Association of low serum 25-Hydroxy vitamin D [25(OH) d] with hepatic encephalopathy in patients with decompensated liver cirrhosis

BACKGROUND AND STUDY AIMS

The mechanism of hepatic encephalopathy is complex and has not been conclusively established. Recent studies support lower serum 25-Hydroxy Vitamin D [25(OH) D] levels in patients with hepatic encephalopathy. This study aimed to evaluate the association between serum 25(OH) D and hepatic encephalopathy in patients with decompensated cirrhosis of liver.

PATIENTS AND METHODS

A total of 70 cirrhosis patients (35 cases of hepatic encephalopathy and 35 patients without encephalopathy as control, mean age 53.07 ± 12.99 years, 67 % male) were recruited for this study. Assessment of the severity of cirrhosis was done by using a model for end-stage liver disease(MELD) and Child Turcotte Pugh (CTP) scores, and assessment of the severity of hepatic encephalopathy was done according to West Haven criteria. Serum 25 (OH) D level was measured by Chemiluminescent Microparticle Immuno Assay(CMIA).

RESULTS

The mean serum 25(OH) D level among hepatic encephalopathy patients was significantly lower in comparison to the control group without encephalopathy (18.76 ± 8.84 nmol/L vs 31.19 ± 13.9 nmol/L, P<0.0001). 91.4 % of hepatic encephalopathy patients had moderate to severe 25(OH)D deficiency as compared to 51.4 % in the control group. There was a significant correlation observed between the severity of the 25 (OH) D deficiency and the severity of liver disease (r =  - 0.35, P = 0.002). No statistically significant difference in serum 25(OH) D levels was found among patients with different hepatic encephalopathy grades (P = 0.416).

CONCLUSION

A significant association was found between a low serum 25(OH) D leveland hepatic encephalopathy. It requires further large-scale multicenter studies to establish it as a risk factor and predictor of hepatic encephalopathy.

IL-6 and IL-10 gene polymorphisms and cirrhosis of liver risk from a comprehensive analysis

BACKGROUND

Different inflammatory and immune cytokines play a key role in the development of cirrhosis of liver (CL). To investigate the association between interleukin-6,10 (IL-6,10) genes polymorphisms and CL risk through comparison of the allele and genotype distribution frequencies by meta-analysis.

METHODS

A literature search covered with the PubMed, Embase, Cochrane Library, Web of Science, Google Scholar, SinoMed (CNKI and Wanfang) through 20th April, 2021. Odds ratios (OR) and 95% confidence intervals (CI) were used to assess the strength of associations.

RESULTS

After a comprehensive search, three common polymorphisms (rs1800872, rs1800871, rs1800896) in IL-10 gene were selected, and three common polymorphisms (rs1800795, rs1800796, rs1800797) in IL-6 gene were also identified. The important finding was that IL-10 rs1800872 was a risk factor for CL development. For example, there has a significantly increased relationship between rs1800872 polymorphism and CL both in the whole group (OR: 1.30, 95%CI: 1.01-1.67 in heterozygote model), Asian population (OR: 1.40, 95%CI: 1.03-1.88 in heterozygote model) and hospital-based source of control (OR: 1.40, 95%CI: 1.01-1.96 in dominant model). In addition, significant association was found between rs1800896 and primary biliary cirrhosis subtype disease (OR: 1.30, 95%CI: 1.01-1.68 in allelic contrast model). No association was observed in all three polymorphisms in IL-6 gene.

CONCLUSION

Our present study suggests that the IL-10 rs1800872 and rs1800896 polymorphisms is potentially associated with the risk of CL susceptibility.

Comparison of clinical and metabolic profiles of lean versus non-lean nonalcoholic fatty liver disease

BACKGROUND

Data on nonalcoholic fatty liver disease (NAFLD) in the Philippines are scarce. We aimed to compare the clinical and biochemical profiles of lean (BMI<23) vs. non-lean (BMI≥23) NAFLD patients.

METHODS

Consecutive patients diagnosed with NAFLD on ultrasound in two outpatient hepatology clinics from February 2007-January 2017 were included. Patients with significant alcohol intake, alternative causes of steatosis, and incomplete data were excluded.

RESULTS

A total of 663 patients (57.9% male) were included. Most patients were non-lean (88.1%) and had an elevated alanine aminotransferase (ALT) (63%). Cirrhosis or hepatocellular carcinoma (HCC) were already present in 8.4% on initial consultation. Concomitant hepatitis B was equally common in patients with and without cirrhosis (20.7% vs. 17.5%; p=0.660) or HCC (17.9% vs. 12.8%; p=0.415). Independent factors associated with HCC/cirrhosis on initial consultation were older age (OR=1.038), low albumin (OR=0.428), high BARD score (BMI, AST/ALT ratio, T2 diabetes mellitus; OR=2.548) and the presence of symptoms (OR=1.808). Compared to lean NAFLD patients, non-lean patients were more likely to be younger (51.5±14.4 vs. 55±14.3; p=0.003), have DM (47.9% vs. 29.1%; p=0.002), hypertension (57.5% vs. 38%; p=0.001), dyslipidemia (73.1% vs. 54.4%; p=0.001) and metabolic syndrome (60.3% vs. 30.4%; p<0.0001), abnormal metabolic parameters (LDL-C, HDL-C, triglycerides, uric acid and FBS), and with elevated ALT (65.2% vs. 46.8%; p=0.002) and AST (41.1±29.6 vs. 35.3±28.3; p=0.008).

CONCLUSIONS

The proportion of lean NAFLD was 11.9%. Although metabolic derangements and its clinical consequences were present in about a third of lean patients, these were still more common in non-lean NAFLD. Cirrhosis or HCC were already present in a significant proportion (8.4%) of NAFLD patients on initial presentation.

Factors Predicting Cardiac Dysfunction in Patients with Liver Cirrhosis

BACKGROUND Left ventricular diastolic dysfunction (LVDD) is the earliest cardiac dysfunction noted in patients with liver cirrhosis, which increases the morbidity and mortality in such patients. There are sparse studies from India evaluating the predictive factors of LVDD in patients with cirrhosis. Hence we undertook this prospective study with an aim to evaluate the factors predicting the development of LVDD in liver cirrhosis. METHODS 104 patients with cirrhosis were enrolled in this prospective study. A detailed cardiac evaluation was done by 2 D echocardiography with tissue Doppler imaging by an experienced senior cardiologist. The severity of liver disease was defined by Model For End-Stage Liver Disease (MELD) and Child-Pugh score. RESULTS The prevalence of LVDD was 46% in our study. Multivariate logistic regression analysis revealed that serum albumin, MELD score, and presence of ascites (OR = 0.1, 95%CI 0.03-0.3, p < 0.001; Or = 1.12, 95%CI 1.03-1.22, p < 0.001; OR = 4.19, 95%CI 1.38-12.65, p < 0.01, respectively) were independent predictors of LVDD in patients with cirrhosis. Diastolic dysfunction was unrelated to age, sex, and etiology of cirrhosis. The patients with cirrhosis and LVDD had significantly higher child Pugh score, MELD score, and lower serum albumin than patients without LVDD. The echocardiographic parameters like E/e' ratio, Deceleration time (DT), and Left atrial volume index (LAVI) were significantly different in cirrhotic patients with higher MELD and child Pugh score than lower. CONCLUSION The present study showed a significant correlation of diastolic dysfunction with the severity of the liver disease. Low serum albumin, high MELD score, and presence of ascites significantly predict the development of LVDD in patients with cirrhosis.

A Study on the Temporal Trends in the Etiology of Cirrhosis of Liver in Coastal Eastern Odisha

Background

The etiology of cirrhosis of liver is known to change with time due to various factors including awareness, preventive interventions, and lifestyle changes in society. However, there is scarce Indian data available about temporal trends in etiology of cirrhosis of liver. Hence, the aim of this study was to study the temporal trends in the etiology of cirrhosis of liver.

Materials and methods

This is a retrospective study conducted in the Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, from January 2005 to December 2017. Data were collected from hospital records of all patients admitted to the Gastroenterology unit. A Poisson regression model was used to compare the hospitalization rate for different etiologies of cirrhosis of liver. All data were analyzed using Stata version 5.1 software.

Results

A total of 4,331 hospitalized patients of cirrhosis of liver were included in the analysis, of whom 2,742 (63.3%) had alcohol-related cirrhosis, 858 (19.8%) had viral hepatitis-related cirrhosis, and 731 (16.9%) had cirrhosis of liver due to nonalcohol and nonviral causes. The proportion of alcohol-related cirrhosis was increased by 26% from 2005 to 2017 (RR 1.26, p for trend <0.001). Though there were minimal ups and downs observed in the admission rate of viral hepatitis-related liver cirrhosis during later years, this was remarkably reduced by 73% (RR 0.27, p for trend <0.001) in the year 2017 at the end of the study. Similarly, the proportion of cirrhosis due to nonalcohol and nonviral causes decreased by 26% (RR 0.74, p for trend <0.001) by 2017.

Conclusion

Alcohol is the most common cause of cirrhosis of liver and the burden of alcohol-related cirrhosis is significantly increasing in comparison to other causes including viral infection, nonalcoholic steatohepatitis (NASH), and autoimmune hepatitis.

How to cite this article

Mishra D, Dash KR, Khatua C, et al. A Study on the Temporal Trends in the Etiology of Cirrhosis of Liver in Coastal Eastern Odisha. Euroasian J Hepato-Gastroenterol 2020;10(1):1–6.

Acute kidney injury in patients with cirrhosis of liver: Clinical profile and predictors of outcome

BACKGROUND

Acute kidney injury (AKI) is a common complication of liver cirrhosis and is associated with poor survival. We studied the clinical profile and predictors of in-hospital mortality in patients with cirrhosis of the liver with AKI.

METHODS

This retrospective cohort study examined patients at a tertiary care hospital. AKI staging was done based on the new 2015 Ascites Club Criteria. Patients were grouped into three types of AKI: pre-renal azotemia (PRA), hepatorenal syndrome (HRS), and acute tubular necrosis (ATN).

RESULTS

Data of 123 patients with cirrhosis and AKI were analyzed. Most patients had AKI stage 3 (57.7%). ATN (42.3%) and HRS (43.9) were the predominant types of AKI followed by PRA (13.8%). The overall in-hospital mortality in our study was 44.7%. The mortality increased with increasing severity of AKI (p = 0.0001) and was the highest in AKI stage 3 (p = 0.001) and those who required hemodialysis (p = 0.001). There was a significant in-hospital mortality in patients with ATN and HRS in comparison to PRA (p = 0.001). On multivariate analysis, the factors predicting in-hospital mortality were AKI stage 3, and oliguria (p = 0.0001).

CONCLUSIONS

Acute kidney injury in cirrhosis of liver carries high in-hospital mortality. Pre-renal AKI has a better survival compared to ATN and HRS. The higher stage of AKI at presentation and the presence of oliguria are two important predictors of in-hospital mortality.

Sofosbuvir based therapy in hepatitis C patients with and without cirrhosis: Is there difference?

Objective:

To compare sustained viral response to sofosbuvir/ribavirin ±interferon therapy in patients of hepatitis C with and without liver cirrhosis.

Methods:

This observational study of chronic hepatitis C patients was carried out at Doctors Hospital and Medical Center (DH&MC). After diagnostic workup, Sofosbuvir/ribavirin for 24 weeks or sofosbuvir/ribavirin/pegylated interferon for 12 weeks were prescribed. Primary outcome was negative HCV RNA by PCR 12 weeks after treatment completion (SVR₁₂). Chi square χ² and student’s t test were used to analyze data.

Results:

Of 216 patients included, liver cirrhosis was present in 112 (51.9%) patients and 69(31.9%) were treatment experienced. Liver disease was decompensated in 37 (17.1%) patients. Of 206 patient who completed study protocol, 173(83.1%) achieved SVR₁₂, 89.2% (25/28) with triple therapy and 82.2% (148/180) with sofosbuvir/ribavirin therapy. Treatment response was similar between treatment naïve 86.2% (119/138) and treatment experienced 79.4% (54/68) patents. (p value 0.19) SVR₁₂ was inferior in cirrhosis patients 75.4% (80/106) as compared to those with no cirrhosis 93% (93/100) (p value < 0.000). It was even lesser in those with decompensated liver disease 68.8% (24/35) (p value < 0.000).

Conclusion:

Treatment outcome with sofosbuvir/ribavirin combination therapy in cirrhosis patients is suboptimal especially in those with decompensation as compared to patients without liver cirrhosis.

Acute on Chronic Liver Failure-What is in a 'Definition'?

Acute on chronic liver failure (ACLF) is a recently recognized syndrome and its definition has been evolving over last two decades. Currently, there is no universal consensus about the definition as kind of cases being seen in the Western world appear to be somewhat different from those that are seen in Asia Pacific region. But every one agrees that definition of ACLF should include following components. (a) The status of pre-existing liver disease, (b) defining the acute insult that leads to rapid deterioration of liver status, (c) time frame during which the acute insult can lead to rapid deterioration, (d) the quantification and definition of liver failure status after deterioration, which will determine the severity of ACLF, and (e) prediction of prognosis after analyzing first four components in the short and long terms. There is some consensus that number of organ failures may be the main determinant of prognosis. Whatever the definition is being used, the central role that superadded infections play in ACLF cannot be denied and need to be tackled aggressively. Apart from that, recovery may be possible if the acute insult or the baseline disease is curable, i.e. with the use of nucleoside analogs for hepatitis B, and corticosteroids for severe autoimmune hepatitis. Development of dynamic criteria with observations in Hospital may improve our understanding of prognosis as well as our approach to the management of ACLF.

Simple biochemical parameters and a novel score correlate with absence of fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND/AIMS

Liver biopsy is the gold standard for detecting fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). Due to limitations of biopsy, various combinations of serum markers have been studied to predict liver fibrosis; many of these are patented and expensive, thereby restricting their evaluation. We prospectively evaluated the correlation of commonly used serum markers with fibrosis in Indian patients with NAFLD.

METHODS

Fifty-one patients (age 50.4 [SD 11.5] years) with biopsy-proven NAFLD underwent estimation of platelet count, total bilirubin, AST, ALT, serum albumin, γ-glutamyl transpeptidase (GGT), prothrombin time, serum cholesterol, triglycerides, α2-macroglobulin (A2M), apolipoprotein A1 (Apo A1), and haptoglobin. FIB-4, AST/platelet ratio index (APRI), and AST/ALT ratio were calculated and correlated with fibrosis (NAS-II score) on liver biopsy.

RESULTS

Thirty-eight (74.5 %) patients had inflammation and 48 (94.1 %) had ballooning degeneration on histology; 29 had fibrosis, of whom 11 had ≥F2 fibrosis. High GGT (odds ratio [OR] 8.4 [1.85-38.10]; p = 0.007, area under the curve [AUROC] 0.65), low platelet count (OR 7.57 [1.83-31.45]; p = 0.001, AUROC 0.833), and low Apo A1 (OR 12.04 [2.98-47.3]; p = 0.0002, AUROC 0.76) were associated with advanced fibrosis on multiple logistic regression; a novel score formulated by assigning 1 point for an abnormal value for each of these parameters correlated with absence of fibrosis (p = 0.0001; OR 0.102 [95 % confidence interval (CI) CI 0.025-0.418]), with negative predictive value of 94.29 % [95 % CI 80.81 to 99.13].

CONCLUSIONS

A score using simple markers including GGT, Apo A1, and platelet count correlated with absence of liver fibrosis in patients with NAFLD.

Cirrhosis with infective endocarditis: Report of two cases

Epidemiological studies have shown that the incidence of infective endocarditis (IE) has dropped, but it is not clinically rare. If not treated timely, the patients will suffer from a high risk of mortality. Early prevention, timely diagnosis, rational use of antimicrobial drugs and proper operation timing are important for decreasing the fatality rate. Cirrhotic patients are prone to low immunity and intestinal bacterial translocation. When unexplained fever, septicemia, new heart murmurs or the changes of primary heart murmurs are noted clinically, the physicians should pay attention to IE, and blood culture and cardiac ultrasound are needed to establish a diagnosis.

Effect of reducing portal pressure on intestinal barrier function in patients with decompensated cirrhosis

AIM: To explore the effect of reducing portal pressure on intestinal barrier function in patients with decompensated cirrhosis.

METHODS: Eighty-six patients with decompensated viral liver cirrhosis or alcoholic cirrhosis were randomly divided into either an experiment group or a control group. The control group received conventional symptomatic and supportive treatment, and the experiment group was additionally given propranolol hydrochloride tablets. The width of the portal vein, alanine aminotransferase (ALT), aspartic transaminase (AST), total bilirubin (TBIL), serum albumin (ALB), plasma endotoxin level, D-lactic acid content and plasma diamine oxidase (DAO) were compared between the two groups.

RESULTS: The width of the portal vein in the experiment group posttreatment was significantly lower than that before treatment (1.37 cm ± 0.09 cm vs 1.41 cm ± 0.11 cm, P < 0.05) and that in the control group (1.37 cm ± 0.09 cm vs 1.39 cm ± 0.10 cm, P < 0.05). The levels of ALT, AST and TBIL in both groups posttreatment were significantly lower and the levels of ALB were significantly higher than those before treatment (35.15 U/L ± 11.92 U/L vs 42.76 U/L ± 18.06 U/L, 29.03 U/L ± 13.88 U/L vs 35.04 U/L ± 19.84 U/L, 19.57 μmol/L ± 10.59 μmol/L vs 25.65 μmol/L ± 15.09 μmol/L, 32.69 g/L ± 3.96 g/L vs 30.16 g/L ± 5.63 g/L, 34.03 U/L ± 11.46 U/L vs 42.91 U/L ± 17.67 U/L, 28.36 U/L ± 14.37 U/L vs 36.62 U/L ± 20.54 U/L, 18.94 μmol/L ± 9.56 μmol/L vs 24.92 μmol/L ± 16.60 μmol/L, 32.28 g/L ± 6.13 g/L vs 29.94 g/L ± 5.06 g/L, P < 0.05), although there were no significant differences in the levels of ALT, AST, TBIL and ALB between the two groups posttreatment (35.15 U/L ± 11.92 U/L vs 34.03 U/L ± 11.46 U/L, 29.03 U/L ± 13.88 U/L vs 28.36 ± 14.37 U/L, 19.57 μmol/L ± 10.59 μmol/L vs 18.94 μmol/L ± 9.56 μmol/L, 32.69 g/L ± 3.96 g/L vs 32.28 g/L ± 6.13 g/L, P > 0.05). Plasma endotoxin level, D-lactic acid content and DAO in the two groups posttreatment were significantly lower than those before treatment (0.53 EU/mL ± 0.12 EU/mL vs 0.72 EU/mL ± 0.11 EU/mL, 2.71 Ku/L ± 0.84 Ku/L vs 5.19 Ku/L ± 2.12 Ku/L, 7.85 mg/L ± 0.62 mg/L vs 12.95 mg/L ± 4.27 mg/L, 0.62 EU/mL ± 0.11 EU/mL vs 0.75 EU/mL ± 0.14 EU/mL, 3.83 Ku/L ± 1.70 Ku/L vs 5.34 Ku/L ± 2.08 Ku/L, 9.90 mg/L ± 6.70 mg/L vs 13.24 mg/L ± 4.42 mg/L, P < 0.05). Plasma endotoxin level, D-lactic acid content and DAO in the experiment group were significantly lower than those in the control group (0.53 EU/mL ± 0.12 EU/mL vs 0.62 EU/mL ± 0.11 EU/mL, 2.71 Ku/L ± 0.84 Ku/L vs 3.83 Ku/L ± 1.70 Ku/L, 7.85 mg/L ± 0.62 mg/L vs 9.90 mg/L ± 6.70 mg/L, P < 0.05).

CONCLUSION: Propranolol can not only improve liver function, reduce the width of the portal vein, decrease the levels of plasma endotoxin, D-lactic acid content and DAO, reduce portal hypertension, but also improve intestinal mucosal repair, reduce intestinal permeability, and improve intestinal barrier function.

Role of Helicobacter pylori and hyperammonemia in subclinical hepatic encephalopathy in cirrhosis of liver

In a prospective study of 47 patients of subclinical hepatic encephalopathy in cirrhosis of liver, aged between 23 and 60 years, 49% showed Helicobacter pylori positivity by rapid urease test. The baseline characters of patients (mean age, serum creatinine, sereum albumin, serum bilirubin, prothrombin time) were similar among patients with and without Helicobacter infection in all the patients. There was no statistically significant difference in blood ammonia levels in either group of patients. Blood ammonia values showed good correlation with the functional state of liver function but they did not show statistically significant difference between two groups of patients in any of Child Pugh classes. It is concluded that Helicobacter pylori does not contribute significantly to blood ammonia levels and the severity of hepatic encephalopathy.