REVIEW. Ariel W. Aday, M.D.,* Nicole E. Rich, M.D.,* Arjmand R. Mufti, M.D., and Shannan R. Tujios, M.D.
|
|
- Tyrone Hilary Lane
- 5 years ago
- Views:
Transcription
1 REVIEW CON ( The Window Is Closed ): In Patients With Cirrhosis With Ascites, the Clinical Risks of Nonselective beta-blocker Outweigh the Benefits and Should NOT Be Prescribed Ariel W. Aday, M.D.,* Nicole E. Rich, M.D.,* Arjmand R. Mufti, M.D., and Shannan R. Tujios, M.D. KEY POINTS Even though nonselective beta-blockers (NSBBs) have proven benefits in cirrhosis, some evidence suggests they may be harmful in a subset of patients with decompensated cirrhosis, in particular those with refractory ascites, baseline hypotension, or at high risk for infection. The decision to initiate a NSBB should be individualized; continuation of NSBB should be continually reassessed in decompensated patients with ascites. Consider decreasing or stopping the NSBB in patients with low mean arterial pressure (<80 mm Hg), hyponatremia, renal insufficiency, ongoing infection, or refractory ascites requiring frequent paracentesis. Nonselective beta-blockers (NSBBs) have proven benefits in patients with cirrhosis with portal hypertension, particularly for secondary prophylaxis of variceal hemorrhage. 1 However, growing evidence suggests NSBB may be harmful in a subset of patients with decompensated cirrhosis, particularly those Abbreviations: ADH, antidiuretic hormone; EABV, effective arterial blood volume; HRS, hepatorenal syndrome; HVPG, hepatic venous pressure gradient; LVP, large-volume paracenteses; MAP, mean arterial pressure; NSBB, nonselective beta-blocker; PICD, paracentesis-induced circulatory dysfunction; RAAS, renin-angiotensin-aldosterone system; RCT, randomized controlled trial; SBP, spontaneous bacterial peritonitis; SNS, sympathetic nervous system. From the Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX. *These authors contributed equally to this work. Potential conflict of interest: Nothing to report. Received 17 December 2017; accepted 2 February 2018 View this article online at wileyonlinelibrary.com VC 2018 by the American Association for the Study of Liver Diseases 123 CLINICAL LIVER DISEASE, VOL 11, NO 5, MAY 2018 An Official Learning Resource of AASLD
2 FIG 1 The various effects of beta-blockers in cirrhosis. 3 Studies suggest that beta-blockers may be effective only within a particular clinical window of advanced liver disease and, outside of this window, may be ineffective and potentially harmful in advanced decompensated disease. Abbreviations: RAAS, renin--angiotensin--aldosterone system; SNS, sympathetic nervous system. with refractory ascites, spontaneous bacterial peritonitis (SBP), or low mean arterial pressure (MAP). This has led to the proposal of the window hypothesis, suggesting a physiological window within which patients with cirrhosis benefit from NSBB and outside of which they may experience deleterious effects (Fig. 1). 2,3 This article will discuss key points for the clinician to consider prior to starting the aforementioned patient on a NSBB. NSBBs MAY INCREASE MORTALITY In an observational study of 151 patients with decompensated cirrhosis and refractory ascites, Serste andcolleagues 4 found that patients taking NSBBs had significantly higher mortality than patients not taking NSBBs (median survival 5 versus 20 months; p < ). In addition, on multivariate analysis, NSBBs were independently associated with a 2.6- fold increased risk for death. 4 The authors advocate that caution should be used when starting NSBBs in patients with refractory ascites, prompting significant debate and further studies. NSBBs MAY CAUSE HARM AND FURTHER HEMODYNAMIC COMPROMISE Systemic vasodilation, leading to low MAP and decreased effective arterial blood volume (EABV), is a hallmark of late decompensated cirrhosis (Fig. 2). 5 Prior data suggest that 124 CLINICAL LIVER DISEASE, VOL 11, NO 5, MAY 2018 An Official Learning Resource of AASLD
3 FIG 2 Mechanisms leading to circulatory and renal dysfunction in cirrhosis. 5 The main mechanism is a progressive splanchnic arterial vasodilatation caused by the overproduction of vasodilator molecules. During the initial phases of decompensated cirrhosis, when the activation of vasoconstrictor systems is moderate, patients experience sodium retention and ascites. In subsequent stages, activation of ADH leads to dilutional hyponatremia. Finally, in the most advanced phase, when circulatory dysfunction is extreme, the renal vasodilatory systems are overcome and patients experience severe renal vasoconstriction and type 2 HRS. Abbreviations: ADH, antidiuretic hormone; RAAS, renin-angiotensin-aldosterone system; SNS, sympathetic nervous system. Reproduced with permission from Annals of Hepatology. 6 Copyright 2011, Mexican Association of Hepatology, the Latin-American Association for the Study of the Liver and the Canadian Association for the Study of the Liver. patients with cirrhosis with ascites and mean MAP <80 mm Hg have worse 1-year survival compared with those with MAP >80 mm Hg (P < 0.05). 6 In addition, prior studies showing a higher mortality with NSBB also noted lower MAP in the NSBB group. 4,7 In the case presented earlier, the patient s baseline MAP is already low (70 mm Hg), and addingannsbbwouldonlyleadtofurtherdeclineinmap. Although it may be possible to use lower doses of NSBB in some patients with decompensated cirrhosis, it is unlikely to be tolerated in this case. In addition, a patient with refractory ascites requiring frequent large-volume paracenteses (LVP) is at increased risk for paracentesis-induced circulatory dysfunction (PICD), which can precipitate impaired renal perfusion and hepatorenal syndrome (HRS). NSBB may exacerbate this risk by reducing the patient s ability to mount a compensatory increase in cardiac output. This was demonstrated in a crossover study by Serste andcolleagues 8 in which they found 9/10 patients taking NSBBs experienced PICD following LVP. Once the NSBB was discontinued, only 1/10 experienced PICD. Crucially, to date, there are no randomized controlled trials (RCTs) that show a mortality benefit of NSBBs in patients with refractory ascites. Several studies have also shown an increased risk for renal injury in patients with decompensated cirrhosis who are taking NSBBs. Kalambokis et al. 9 found that NSBBs increased risk for HRS in patients with Child C cirrhosis (36% versus 0% in the non-nsbb group; P ). Similarly, in a cohort of patients on the liver transplant wait list, those with ascites who were taking NSBBs had a 3-fold increased risk (hazard ratio 3.31, 95% confidence interval ) of experiencing development 125 CLINICAL LIVER DISEASE, VOL 11, NO 5, MAY 2018 An Official Learning Resource of AASLD
4 TABLE 1. LIMITATIONS OF AVAILABLE DATA ON USE OF NSBBS Observational/retrospective cohorts; no RCT to date Populations include a small proportion of patients with refractory ascites Variation in type and dose of NSBB prescribed Highly selected populations (e.g. patients listed for liver transplantation) Short durations of follow-up Use of administrative datasets lacking granular data of acute kidney injury compared with those without ascites. 10 The aforementioned patient already shows evidence of renal dysfunction, and addition of a NSBB will decrease EABV and risk worsening renal function. Furthermore, patients with decompensated cirrhosis, especially those with refractory ascites, are at increased risk for infections including SBP. Mandorfer and colleagues 7 found exaggerated hemodynamic compromise and hypotension in patients with cirrhosis with SBP while taking NSBBs, as well as reduced transplant-free survival, increased duration of hospitalization, and increased rates of HRS and acute kidney injury. NSBBs HAVE UNCLEAR EFFICACY Although there is abundant evidence supporting the use of NSBBs as both primary and secondary prophylaxis for variceal hemorrhage, prior RCTs largely excluded patients such as the earlier case with Child C cirrhosis, refractory ascites, and renal failure. 1,11 A meta-analysis by D Amico and colleagues 12 found risk for variceal hemorrhage and death were both significantly lower in patients taking NSBBs who were hepatic venous pressure gradient (HVPG) responders (defined as decrease in HVPG to <12 mm Hg or >20% from baseline). However, measurement of HVPG is invasive, not all patients are hemodynamic responders to NSBB, and it remains unclear whether the same benefit would be seen in the late decompensated patient. Although combination endoscopic ligation and NSBB remain optimal therapy for variceal management, risk for bleeding is directly related to variceal size. 13 The risk for bleeding from small varices, such as in this patient who has undergone successful ligation protocol, is low and likely lower than the potential hemodynamic consequences of NSBBs in a patient with refractory ascites, decreased estimated glomerular filtration rate, and already low MAP at baseline. TABLE 2. SITUATIONS IN WHICH TO CONSIDER REDUCING NSBB DOSE OR DISCONTINUING NSBB THERAPY IN THE PATIENT WITH DECOMPENSATED CIRRHOSIS AND ASCITES Systolic blood pressure < 90 mm Hg or MAP < 80 mm Hg Renal insufficiency (acute kidney injury or HRS) Hyponatremia Refractory ascites requiring frequent LVP Concern for spontaneous bacterial peritonitis or other active infection EVIDENCE SUPPORTING USE OF NSBBs IN DECOMPENSATED CIRRHOSIS IS LACKING Although some data suggest a benefit of NSBBs in decompensated cirrhosis, none of these studies would have included the patient described in the earlier case. For instance, although Mookerjee and colleagues 14 suggested a beneficial effect of NSBBs in hospitalized patients with acute-on-chronic liver failure and high Model for End- Stage Liver Disease-Na scores, the mean MAP was significantly higher (78 mm Hg) than our patient s MAP of 70 mm Hg. Additional limitations of these studies, outlined in Table 1, include: (1) short duration of follow-up 15 ; (2) lack of granular data on underlying liver function 16 ; and (3) a low proportion of patients with refractory ascites (36% in Leithead et al. 15 and 17% in Bang et al. 16 ). In summary, although NSBBs have proven beneficial effects in cirrhosis, the available data suggest they may be harmful in a subset of patients with late decompensated cirrhosis, particularly those with refractory ascites. Given the lack of level I evidence, clinicians should carefully weigh the risks and benefits of starting an NSBB in each individual patient. In patients currently taking NSBB, it is important to periodically reassess the patient s underlying liver function and hemodynamic status to recognize when previously tolerated NSBBs should be discontinued to optimize survival (Table 2). CORRESPONDENCE Shannan R. Tujios, M.D., Division of Digestive and Liver Diseases, University of Texas Southwestern, 5959 Harry Hines Boulevard, POB 1, Suite 520, Dallas, TX shannan.tujios@utsouthwestern.edu REFERENCES 1) Albillos A, Zamora J, Martinez J, et al. Stratifying risk in the prevention of recurrent variceal hemorrhage: results of an individual patient meta-analysis. Hepatology 2017;66: CLINICAL LIVER DISEASE, VOL 11, NO 5, MAY 2018 An Official Learning Resource of AASLD
5 2) Krag A, Wiest R, Albillos A, et al. The window hypothesis: haemodynamic and non-haemodynamic effects of beta-blockers improve survival of patients with cirrhosis during a window in the disease. Gut 2012;61: ) Ge PS, Runyon BA. The changing role of beta-blocker therapy in patients with cirrhosis. J Hepatol 2014;60: ) Serste T, Melot C, Francoz C, et al. Deleterious effects of betablockers on survival in patients with cirrhosis and refractory ascites. Hepatology 2010;52: ) Arroyo V, Fernandez J. Pathophysiological basis of albumin use in cirrhosis. Ann Hepatol 2011;10(suppl 1):S6-S14. 6) Krag A, Bendtsen F, Henriksen JH, et al. Low cardiac output predicts development of hepatorenal syndrome and survival in patients with cirrhosis and ascites. Gut 2010;59: ) Mandorfer M, Bota S, Schwabl P, et al. Nonselective beta blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology 2014;146: e1. 8) Serste T, Francoz C, Durand F, et al. Beta-blockers cause paracentesisinduced circulatory dysfunction in patients with cirrhosis and refractory ascites: a cross-over study. J Hepatol 2011;55: ) Kalambokis GN, Baltayiannis G, Christou L, et al. Red signs and not severity of cirrhosis should determine non-selective b-blocker treatment in Child--Pugh C cirrhosis with small varices: increased risk of hepatorenal syndrome and death beyond 6 months of propranolol use. Gut 2016;65: ) Kim SG, Larson JJ, Lee JS, et al. Beneficial and harmful effects of nonselective beta blockade on acute kidney injury in liver transplant candidates. Liver Transpl 2017;23: ) Bernard B, Lebrec D, Mathurin P, et al. Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis. Hepatology 1997;25: ) D Amico G, Garcia-Pagan JC, Luca A, et al. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology 2006;131: ) Lebrec D, De Fleury P, Rueff B, et al. Portal hypertension, size of esophageal varices, and risk of gastrointestinal bleeding in alcoholic cirrhosis. Gastroenterology 1980;79: ) Mookerjee RP, Pavesi M, Thomsen KL, et al. Treatment with nonselective beta blockers is associated with reduced severity of systemic inflammation and improved survival of patients with acute-onchronic liver failure. J Hepatol 2016;64: ) Leithead JA, Rajoriya N, Tehami N, et al. Non-selective beta-blockers are associated with improved survival in patients with ascites listed for liver transplantation. Gut 2015;64: ) Bang UC, Benfield T, Hyldstrup L, et al. Effect of propranolol on survival in patients with decompensated cirrhosis: a nationwide study based Danish patient registers. Liver Int 2016;36: CLINICAL LIVER DISEASE, VOL 11, NO 5, MAY 2018 An Official Learning Resource of AASLD
Beta-blockers in cirrhosis: Cons
Beta-blockers in cirrhosis: Cons Eric Trépo MD, PhD Dept. of Gastroenterology. Hepatopancreatology and Digestive Oncology. C.U.B. Hôpital Erasme. Université Libre de Bruxelles. Bruxelles. Belgium Laboratory
More informationNONSELECTIVE BETA-BLOCKERS IN PATIENTS WITH CIRRHOSIS: THE THERAPEUTIC WINDOW
Rev. Med. Chir. Soc. Med. Nat., Iaşi 2016 vol. 120, no. 1 INTERNAL MEDICINE UPDATES NONSELECTIVE BETA-BLOCKERS IN PATIENTS WITH CIRRHOSIS: THE THERAPEUTIC WINDOW Mihaela Dimache 1,2*, Irina Gîrleanu 1,2,
More informationBETA-BLOCKERS IN CIRRHOSIS.PRO.
BETA-BLOCKERS IN CIRRHOSIS.PRO. Angela Puente Sánchez. MD PhD Hepatology Unit. Gastroenterology department Marques de Valdecilla University Hospital. Santander INTRODUCTION. Natural history of cirrhosis
More informationAre the benefits of beta blockers in cirrhotics only related to decreased portal hypertension?
Editorial Page 1 of 5 Are the benefits of beta blockers in cirrhotics only related to decreased portal hypertension? Felix Piecha 1, Sebastian Mueller 2 1 Department of Medicine, University Medical Center
More informationPrimary Prophylaxis against Variceal Hemorrhage Pharmacotherapy vs Endoscopic Band Ligation
Primary Prophylaxis against Variceal Hemorrhage Pharmacotherapy vs Endoscopic Band Ligation Siwaporn Chainuvati, MD Faculty of Medicine Siriraj Hospital Outline Natural history of esophageal varices Which
More informationManagement of Cirrhotic Complications Uncontrolled Ascites. Siwaporn Chainuvati, MD Siriraj Hospital Mahidol University
Management of Cirrhotic Complications Uncontrolled Ascites Siwaporn Chainuvati, MD Siriraj Hospital Mahidol University Topic Definition, pathogenesis Current therapeutic options Experimental treatments
More informationCarvedilol or Propranolol in the Management of Portal Hypertension?
Evidence Based Case Report Carvedilol or Propranolol in the Management of Portal Hypertension? Arranged by: dr. Saskia Aziza Nursyirwan RESIDENCY PROGRAM OF INTERNAL MEDICINE DEPARTMENT UNIVERSITY OF INDONESIA
More informationInitial approach to ascites
Ascites: Filling and Draining the Water Balloon Common Pathogenesis in Refractory Ascites, Hyponatremia, and Cirrhosis intrahepatic resistance sinusoidal portal hypertension Splanchnic vasodilation (effective
More informationAscites Management. Atif Zaman, MD MPH Oregon Health & Science University Professor of Medicine Division of Gastroenterology and Hepatology
Ascites Management Atif Zaman, MD MPH Oregon Health & Science University Professor of Medicine Division of Gastroenterology and Hepatology Disclosure 1. The speaker Atif Zaman, MD MPH have no relevant
More informationVariceal bleeding. Mainz,
Variceal bleeding Mainz, 21.09.2008 Risk of complications 5 years 10 years Ascites 10 % 25 % HCC 10 % 25 % Bleeding < 5 % 5-10 % Enceph. < 5 % < 5 % Typical situation : Mortality 10 % to 40 % Sequence
More informationEvidence-Base Management of Esophageal and Gastric Varices
Evidence-Base Management of Esophageal and Gastric Varices Rino Alvani Gani Hepatobiliary Division Department of Internal Medicine Faculty of Medicine Universitas Indonesia Cipto Mangunkusumo National
More informationJOURNAL PRESENTATION. Dr Tina Fan Tseung Kwan O Hospital 17 th Jan 2013
JOURNAL PRESENTATION Dr Tina Fan Tseung Kwan O Hospital 17 th Jan 2013 THE COMBINATION OF OCTREOTIDE AND MIDODRINE IS NOT SUPERIOR TO ALBUMIN IN PREVENTING RECURRENCE OF ASCITES AFTER LARGE-VOLUME PARACENTESIS
More informationEdinburgh Research Explorer
Edinburgh Research Explorer Carvedilol is associated with improved survival in patients with liver cirrhosis and ascites Citation for published version: Sinha, R, Lockman, KA, Mallawaarachchi, N, Robertson,
More informationProf. Mohammad Umar. MBBS, MCPS, FCPS, FACG (USA), FRCP (London), FRCP (Glasgow), FAGA
Prof. Mohammad Umar MBBS, MCPS, FCPS, FACG (USA), FRCP (London), FRCP (Glasgow), FAGA Chairman and Head Department of Medicine Rawalpindi Medical College, Rawalpindi. Consultant Gastroenterologist / Hepatologist
More informationManagement of Ascites and Hepatorenal Syndrome. Florence Wong University of Toronto. June 4, /16/ Gore & Associates: Consultancy
Management of Ascites and Hepatorenal Syndrome Florence Wong University of Toronto June 4, 2016 6/16/2016 1 Disclosures Gore & Associates: Consultancy Sequana Medical: Research Funding Mallinckrodt Pharmaceutical:
More informationPortal hypertension is the main complication of cirrhosis
GASTROENTEROLOGY 2001;120:726 748 Current Management of the Complications of Cirrhosis and Portal Hypertension: Variceal Hemorrhage, Ascites, and Spontaneous Bacterial Peritonitis GUADALUPE GARCIA TSAO
More informationThe Management of Ascites & Hepatorenal Syndrome. Florence Wong University of Toronto. Falk Symposium March 14, 2008
The Management of Ascites & Hepatorenal Syndrome Florence Wong University of Toronto Falk Symposium March 14, 2008 Management of Ascites Sodium Restriction Mandatory at all stages of ascites in order to
More informationDiagnostic Procedures. Measurement of Hepatic venous pressure in management of cirrhosis. Clinician s opinion
5 th AISF Post-Meeting Course Diagnostic and Therapeutic Invasive Procedures in Hepatology Rome, February 25 th Diagnostic Procedures Measurement of Hepatic venous pressure in management of cirrhosis Clinician
More informationHepatorenal Syndrome
Necker Seminars in Nephrology Institut Pasteur Paris, April 22, 2013 Hepatorenal Syndrome Dr. Richard Moreau 1 INSERM U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, 2 Université Paris Diderot
More informationEsophageal Varices Beta-Blockers or Band Ligation. Cesar Yaghi MD Hotel-Dieu de France University Hospital Universite Saint Joseph
Esophageal Varices Beta-Blockers or Band Ligation Cesar Yaghi MD Hotel-Dieu de France University Hospital Universite Saint Joseph Esophageal Varices Beta-Blockers or Band Ligation? Risk of esophageal variceal
More informationCLINICAL How Should a Hospitalized Patient with Newly Diagnosed Cirrhosis Be Evaluated and Managed?
CLINICAL How Should a Hospitalized Patient with Newly Diagnosed Cirrhosis Be Evaluated and Managed? The Hospitalist. 2016 August;2016(8) Author(s): Raj Sehgal, MD; Joshua Hanson, MD, MPH; Division OF The
More informationCase Report: Acute-on-Chronic Liver Failure: Making the Diagnosis between Infection and Acute Alcoholic Hepatitis
Diagnostic Problems in Hepatology 181 Case Report: Acute-on-Chronic Liver Failure: Making the Diagnosis between Infection and Acute Alcoholic Hepatitis Carmen Sendra, MD 1 Javier Ampuero, MD, PhD 1,2 Álvaro
More informationFilippo Schepis, MD Università degli Studi di Modena e Reggio Emilia
Filippo Schepis, MD Università degli Studi di Modena e Reggio Emilia Il sottoscritto dichiara di non aver avuto/di aver avuto negli ultimi 12 mesi conflitto d interesse in relazione a questa presentazione
More informationAscites is the most frequent complication of cirrhosis,
Beneficial Effect of Midodrine in Hypotensive Cirrhotic Patients with Refractory Ascites G & H C l i n i c a l C a s e S t u d i e s Achuthan Sourianarayanane, MD, MRCP 1 David S. Barnes, MD 1,2 Arthur
More informationManagement of the Cirrhotic Patient in the ICU
Management of the Cirrhotic Patient in the ICU Peter E. Morris, MD Professor & Chief, Pulmonary, Critical Care and Sleep Medicine University of Kentucky Conflict of Interest Funding US National Institutes
More informationACG & AASLD Joint Clinical Guideline: Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis
ACG & AASLD Joint Clinical Guideline: Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis Guadalupe Garcia-Tsao, M.D., 1 Arun J. Sanyal, M.D., 2 Norman D. Grace,
More informationElevated Creatinine in a Patient With Cirrhosis
REVIEW Elevated Creatinine in a Patient With Cirrhosis Heather L. Klavan, M.D., and Brett E. Fortune, M.D., M.S. Elevation in serum creatinine is a common laboratory finding for patients with cirrhosis
More informationCIRCULATORY AND RENAL FAILURE IN CIRRHOSIS
CIRCULATORY AND RENAL FAILURE IN CIRRHOSIS Pere Ginès, MD Liver Unit, Hospital Clínic Barcelona, Catalunya, Spain CIRCULATORY AND RENAL FAILURE IN CIRRHOSIS Hecker R and Sherlock S, The Lancet 1956 RENAL
More informationCauses of Liver Disease in US
Learning Objectives Updates in Outpatient Cirrhosis Management Jennifer Guy, MD MAS Director, Liver Cancer Program California Pacific Medical Center guyj@sutterhealth.org Review cirrhosis epidemiology,
More informationFrom Sodium Retention to Therapy for Refractory Ascites The Role for New Drugs. Florence Wong University of Toronto. Falk Symposium October 14, 2007
From Sodium Retention to Therapy for Refractory Ascites The Role for New Drugs Florence Wong University of Toronto Falk Symposium October 14, 2007 Sodium Retention in Cirrhosis Occurs as a result of hemodynamic
More informationHepatorenal syndrome. Jan T. Kielstein Departent of Nephrology Medical School Hannover
Hepatorenal syndrome Jan T. Kielstein Departent of Nephrology Medical School Hannover Hepatorenal Syndrome 1) History of HRS 2) Pathophysiology of HRS 3) Definition of HRS 4) Clinical presentation of HRS
More informationCare of the Patient With Cirrhosis
REVIEW Care of the Patient With Cirrhosis Anitha Yadav, M.D., and Hugo E. Vargas, M.D. Caring for patients with cirrhosis involves multidisciplinary and timely management of several complications while
More informationIs pharmacological therapy the best choice for primary prevention of variceal hemmorhaging in patients with hepatic cirrhosis?
Controversies en Gastroenterology Is pharmacological therapy the best choice for primary prevention of variceal hemmorhaging in patients with hepatic cirrhosis? Rolando José Ortega Quiroz, MD, 1 Adalgiza
More informationConflict of interest disclosures. Complications of end stage liver disease. None. The many complications of Cirrhosis. Portal Hypertension.
Complications of end stage liver disease Conflict of interest disclosures None Amir Qamar, MD Instructor of Medicine Brigham and Women s s Hospital Harvard Medical School Boston, MA 02115 The many complications
More informationVARICEAL BLEEDING. Ram Subramanian MD Hepatology & Critical Care Medical Director of Liver Transplant Emory University, Atlanta.
VARICEAL BLEEDING Ram Subramanian MD Hepatology & Critical Care Medical Director of Liver Transplant Emory University, Atlanta Disclosures: None OUTLINE Pathophysiology of portal hypertension Splanchnic
More informationNorepinephrine versus Terlipressin for the Treatment of Hepatorenal Syndrome
Norepinephrine versus Terlipressin for the Treatment of Hepatorenal Syndrome Disclosure I have no conflicts of interest to disclose Name: Margarita Taburyanskaya Title: PharmD, PGY1 Pharmacy Practice Resident
More informationDefinition of Congestive Heart Failure
Heart Failure Definition of Congestive Heart Failure A clinical syndrome of signs & symptoms resulting from the heart s inability to supply adequate tissue perfusion. CHF Epidemiology Affects 4.7 million
More informationTreatment of portal hypertension in the light of the Baveno VI Consensus Conference
r e v I E w A R T I C l e S Curierul medical, December 2015, Vol. 58, No 6 Treatment of portal hypertension in the light of the Baveno VI Consensus Conference E. Tcaciuc Department of Internal Medicine,
More informationIndex. Note: Page numbers of article titles are in boldface type.
Index Note: Page numbers of article titles are in boldface type. A Accelerated intravascular coagulation and fibrinolysis (AICF) in liver disease, 390 391 Acid suppression in liver disease, 403 404 ACLF.
More informationComplication of Portal Hypertension: should the patients in the waiting list be treated differently?
Wilma Debernardi Venon Gastroepatologia, Az. Osp. San Giovanni Battista ditorino Complication of Portal Hypertension: should the patients in the waiting list be treated differently? Il sottoscritto dichiara
More informationCIRRHOSIS Definition
Cirrhosis Update Robert S. Brown, Jr., MD, MPH Vice Chair, Transitions of Care Interim Chief, Division of Gastroenterology & Hepatology Weill Cornell Medical College CIRRHOSIS Definition Irreversible fibrous
More informationHepatology on the AMU
Hepatology on the AMU RCP day, 8 th February 2018 Jo Leithead Consultant in Hepatology and Liver Transplantation Addenbrookes Hospital Cambridge Is liver disease relevant to me? Williams R, Lancet 2014
More informationContraindications. Indications. Complications. Currently TIPS is considered second or third line therapy for:
Contraindications Absolute Relative Primary prevention variceal bleeding HCC if centrally located Active congestive heart failure Obstruction all hepatic veins Thomas D. Boyer, M.D. University of Arizona
More informationSign up to receive ATOTW weekly -
HEPATORENAL SYNDROME ANAESTHESIA TUTORIAL OF THE WEEK 240 10 TH SEPTEMBER 2011 Gerry Lynch Rotherham General Hospital Correspondence to gerry.lynch@rothgen.nhs.uk QUESTIONS Before continuing, try to answer
More informationControversies in Management of Portal Hypertension and Cirrhosis Complications in the Transplant Candidate
Controversies in Management of Portal Hypertension and Cirrhosis Complications in the Transplant Candidate Patrick Northup, MD, FAASLD, FACG Medical Director, Liver Transplantation University of Virginia
More informationTherapy Insight: management of hepatorenal syndrome
Therapy Insight: management of hepatorenal syndrome Andrés Cárdenas and Pere Ginès* SUMMARY Hepatorenal syndrome (HRS), a feared complication of advanced cirrhosis, is characterized by functional renal
More informationThe Yellow Patient. Dr Chiradeep Raychaudhuri, Consultant Hepatologist, Hull University Teaching Hospitals NHS Trust
The Yellow Patient Dr Chiradeep Raychaudhuri, Consultant Hepatologist, Hull University Teaching Hospitals NHS Trust there s a yellow patient in bed 40. It s one of yours. Liver Cirrhosis Why.When.What.etc.
More informationManaging Cirrhosis. Cirrhosis of the liver is a progressive, fibrosing. Ascites. By Cameron Ghent, MD, FRCPC. Complications of Cirrhosis
Focus on CME at the University of Western Ontario Managing Cirrhosis By Cameron Ghent, MD, FRCPC Cirrhosis of the liver is a progressive, fibrosing process resulting in nodule formation and microvascular
More informationEDUCATION PRACTICE. Management of Refractory Ascites. Clinical Scenario. The Problem
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2005;3:1187 1191 EDUCATION PRACTICE Management of Refractory Ascites ANDRÉS CÁRDENAS and PERE GINÈS Liver Unit, Institute of Digestive Diseases, Hospital Clínic,
More informationth Annual AISF Meeting 44 th th th, 2011 Rome, February 23 rd -26
44 th 44 th Annual AISF Meeting Rome, February 23 rd -26 th th, 2011 Update on the Baveno Consensus Conference Roberto de Franchis Department of of Clinical Sciences, University of of Milan, Head, Gastroenterology
More informationHepatorenal syndrome a defined entity with a standard treatment?
Hepatorenal syndrome a defined entity with a standard treatment? Falk Symposium 162 Dresden - October 14, 2007 Alexander L. Gerbes Klinikum of the University of Munich Grosshadern Department of Medicine
More informationMANAGING END STAGE LIVER DISEASE IN RESOURCE LIMITED SETTINGS
MANAGING END STAGE LIVER DISEASE IN RESOURCE LIMITED SETTINGS Mark W. Sonderup Division of Hepatology and Liver Laboratory Department of Medicine University of Cape Town & Groote Schuur Hospital Cirrhosis..
More informationAkash Ghai MD, FACC February 27, No Disclosures
Akash Ghai MD, FACC February 27, 2015 No Disclosures Epidemiology Lifetime risk is > 20% for American s older than 40 years old. > 650,000 new cases diagnosed each year. Incidence increases with age: 2%
More informationRENAL DISEASE IN END STAGE LIVER DISEASE
RENAL DISEASE IN END STAGE LIVER DISEASE Mitchell L Shiffman, MD Director Health System Richmond and Newport News, VA Medical Group Good Help to Those in Need Mitchell L Shiffman, MD POTENTIAL CONFLICTS
More informationPathophysiology, diagnosis and treatment of ascites in cirrhosis
Annals of hepatology 2002; 1(2): April-June: 72-79 Concise Review Annals of hepatology Pathophysiology, diagnosis and treatment of ascites in cirrhosis Vicente Arroyo 1, M.D. Abstract The mechanism by
More informationProgram Disclosure. This program is supported by an educational grant from Salix Pharmaceuticals.
Program Disclosure This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship
More informationVirtual Mentor American Medical Association Journal of Ethics December 2008, Volume 10, Number 12:
Virtual Mentor American Medical Association Journal of Ethics December 2008, Volume 10, Number 12: 805-809. CLINICAL PEARL Indications for Use of TIPS in Treating Portal Hypertension Elizabeth C. Verna,
More informationCirrhosis the end stage of chronic liver disease characterized
Suzanne E. Minor, MD, FAAFP; Irmanie Eliacin, MD; Sanaz Kashan, MD; Ebony B. Whisenant, MD Florida International University, Herbert Wertheim College of Medicine, Miami seminor@fiu.edu The authors reported
More informationHepatorenal syndrome. Jan Jan T. T. Kielstein Departent of of Nephrology Medical School School Hannover
Hepatorenal syndrome Jan Jan T. T. Kielstein Departent of of Nephrology Medical School School Hannover Hepatorenal Syndrome 1) History of HRS 2) Pathophysiology of HRS 3) Definition of HRS 4) Clinical
More informationManagement of Cirrhosis Related Complications
Management of Cirrhosis Related Complications Ke-Qin Hu, MD, FAASLD Professor of Clinical Medicine Director of Hepatology University of California, Irvine Disclosure I have no disclosure related to this
More informationOptimal management of ascites
Optimal management of ascites P. Angeli, Dept. of Medicine, Unit of Internal Medicine and epatology (), University of Padova (Italy) pangeli@unipd.it 10th Paris epatology Conference National Conference
More informationINCIDENCE OF BACTERIAL INFECTIONS IN CIRRHOSIS
INCIDENCE OF BACTERIAL INFECTIONS IN CIRRHOSIS Yoshida H et al (1993)* Deschenes M et al (1999)** Strauss E et al (1993) Borzio M et al (2002) PATIENTS 1140 140 170 405 INFECTIONS 15.4% 20% 47% 34% * Many
More informationCirrhosis Complications
Cirrhosis Complications and Spontaneous Bacterial Peritonitis While these complications greatly increase mortality from decompensated cirrhosis, effective treatment is possible with early diagnosis. Vigilant
More informationCirrhosis is the irreversible fibrosis of the liver, the end stage
The new england journal of medicine Review Article Edward W. Campion, M.D., Editor Treatment of Patients with Cirrhosis Phillip S. Ge, M.D., and Bruce A. Runyon, M.D. Cirrhosis is the irreversible fibrosis
More informationReview article: hepatorenal syndrome definitions and diagnosis
Aliment Pharmacol Ther 2004; 20 (Suppl. 3): 24 28. Review article: hepatorenal syndrome definitions and diagnosis R. MOREAU & D. LEBREC Laboratoire d Hémodynamique Splanchnique et de Biologie Vasculaire,
More informationEuropean. Young Hepatologists Workshop. Organized by : Quantification of fibrosis and cirrhosis outcomes
supported by from Gilea Quantification of fibrosis and cirrhosis outcomes th 5 European 5 European Young Hepatologists Workshop Young Hepatologists Workshop August, 27-29. 2015, Moulin de Vernègues Vincenza
More informationTerlipressin: An Asset for Hepatologists!
DIAGNOSTIC AND THERAPEUTIC ADVANCES IN HEPATOLOGY Terlipressin: An Asset for Hepatologists! S.K. Sarin and Praveen Sharma One Case Scenario A 48-year-old male with alcoholic cirrhosis who was abstinent
More informationComplications of Cirrhosis
Complications of Cirrhosis Causes of Cirrhosis Alcohol Chronic Viral Hepatitis (B/C) Haemochromatosis Autoimmune Hepatitis NAFLD/NASH Primary Biliary Cirrhosis Primary Sclerosing Cholangitis 1-AT deficiency
More informationPharmacology - Problem Drill 11: Vasoactive Agents
Pharmacology - Problem Drill 11: Vasoactive Agents Question No. 1 of 10 1. Vascular smooth muscle contraction is triggered by a rise in. Question #01 (A) Luminal calcium (B) Extracellular calcium (C) Intracellular
More informationEnd-Stage Liver Disease (ESLD): A Guide for HIV Physicians
Slide 1 of 32 End-Stage Liver Disease (ESLD): A Guide for HIV Physicians Marion G. Peters, MD John V. Carbone, MD, Endowed Chair Professor of Medicine Chief of Hepatology Research University of California
More informationLong term administration of human albumin improves survival in patients with cirrhosis and refractory ascites
Received: 3 May 2018 Revised: 2 August 2018 Accepted: 12 September 2018 DOI: 10.1111/liv.13968 CIRRHOSIS AND LIVER FAILURE Long term administration of human albumin improves survival in patients with cirrhosis
More informationCase Report: Refractory variceal bleeding Christophe Hézode, Henri Mondor Hospital, Paris-Est University, Créteil, France
Case Report: Refractory variceal bleeding Christophe Hézode, Henri Mondor Hospital, Paris-Est University, Créteil, France Thank you to Marika Rudler, Dominique Thabut, Adrian Gadano, and Jaime Bosch for
More informationCIRROSI E IPERTENSIONE PORTALE NELLA DONNA
Cagliari, 16 settembre 2017 CIRROSI E IPERTENSIONE PORTALE NELLA DONNA Vincenza Calvaruso, MD, PhD Ricercatore di Gastroenterologia Gastroenterologia & Epatologia, Di.Bi.M.I.S. Università degli Studi di
More informationSpecial Lecture 11/08/2013. Hypertension Dr. HN Mayrovitz
Special Lecture 11/08/2013 Hypertension Dr. HN Mayrovitz Arterial Blood Pressure (ABP) Major Factors Summarized Sympathetic Hormones Arteriole MAP ~ Q x TPR + f (V / C) SV x HR Renal SBP Hypertension =
More informationManagement of refractory ascites in cirrhosis: Are we out of date?
Submit a Manuscript: http://www.wjgnet.com/esps/ Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx DOI: 10.4254/wjh.v8.i28.1182 World J Hepatol 2016 October 8; 8(28): 1182-1193 ISSN 1948-5182 (online)
More informationInvasive Evaluation of Portal Hypertension. Vincenzo La Mura, MD PhD Department of Biomedical Sciences for Health University of Milan
Invasive Evaluation of Portal Hypertension Vincenzo La Mura, MD PhD Department of Biomedical Sciences for Health University of Milan Vincenzo La Mura, MD, PhD Dipartimento di scienze Biomediche per la
More informationCardiorenal Syndrome
SOCIEDAD ARGENTINA DE CARDIOLOGIA Cardiorenal Syndrome Joint session ESC-SAC ESC Congress 2012, Munich César A. Belziti Hospital Italiano de Buenos Aires I have no conflicts of interest to declare Cardiorenal
More informationAscites and hepatorenal syndrome in cirrhosis: pathophysiological basis of therapy and current management
Journal of Hepatology 38 (2003) S69 S89 www.elsevier.com/locate/jhep Ascites and hepatorenal syndrome in cirrhosis: pathophysiological basis of therapy and current management Vicente Arroyo*, Jordi Colmenero
More informationESLD a Guide for HIV Physicians. Marion Peters University of California San Francisco June 2015
ESLD a Guide for HIV Physicians Marion Peters University of California San Francisco June 2015 Disclosures Honararia from Johnson and Johnson Roche Merck Gilead Spouse employee of Hoffman La Roche Natural
More informationHepatorenal syndrome
Annals of Hepatology 2003; 2(1): January-March: 23-29 Concise Review Annals of Hepatology Hepatorenal syndrome Andrés Cárdenas, M.D., 1 Vicente Arroyo, M.D. 2 Abstract Hepatorenal syndrome is complication
More informationThe Use of Albumin for the Prevention of Hepatorenal Syndrome in Patients with Spontaneous Bacterial Peritonitis and Cirrhosis
The Use of Albumin for the Prevention of Hepatorenal Syndrome in Patients with Spontaneous Bacterial Peritonitis and Cirrhosis http://www.funnyjunk.com/funny_pictures/1743659/enlarged/ Daniel Giddings,
More informationHepatorenal Syndrome in Cirrhosis: Pathogenesis and Treatment
GASTROENTEROLOGY 2002;122:1658-1676 Hepatorenal Syndrome in Cirrhosis: Pathogenesis and Treatment VICENTE ARROYO, MONICA GUEVARA, and PERE GINI~S Liver Unit, Institute of Digestive Disease, Hospital Clinic,
More informationHeart Failure (HF) Treatment
Heart Failure (HF) Treatment Heart Failure (HF) Complex, progressive disorder. The heart is unable to pump sufficient blood to meet the needs of the body. Its cardinal symptoms are dyspnea, fatigue, and
More informationISPUB.COM. Management of Ascites. V Mahesh SOURCE OF SUPPORT DIAGNOSIS OF ASCITES INTRODUCTION CAUSES [,] DIAGNOSTIC TESTS
ISPUB.COM The Internet Journal of Gastroenterology Volume 5 Number 2 Management of Ascites V Mahesh Citation V Mahesh. Management of Ascites. The Internet Journal of Gastroenterology. 2006 Volume 5 Number
More informationCost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding Raines D L, Dupont A W, Arguedas M R
Cost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding Raines D L, Dupont A W, Arguedas M R Record Status This is a critical abstract of an economic
More informationBlood Pressure Regulation 2. Faisal I. Mohammed, MD,PhD
Blood Pressure Regulation 2 Faisal I. Mohammed, MD,PhD 1 Objectives Outline the intermediate term and long term regulators of ABP. Describe the role of Epinephrine, Antidiuretic hormone (ADH), Renin-Angiotensin-Aldosterone
More informationBlood Pressure Regulation 2. Faisal I. Mohammed, MD,PhD
Blood Pressure Regulation 2 Faisal I. Mohammed, MD,PhD 1 Objectives Outline the intermediate term and long term regulators of ABP. Describe the role of Epinephrine, Antidiuretic hormone (ADH), Renin-Angiotensin-Aldosterone
More informationClinical Trials & Endpoints in NASH Cirrhosis
Clinical Trials & Endpoints in NASH Cirrhosis April 25, 2018 Peter G. Traber, MD CEO & CMO, Galectin Therapeutics 2018 Galectin Therapeutics NASDAQ: GALT For more information, see galectintherapeutics.com
More informationSteps in Assessing Fibrosis 4/30/2015. Overview of Liver Disease Associated With HCV
Overview of Liver Disease Associated With HCV Marion G. Peters, MD John V. Carbone, Endowed Chair Professor of Medicine Chief of Hepatology Research University of California San Francisco San Francisco,
More informationAcute kidney injury and hepatorenal syndrome in cirrhosis
bs_bs_banner doi:10.1111/jgh.12709 REVIEW ARTICLE Acute kidney injury and hepatorenal syndrome in cirrhosis Mads Egerod Israelsen,* Lise Lotte Gluud and Aleksander Krag* *Department of Gastroenterology,
More informationCardiorenal and Renocardiac Syndrome
And Renocardiac Syndrome A Vicious Cycle Cardiorenal and Renocardiac Syndrome Type 1 (acute) Acute HF results in acute kidney injury Type 2 Chronic cardiac dysfunction (eg, chronic HF) causes progressive
More informationVeins. VENOUS RETURN = PRELOAD = End Diastolic Volume= Blood returning to heart per cardiac cycle (EDV) or per minute (Venous Return)
Veins Venous system transports blood back to heart (VENOUS RETURN) Capillaries drain into venules Venules converge to form small veins that exit organs Smaller veins merge to form larger vessels Veins
More informationAdrenal Insufficiency in Patients with Liver Cirrhosis and Severe Sepsis: Effect on Survival after Treatment with Hydrocortisone ABSTRACT
20 Original Article Adrenal Insufficiency in Patients with Liver Cirrhosis and Severe Sepsis: Effect on Survival after Treatment with Hydrocortisone Pattanasirigool C Prasongsuksan C Settasin S Letrochawalit
More informationManagement of Portal Vein Thrombosis With and Without Cirrhosis
Management of Portal Vein Thrombosis With and Without Cirrhosis Dominique-Charles Valla Service d Hépatologie,Hôpital Beaujon, APHP, Université Paris-Diderot, Inserm CRB3 Extrahepatic Portal Vein Obstruction
More informationA randomized study of losartan vs propranolol: Effects on hepatic and systemic hemodynamics in cirrhotic patients
Annals of Hepatology 2003; 2(1): January-March: 36-40 Original Article Annals of Hepatology A randomized study of losartan vs propranolol: Effects on hepatic and systemic hemodynamics in cirrhotic patients
More informationGI bleeding in chronic liver disease
GI bleeding in chronic liver disease Stuart McPherson Consultant Hepatologist Liver Unit, Freeman Hospital, Newcastle upon Tyne and Institute of Cellular Medicine, Newcastle University. Case 54 year old
More informationWhat would be the response of the sympathetic system to this patient s decrease in arterial pressure?
CASE 51 A 62-year-old man undergoes surgery to correct a herniated disc in his spine. The patient is thought to have an uncomplicated surgery until he complains of extreme abdominal distention and pain
More informationJong Young Choi, M.D.
The Liver Week 2014 Jong Young Choi, M.D. Dept. of Internal Medicine The Catholic University of Korea, College of Medicine The clinical study for natural history of LC is not many. Most of them was done
More informationEvaluating HIV Patient for Liver Transplantation. Marion G. Peters, MD Professor of Medicine University of California San Francisco USA
Evaluating HIV Patient for Liver Transplantation Marion G. Peters, MD Professor of Medicine University of California San Francisco USA Slide 2 ESLD and HIV Liver disease has become a major cause of death
More informationACUTE-ON-CHRONIC LIVER FAILURE: DEFINITION, DIAGNOSIS AND CLINICAL CHARACTERISTICS.
ACUTE-ON-CHRONIC LIVER FAILURE: DEFINITION, DIAGNOSIS AND CLINICAL CHARACTERISTICS. Vicente Arroyo 1, 2, Rajiv Jalan 2, 3 1 Institut de Investigacions Biomèdiques August Pi I Sunyer. University of Barcelona.
More information