Can non-invasive measurements aid clinical assessment of volume in patients with cirrhosis?

Review article: Practical considerations for fluid resuscitation in cirrhosis

BACKGROUND

Standard clinical methods of assessing volume and providing resuscitation are not always applicable to patients with advanced or decompensated cirrhosis. Despite this being well known from a clinical perspective, there remains relatively little evidence to guide clinicians though fluid management in patients with cirrhosis and, often, multi-organ system dysfunction.

AIMS

This review summarises the current understanding of the circulatory dysfunction in cirrhosis, modalities for assessing volume status, and considerations for fluid selection. It additionally provides a practical approach to fluid resuscitation.

METHODS

We review current literature on cirrhosis pathophysiology in steady-state and shock, clinical implications of fluid resuscitation, and strategies to assess intravascular volume. Literature reviewed here was identified by the authors through PubMed search and review of selected papers' references.

RESULTS

Clinical management of resuscitation in advanced cirrhosis remains relatively stagnant. Although several trials have attempted to establish the superior resuscitative fluid, the lack of improvement in hard clinical outcomes leaves clinicians without clear guidance.

CONCLUSIONS

The absence of consistent evidence for fluid resuscitation in patients with cirrhosis limits our ability to produce a clearly evidence-based protocol for fluid resuscitation in cirrhosis. However, we propose a preliminary practical guide to managing fluid resuscitation in patients with decompensated cirrhosis. Further studies are needed to develop and validate volume assessment tools in the specific context of cirrhosis, while randomised clinical trials of protocolized resuscitation may improve care of this patient population.

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.

Evaluation and management of emergencies in the patient with cirrhosis

The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.

Evaluation and management of emergencies in the patient with cirrhosis

The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.

Low sodium to potassium ratio in spot urine sample is associated with progression to acute kidney injury and mortality in hospitalized patients with cirrhosis

BACKGROUND

sodium to potassium ratio in spot urine sample (Na/Kur) is a surrogate marker of sodium excretion that is recommended for the management of patients with ascites due to cirrhosis.

AIMS

to investigate Na/Kur ratio and fractional excretion of sodium (FENa) in patients admitted with decompensated cirrhosis, evaluating its relationship with acute kidney injury (AKI) and prognosis.

METHODS

prospective cohort study included 225 adult subjects. Urine samples were obtained within 48 h of hospitalization.

RESULTS

AKI at admission was observed in 32.9% of patients and was associated with lower Na/Kur ratio, but not FENa. Among 151 subjects initially without kidney dysfunction, AKI at some point during hospitalization occurred in 26.2% and was independently associated with low Na/Kur ratio at admission. AKI was observed in 44% of the patients with Na/Kur ratio < 1 and only in 8% when values ≥ 2. Na/Kur ratio at admission was independently associated with 30-day mortality, with Kaplan-Meier survival probability of 78.8% for Na/Kur ratio < 1 and 93.6% for values ≥ 1.

CONCLUSIONS

low Na/Kur ratio in spot urine sample is associated with progression to AKI and lower short-term survival in patients hospitalized for decompensated cirrhosis.

The Conundrum of Volume Status Assessment: Revisiting Current and Future Tools Available for Physicians at the Bedside

Assessment of patients’ volume status at the bedside is a very important clinical skill that physicians need in many clinical scenarios. Hypovolemia with hypotension and tissue under-perfusion are usually more alarming to physicians, but hypervolemia is also associated with poor outcomes, making euvolemia a crucial goal in clinical practice. Nevertheless, the assessment of volume status can be challenging, especially in the absence of a gold standard test that is reliable and easily accessible to assist with clinical decision-making. Physicians need to have a broad knowledge of the individual non-invasive clinical tools available for them at the bedside to evaluate volume status. In this review, we will discuss the strengths and limitations of the traditional tools, which include careful history taking, physical examination, and basic laboratory tests, and also include the relatively new tool of point-of-care ultrasound.

[Chronic kidney injury in patients with liver diseases - Reappraising pathophysiology and treatment options]

Acute and chronic kidney disease concurs commonly with liver disease and is associated with a wide array of complications including dialysis dependency and increased mortality. Patients with liver disease or liver cirrhosis show a higher prevalence of chronic kidney disease. This is attributed to concomitant comorbidities, such as metabolic syndrome, chronic inflammation, hypercoagulability, hyperfibrinolysis, diabetes mellitus and dyslipidaemias. But chronic progressive kidney disease is not always due to hepatorenal syndrome. Beyond that, other diseases or disease entities should be considered. Among them are diabetic nephropathy, secondary IgA nephropathy, hepatitis C -associated membranoproliferative Glomerulonephritis (MPGN) and hepatitis B-associated membranous nephropathy.Coexisting diseases, similar underlying pathophysiologic mechanisms, or simultaneously concurring pathophysiological processes and overlapping clinical manifestations, impede the etiologic diagnosis and corresponding treatment of chronic kidney disease in the setting of chronic liver disease. In this review, we focus on common and rare pathologies, which can lead to chronic kidney disease in this particular patient group and try to summarize the most recent therapeutic modalities.

Global strategy for the diagnosis and management of acute kidney injury in patients with liver cirrhosis

Acute kidney injury (AKI) is a clinical syndrome that complicates the course and worsens clinical outcomes in patients with chronic liver diseases. It is a common complication in hospitalised patients with liver cirrhosis, especially those with decompensated cirrhosis, associated with a high mortality rate. Considering its impact on patient prognosis, efforts should be made to diagnose and tailor therapeutic interventions for AKI at an early stage. In the past decade, a significant progress has been made to understand the key events and define major prognostic factors for the onset and progression of AKI in the cirrhotic population leading hepatologists to redefine the classic definition of hepatorenal syndrome and renal failure in this specific population.

Arm Skeletal Muscle Mass Is Associated With the Prognosis of Patients With Cirrhosis

BACKGROUND/AIM

This study aimed to assess the clinical significance of measuring the arm skeletal muscle mass in patients with cirrhosis.

PATIENTS AND METHODS

Using body composition data measured with the bioimpedance analysis (BIA) method, the skeletal muscle mass index (SMI) values of the arm (arm skeletal muscle mass/height²) and leg (leg skeletal mass muscle/height²) were calculated for 353 patients with cirrhosis, and the relationships of these indices to their prognosis were assessed. In addition, overhydration of the upper and lower limbs was compared.

RESULTS

Arm SMI was significantly positively associated with the prognosis of patients with cirrhosis (p=0.0002) but leg SMI was not (p=0.0829). The rate of overhydration in the lower limbs was significantly higher than that in the upper limbs (p<0.0001).

CONCLUSION

Arm SMI measured with the BIA method was suggested to be minimally affected by water retention, and might be clinically useful for patients with cirrhosis.

[Acute kidney injury following acute pancreatitis (AP-AKI): Definition, Pathophysiology, Diagnosis and Therapy]

Acute pancreatitis (AP) is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Severe acute pancreatitis is often associated with multiorgan failure and especially with acute kidney injury (AKI). AKI can develop early or late in the course of the disease and is a strong determinator of outcome. The mortality in the case of dialysis-dependent AKI and acute pancreatitis raises exponentially in the affected patients. AP-induced AKI (AP-AKI) shows many similarities but also distinct differences to other causes of AKI occurring in the intensive care unit setting. The knowledge of the exact pathophysiology can help to adjust, control and improve therapeutic approaches to the disease. Unfortunately, there are only a few studies dealing with AP and AKI.In this review, we discuss recent data about pathogenesis, causes and management of AP-AKI in patients with severe acute pancreatitis and exploit in this regard the diagnostic and prognostic potential of respective newer serum and urine markers.

Differences in pharmacological property between combined therapy of the vasopressin V2-receptor antagonist tolvaptan plus furosemide and monotherapy of furosemide in patients with hospitalized heart failure

BACKGROUND

Tolvaptan has been shown to improve congestion in heart failure patients. The purpose of this study was to evaluate the pharmacology and clinical efficacy of combined tolvaptan and furosemide therapy.

METHODS

This study included 40 patients with systemic volume overload who were hospitalized for heart failure. Patients who showed no improvement in the condition after receiving 20 mg intravenous furosemide were included and were randomly selected to receive tolvaptan as an add-on to furosemide or to receive an increased dose of furosemide. We evaluated the bioelectrical impedance analyzer parameters, the parameters of the inferior vena cava using echocardiography, vital signs, body weight, urine output, and laboratory data for 5 days.

RESULTS

In the changes from baseline between intracellular water volume (ICW) and extracellular water volume (ECW) after additional use of tolvaptan or furosemide from Day 1 to Day 5, there were no significant differences observed between ICW and ECW over 5 days in the tolvaptan + furosemide group, although differences were found in the furosemide group from Day 2 onward. Changes in the respiratory collapse of inferior vena cava increased significantly, and systolic blood pressure decreased significantly only in the furosemide group.

CONCLUSIONS

The present study clearly demonstrates that combined therapy with tolvaptan and furosemide removed excess ICW and ECW to an equal extent, while furosemide alone primarily removed ECW, including intravascular water.

Clinical implications with tolvaptan on monitored bioimpedance-defined fluid status in patients with cirrhotic ascites: an observational study

Background

Prognostic value or clinical implications of fluid status monitoring in liver cirrhosis are not fully elucidated. Tolvaptan, an orally available, selective vasopressin V2-receptor antagonist approved for hyponatremia in the United States and European Union. It is also used for cirrhotic ascites at a relatively low dose (3.75 mg to 7.5 mg) in Japan, exerts its diuretic function by excreting electrolyte-free water. We hypothesized that bioimpedance-defined dynamic changes in fluid status allow prediction of response of V2 antagonism and survival in cirrhotic patients.

Methods

In this prospective observational study, 30 patients with decompensated liver cirrhosis who were unresponsive to conventional diuretics were enrolled. Detailed serial changes of body composition that were assessed by using non-invasive bioimpedance analysis (BIA) devices, along with biochemical studies, were monitored at 5 time points.

Results

Sixteen patients were classified as short-term responders (53%). Rapid and early decrease of BIA-defined intracellular water, as soon as 6 h after the first dose (ΔICW_BIA%-6 h), significantly discriminated responders from non-responders (AUC = 0.97, P < 0.0001). ΔICW_BIA%-6 h was highly correlated with the change of BIA-derived phase angle of trunk, e.g. reduced body reactance operated at 50 kHz after 24 h of the first dose of tolvaptan. Lower baseline blood urea nitrogen and lower serum aldosterone were predictive of a rapid and early decrease of ICW_BIA. A rapid and early decrease of ICW_BIA in response to tolvaptan was also predictive of a better transplant-free survival.

Conclusions

BIA-defined water compartment monitoring may help predict short-term efficacy and survival in decompensated cirrhotic patients treated with tolvaptan.

Bioimpedance spectroscopy for fluid status assessment in patients with decompensated liver cirrhosis: Implications for peritoneal dialysis

Bioimpedance spectroscopy (BIS) is routinely used in peritoneal dialysis patients and might aid fluid status assessment in patients with liver cirrhosis, but the effect of ascites volume removal on BIS-readings is unknown. Here we determined changes in BIS-derived parameters and clinical signs of fluid overload from before to after abdominal paracentesis. Per our pre-specified sample size calculation, we studied 31 cirrhotic patients, analyzing demographics, labs and clinical parameters along with BIS results. Mean volume of the abdominal paracentesis was 7.8 ± 2.6 L. From pre-to post-paracentesis, extracellular volume (ECV) decreased (20.2 ± 5.2 L to 19.0 ± 4.8 L), total body volume decreased (39.8 ± 9.8 L to 37.8 ± 8.5 L) and adipose tissue mass decreased (38.4 ± 16.0 kg to 29.9 ± 12.9 kg; all p < 0.002). Correlation of BIS-derived parameters from pre to post-paracentesis ranged from R² = 0.26 for body cell mass to R² = 0.99 for ECV. Edema did not correlate with BIS-derived fluid overload (FO ≥ 15% ECV), which occurred in 16 patients (51.6%). In conclusion, BIS-derived information on fluid status did not coincide with clinical judgement. The changes in adipose tissue mass support the BIS-model assumption that fluid in the peritoneal cavity is not detectable, suggesting that ascites (or peritoneal dialysis fluid) mass should be subtracted from adipose tissue if BIS is used in patients with a full peritoneal cavity.

Noninvasive estimation of intravascular volume status in cirrhosis by dynamic size and collapsibility indices of the inferior vena cava using bedside echocardiography

Background and Aim

Echocardiographic assessment of the inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) is a noninvasive estimate of intravascular volume status (IVS) but requires validation for cirrhosis. We evaluated IVC dynamics in cirrhosis and correlated it with conventional tools such as central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and right atrial pressure (RAP).

Methods

A total of 673 consecutive cirrhotic patients were screened by echocardiography, and 125 patients underwent right heart catheterization with recording of hepatic venous pressure gradient (HVPG), RAP, pulmonary artery (PA) pressure, and PCWP. CVP data were available for 80 (64%) patients, and finally, 76 patients (84% male, 50% ethanol related, mean age 52.1 years, 57.8% with ascites) with complete data were enrolled.

Results

The mean CVP measured was 12.8 ± 4.8 mmHg, and IVCCI was 29.5 ± 10.9%. The IVCD ranged from 0.97 to 2.26 cm and from 0.76 to 1.84 cm during expiration and inspiration, respectively, with a mean of 1.8 ± 0.9 cm. The mean IVCD correlated with RAP (r = 0.633, P = 0.043) but not with HVPG (r = 0.344, P = 0.755), PCWP (r = 0.562, P = 0.072), or PA pressure (r = 0.563, P = 0.588). A negative linear correlation was observed between the CVP and the IVCCI (r = −0.827, P = 0.023) in all patients and substratified for those with (r = −0.748, P = 0.039) and without ascites (r = −0.761, P = 0.047). A positive correlation was observed between CVP and IVCD_max (r = 0.671, P = 0.037) and IVCD_min (r = 0.612, P = 0.040).

Conclusions

IVCD and collapsibility index provides noninvasive IVS assessment, independent of HVPG or ascites, with the potential for calculating fluid requirements in cirrhosis.

Extracellular Fluid Excess Is Significantly Associated With Coronary Artery Calcification in Patients With Chronic Kidney Disease

BACKGROUND

Extracellular fluid (ECF) excess is an independent predictor of cardiovascular morbidity in patients undergoing dialysis. This study aimed to investigate the relationship between ECF status, which is affected by renal function, and coronary artery calcification (CAC), which is a marker of cardiovascular disease, in patients with chronic kidney disease (CKD).

METHODS AND RESULTS

A total of 1741 patients at all stages of pre-dialysis CKD from the prospective observational cohort of CMERC-HI (Cardiovascular and Metabolic Disease Etiology Research Center-High Risk) were analyzed for the association between ECF status and CAC. ECF status was defined as extracellular water-to-total body water ratio (ECW/TBW) measured using bioelectrical impedance analysis. ECF excess was defined as ECW/TBW ≥0.390 or ≥0.400 depending on its severity. To define CAC, Agatston coronary artery calcium scores were measured. A total coronary artery calcium score of ≥400 was defined as CAC. The CKD stages were defined according to estimated glomerular filtration rate calculated using the CKD Epidemiology Collaboration equation. ECW/TBW and the proportion of ECF excess increased with progressing CKD stages. Multivariable logistic regression analyses showed that ECW/TBW was independently associated with CAC (per 0.01 increase of ECW/TBW, odds ratio 1.168, 95% confidence interval, 1.079-1.264, P<0.001). The adjusted R2 for predicting higher coronary artery calcium scores and CAC significantly improved after ECW/TBW was added to conventional factors. This association was further confirmed by net reclassification and integrated discriminant improvements, sensitivity analysis, and subgroup analysis.

CONCLUSIONS

ECF status is independently associated with a high risk of CAC in patients with CKD.

STUDY REGISTRATION

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02003781.

Hemodynamic Evaluation of Nonselective β-Blockers in Patients with Cirrhosis and Refractory Ascites

BACKGROUND

Nonselective β-blockers (NSBB) have been associated with increased incidence of paracentesis-induced circulatory dysfunction (PICD) and reduced survival in patients with cirrhosis and refractory ascites.

AIM

To prospectively evaluate a hemodynamic response to NSBB in cirrhotics listed for liver transplantation with refractory ascites undergoing large volume paracentesis (LVP).

METHODS

Patients with cirrhosis and refractory ascites, with an indication to start NSBB in primary prophylaxis for variceal bleeding, were enrolled. During two consecutive LVP, while being, respectively, off and on NSBB, cardiac output (CO), systemic vascular resistances (SVR), peripheral vascular resistances (PVR), and plasma renin activity (PRA) were noninvasively assessed.

RESULTS

Seventeen patients were enrolled, and 10 completed the study. Before NSBB introduction, SVR (1896 to 1348 dyn·s·cm-5; p = 0.028) and PVR (47 to 30 mmHg·min·dl·ml-1; p = 0.04) significantly decreased after LVP, while CO showed an increasing trend (3.9 to 4.5 l/m; p = 0.06). After NSBB introduction, LVP was not associated with a significant increase in CO (3.4 to 3.8 l/m; p = 0.13) nor with a significant decrease in SVR (2002 versus 1798 dyn·s·cm-5; p = 0.1). Incidence of PICD was not increased after NSBB introduction.

CONCLUSION

The negative inotropic effect of NSBB was counterbalanced by a smaller decrease of vascular resistances after LVP, probably due to splanchnic β2-blockade. This pilot study showed that NSBB introduction may be void of detrimental hemodynamic effects after LVP in cirrhotics with refractory ascites.

Fluid balance concepts in medicine: Principles and practice

The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water (TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment (mainly sodium salts) and in the intracellular compartment (mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume (EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.

The prevalence of muscle wasting (sarcopenia) in peritoneal dialysis patients varies with ethnicity due to differences in muscle mass measured by bioimpedance

BACKGROUND/OBJECTIVES

Sarcopenia is associated with increased mortality. European and North American recommended screening for low muscle mass uses gender specific cut points, with no adjustment for ethnicity. We wished to determine whether the prevalence of sarcopenia was altered by ethnicity in peritoneal dialysis (PD) patients.

SUBJECTS/METHODS

We measured appendicular lean mass indexed to height (ALMI) in PD patients by segmental bioimpedance and determined sarcopenia using different cut off points for reduced muscle mass.

RESULTS

We measured ALMI in 434 PD patients, 55.1% males, mean age 55.3 ± 16.2 years, 32.3% diabetic, 54.1% white, 23.7% Asian, 19.1% black. ALMI was lower in Asian women, compared to white and black women (6.4 ± 1.1 vs. 6.6 ± 1.0 and 6.9 ± 1.4 kg/m²), and lower in Asian men (7.5 ± 1.3 vs. 8.5 ± 1.2 and 8.7 ± 1.3 kg/m²), p < 0.001. Depending on the ALM/ALMI cut point; the prevalence of sarcopenia was greater in Asian patients (25.6-41.2% using North American or European cut points) compared to white (12.3-18.7%) and black patients (3.8-15.7%), p < 0.001, but <11% when using Asian-specific cut points. The prevalence of sarcopenia obesity (BMI ≥ 30 kg/m²) was <3%, for all groups. There was no association with duration of PD, dialysis prescription, residual renal function or small solute clearances.

CONCLUSIONS

There is no universally agreed consensus definition for loss of muscle mass (sarcopenia) and current European and North American recommended cut points for screening are adjusted only for gender. As body composition differs also with age and ethnicity, then ideally cut points should be based on age, gender and ethnicity normative values.

Acute kidney injury in acute-on-chronic liver failure: where does hepatorenal syndrome fit?

Renal dysfunction occurs in 25% to 50% of patients with cirrhosis admitted to the hospital with an acute episode of hepatic decompensation and may be due to underlying chronic kidney disease, an acute deterioration, or both. An acute deterioration in renal function in cirrhotic patients is now collectively referred to as acute kidney injury (AKI), which has been subclassified into different grades of severity that identify prognostic groups. Acute-on-chronic liver failure is characterized by acute hepatic and/or extrahepatic organ failure driven by a dysregulated immune response and systemic inflammatory response. AKI is also one of the defining features of ACLF and a major component in grading the severity of acute-on-chronic liver failure. As such, the pattern of AKI now observed in patients admitted to the hospital with acutely decompensated liver disease is likely to be one of inflammatory kidney injury including acute tubular injury (referred in this review as non-hepatorenal syndrome [HRS]-AKI) rather than HRS. As the management and supportive treatment of non-HRS-AKI potentially differ from those of HRS, then from the nephrology perspective, it is important to distinguish between non-HRS-AKI and HRS-AKI when reviewing patients with acute-on-chronic liver failure and AKI, so that appropriate and early management can be instituted.

A Comprehensive Review of Bioelectrical Impedance Analysis and Other Methods in the Assessment of Nutritional Status in Patients with Liver Cirrhosis

It is assumed that approximately 24-66% of patients with liver cirrhosis develop malnutrition. Numerous pathological processes lead to serious disorders of nutritional status in this group of patients. Malnutrition in the course of liver cirrhosis is associated with increased morbidity, complications, and low quality of life. Under these conditions, detection of malnutrition is of crucial importance. This review explores the complex mechanisms that lead to malnutrition in the course of liver cirrhosis and focuses on methods used in the assessment of nutritional status in cirrhotic patients. Among others, the role of bioelectrical impedance is highlighted. This noninvasive tool is promising and quite an accurate method of estimating body composition.

Effects of nucleos(t)ide analogs on body composition in HBV-infected men: An age- and BMI-matched, cross-sectional study

OBJECTIVE

Chronic hepatitis B (CHB) requires long-term treatment with nucleos(t)ide analogs (NAs). The goal of the present study was to evaluate the effects of long-term treatment with NAs on body composition in men with CHB.

METHOD

We performed a cross-sectional study of men infected with hepatitis B virus (HBV) who have never been on NAs with high HBV-DNA (naïve group; n = 30), those on NAs for 7 y with virologic suppression (NA-treated group; n = 50), and healthy men (control group; n = 30) matched by age and body mass index (BMI) to evaluate whether body composition differed. Body composition was assessed by multiple-frequency bioelectrical impedance analysis. All patients and healthy controls underwent anthropometric measures, dietary intake, and physical activity level survey.

RESULTS

Body fat mass (BFM) and visceral fat area (VFA) were significantly lower in HBV-infected men naïve to NAs than in controls (P < 0.05). With virology suppression after treatment with NAs, BFM, VFA, and waist-to-hip ratio (WHR) were significantly increased in the NA-treated group compared with the naïve group (P < 0.05). Although there were no significant differences in BFM, VFA, and WHR between NA-treated men and controls (P > 0.05), WHR in the NA-treated group was 0.94 ± 0.06, indicating central obesity. Liver function, liver stiffness measurement, dietary intake, and physical activity level were the same between NA-treated and naïve men with CHB.

CONCLUSIONS

BFM and VFA is elevated in CHB men on NAs with virologic suppression compared with age and BMI-matched NA-naïve CHB men, which suggests that NAs may increase BFM and VFA of CHB men by virologic suppression. Further study is needed to clarify the adverse effects related to metabolic complications of lipid metabolism due to NA therapy.

Human albumin solution for patients with cirrhosis and acute on chronic liver failure: Beyond simple volume expansion

To provide an overview of the properties of human serum albumin (HSA), and to review the evidence for the use of human albumin solution (HAS) in critical illness, sepsis and cirrhosis. A MEDLINE search was performed using the terms “human albumin”, “critical illness”, “sepsis” and “cirrhosis”. The references of retrieved articles were reviewed manually. Studies published between 1980 and 2014 were selected based on quality criteria. Data extraction was performed by all authors. HSA is the main plasma protein contributing greatly to its oncotic pressure. HSA demonstrates important binding properties for endogenous and exogenous toxins, drugs and drug metabolites that account for its anti-oxidant and anti-inflammatory properties. In disease states, hypoalbuminaemia is secondary to decreased HSA production, increased loss or transcapillary leakage into the interstitial space. HSA function can be also altered in disease with reduced albumin binding capacity and increased production of modified isoforms. HAS has been used as volume expander in critical illness, but received criticism due to cost and concerns regarding safety. More recent studies confirmed the safety of HAS, but failed to show any survival benefit compared to the cheaper crystalloid fluids, therefore limiting its use. On the contrary, in cirrhosis there is robust data to support the efficacy of HAS for the prevention of circulatory dysfunction post-large volume paracentesis and in the context of spontaneous bacterial peritonitis, and for the treatment of hepato-renal syndrome and hypervolaemic hyponatraemia. It is likely that not only the oncotic properties of HAS are beneficial in cirrhosis, but also its functional properties, as HAS replaces the dysfunctional HSA. The role of HAS as the resuscitation fluid of choice in critically ill patients with cirrhosis, beyond the established indications for HAS use, should be addressed in future studies.

Safety and efficacy of long-term tolvaptan therapy for decompensated liver cirrhosis

AIM

Recently, the short-term efficacy of the vasopressin V2 receptor antagonist tolvaptan for the treatment of ascites in cirrhosis was reported. However, the long-term effects remain unknown. Here, we report the clinical features of decompensated cirrhosis treated using long-term tolvaptan therapy, and evaluate its safety and efficacy.

METHODS

Fifty-five cirrhotic patients hospitalized due to ascites, despite receiving appropriate diuretic treatment, were treated with tolvaptan. We excluded 35 patients due to liver transplant (20.0%), death (28.6%), poor general status (14.3%), improved ascites (5.7%) or other reasons (31.4%). In 20 cases treated with tolvaptan for 6 months, total body water (TBW) and extracellular fluids (ECW) were measured using bioelectric impedance analysis (BIA) with an InBody720.

RESULTS

The median age of the 20 patients was 64 years (range, 48-90), and 60% were male. The etiology of cirrhosis included hepatitis C (45%), alcohol-induced (20%) and other (35%). The percentage of patients with Child-Pugh class A, B and C was 0%, 40% and 60%, respectively. Biochemical findings revealed that serum creatinine levels and estimated glomerular filtration rate were not affected during 6 months of treatment with tolvaptan, and there was no renal disturbance. The median serum sodium levels were increased from 138 to 139 mEq/L, but serious adverse events related to renal and liver function were not observed. Data also revealed that long-term treatment reduced the BIA-estimated ECW/TBW ratio.

CONCLUSION

Long-term tolvaptan treatment was a safe and effective treatment for decompensated cirrhosis.

The importance of overhydration in determining peritoneal dialysis technique failure and patient survival in anuric patients

PURPOSE

Loss of residual renal function (RRF) is associated with an increased risk for peritoneal dialysis (PD) technique failure and patient death. We wished to determine which factors were associated with PD technique failure and patient mortality once urine output had fallen to &lt;100 mL/day.

METHODS

We followed 183 PD patients who lost RRF and who had measurements taken at that time of PD small solute clearances, ultrafiltration volume, PD transport status and multiple frequency bioelectrical impedance assessments (MFBIA) of extracellular water (ECW).

RESULTS

RESULTS

119 (65%) patients had PD technique failure or died during a median follow-up of 20.8 (10.5-36) months. This group had more men (58.8% vs. 31.9%, p = 0.011), and were older 57.9 ± 14.7 vs. 49.3 years (p = 0.002). These patients had a higher median C-reactive protein 5.5 [4.8-8.2] vs (5.0 [2-6] p = 0.013), and greater comorbidity (Davies grade 1 [0-1] vs. 0[0-1], p&lt;0.001, and a higher ratio of ECW/TBW (0.45 ± 0.07 vs 0.42 ± 0.04, p&lt;0.001). There were no differences in icodextrin usage, small solute clearance or ultrafiltration volumes. On multivariate Cox regression, ECW excess was significantly associated with PD technique failure and patient survival (β 1.09, p&lt;0.001 and β1.17, p = 0.005), respectively.

CONCLUSIONS

Loss of urine output requires PD to provide both adequate solute clearances and volume control. We found that PD technique failure and patient death were associated with ECW excess. Prospective interventional studies are required to determine whether correction of volume status improves PD patient outcomes.

Does the presence of an arteriovenous fistula alter changes in body water following hemodialysis as determined by multifrequency bioelectrical impedance assessment?

Multifrequency bioelectrical impedance assessments (MFBIAs) aid clinical assessment of hydration status for hemodialysis (HD) patients. Many MFBIA devices are restricted to whole body measurements and as many patients dialyze using arteriovenous fistulas (AVFs), we wished to determine whether AVFs affected body water measurements. We reviewed pre- and post-HD segmental MFBIA measurements in 229 patients attending for midweek HD sessions. Up to 144 were dialyzed with a left arm AVF (L-AVF), 42 with a right arm AVF (R-AVF), and 43 by central venous access catheter (CVC). Water content and lean tissue were greater in the left compared to right arm in those patients with L-AVFs both pre and post dialysis (pre 2.1 ± 0.7 vs. 2.0 ± 0.7 L, and post 1.9 ± 0.6 vs. 1.8 ± 0.6 L and pre 2.65 ± 0.9 vs. 2.56 ± 0.8 kg, and post 2.34 ± 0.8 vs. 2.48 ± 0.8 vs. 2.34 ± 0.8 kg, respectively) and were also greater in the right compared to left arm for those patients dialyzing with R-AVFs (pre-HD 1.92 ± 0.5 vs. 1.86 ± 0.6 L and post-HD 1.79 ± 0.5 vs. 1.7 ± 0.5 L, and pre-HD 2.47 ± 0.6 vs. 2.38 ± 0.7 kg and post-HD 2.3 ± 0.74 vs. 1.28 ± 0.7 kg, respectively), all Ps < 0.05. There were no significant differences in arm volumes or composition pre or post dialysis in those dialyzing with CVCs. Segmental MFBIA detects differences in arm water and lean mass in patients with AVFs. The presence on an AVF increases the water content in the ipsilateral arm both pre and post HD. This increased water content of the fistula arm will not be detected by whole body bioimpedance devices.

Difficulties in diagnosing acute kidney injury post liver transplantation using serum creatinine based diagnostic criteria

Renal function in patients with advanced cirrhosis is an important prognostic factor for survival both prior to and following liver transplantation. The importance of renal function is reflected by the introduction of the model for end stage liver disease (MELD) score, which includes serum creatinine. The MELD score has been shown to predict the short term risk of death for transplant wait listed patients and is currently used by many countries to allocate liver transplants on the basis of severity of underlying illness. Changes in serum creatinine are also used to stage acute kidney injury. However prior to liver transplantation the serum creatinine typically over estimates underlying renal function, particularly when a colorimetric Jaffe based assay is used, and paradoxically then under estimates renal function post liver transplantation, particularly when immunophyllins are started early as part of transplant immunosuppression. As acute kidney injury is defined by changes in serum creatinine, this potentially leads to over estimation of the incidence and severity of acute kidney injury in the immediate post-operative period.