Documento de consenso sobre el tratamiento de la ascitis, la hiponatremia dilucional y el síndrome hepatorrenal en la cirrosis hepática

Diagnosis and treatment of hyponatremia: a systematic review of clinical practice guidelines and consensus statements

BACKGROUND

Hyponatremia is a common electrolyte disorder. Multiple organizations have published guidance documents to assist clinicians in managing hyponatremia. We aimed to explore the scope, content, and consistency of these documents.

METHODS

We searched MEDLINE, EMBASE, and websites of guideline organizations and professional societies to September 2014 without language restriction for Clinical Practice Guidelines (defined as any document providing guidance informed by systematic literature review) and Consensus Statements (any other guidance document) developed specifically to guide differential diagnosis or treatment of hyponatremia. Four reviewers appraised guideline quality using the 23-item AGREE II instrument, which rates reporting of the guidance development process across six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Total scores were calculated as standardized averages by domain.

RESULTS

We found ten guidance documents; five clinical practice guidelines and five consensus statements. Overall, quality was mixed: two clinical practice guidelines attained an average score of >50% for all of the domains, three rated the evidence in a systematic way and two graded strength of the recommendations. All five consensus statements received AGREE scores below 60% for each of the specific domains.The guidance documents varied widely in scope. All dealt with therapy and seven included recommendations on diagnosis, using serum osmolality to confirm hypotonic hyponatremia, and volume status, urinary sodium concentration, and urinary osmolality for further classification of the hyponatremia. They differed, however, in classification thresholds, what additional tests to consider, and when to initiate diagnostic work-up. Eight guidance documents advocated hypertonic NaCl in severely symptomatic, acute onset (<48 h) hyponatremia. In chronic (>48 h) or asymptomatic cases, recommended treatments were NaCl 0.9%, fluid restriction, and cause-specific therapy for hypovolemic, euvolemic, and hypervolemic hyponatremia, respectively. Eight guidance documents recommended limits for speed of increase of sodium concentration, but these varied between 8 and 12 mmol/L per 24 h. Inconsistencies also existed in the recommended dose of NaCl, its initial infusion speed, and which second line interventions to consider.

CONCLUSIONS

Current guidance documents on the assessment and treatment of hyponatremia vary in methodological rigor and recommendations are not always consistent.

Hepatoprotective effects of Limonium tetragonum, edible medicinal halophyte growing near seashores

Background:

During the process of hepatic fibrosis, the activation of hepatic stellate cells (HSCs) is responsible for the increased formation and reduced degradation of extracellular matrix in the liver. By employing the hepatic stellate cell line, HSC-T6, it was found that the methanol extract of Limonium tetragonum, a halophyte living in salt marsh near south and western seashores of Korea significantly inhibited the proliferation of HSC-T6 cells.

Objective:

In the present study, we attempted to investigate the antifibrotic effects of the mathanolic extract of L. tetragonum (MELT) in the activated HSC-T6 cells.

Materials and Methods:

The proliferation of HSC-T6 was stimulated by culturing environment or platelet-derived growth factor (PDGF-BB) insult, and then the inhibitory activities of MELT were measured.

Results:

It was found that MELT suppressed the proliferation of the activated HSC-T6 in concentration- and time-dependent manners. The increased collagen deposition in the activated HSC-T6 cells was also decreased by the treatment of MELT. The maximal dose of MELT, however, had little effect on primary cultured rat hepatocytes. Wlammatory cytokine, tumor necrosis factor alpha (TNF-α) produced by lipopolysaccharide-stimulated RAW264.7 macrophages was inhibited by MELT.

Conclusion:

Collectively, the above results demonstrated that MELT suppressed HSCs proliferation but not in hepatocytes, implying that L. tetragonum may be useful candidates for developing therapeutic agents for the prevention and treatment of hepatic fibrosis.

[Acute on chronic liver failure]

Acute-on-Chronic Liver Failure (ACLF) is a recently introduced term defined as severe acute deterioration of an established liver disease. This entity usually develops after an acute insult. The main clinical manifestations are hepatorenal syndrome, hepatic encephalopathy and organ failure, with a high risk of death in the short term. The true incidence of ACLF remains difficult to determine due to confusions surrounding the definition of this entity, but seems to be 40% at 5 years in patients with advanced cirrhosis, which translates into 4,000 cases in Europe within this time span. The treatment of choice is liver transplantation. However, due to the shortage of suitable organs and morbidity and mortality in these patients, other options must be used.

[Dilutional hyponatremia, hepatorenal syndrome and liver transplantation]

Cirrhosis is a chronic, progressive disease characterized by complications associated with portal hypertension and liver failure. Renal function disorders are a common complication in patients with cirrhosis and are associated with high morbidity and mortality and poor prognosis. Renal function alterations in these patients include sodium and water retention and renal vasoconstriction. Sodium retention causes the formation of ascites and edema, solute-free water leads to dilutional hyponatremia, and renal vasoconstriction gives rise to the development of hepatorenal syndrome (HRS). Due to their poor prognosis, the presence of ascites, dilutional hyponatremia and HRS are indications for liver transplantation (LT). Recent studies have allowed new prognostic factors in these patients to be identified, novel treatments for dilutional hyponatremia and HRS to be applied, and the association of these complications with disease course and outcome before and after LT to be described. The present review discusses new concepts of the physiopathology, evaluation and treatment of cirrhotic patients with dilutional hyponatremia and HRS and the relationship of these entities with LT.

Natural History of Compensated and Decompensated HCV-Related Cirrhosis in HIV-Infected Patients: A Prospective Multicentre Study

Objective

To define the course of HIV-HCV-coinfected patients with compensated and decompensated liver cirrhosis and to investigate the survival and the risk factors for death.

Patients and methods

Ninety-two HIV-infected patients with HCV-related cirrhosis (50 of them without and 42 with previous decompensations) were prospectively followed up during a median period of 20 months. Clinical, biochemical, virological and immunological factors were analysed. Multivariate analyses were performed of those factors associated with decompensations and mortality.

Results

There were 168 readmissions due to liver-disease-related causes. A Child-Pugh index ≥6 in those without previous decompensations (hazard ratio [HR] 7.94, 95% confidence interval [CI] 1.59–39.58; P=0.014), and Child-Pugh index ≥9 (HR 2.68, 95% CI 1.13–6.33; P=0.003) and absence of HAART (HR 0.44, 95% CI 0.19–0.98; P=0.048) in those with previous decompensations were independently associated with decompensation during the follow up. There were 27 deaths, 22 of them attributable to liver disease. Independent factors associated with liver-related mortality were a Child-Pugh index ≥9 (HR 6.24, 95% CI 2.31–16.85; P<0.001), progression of Child-Pugh index during the follow up (HR 4.27, 95% CI 1.54–11.80; P=0.008), more than one decompensation (HR 24.25, 95% CI 7.27–40.45; P<0.001) and absence of HAART (HR 0.35, 95% CI 0.12–0.98; P=0.002).

Conclusions

Evolution from compensated to decompensated cirrhosis and death is influenced by markers of liver function and the absence of HAART. The importance of this last element must be adequately stressed.