Alfredo Israel Servín-Caamaño

Malnutrition negatively impacts the quality of life of patients with cirrhosis: An observational study

AIM To verify how malnutrition is related to health-related quality of life (HRQL) impairment in patients with cirrhosis. METHODS Data was retrospectively abstracted from medical records and obtained by direct interview. We included patients with cirrhosis from any etiology, evaluated at the Liver Clinic from Gastroenterology Department in a tertiary healthcare center, from June 2014 to June 2016. Child-Pugh score, data about complications, and demographic, clinical and anthropometric characteristics of patients were obtained. Nutritional status was evaluated by the Subjective Global Assessment (SGA). HRQL was evaluated through the Chronic Liver Disease Questionnaire. Patients were requested to assess their global HRQL with the following code: 0 = impairment of HRQL, when it was compared with other healthy subjects; 1 = good HRQL, if it was similar to the quality of life of other healthy subjects. To compare the primary outcome between malnourished and well-nourished groups, the χ2 test, Fisher’s exact test or Student’s t-test were used, based on the variable type. Associations between predictor variables and deterioration of HRQL were determined by calculating the hazard ratio and 95% confidence interval using Cox proportional hazards regression. RESULTS A total of 127 patients with cirrhosis were included, and the mean age was 54.1 ± 12.3 years-old. According to Child-Pugh scoring, 25 (19.7%) were classified as A (compensated), 76 (59.8%) as B, and 26 (20.5%) as C (B/C = decompensated). According to SGA, 58 (45.7%) patients were classified as well-nourished. Sixty-nine patients identified HRQL as good, and 76 patients (59.8%) perceived impairment of their HRQL. Multivariate analysis to determine associations between predictor variables and self-perception of an impairment of HRQL found strong association with malnutrition (P < 0.0001). The most important impaired characteristics in malnourished patients were: Presence of body pain, dyspnea on exertion with daily activities, decreased appetite, generalized weakness, trouble lifting or carrying heavy objects, and decreased level of energy (P < 0.0001). CONCLUSION Malnutrition is a key factor related to impairment of HRQL in patients with cirrhosis.

Malnutrition is a key prognostic factor related to high mortality-rate in patients with severe alcoholic hepatitis

BACKGROUND AND AIM comparatively with European or North-American populations, severe alcoholic hepatitis has a high mortality rate in Mexican population, becoming as high as 50 to 81% in those classified as ABIC B or C; this is true even when they receive specific therapy with steroids or pentoxifylline. The aim of this study was to know which clinical factors are related to early mortality (first 30 days) in Mexican patients with severe alcoholic hepatitis. SUBJECTS AND METHODS this was a retrospective cohort study that included patients with severe alcoholic hepatitis, defined by a Maddreys discriminant function ≥ 32, treated at a tertiary care center in a period of five years (2010 to 2015). RESULTS seventy-six patients were included, 72 (94.7%) were males, mean age was 43 ± 9.1 year-old, and 58 (76.3%) had also cirrhosis. According to the subjective global assessment (SGA), 38 (50%) had severe malnutrition, 22 (28.9%) were at risk of malnutrition, and 16 (21.1%) were well-nourished. At 30 days, 46 patients (60.5%) died. In the multivariate analysis, only the presence of severe malnutrition was associated with 30-day mortality: OR = 6.4; 95% CI: 1.9-22.1; p = 0.003. CONCLUSIONS the nutritional status seems to be a cardinal prognostic factor associated with early mortality (first 30 days). Malnutrition can explain the high mortality rate observed in Mexican patients with severe alcoholic hepatitis.

Primary Prophylaxis to Prevent the Development of Hepatic Encephalopathy in Cirrhotic Patients with Acute Variceal Bleeding

Background and Aim Variceal bleeding is the second most important precipitating factor related to the development of episodic hepatic encephalopathy; but to date there are no recommendations to prevent this complication. The aim of this study was to compare if primary prophylaxis with lactulose or L-ornithine L-aspartate or rifaximin, in cirrhotic patients with variceal bleeding, is better than placebo for avoiding the development of hepatic encephalopathy. Methods A randomized, double-blind, placebo-controlled clinical trial (ClinicalTrials.gov identifier: NCT02158182) which included cirrhotic patients with variceal bleeding, without minimal or clinical hepatic encephalopathy at admission. Findings 87 patients were randomized to one of four groups. The basal characteristics were similar between groups. Comparatively with placebo, the frequency with regard to the development of hepatic encephalopathy was as follows: lactulose (54.5% versus 27.3%; OR = 0.3, 95% CI 0.09-1.0; P = 0.06); L-ornithine L-aspartate (54.5% versus 22.7%, OR = 0.2, 95% CI 0.06-0.88; P = 0.03); rifaximin (54.5% versus 23.8%; OR = 0.3, 95% CI 0.07-0.9; P = 0.04). There was no significant difference between the three groups receiving any antiammonium drug (P = 0.94). In the group receiving lactulose, 59.1% had diarrhea, and 45.5% had abdominal discomfort, bloating, and flatulence. Two patients (10%) treated with lactulose and a patient (4.5%) in the placebo group developed spontaneous bacterial peritonitis due to E. coli; one of them died due to recurrent variceal bleeding. There were no other adverse effects. Conclusions Antiammonium drugs, particularly L-ornithine L-aspartate and rifaximin, proved to be effective in preventing the development of hepatic encephalopathy in those cirrhotic patients with variceal bleeding.

Febrile Syndrome as a First Clinical Manifestation of Wilson Disease

Wilson disease (WD) is a rare autosomal recessive genetic disorder associated with copper metabolism. ATP7B protein function is reduced or absent. The classical clinical presentation with positivity for Kayser-Fleischer rings, neurological and hepatic manifestations is not the rule. About half of the patients presenting liver disease may have atypical clinical manifestations and do not possess two of the three classical criteria. Presentation of case: A 36 year-old male with atypical WD clinical presentation characterized by febrile syndrome and jaundice as the predominant manifestations of the disease.