Kamolyut Lapumnuaypol

Overcoming a treatment barrier in treating hepatitis C in dialysis patients

To the Editor I read the recent review article by Davis et al. with great interest. The authors raised the important issue of HCV treatment by nephrologists. Since direct-acting antiviral therapies were approved, the sustained virologic response (SVR) has reached 90%. However, the “population” SVR is still very low; i.e treatment is not widely provided. We agree that the next step to eradicate HCV is to expand the delivery of treatment and to decrease treatment barriers. In our institution, we have been using a new approach in which the primary care physician starts the HCV treatment. This approach has significantly decreased the delay in initiating treatment from 273 to 77 days. The program was first implemented to increase screening, diagnosis, and treatment of HCV by actively incorporating primary care providers (PCP) at every step of the HCV care process. We believe this multidisciplinary team approach for the HCV treatment will improve the quality of care for HCV patient. A second issue relates to the method of determining advanced liver fibrosis/cirrhosis. The authors state that transient elastography is a preferred approach and recommend that the test be performed after dialysis because central venous pressure can affect the result. Indeed, the few articles on the subject show conflicting data and this question still requires more research to answer. Keller et al. found a significant decrease in liver stiffness after hemodialysis only if predialysis liver stiffness is above 7.1 kPa. They recommended doing transient elastography before dialysis to increase detection of liver fibrosis. Liu et al. have proposed optimized liver stiffness values offering high accuracy for detecting liver fibrosis in hemodialysis patients using transient elastography 1 day after hemodialysis. To routinely obtain transient elastography after hemodialysis may not be feasible. We agree that the test should be done when the patient is euvolemic. However, hemodialysis units are unlikely to have elastography machines at the center, at least for nonhospital based programs. The appropriate timing for elastography in hemodialysis patient still needs further investigations.

Risk of Fall in Patients Taking Proton Pump Inhibitors: A Meta-Analysis

Background Fall prevention among older adults is a worldwide public health advocacy because of negative consequences of fall. Recent studies have shown that proton pump inhibitors (PPIs) increase the risk of fall. PPIs are among the widely prescribed medications oftentimes without clear indications. Concerns for safety of long-term use of PPIs have been raised by numerous studies. Methods A systematic review was conducted in MEDLINE and EMBASE databases from inception through March 2018 to identify studies that assessed the association between the use of PPIs and the risk of fall. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. Results Eight observational studies with a total of 367,068 patients were enrolled. There was a significant association between the use of PPIs and the risk of fall with the pooled OR of 1.27 (95% CI, 1.07-1.50). Meta-regression showed significant positive correlations between risk of fall in patients using PPIs and year of study (slopes = +0.25, p <0.001). The data on the risk of fall in patients using H2 receptor antagonists (H2RAs) were limited in 3 studies. The pooled OR of fall in patients using H2RAs was 0.95 (95% CI, 0.75-1.20). Conclusions We demonstrate a significant association between the use of PPIs and increased risk of fall. There is a significant positive correlation between the risk of fall in patients using PPIs and year of study. In addition, there is potentially higher risk of fall among PPIs users over time.

Anaemia and mortality in patients with transcatheter aortic valve replacement: a systematic review and meta-analysis

Abstract Objective: This study was done to determine the relationship between pre-procedural anaemia and mortality post transcatheter aortic valve replacement (TAVR). Introduction: TAVR is now a treatment option for patients with severe aortic stenosis (AS) with high surgical risk. Anaemia is a common comorbidity in the TAVR population. Small studies have suggested that anaemia is associated with worse short-term and long-term mortality in patients who underwent TAVR. However, there are no meta-analyses to further assess this association. Method: Studies were systematically searched from electronic databases (EMBASE and MEDLINE). Inclusion criteria were adult population with aortic stenosis who underwent TAVR, and number of patients with pre-procedural anaemia reported. Outcomes were short-term mortality or long-term mortality. Pooled effect size was calculated with a random-effect model, weighted for the inverse of variance. Heterogeneity was assessed with I2. Results: Six studies were included in the final analysis. Of these, pooled analysis of four studies examining association between anaemia and 30-day mortality did not show a statistically significant relationship. A pooled analysis of four studies examining the association of anaemia and long-term mortality after TAVR showed pooled adjusted risk ratio (RR) of 1.43, 95% CI 1.22–1.67 with low heterogeneity (I2 = 33%). Subgroup analysis after exclusion of one smaller study showed that the association remained significant (RR 1.41, 95% CI 1.27–1.56) with decreased heterogeneity (I2 = 0%). Conclusion: This systematic review and meta-analysis found an association between pre-procedural anaemia and increased long-term but not short-term mortality after TAVR. Further study of the pathophysiology underlying this association is needed.

Gallstone Pancreatitis: A Common but Often Overlooked Cause of Abdominal Pain in Post-Liver-Transplant Patients

Introduction In general population, gallstone pancreatitis is the most common cause of pancreatitis. However, there are very few literatures that address this topic in post-liver-transplant patients. Clinical Case A 69-year-old female who had a liver transplant in 2015 due to hepatocellular carcinoma and nonalcoholic steatohepatitis (NASH) cirrhosis. She had a recent episode of acute cellular rejection that was treated with high dose methylprednisolone 1 week prior to admission. She presented with severe epigastric abdominal pain associated with nausea and vomiting. Her laboratory studies showed significantly elevated serum lipase, AST, and ALT from her baseline. She underwent urgent Endoscopic Ultrasound (EUS) with Endoscopic Retrograde Cholangiopancreatography (ERCP) that showed common bile duct stone that was extracted. Discussion Biliary sludge and stones accounted for 22% of late onset acute pancreatitis after liver transplant. Corticosteroids have been identified as one of the potential causes of drug-induced pancreatitis. However, she is more likely to have gall stone pancreatitis since she also had dilated common bile duct and intrahepatic duct. In addition, there was CBD stone noted on ERCP. Conclusion Acute gallstone associated pancreatitis after liver transplant is not uncommon. Patients generally have good outcomes. Further prospective studies are warranted.