Mireia Miquel

Incidence and Prognosis of Different Types of Functional Renal Failure in Cirrhotic Patients With Ascites

BACKGROUND & AIMS Hepatorenal syndrome is a well-characterized type of terminal renal failure that occurs in patients with cirrhosis with ascites. Information about other types of functional renal failure in these patients is scarce. We assessed the incidence and prognosis of different types of functional renal failure in cirrhotic patients with ascites and investigated prognostic factors for these disorders. METHODS Consecutive cirrhotic patients (n = 263) were followed for 41 +/- 3 months after their first incidence of ascites. Three types of functional renal failure were considered: pre-renal failure (when renal failure was associated with a depletion of intravascular volume), renal failure induced by infection that did not result in hepatorenal syndrome, and hepatorenal syndrome. RESULTS During the follow-up period, 129 (49%) patients developed some type of functional renal failure. The most frequent was pre-renal failure (27.4%), followed by renal failure induced by infection (14.1%), and then hepatorenal syndrome (7.6%). The 1-year probability of developing the first episode of any functional renal failure was 23.6%. The independent predictors of functional renal failure development were baseline age, Child-Pugh score, and serum creatinine. Although the 1-year probability of survival was 91% in patients without renal failure, it decreased to 46.9% in those patients who developed any functional renal failure (P = .0001). CONCLUSIONS Approximately 50% of the cirrhotic patients with ascites developed some type of functional renal failure during the follow-up period; renal failure was associated with worse prognosis. Efforts should be made to prevent renal failure in cirrhotic patients with ascites.

Cost-minimization analysis favours intravenous ferric carboxymaltose over ferric sucrose for the ambulatory treatment of severe iron deficiency.

Objective Intravenous iron is widely used to treat iron deficiency in day-care units. Ferric carboxymaltose (FCM) allows administration of larger iron doses than iron sucrose (IS) in each infusion (1000 mg vs. 200 mg). As FCM reduces the number of infusions required but is more expensive, we performed a cost-minimization analysis to compare the cost impact of the two drugs. Materials and Methods The number of infusions and the iron dose of 111 consecutive patients who received intravenous iron at a gastrointestinal diseases day-care unit from 8/2007 to 7/2008 were retrospectively obtained. Costs of intravenous iron drugs were obtained from the Spanish regulatory agencies. The accounting department of the Hospital determined hospital direct and indirect costs for outpatient iron infusion. Non-hospital direct costs were calculated on the basis of patient interviews. In the pharmacoeconomic model, base case mean costs per patient were calculated for administering 1000 mg of iron per infusion using FCM or 200 mg using IS. Sensitivity analysis and Monte Carlo simulation were performed. Results Under baseline assumptions, the estimated cost of iron infusion per patient and year was €304 for IS and €274 for FCM, a difference of €30 in favour of FCM. Adding non-hospital direct costs to the model increased the difference to €67 (€354 for IS vs. €287 for FCM). A Monte Carlo simulation taking into account non-hospital direct costs favoured the use of FCM in 97% of simulations. Conclusion In this pharmacoeconomic analysis, FCM infusion reduced the costs of iron infusion at a gastrointestinal day-care unit.

Accuracy of Monoclonal Stool Tests for Determining Cure of Helicobacter pylori Infection After Treatment

Background:  Studies comparing new monoclonal fecal tests for evaluating cure of Helicobacter pylori infection after treatment are scarce. The objective was to compare the diagnostic accuracy of three monoclonal stool tests: two rapid in‐office tools –RAPID Hp StAR and ImmunoCard STAT! HpSA – and an EIA test – Amplified IDEIA Hp StAR.

Probability of liver cancer and survival in HCV-related or alcoholic-decompensated cirrhosis. A study of 377 patients

Abstract: Background: Although chronic alcohol intake and chronic hepatitis C may progress to cirrhosis and hepatocellular carcinoma (HCC), few data are available about survival and probability of developing HCC in decompensated cirrhosis of both aetiologies.

Development and validation of the Crohn's disease perceived work disability questionnaire.

Background: No validated instruments have been developed to measure work disability in Crohns disease (CD). The aim of our study was to develop and validate a CD perceived work disability questionnaire (CPWDQ). Methods: Development phase: an initial questionnaire containing 52 items was obtained from patients’ interviews plus additional sources; it was completed by 106 patients and the 16 most significant items were selected using a psychometric method in order to create the CPWDQ. Validation phase: The validation assessed the questionnaires convergent validity, discriminant validity, test–retest reproducibility, and internal consistency in 108 patients. Spearman rank correlation, t‐test, intraclass correlation, and Cronbachs alpha were used for the analysis. Results: Convergent validity was confirmed by good correlations between the CPWDQ and: clinical activity (r = 0.59, P < 0.01), the Short Inflammatory Bowel Disease Questionnaire, IBDQ‐9, (r = 0.76, P < 0.001), Euroqol‐5D (r = 0.53, P < 0.01), and overall work impairment (WPAI_CD) r = 0.66 (P < 0.01). Discriminant validity: CPWQ scores were higher in patients expected to have more severe disability, that is, in patients with active disease (n = 38) 32.3 ± 7.3 versus inactive (n = 70) 22.6 ± 5.9 (P < 0.001), in those requiring previous sick leave 30.7 ± 7.5 (n = 45) versus no sick leave 22.6 ± 6.6 (n = 63) (P < 0.01), and in those requiring hospitalization 32.2 ± 8.6 (n = 18) versus no hospitalization 24.7 ± 7.1 (n = 90) (P < 0.01). Internal consistency was also good (Cronbachs alpha = 0.89). Reproducibility: CPWDQ measures obtained 2 weeks apart showed an excellent intraclass correlation coefficient: 0.89 (95% CI: 0.83–0.93). Conclusions: The CPWDQ seems to be a valid, reliable tool for measuring subjective work disability in CD. (Inflamm Bowel Dis 2011;)

Suspected cross-hepatotoxicity of flutamide and cyproterone acetate

Flutamide and cyproterone acetate (CPA) are both oral anti‐androgens commonly used to treat advanced prostatic cancer. We report a case of drug‐induced hepatotoxicity after consecutive treatment with flutamide and CPA. A 78‐year‐old male with advanced prostatic adenocarcinoma had been treated with flutamide 750 mg/day p.o. and leuproleride acetate 22.5 mg/3 months i.m. Three months later, the patient complained of choluria and jaundice. Laboratory examination revealed severe hepatocellular insufficiency. Flutamide‐induced hepatotoxicity was suspected and therefore flutamide was withdrawn. His liver function abnormalities resolved after drug discontinuation. He was subsequently started on CPA 150 mg/day and again developed hepatotoxicity with severe hepatocellular impairment, which completely recovered after drug discontinuation. Other causes of acute liver failure were appropriately ruled out in both episodes and there was no evidence of active prostate cancer or liver metastases in both episodes. The occurrence of hepatotoxicity associated with flutamide and CPA on separated occasions suggests the possibility of a common mechanism of injury. It may become necessary to reassess the common practice of switching to another anti‐androgen when hepatotoxicity appears. A closer monitoring of liver enzymes might be necessary in such cases, as an increased risk of a new severe hepatotoxicity event cannot be ruled out.

Hospital mortality over time in patients with specific complications of cirrhosis

Hospital mortality secondary to cirrhosis is high.

Rifaximin, but not growth factor 1, reduces brain edema in cirrhotic rats

AIM To compare rifaximin and insulin-like growth factor (IGF)-1 treatment of hyperammonemia and brain edema in cirrhotic rats with portal occlusion. METHODS Rats with CCl₄-induced cirrhosis with ascites plus portal vein occlusion and controls were randomized into six groups: Cirrhosis; Cirrhosis + IGF-1; Cirrhosis + rifaximin; Controls; Controls + IGF-1; and Controls + rifaximin. An oral glutamine-challenge test was performed, and plasma and cerebral ammonia, glucose, bilirubin, transaminases, endotoxemia, brain water content and ileocecal cultures were measured and liver histology was assessed. RESULTS Rifaximin treatment significantly reduced bacterial overgrowth and endotoxemia compared with cirrhosis groups, and improved some liver function parameters (bilirubin, alanine aminotransferase and aspartate aminotransferase). These effects were associated with a significant reduction in cerebral water content. Blood and cerebral ammonia levels, and area-under-the-curve values for oral glutamine-challenge tests were similar in rifaximin-treated cirrhotic rats and control group animals. By contrast, IGF-1 administration failed to improve most alterations observed in cirrhosis. CONCLUSION By reducing gut bacterial overgrowth, only rifaximin was capable of normalizing plasma and brain ammonia and thereby abolishing low-grade brain edema, alterations associated with hepatic encephalopathy.

Rat CCl4‐induced cirrhosis plus total portal vein ligation: a new model for the study of hyperammonaemia and brain oedema

Introduction: Animal models used to study hyperammonaemic disorders related to chronic liver disease are unsatisfactory. These animals only develop hyperammonaemia and brain oedema when fed with diets supplemented with amonium acetate.

Presentación atípica de metástasis a distancia de hepatocarcinoma

Resumen El hepatocarcinoma (HCC) es el tumor primario maligno de higado mas frecuente. Habitualmente asienta sobre un higado cirrotico, lo que justifica su cribado mediante determinacion de las concentraciones de alfafetoproteina y ecografia abdominal de forma semestral en todo paciente cirrotico con funcion hepatocelular preservada. Esto permite la deteccion precoz de tumores, lo que incrementa la proporcion de casos potencialmente curables. La diseminacion metastasica mas frecuente del HCC es la trombosis de la vena porta, mientras que es poco frecuente la diseminacion a distancia. Presentamos 3 casos de HCC con metastasis de localizacion infrecuente y sintomas inespecificos, que motivaron una orientacion diagnostica inicial erronea. Dada la mayor supervivencia actual de este tipo de pacientes, debe considerarse la posibilidad de metastasis a distancia ante la aparicion de sintomas inespecificos en pacientes portadores de HCC.