Hepatic encephalopathy (HE) is a potentially reversible neurocognitive condition seen in patients with advanced liver disease. The overt form of HE has been reported in up to 45% of patients with cirrhosis. This debilitating condition is associated with increased morbidity and mortality and imposes a significant burden on the caregivers and healthcare system. After providing an overview of HE epidemiology and pathophysiology, this review focuses on the interaction of HE and frailty, nutrition requirements and recommendations in cirrhotic patients with HE, and current dietary and pharmacologic options for HE treatment. (Nutr Clin Pract. 2020;35:36-48)

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Renal or calyceal microlithiasis is a common disorder with increasing prevalence especially in infants and younger children. The main presenting symptoms and the underlying metabolic abnormalities of renal microlithiasis are similar to renal stone. Although renal microlithiasis is considered as a main problem of the health system with diverse etiologies, our information about its natural course is very limited. Hence, further investigations to make an appropriate clinical approach to this entity is mandatory. Also, general practitioners, pediatricians, nephrologists and urologists have to be well educated regarding renal microlithiasis for early diagnosis, appropriate evaluation and proper management of this entity. In this review study, we focused on collection of the present information about different aspects of renal microlithiasis in children

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BackgroundExercise is a physiologic stress that helps the physicians to clarify the presence or absence of cardiovascular disease which may be obscure at rest. Although it is sensitive, its specificity is affected by several parameters, such as some metabolic conditions, some structural heart diseases, and some baseline electrocardiogram abnormalities. Currently, the relationship between coronary dominance and accuracy of EET is not examined. Therefore, this study was conducted to determine the potential impact of coronary dominance on the accuracy of EET.MethodsIn this retrospective study, data were gathered from 720 patients from four medical centers. The pattern of dominancy was determined, and the coronary dominance pattern of the patients who had normal angiograms despite abnormal EETs was compared to that from all the patients.ResultsAmong the patients who had a normal angiogram despite an abnormal EET, 27% were left dominant while the frequency of left dominancy in the whole population of the study was only 10.9% (P = 0.013). There were no significant differences in baseline characteristics, such as age and sex, between the two studied groups.ConclusionThe results indicated that the presence of left dominance in patients who had normal angiograms despite an abnormal EET was significantly higher than general population. Therefore, left dominance may be considered a confounding factor for EET, producing false positive results.

The role of noninvasive liver disease assessment by two-dimensional shear wave elastography (2D-SWE) to diagnose fibrosis is well described in patients with chronic liver disease. However, its role in prognosis, especially after liver transplantation (LT) has not been adequately examined. We hypothesized that elevated liver stiffness measurement (LSM) as measured by 2D-SWE after LT predicts future morbidity and mortality independent of fibrosis by liver biopsy.In a prospective cohort study, consecutive LT recipients underwent concomitant protocol 2D-SWE and protocol liver biopsy (2012)(2013)(2014), with the assessor blinded to biopsy findings. We examined the baseline correlation of LSM with fibrosis stage and the association between elevated LSM and the development of subsequent clinical outcomes and all-cause mortality. A total of 187 LT recipients (median age 58 years, 38.5% women, median body mass index 26.5 kg/m 2 , 55.1% hepatitis C virus, 17.6% nonalcoholic steatohepatitis/cryptogenic) were examined. Median time between LT and biopsy/2D-SWE assessment was 4.0 years, and the median follow-up time after LSM determination was 3.5 years. Median LSM was 9 kPa (8 kPa [F0/F1], 11.5 kPa [F2], 12 kPa [F3/ F4]). There was a positive correlation between LSM and fibrosis stage (r s = 0.41; p < 0.001). LSM ≥11 kPa was associated with lower survival within 3 years (84.8 vs. 93.7%; p = 0.04). After adjusting for age, sex, and fibrosis stage, LSM ≥11 kPa was independently associated with mortality (hazard ratio, 2.45; 95% confidence interval, 1.08-5.60). Elevated LSM by 2D-SWE is associated with increased mortality after LT independent of hepatic fibrosis. Given the overall decrease in the use of liver biopsy in the current era, 2D-SWE may serve as a novel noninvasive prognostic tool to predict relevant outcomes late after LT.

BackgroundHemoglobin levels measured after hemodialysis, as compared to hemoglobin levels measured before hemodialysis, are suggested to be a more accurate reflection of the hemoglobin levels between hemodialysis sessions, and to be a better reference point for adjusting erythropoietin dosing.ObjectivesThe aim of this study was to compare the hemoglobin levels before and after hemodialysis, to calculate the required erythropoietin doses based on these levels, and to develop a model to predict effective erythropoietin dosing.Patients and MethodsIn this cross-sectional study, the hemoglobin levels of 52 patients with end-stage renal disease were measured before and after hemodialysis. The required erythropoietin doses and the differences in cost were calculated based on the hemoglobin levels before and after hemodialysis. A model to predict the adjusted erythropoietin dosages based on post-hemodialysis hemoglobin levels was proposed.ResultsHemoglobin levels measured after hemodialysis were significantly higher than the hemoglobin levels before hemodialysis (11.1 ± 1.1 vs. 11.9 ± 1.2 g/dL, P < 0.001, 7% increase). The mean required erythropoietin dose based on post-hemodialysis hemoglobin levels was significantly lower than the corresponding erythropoietin dose based on pre-hemodialysis hemoglobin levels (10947 ± 6820 vs. 12047 ± 7542 U/week, P < 0.001, 9% decrease). The cost of erythropoietin was also significantly lower when post-hemodialysis levels were used (15.96 ± 9.85 vs. 17.57 ± 11.00 dollars/patient/week, P < 0.001). This translated into 83.72 dollars/patient/year in cost reduction. The developed model for predicting the required dosage is: Erythropoietin (U/week) = 43540.8 + (-2734.8) × Post-hemodialysis Hb* (g/dL). [(R2) = 0.221; *P < 0.001].ConclusionsUsing post-hemodialysis hemoglobin levels as a reference point for erythropoietin dosing can result in significant dose and cost reduction, and can protect hemodialysis patients from hemoconcentration. The prediction of the erythropoietin adjusted dosage based on post-hemodialysis Hb may also help in avoiding overdosage.