Apurva Shah

Spectrum of hepatitis B and renal involvement

Renal involvement in hepatitis B occurs in various spectrums and its knowledge is important for clinicians in management of patients. The renal diseases most commonly associated with hepatitis B virus (HBV) infection include membranous nephropathy, membranoproliferative glomerulonephritis and Polyarteritis nodosa. The widespread use of hepatitis B vaccination has decreased the incidence of HBV‐related renal diseases. The incidence of HBV infection in dialysis patients has significantly decreased over the past few decades because of screening of blood products for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody, implementation of infection control measures and hepatitis B vaccination. The definition of acute kidney injury has been recently modified in cirrhotic population, helping in prognosis and prediction of mortality. The most common etiologies of acute kidney injury in this cirrhotic population, which account for 80% to 90% of all cases, include volume depletion, acute tubular necrosis and hepatorenal syndrome. Treatment with oral nucleoside/tide analogues (NA) brought a new paradigm in the management of HBsAg positive glomerulonephritis, kidney transplant recipients and dialysis patients, resulting in effective viral suppression, reduced hepatic complications and improved patient survival, without compromising renal allograft outcome. NAs are cleared by the kidneys and therefore their dosage has to be adjusted in all patients with impaired renal function. This article reviews the recent knowledge of the pathogenesis and treatment of HBV‐related glomerulonephritis and discusses the management of hepatitis B in patients on dialysis, kidney transplant recipients and cirrhotics, which is continuously evolving.

Gastric schwannoma: a benign tumor often misdiagnosed as gastrointestinal stromal tumor

Gastric schwannomas are rare mesenchymal tumors that arise from the nerve plexus of gut wall. They present with nonspecific symptoms and are often detected incidentally. Preoperative investigation is not pathognomic and many are therefore misdiagnosed as gastrointestinal stromal tumors. We report a rare case of a 37-year old woman who underwent laparotomy for complex bilateral ovarian cyst with resection of gastric-gastrointestinal stromal tumor preoperatively, but confirmed to have a gastric schwannomas postoperatively. This case underscores the differential diagnosis of submucosal, exophytic gastric mass as schwannoma.

Tu1048 Coagulopathy in Cirrhosis a Prospective Study to Correlate Conventional Tests of Coagulation and Bleeding Following Invasive Procedures in Cirrhotics

BACKGROUND Conventional tests of coagulation which only measure procoagulant factors do not correctly estimate the actual in vivo hemostatic balance in cirrhosis. This prospective multicenter study was conducted to evaluate safety of various invasive procedures in the presence of abnormal coagulation tests and to correlate conventional coagulation parameters with clinically significant bleeding in cirrhotics. METHODS Three hundred and eighty patients (median age 54 years, 287 males) enrolled in the study were divided into two groups (A and B), according to the presence or absence of abnormal coagulation parameters (defined as INR ≥1.5 and/or platelet count ≤50,000/cum). RESULTS One hundred and twenty-eight patients (33.68%) were qualified in group A. Alcohol was the predominant etiology of cirrhosis (40% and 32% in groups A and B, respectively). The two groups were similar in baseline characteristics other than tests of coagulation and severity of liver disease. Low risk procedures (abdominal paracentesis most common) were carried out in 47% and 53% patients in two groups, respectively. None of the patients in either group had clinically significant bleeding. Similarly, high risk procedures (central vein cannulation, liver biopsy, etc.) were carried out in 14% and 10%, respectively, in two groups. Three patients in group A developed clinically significant bleeding, however, the difference was statistically nonsignificant (p=0.061). None of our patients received periprocedural correction of abnormal coagulation parameters with plasma/platelet concentrate. CONCLUSIONS Deranged conventional coagulation parameters did not predict clinically significant bleeding in cirrhosis. Whenever indicated, any invasive procedure could be safely carried out in patients with cirrhosis without prior correction of coagulation abnormalities.

Thromboelastography for Assessing the Risk of Bleeding in Patients With Cirrhosis—Moving Closer

Background and aims Conventional coagulation tests (CCTs) in patients with cirrhosis only assess procoagulant factors and are poor predictors of bleeding risk. In spite of this knowledge, they are routinely used prior to invasive procedures, and attempts are made to correct these abnormalities before invasive procedures. These practices are not supported by the evidence and are harmful to the patients. Methods This prospective study included 150 patients of cirrhosis undergoing invasive procedures. CCTs [bleeding time (BT), clotting time (CT), international normalized ratio (INR), activated partial thromboplastin time (aPTT) and platelet count], thromboplastin generation time (TGT) and thromboelastography (TEG) were done in all patients, and they were observed for post procedural bleeding. None of the patients received prophylactic transfusion before the procedure. Results BT, CT and TGT were normal in all 150 patients. One of 150 patients developed clinically significant post procedural bleeding. No statistically significant association was seen among INR, aPTT, platelet count and Child class with bleeding. TEG values (R time and MA value) were normal in 61% and 75% patients respectively in spite of abnormal CCTs in most of them. Comparison of abnormal TEG values (R time and MA value) with INR and platelet count, respectively, in patients with no bleeding showed a statistically significant lower percentage of abnormal values of R time and MA value compared to INR and platelet count. Conclusion Abnormal CCTs in patients of cirrhosis do not predict bleeding risk. TEG may be useful in patients undergoing invasive procedures to assess bleeding risk and prevents erroneous prophylactic transfusions.

Do we need to correct coagulation abnormalities prophylactically in patients with cirrhosis undergoing invasive procedures? a dilemma: Correspondence Hepatology, Month 2016

To the editor, We read with great interest the recently published study by Lesley et al 1 . Authors compared Thromboelastography (TEG) with routine coagulation tests [prothrombin time (PT) and platelet count] to assess the risk of bleeding before invasive procedures in cirrhotics. They concluded that TEG-guided transfusion strategy leads to a significantly lower use of blood products compared to standard of care (transfusion guided by PT and platelet count) without an increase in bleeding complications in patients with significant coagulopathy. Authors used pre-procedural transfusions as standard of care but there is no recommendation for prophylactic transfusion in cirrhotics undergoing invasive procedures. Prophylactic transfusions have not been beneficial on the contrary they have been harmful. As there was a very low incidence of bleeding in both the groups, Intagliata N et al 2 in a correspondence letter suggested need a study without prophylactic correction of routine coagulation tests. In a multicenter prospective study of 388 cirrhotic patients undergoing invasive procedures, we did not use prophylactic transfusion and demonstrated that this strategy is extremely safe. Whenever indicated, any invasive procedures could be safely carried out in patients with cirrhosis without prior correction of abnormal routine coagulation tests. 3 In the preliminary data of ongoing prospective study of 60 cirrhotic patients who underwent invasive procedures, we compared TEG with conventional coagulation tests in all patients, none of the patient in the study received prophylactic correction of abnormal conventional coagulation tests before the invasive procedure or surgery. We found that only one patient developed post procedural clinically significant bleeding. 4 A recently published guideline by Nadim et al 5

Do we need to correct coagulation abnormalities prophylactically in patients with cirrhosis undergoing invasive procedures? a dilemma

To the editor, We read with great interest the recently published study by Lesley et al 1 . Authors compared Thromboelastography (TEG) with routine coagulation tests [prothrombin time (PT) and platelet count] to assess the risk of bleeding before invasive procedures in cirrhotics. They concluded that TEG-guided transfusion strategy leads to a significantly lower use of blood products compared to standard of care (transfusion guided by PT and platelet count) without an increase in bleeding complications in patients with significant coagulopathy. Authors used pre-procedural transfusions as standard of care but there is no recommendation for prophylactic transfusion in cirrhotics undergoing invasive procedures. Prophylactic transfusions have not been beneficial on the contrary they have been harmful. As there was a very low incidence of bleeding in both the groups, Intagliata N et al 2 in a correspondence letter suggested need a study without prophylactic correction of routine coagulation tests. In a multicenter prospective study of 388 cirrhotic patients undergoing invasive procedures, we did not use prophylactic transfusion and demonstrated that this strategy is extremely safe. Whenever indicated, any invasive procedures could be safely carried out in patients with cirrhosis without prior correction of abnormal routine coagulation tests. 3 In the preliminary data of ongoing prospective study of 60 cirrhotic patients who underwent invasive procedures, we compared TEG with conventional coagulation tests in all patients, none of the patient in the study received prophylactic correction of abnormal conventional coagulation tests before the invasive procedure or surgery. We found that only one patient developed post procedural clinically significant bleeding. 4 A recently published guideline by Nadim et al 5

Do we need to correct coagulation abnormalities prophylactically in cirrhotics undergoing invasive procedures? ‐ A Dilemma

To the editor, We read with great interest the recently published study by Lesley et al 1 . Authors compared Thromboelastography (TEG) with routine coagulation tests [prothrombin time (PT) and platelet count] to assess the risk of bleeding before invasive procedures in cirrhotics. They concluded that TEG-guided transfusion strategy leads to a significantly lower use of blood products compared to standard of care (transfusion guided by PT and platelet count) without an increase in bleeding complications in patients with significant coagulopathy. Authors used pre-procedural transfusions as standard of care but there is no recommendation for prophylactic transfusion in cirrhotics undergoing invasive procedures. Prophylactic transfusions have not been beneficial on the contrary they have been harmful. As there was a very low incidence of bleeding in both the groups, Intagliata N et al 2 in a correspondence letter suggested need a study without prophylactic correction of routine coagulation tests. In a multicenter prospective study of 388 cirrhotic patients undergoing invasive procedures, we did not use prophylactic transfusion and demonstrated that this strategy is extremely safe. Whenever indicated, any invasive procedures could be safely carried out in patients with cirrhosis without prior correction of abnormal routine coagulation tests. 3 In the preliminary data of ongoing prospective study of 60 cirrhotic patients who underwent invasive procedures, we compared TEG with conventional coagulation tests in all patients, none of the patient in the study received prophylactic correction of abnormal conventional coagulation tests before the invasive procedure or surgery. We found that only one patient developed post procedural clinically significant bleeding. 4 A recently published guideline by Nadim et al 5