Avik Majumdar

Bacterial Infections Change Natural History of Cirrhosis Irrespective of Liver Disease Severity

Objectives:We assessed the prognostic significance of infections in relation to current prognostic scores and explored if infection could be considered per se a distinct clinical stage in the natural history of cirrhosis.Methods:We included consecutive patients with cirrhosis admitted to a tertiary referral liver unit for at least 48 h over a 2-year period. Diagnosis of infection was based on positive cultures or strict established criteria. We used competing risk analysis and propensity score matching for data analysis.Results:501 patients (63% male, 48% alcoholic liver disease, median Model of End-stage Liver Disease (MELD)=17) underwent 781 admissions over the study period. Portal hypertensive bleeding and complicated ascites were the commonest reasons of admission. The incidence of proven bacterial infection was 25.6% (60% community acquired and 40% nosocomial). Survival rates at 3, 6, 12, and 30 months were 83%, 77%, 71%, and 62% in patients without diagnosis of infection, vs. 50%, 46%, 41%, and 34% in patients with diagnosis of infection. Overall survival was independently associated with MELD score (hazards ratio (HR) 1.099), intensive care (ITU) stay (HR 1.967) and bacterial infection (HR 2.226). Bacterial infection was an independent predictor of survival even when patients who died within the first 30 days were excluded from the analysis in Cox regression (HR 2.013) and competing risk Cox models in all patients (HR 1.46) and propensity risk score-matched infected and non-infected patients (HR 1.67).Conclusions:Infection most likely represents a distinct prognostic stage of cirrhosis, which affects survival irrespective of disease severity, even after recovery from the infective episode.

Non-selective beta-blockers are not associated with increased mortality in cirrhotic patients with ascites

Controversy exists on the impact of non‐selective beta‐blockers (NSBBs) on survival in patients with ascites. We assessed whether NSBB treatment affects survival in a cohort of 316 consecutive patients with ascites undergoing evaluation for liver transplantation.

The holy grail of a biomarker for “liver function”

The past decade has given rise to many innovations in hepatology, particularly in the fields of noninvasive fibrosis assessment and viral hepatitis. Comparatively, advances in the functional assessment of the liver have progressed at a much slower rate. It is an ambitious proposal to develop a single unifying biomarker to assess global liver function, but one that highlights the inadequacies of current methods of assessment. A major impediment to the pursuit of this ‘‘holy grail’’ is the broad range of functions performed by the liver. Moreover, liver function per se is only one determinant of prognosis in chronic liver diseases, with portal hypertension and hepatocarcinogenesis being two other major factors. For this reason, any progress in the pure functional assessment of the liver has been made predominantly in the settings of acute liver failure and the preoperative assessment for liver resection. This brief review aims to discuss the current and future status of the hepatic functional assessment.

When and How to Perform Surveillance

Detecting clinically significant portal hypertension (CSPH), defined by a hepatic venous pressure gradient (HVPG) of greater than or equal to 10 mmHg, is an important goal for surveillance in chronic liver diseases. In particular, the onset of CSPH is the threshold for the development of oesophageal varices and delineates the potential for clinical decompensation. Upper gastrointestinal endoscopy and HVPG measurement have been regarded as the gold standards of diagnosing gastro-oesophageal varices and CSPH, respectively; however, both are invasive and costly. The ideal surveillance programme should have excellent diagnostic capability and be easily reproducible, widely available, cost-effective and non-invasive. Since Baveno V, numerous non-invasive modalities of detecting both CSPH and oesophageal varices have been developed as potential surveillance tools, either as sole techniques or in combination algorithms. Current surveillance guidelines have many unresolved issues, particularly regarding surveillance intervals, consensus on endoscopic criteria, the economic cost and whether non-invasive markers can reduce unnecessary invasive procedures. This chapter aims to discuss these issues by highlighting the key developments since Baveno V and their applicability to surveillance guidelines.