#Statins Shown to Reduce Risk of Death in People with Alcoholic #Cirrhosis
https://www.aasld.org/events-professional-development/liver-meeting/press/statins-shown-reduce-risk-death-people-alcoholic-cirrhosis
This study -- along with other similar studies -- strongly supports the hypothesis that these patients may benefit from statins, and a randomized study with placebo is the next natural step in the investigation of statins and cirrhosis
https://www.aasld.org/events-professional-development/liver-meeting/press/statins-shown-reduce-risk-death-people-alcoholic-cirrhosis
This study -- along with other similar studies -- strongly supports the hypothesis that these patients may benefit from statins, and a randomized study with placebo is the next natural step in the investigation of statins and cirrhosis
Association Between #Cirrhosis and #Stroke in a Nationally Representative Cohort
http://jamanetwork.com/journals/jamaneurology/fullarticle/2629721
Importance Cirrhosis is associated with hemorrhagic and thrombotic extrahepatic complications. The risk of cerebrovascular complications is less well understood.
After adjustment for demographic characteristics and stroke risk factors, patients with cirrhosis had a higher risk of stroke (hazard ratio HR, 1.4; 95% CI, 1.3-1.5). The magnitude of association appeared to be higher for intracerebral hemorrhage (HR, 1.9; 95% CI, 1.5-2.4) and subarachnoid hemorrhage (HR, 2.4; 95% CI, 1.7-3.5) than for ischemic stroke (HR, 1.3; 95% CI, 1.2-1.5).
Conclusions and Relevance In a nationally representative sample of Medicare beneficiaries, cirrhosis was associated with an increased risk of stroke, particularly hemorrhagic stroke. A potential explanation of these findings implicates the mixed coagulopathy observed in cirrhosis.
http://jamanetwork.com/journals/jamaneurology/fullarticle/2629721
Importance Cirrhosis is associated with hemorrhagic and thrombotic extrahepatic complications. The risk of cerebrovascular complications is less well understood.
After adjustment for demographic characteristics and stroke risk factors, patients with cirrhosis had a higher risk of stroke (hazard ratio HR, 1.4; 95% CI, 1.3-1.5). The magnitude of association appeared to be higher for intracerebral hemorrhage (HR, 1.9; 95% CI, 1.5-2.4) and subarachnoid hemorrhage (HR, 2.4; 95% CI, 1.7-3.5) than for ischemic stroke (HR, 1.3; 95% CI, 1.2-1.5).
Conclusions and Relevance In a nationally representative sample of Medicare beneficiaries, cirrhosis was associated with an increased risk of stroke, particularly hemorrhagic stroke. A potential explanation of these findings implicates the mixed coagulopathy observed in cirrhosis.
Jamanetwork
Cirrhosis and Stroke in a Nationally Representative Cohort
This cohort study of Medicare claims data investigates the association between cirrhosis and various stroke types.
Hepatitis B virus #core -related antigen levels predict progression to liver #cirrhosis in hepatitis B carriers
http://onlinelibrary.wiley.com/doi/10.1111/jgh.13989/full
Several hepatitis B virus (HBV) markers have been identified as risk factors for progression to liver cirrhosis in patients with chronic HBV infection. We clarified the predictive impact of HBV markers on progression to cirrhosis in HBV carriers
Eighty-four patients progressed to cirrhosis (FIB-4 index >3.6) during the follow-up period. Hepatitis B surface antigen (HBsAg), HBV DNA, hepatitis B virus core-related antigen (HBcrAg), and basal core promoter (BCP) status, but not genotype and precure status, were significantly associated with progression to cirrhosis in univariate Cox proportional hazards models. Multivariate Cox proportional hazards models adjusted for HBV genotype, HBsAg, HBV DNA, HBcrAg, precore status, and BCP status indicated that HBsAg ≥3.0 log IU/ml (HR, 0.53; 95% confidence interval (CI), 0.30–0.94) and HBcrAg ≥3.7 log U/ml (HR, 3.28; 95% CI, 1.60–6.75) are independently associated with progression to cirrhosis. In the HR spline curve analysis, HR and 95% CI gradually increased as HBcrAg levels increased. Conversely, HRs and 95% CIs for HBsAg and HBV DNA did not show this tendency as their levels increased.
Conclusions
Elevated HBcrAg levels in HBV carriers increases the risk for progression to cirrhosis. HBcrAg is an excellent predictor of the development of cirrhosis
http://onlinelibrary.wiley.com/doi/10.1111/jgh.13989/full
Several hepatitis B virus (HBV) markers have been identified as risk factors for progression to liver cirrhosis in patients with chronic HBV infection. We clarified the predictive impact of HBV markers on progression to cirrhosis in HBV carriers
Eighty-four patients progressed to cirrhosis (FIB-4 index >3.6) during the follow-up period. Hepatitis B surface antigen (HBsAg), HBV DNA, hepatitis B virus core-related antigen (HBcrAg), and basal core promoter (BCP) status, but not genotype and precure status, were significantly associated with progression to cirrhosis in univariate Cox proportional hazards models. Multivariate Cox proportional hazards models adjusted for HBV genotype, HBsAg, HBV DNA, HBcrAg, precore status, and BCP status indicated that HBsAg ≥3.0 log IU/ml (HR, 0.53; 95% confidence interval (CI), 0.30–0.94) and HBcrAg ≥3.7 log U/ml (HR, 3.28; 95% CI, 1.60–6.75) are independently associated with progression to cirrhosis. In the HR spline curve analysis, HR and 95% CI gradually increased as HBcrAg levels increased. Conversely, HRs and 95% CIs for HBsAg and HBV DNA did not show this tendency as their levels increased.
Conclusions
Elevated HBcrAg levels in HBV carriers increases the risk for progression to cirrhosis. HBcrAg is an excellent predictor of the development of cirrhosis
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Predicting Hepatic #Encephalopathy -Related Hospitalizations Using a Composite Assessment of Cognitive Impairment and Frailty in 355 Patients With #Cirrhosis
https://www.nature.com/articles/s41395-018-0243-0
We aimed to assess the utility of a composite score (MoCA–CFS) developed using the Montreal Cognitive Assessment (MoCA) and the Clinical Frailty Scale (CFS) for predicting HE admissions within 6 months
A total of 355 patients were included; mean age 55.9 ± 9.6; 62.5% male; Hepatitis C and alcohol etiology in 64%. Thirty-six percent of patients had cognitive impairment according to the MoCA (≤24) and 14% were frail on the CFS (>4). The MoCA–CFS independently predicted HE hospitalization within 6 months, a MoCA–CFS score of 1 and 2 respectively increasing the odds of hospitalization by 3.3 (95% CI:1.5–7.7) and 5.7 (95% CI:1.9–17.3). HRQoL decreased with increasing MoCA–CFS. Depression and older age were independent predictors of a low MoCA.
Conclusions
Cognitive and physical frailty are common in patients with cirrhosis. In addition to being an independent predictor of HE admissions within 6 months, the MoCA-CFS composite score predicts impaired HRQoL and all-cause admissions within 6 months. These data support the predictive value of a “multidimensional” frailty tool for the prediction of adverse clinical outcomes and highlight the potential for a multi-faceted approach to therapy targeting cognitive impairment, physical frailty and depression
Predicting Hepatic #Encephalopathy -Related Hospitalizations Using a Composite Assessment of Cognitive Impairment and Frailty in 355 Patients With #Cirrhosis
https://www.nature.com/articles/s41395-018-0243-0
We aimed to assess the utility of a composite score (MoCA–CFS) developed using the Montreal Cognitive Assessment (MoCA) and the Clinical Frailty Scale (CFS) for predicting HE admissions within 6 months
A total of 355 patients were included; mean age 55.9 ± 9.6; 62.5% male; Hepatitis C and alcohol etiology in 64%. Thirty-six percent of patients had cognitive impairment according to the MoCA (≤24) and 14% were frail on the CFS (>4). The MoCA–CFS independently predicted HE hospitalization within 6 months, a MoCA–CFS score of 1 and 2 respectively increasing the odds of hospitalization by 3.3 (95% CI:1.5–7.7) and 5.7 (95% CI:1.9–17.3). HRQoL decreased with increasing MoCA–CFS. Depression and older age were independent predictors of a low MoCA.
Conclusions
Cognitive and physical frailty are common in patients with cirrhosis. In addition to being an independent predictor of HE admissions within 6 months, the MoCA-CFS composite score predicts impaired HRQoL and all-cause admissions within 6 months. These data support the predictive value of a “multidimensional” frailty tool for the prediction of adverse clinical outcomes and highlight the potential for a multi-faceted approach to therapy targeting cognitive impairment, physical frailty and depression
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#Coagulation in #Cirrhosis
https://www.gastrojournal.org/article/S0016-5085(19)35694-X/pdf
Best Practice Advice
1. Global tests of clot formation such as rotational thromboelastometry (ROTEM), thromboelastography (TEG), Sonorheometry and Thrombin generation may eventually have a role in the evaluation of clotting in patients with cirrhosis but currently lack validated target levels.
2. In general, clinicians should not routinely correct thrombocytopenia and coagulopathy before low risk therapeutic paracentesis, thoracentesis, and routine upper endoscopy for variceal ligation in patients with hepatic synthetic dysfunction induced coagulation abnormalities.
3. Blood products should be used sparingly because they increase portal pressure and carry a risk of Transfusion Associated Circulatory Overload (TACO), Transfusion Related Acute Lung Injury (TRALI), infection transmission, alloimmunization and/or transfusion reactions.
4. The following transfusion thresholds for management of active bleeding or high-risk procedures may optimize clot formation in advanced liver disease: hematocrit ≥25, platelet count >50,000, and Fibrinogen >120. Commonly utilized thresholds for INR correction are not supported by evidence.
5. Thrombopoietin (TPO) agonists are a good alternative to platelet transfusion but require time (about 10 days) to elevate platelet levels.
6. The large volume of fresh frozen plasma (FFP) required to reach an arbitrary INR target, limitations of the usual target, minimal effect on thrombin generation and adverse effects on portal pressure significantly limit the utility of this agent.
7. The 4-factor Prothrombin Complex Concentrate (PCC) contains both pro- and anticoagulant factors which offer an attractive low volume therapeutic to re-balance a disturbed hemostatic system. However, dosage is, in part, based on INR which is problematic in cirrhosis and published experience in liver disease is limited.
8. Anti-fibrinolytic therapy may be considered in patients with persistent bleeding from mucosal oozing or puncture wound bleeding consistent with impaired clot integrity. Both epsilon-aminocaproic acid and tranexamic acid inhibit clot dissolution. Neither is felt to generate a hypercoagulable state although both may exacerbate pre-existing thrombi.
9. Desmopressin (DDAVP) releases von Willebrand Factor (vWF) as its primary hemostatic mechanism. As this factor is usually elevated in cirrhosis, the agent lacks a sound evidence based foundation but may be useful in patients with concomitant renal failure.
10. Systemic heparin infusion is recommended for symptomatic DVT and PVT but there are unresolved issues regarding monitoring with both the anti-Xa assay and the partial thromboplastin time due to cirrhosis related antithrombin deficiency (heparin cofactor).
11. Treatment of incidental PVT depends upon estimated impact on transplant surgical complexity versus risks of bleeding and falls. Therapy with LMWH, vitamin K antagonists, and direct-acting anticoagulants (DOACs) improve PV repermeation versus observation alone.
12. DOACs such as the factor Xa and thrombin inhibitors are relatively safe and effective in stable cirrhotic patients but are in need of further study in patients with more advanced liver disease.
#Coagulation in #Cirrhosis
https://www.gastrojournal.org/article/S0016-5085(19)35694-X/pdf
Best Practice Advice
1. Global tests of clot formation such as rotational thromboelastometry (ROTEM), thromboelastography (TEG), Sonorheometry and Thrombin generation may eventually have a role in the evaluation of clotting in patients with cirrhosis but currently lack validated target levels.
2. In general, clinicians should not routinely correct thrombocytopenia and coagulopathy before low risk therapeutic paracentesis, thoracentesis, and routine upper endoscopy for variceal ligation in patients with hepatic synthetic dysfunction induced coagulation abnormalities.
3. Blood products should be used sparingly because they increase portal pressure and carry a risk of Transfusion Associated Circulatory Overload (TACO), Transfusion Related Acute Lung Injury (TRALI), infection transmission, alloimmunization and/or transfusion reactions.
4. The following transfusion thresholds for management of active bleeding or high-risk procedures may optimize clot formation in advanced liver disease: hematocrit ≥25, platelet count >50,000, and Fibrinogen >120. Commonly utilized thresholds for INR correction are not supported by evidence.
5. Thrombopoietin (TPO) agonists are a good alternative to platelet transfusion but require time (about 10 days) to elevate platelet levels.
6. The large volume of fresh frozen plasma (FFP) required to reach an arbitrary INR target, limitations of the usual target, minimal effect on thrombin generation and adverse effects on portal pressure significantly limit the utility of this agent.
7. The 4-factor Prothrombin Complex Concentrate (PCC) contains both pro- and anticoagulant factors which offer an attractive low volume therapeutic to re-balance a disturbed hemostatic system. However, dosage is, in part, based on INR which is problematic in cirrhosis and published experience in liver disease is limited.
8. Anti-fibrinolytic therapy may be considered in patients with persistent bleeding from mucosal oozing or puncture wound bleeding consistent with impaired clot integrity. Both epsilon-aminocaproic acid and tranexamic acid inhibit clot dissolution. Neither is felt to generate a hypercoagulable state although both may exacerbate pre-existing thrombi.
9. Desmopressin (DDAVP) releases von Willebrand Factor (vWF) as its primary hemostatic mechanism. As this factor is usually elevated in cirrhosis, the agent lacks a sound evidence based foundation but may be useful in patients with concomitant renal failure.
10. Systemic heparin infusion is recommended for symptomatic DVT and PVT but there are unresolved issues regarding monitoring with both the anti-Xa assay and the partial thromboplastin time due to cirrhosis related antithrombin deficiency (heparin cofactor).
11. Treatment of incidental PVT depends upon estimated impact on transplant surgical complexity versus risks of bleeding and falls. Therapy with LMWH, vitamin K antagonists, and direct-acting anticoagulants (DOACs) improve PV repermeation versus observation alone.
12. DOACs such as the factor Xa and thrombin inhibitors are relatively safe and effective in stable cirrhotic patients but are in need of further study in patients with more advanced liver disease.
!!
Risks and clinical predictors of #cirrhosis and #hepatocellular #carcinoma diagnoses in adults with diagnosed NAFLD: real-world study of 18 million patients in four European cohorts
https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1321-x
Non-alcoholic fatty liver disease (NAFLD) is a common condition that progresses in some patients to steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC)..
Coded NAFLD/NASH patients were more likely to have diabetes, hypertension and obesity than matched controls. HR for cirrhosis in patients compared to controls was 4.73 (95% CI 2.43–9.19) and for HCC, 3.51 (95% CI 1.72–7.16). HR for either outcome was higher in patients with NASH and those with high-risk Fib-4 scores. The strongest independent predictor of a diagnosis of HCC or cirrhosis was baseline diagnosis of diabetes.
Conclusions
Real-world population data show that recorded diagnosis of NAFLD/NASH increases risk of life-threatening liver outcomes. Diabetes is an independent predictor of advanced liver disease diagnosis, emphasising the need to identify specific groups of patients at highest risk.
Risks and clinical predictors of #cirrhosis and #hepatocellular #carcinoma diagnoses in adults with diagnosed NAFLD: real-world study of 18 million patients in four European cohorts
https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1321-x
Non-alcoholic fatty liver disease (NAFLD) is a common condition that progresses in some patients to steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC)..
Coded NAFLD/NASH patients were more likely to have diabetes, hypertension and obesity than matched controls. HR for cirrhosis in patients compared to controls was 4.73 (95% CI 2.43–9.19) and for HCC, 3.51 (95% CI 1.72–7.16). HR for either outcome was higher in patients with NASH and those with high-risk Fib-4 scores. The strongest independent predictor of a diagnosis of HCC or cirrhosis was baseline diagnosis of diabetes.
Conclusions
Real-world population data show that recorded diagnosis of NAFLD/NASH increases risk of life-threatening liver outcomes. Diabetes is an independent predictor of advanced liver disease diagnosis, emphasising the need to identify specific groups of patients at highest risk.
BioMed Central
Risks and clinical predictors of cirrhosis and hepatocellular carcinoma diagnoses in adults with diagnosed NAFLD: real-world study…
Background Non-alcoholic fatty liver disease (NAFLD) is a common condition that progresses in some patients to steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC). Here we used healthcare records of 18 million adults to estimate risk of acquiring…
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#Alcohol Consumption and Risk of Liver #Cirrhosis
A Systematic Review and Meta-Analysis
..There was no increased risk for occasional drinkers. Consumption of one drink per day in comparison to long-term abstainers showed an increased risk for liver cirrhosis in women, but not in men. The risk for women was consistently higher compared to men. Drinking ≥5 drinks per day was associated with a substantially increased risk in both women (relative risk [RR] = 12.44, 95% confidence interval [CI]: 6.65–23.27 for 5–6 drinks, and RR = 24.58, 95% CI: 14.77–40.90 for ≥7 drinks) and men (RR = 3.80, 95% CI: 0.85–17.02, and RR = 6.93, 95% CI: 1.07–44.99, respectively). Heterogeneity across studies indicated an additional impact of other risk factors.
DISCUSSION: Alcohol is a major risk factor for liver cirrhosis with risk increasing exponentially. Women may be at higher risk compared to men even with little alcohol consumption. More high-quality research is necessary to elucidate the role of other risk factors, such as genetic vulnerability, body weight, metabolic risk factors, and drinking patterns over the life course. High alcohol consumption should be avoided, and people drinking at high levels should receive interventions to reduce their intake.
https://journals.lww.com/ajg/Fulltext/2019/10000/Alcohol_Consumption_and_Risk_of_Liver_Cirrhosis__A.8.aspx
#Alcohol Consumption and Risk of Liver #Cirrhosis
A Systematic Review and Meta-Analysis
..There was no increased risk for occasional drinkers. Consumption of one drink per day in comparison to long-term abstainers showed an increased risk for liver cirrhosis in women, but not in men. The risk for women was consistently higher compared to men. Drinking ≥5 drinks per day was associated with a substantially increased risk in both women (relative risk [RR] = 12.44, 95% confidence interval [CI]: 6.65–23.27 for 5–6 drinks, and RR = 24.58, 95% CI: 14.77–40.90 for ≥7 drinks) and men (RR = 3.80, 95% CI: 0.85–17.02, and RR = 6.93, 95% CI: 1.07–44.99, respectively). Heterogeneity across studies indicated an additional impact of other risk factors.
DISCUSSION: Alcohol is a major risk factor for liver cirrhosis with risk increasing exponentially. Women may be at higher risk compared to men even with little alcohol consumption. More high-quality research is necessary to elucidate the role of other risk factors, such as genetic vulnerability, body weight, metabolic risk factors, and drinking patterns over the life course. High alcohol consumption should be avoided, and people drinking at high levels should receive interventions to reduce their intake.
https://journals.lww.com/ajg/Fulltext/2019/10000/Alcohol_Consumption_and_Risk_of_Liver_Cirrhosis__A.8.aspx
LWW
Alcohol Consumption and Risk of Liver Cirrhosis: A... : American Journal of Gastroenterology
categories of drinking in relation to the incidence of liver cirrhosis. Study characteristics were extracted and random-effects meta-analyses and meta-regressions were conducted.
RESULTS:
A total of 7 cohort studies and 2 case–control studies met the inclusion…
RESULTS:
A total of 7 cohort studies and 2 case–control studies met the inclusion…
Elevated serum #procalcitonin levels and their association with the prognosis of patients with liver #cirrhosis
https://2medical.news/2020/08/13/elevated-serum-procalcitonin-levels-and-their-association-with-the-prognosis-of-patients-with-liver-cirrhosis/
Bacterial infection is a major complication in patients with liver cirrhosis. Procalcitonin is an early diagnostic marker of bacterial infection. This study aimed to investigate the association between the serum procalcitonin levels and the prognosis of patients with liver cirrhosis.. The serum procalcitonin level was higher (≥0.05 ng/mL) in 151 (64%) patients, and it was significantly higher in the patients with Child-Turcotte-Pugh class C than in …
https://2medical.news/2020/08/13/elevated-serum-procalcitonin-levels-and-their-association-with-the-prognosis-of-patients-with-liver-cirrhosis/
Bacterial infection is a major complication in patients with liver cirrhosis. Procalcitonin is an early diagnostic marker of bacterial infection. This study aimed to investigate the association between the serum procalcitonin levels and the prognosis of patients with liver cirrhosis.. The serum procalcitonin level was higher (≥0.05 ng/mL) in 151 (64%) patients, and it was significantly higher in the patients with Child-Turcotte-Pugh class C than in …
Natural history of acute #kidney disease in patients with #cirrhosis
https://2medical.news/2020/09/17/natural-history-of-acute-kidney-disease-in-patients-with-cirrhosis/
In 2012, KDIGO group proposed new definitions for Acute Kidney Injury (AKI), Acute Kidney Disease (AKD) and Chronic Kidney Disease (CKD). According to the definition adapted by the International Club of Ascites (ICA), AKI has been extensively investigated in patients with cirrhosis. On the contrary, there are currently no data on the epidemiology and clinical outcome of AKD in these patients. The aim of the …
https://2medical.news/2020/09/17/natural-history-of-acute-kidney-disease-in-patients-with-cirrhosis/
In 2012, KDIGO group proposed new definitions for Acute Kidney Injury (AKI), Acute Kidney Disease (AKD) and Chronic Kidney Disease (CKD). According to the definition adapted by the International Club of Ascites (ICA), AKI has been extensively investigated in patients with cirrhosis. On the contrary, there are currently no data on the epidemiology and clinical outcome of AKD in these patients. The aim of the …
#Elastography is unable to exclude #cirrhosis after sustained virological response in #HCV-infected patients with advanced chronic liver disease
https://2medical.news/2021/09/21/elastography-is-unable-to-exclude-cirrhosis-after-sustained-virological-response-in-hcv-infected-patients-with-advanced-chronic-liver-disease/
https://2medical.news/2021/09/21/elastography-is-unable-to-exclude-cirrhosis-after-sustained-virological-response-in-hcv-infected-patients-with-advanced-chronic-liver-disease/
2Medical.News
#Elastography is unable to exclude #cirrhosis after sustained virological response in #HCV-infected patients with advanced chronic…
Liver fibrosis and transient elastography (TE) correlation in hepatitis C virus (HCV)-infected patients with compensated advanced chronic liver disease (cACLD) after sustained virological response …
Undiagnosed #Cirrhosis and Hepatic #Encephalopathy in a National Cohort of Veterans With #Dementia
https://2medical.news/2024/02/13/undiagnosed-cirrhosis-and-hepatic-encephalopathy-in-a-national-cohort-of-veterans-with-dementia/
https://2medical.news/2024/02/13/undiagnosed-cirrhosis-and-hepatic-encephalopathy-in-a-national-cohort-of-veterans-with-dementia/
2Medical.News
Undiagnosed #Cirrhosis and Hepatic #Encephalopathy in a National Cohort of Veterans With #Dementia
Dementia and hepatic encephalopathy (HE) are challenging to distinguish clinically. Undiagnosed cirrhosis in a patient with dementia can lead to missed opportunities to treat HE.Objective To exami…