Ascites and serum sodium are markers of increased waiting list mortality in children with chronic liver failure

Abstract

Ascites is the most common complication of cirrhosis and in adults it is associated with 50% mortality at 5 years if patients do not receive a liver transplant. The occurrence of hyponatremia in these patients has been associated with increased mortality on the waiting list. The importance of serum sodium levels and the presence of ascites in the pediatric setting remain to be clarified. A retrospective analysis of pediatric patients with cirrhosis on the transplant list was carried out between October 2000 and February 2012. The primary objective of this study was to evaluate the association of pretransplant variables with mortality within 90 days following the inclusion of patients on the waiting list. In all, 522 patients were included in the study; 345 (66%) patients were under 1 year of age; 208 (40%) of the children presented ascites. A multivariate Cox proportional hazards analysis was conducted and total bilirubin (P < 0.001, hazard ratio [HR] 5 2.09, 95% confidence interval [CI] 5 1.35-3.21), international normalized ratio (INR) (P < 0.001, HR 5 9.83, 95% CI 5 4.51-21.45), serum sodium levels (P 5 0.03, HR 5 0.96, 95% CI 5 0.92-0.99), ascites (P 5 0.001, HR 5 2.59, 95% CI 5 1.44-4.64), and categorized age (0-1 versus 1 year old) (P 5 0.025, HR 5 2.33, 95% CI 5 1.11-4.86) were independently associated with risk of death in 90 days. Malnutrition (Z score height/age, weight/age) and serum albumin (pediatric endstage liver disease [PELD] formula) were not included in the final model. Conclusion: The presence of ascites and serum sodium levels are important variables associated with decreased patient survival while candidates wait for a liver graft. Multicenter studies are necessary to validate these findings in order to improve current allocation policies based on the PELD score. (HEPATOLOGY

Cirrhosis in children and adolescents: An overview

“…This is generally associated with a poor prognosis [80] . Pediatric patients with a sudden increase in ascites or new episodes of water retention should undergo paracentesis [34] .…”

Management of cirrhotic ascites in children. Review and recommendations. Part 2: Electrolyte disturbances, nonelectrolyte disturbances, therapeutic options

“…28,68 The presence of HH should also prompt a search for bacterial infections. 8 In spite of its slow progression, allowing the CNS to adapt and causing a low incidence of clinical signs, pretransplantation HH is associated with higher morbidity and mortality, 67,69,70 and there is not adequate evidence regarding when it should be treated in asymptomatic p a t i e n t s . 65,67 A l t h o u g h t h e r e i s consensus not to treat patients when serum values are > 130 mEq/L, values for the discontinuation of diuretics range between ≤ 125 mEq/L and < 120 mEq/L.…”

“…74,75 In most cases, HRS is characterized by oligoanuria and severe prerenal failure lab tests. Serum creatinine levels, specific for the diagnosis of HRS in adults, 5,6,9 are not sensitive in PPCA (usually malnourished), 70 for whom doubling of previous values has been proposed as an indicator. 76 HRS is classified into type 1, which progresses rapidly with multiorgan failure and is triggered by an acute event, such as SBP or acute gastrointestinal bleeding, or type 2, which is chronic and develops f) The patient should not be receiving and/or should not have recently received nephrotoxic drugs, especially non-steroidal anti-inflammatory drugs.…”

Manejo de la ascitis secundaria a cirrosis en el paciente pediátrico. Revisión y recomendaciones. Parte 2: Complicaciones electrolíticas, complicaciones no electrolíticas, opciones terapéuticas

“…74,75 En la mayoría de los casos, el SHR se caracteriza por oligoanuria y laboratorio de insuficiencia prerrenal grave. Los niveles de creatinina sérica, específicos para diagnosticar SHR en adultos, 5,6,9 no son sensibles en el PPAC (usualmente, desnutrido), 70 para quien se ha propuesto utilizar como indicador la duplicación de los valores previos. 76 El SHR se clasifica en tipo 1, que progresa rápidamente acompañado de falla multiorgánica…”

“…28,68 La presencia de HH también debe inducir a la búsqueda de infecciones bacterianas. 8 A pesar de su lenta progresión, q u e p e r m i t e l a a d a p t a c i ó n d e l sistema nervioso central (SNC) con poca sintomatología, la HH pretrasplante está asociada a mayor morbimortalidad 67,69,70 y no existe adecuada evidencia sobre cuándo debe ser tratada en el paciente asintomático. 65,67 Si bien hay consenso p a r a n o t r a t a r v a l o r e s s é r i c o s > 1 3 0 m E q / L , l o s v a l o r e s p a r a discontinuar diuréticos varían entre ≤ 125 mEq/L y < 120 mEq/L.…”