintain antiviral therapy, leading to significantly increased rates of SVR. Clinical trial no: NCT00516321, NCT00529568.

Response And Tolerability Of Sofosbuvir Plus Daclatasvir In Elderly Patients With Chronic Hepatitis-C.

BACKGROUND: The approval of direct acting anti-viral drugs has expanded the treatment access to all patient populations including elderly patients, who were previously neglected. We evaluated the response and tolerability of sofosbuvir plus daclatasvir in old age patients >60 year infected with HCV. METHODS: In this prospective observational study, 100 patients were enrolled and were divided into two groups: aged 60-69 (group A) and aged 70 and older (group B). All the patients were given sofosbuvir plus daclatasvir. Sustained virologic response at 12 weeks was the primary endpoint. Response and tolerability of treatment were analysed and compared between these patient groups. RESULTS: Hundred patients aged ≥60 years were treated with sofosbuvir plus daclatasvir. Sustained virologic response rate was 91% in group A (aged 60- 69 year) and 87.8% in group B (aged 70 year and older). No significant adverse effect was noted in both groups. No treatment discontinuation was encountered. CONCLUSIONS: Direct acting antiviral drug therapy is highly efficacious and safe for the treatment of HCV in older adults.

Statistical Prediction Model for Relapse Rate in Chronic Hepatitis C Patients Treated with Conventional Interferon and Ribavirin Therapy.

Objective: To determine the significantly associated factors with the relapse rate in chronic hepatitis C patients treated with conventional interferon and their predictive strength through the regression model. Material & Methods: In a retrospective analysis of 244 patients, result of PCR, gender, fatty liver, diabetes, abnormal ALT at start and end of treatment were the qualitative variables. Age, weight, ALT at start and end of treatment, hemoglobin, platelets and WBC at start of treatment were quantitative variables. Bivariate, multivariate analysis and odds ratio were computed to verify statistically significant association with relapse rate by running binary logistic regression model. Results: Out of total 244 patients there were 54.1% male and 45.9% female. Eighty two (33.6%) patients had weight > 70 Kg, 30 (12.3%) had fatty liver, 18 were (7.4%) diabetic, 12 (4.9%) had normal ALT at start of therapy and 140 (57.4%) had abnormal ALT at the end. Eighty four (34.4%) patients relapsed while 160 (65.6%) maintained SVR after 6 month to 2 years of completion. In bivariate analysis, age, weight, fatty liver, high fever, decrease and increase in Hb were found significant. The binary logistic regression revealed the significant association of weight (OR=84.813; p=0.000), high fever (OR=4.478; p= 0.038) and Hb increase at 1st month (OR=0.037; p=0.013) with relapse rate. Nagelkerke R Square and Cox & Snell R Square statistics explained 71.1% and 51.1% variation in the model respectively and 93.1% area under the curve gave it very good prediction strength.