Management of adult patients with ascites due to cirrhosis: An update

Runyon, Bruce A.

doi:10.1002/hep.22853

Cited by 874 publications

(844 citation statements)

References 166 publications

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“…In the absence of LT, the outcomes of these candidates are poor, and are associated with very high mortality rates (1). Pre-LT medical management to reduce portal pressure and the need for RRT are not very successful, but are often used to bridge patients to LT (3)(4)(5)(6)(7)(8).…”

Section: Introductionmentioning

confidence: 99%

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Short-Term Pretransplant Renal Replacement Therapy and Renal Nonrecovery after Liver Transplantation Alone

Sharma

Goodrich

Zhang

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Candidates with AKI including hepatorenal syndrome often recover renal function after successful liver transplantation (LT). This study examined the incidence and risk factors associated with renal nonrecovery within 6 months of LT alone among those receiving acute renal replacement therapy (RRT) before LT.Design, setting, participants, & measurements Scientific Registry of Transplant Recipients data were linked with Centers for Medicare and Medicaid Services ESRD data for 2112 adult deceased-donor LT-alone recipients who received acute RRT for #90 days before LT (February 28, 2002 to August 31, 2010. Primary outcome was renal nonrecovery (post-LT ESRD), defined as transition to chronic dialysis or waitlisting or receipt of kidney transplant within 6 months of LT. Cumulative incidence of renal nonrecovery was calculated using competing risk analysis. Cox regression identified recipient and donor predictors of renal nonrecovery.Results The cumulative incidence of renal nonrecovery after LT alone among those receiving the pre-LT acute RRT was 8.9%. Adjusted renal nonrecovery risk increased by 3.6% per day of pre-LT RRT (P,0.001). Age at LT per 5 years (P=0.02), previous-LT (P=0.01), and pre-LT diabetes (P,0.001) were significant risk factors of renal nonrecovery. Twenty-one percent of recipients died within 6 months of LT. Duration of pretransplant RRT did not predict 6-month post-transplant mortality.Conclusions Among recipients on acute RRT before LT who survived after LT alone, the majority recovered their renal function within 6 months of LT. Longer pre-LT RRT duration, advanced age, diabetes, and re-LT were significantly associated with increased risk of renal nonrecovery.

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Section: Introductionmentioning

confidence: 99%

“…Although candidates with AKI including HRS may recover renal function after LT (7)(8)(9), the rate and timing of renal recovery have not been very well elucidated. One study showed the renal nonrecovery to be as high as 32% among LT recipients who were on pre-LTRRT and received LT alone (9).…”

Section: Introductionmentioning

confidence: 99%

Short-Term Pretransplant Renal Replacement Therapy and Renal Nonrecovery after Liver Transplantation Alone

Sharma

Goodrich

Zhang

et al. 2013

Clinical Journal of the American Society of Nephrology

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“…These treatments include transplantation, surgical resection, ablation, catheter-based embolization, medical therapy, and supportive care (i.e., symptomatic management only). Transjugular intrahepatic portosystemic shunt (TIPS) placement is the standard of care for patients with portal hypertension causing variceal bleeding or refractory ascites despite optimal medical management [2,3]. The natural history of patients who develop HCC in the setting of TIPS has not been extensively investigated.…”

Section: Introductionmentioning

confidence: 99%

Outcomes of Locoregional Tumor Therapy for Patients with Hepatocellular Carcinoma and Transjugular Intrahepatic Portosystemic Shunts

Padia

Chewning

Kogut

et al. 2014

Cardiovasc Intervent Radiol

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Purpose Locoregional therapy for hepatocellular carcinoma (HCC) can be challenging in patients with a transjugular intrahepatic portosystemic shunt (TIPS). This study compares safety and imaging response of ablation, chemoembolization, radioembolization, and supportive care in patients with both TIPS and HCC. Methods This retrospective study included 48 patients who had both a TIPS and a diagnosis of HCC. Twenty-nine of 48 (60 %) underwent treatment for HCC, and 19/48 (40 %) received best supportive care (i.e., symptomatic management only). While etiology of cirrhosis and indication for TIPS were similar between the two groups, treated patients had better baseline liver function (34 vs. 67 % Child-Pugh class C). Tumor characteristics were similar between the two groups. A total of 39 ablations, 17 chemoembolizations, and 10 yttrium-90 radioembolizations were performed on 29 patients.Results Ablation procedures resulted in low rates of hepatotoxicity and clinical toxicity. Post-embolization/ ablation syndrome occurred more frequently in patients undergoing chemoembolization than ablation (47 vs. 15 %). Significant hepatic dysfunction occurred more frequently in the chemoembolization group than the ablation group. Follow-up imaging response showed objective response in 100 % of ablation procedures, 67 % of radioembolization procedures, and 50 % of chemoembolization procedures (p = 0.001). When censored for OLT, patients undergoing treatment survived longer than patients receiving supportive care (2273 v. 439 days, p = 0.001). Conclusions Ablation appears to be safe and efficacious for HCC in patients with TIPS. Catheter-based approaches are associated with potential increased toxicity in this patient population. Chemoembolization appears to be associated with increased toxicity compared to radioembolization.

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“…Despite this, even where the most modern practice is applied, ascites fluid culture is negative in approximately 20% of patients with clinical manifestations suggestive of SBP, including elevated ascites polymorphonuclear leukocyte (PMN) counts [11]. Where there is evidence of infection, delaying treatment until the ascitic fluid culture grows bacteria may result in the death of the patient from overwhelming infection [11].…”

Section: Introductionmentioning

confidence: 99%

“…Where there is evidence of infection, delaying treatment until the ascitic fluid culture grows bacteria may result in the death of the patient from overwhelming infection [11]. Therefore, empirical antibiotic treatment for SBP is initiated when objective evidence of a local inflammatory reaction is present, i.e.…”

Section: Introductionmentioning

confidence: 99%

Characterisation of bacteria in ascites—reporting the potential of culture-independent, molecular analysis

Rogers

Russell

Preston

et al. 2010

Eur J Clin Microbiol Infect Dis

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Spontaneous bacterial peritonitis (SBP) is a severe complication of liver disease. A significant proportion of patients have culture-negative ascites, despite having similar signs, symptoms and mortality to those with SBP. Therefore, empirical antibiotic treatment for infection is often started without knowledge of the causative organisms. Here, we investigated the potential of molecular techniques to provide rapid and accurate characterisation of the bacteria present in ascitic fluid. Ascites samples were obtained from 29 cirrhotic patients undergoing clinically indicated therapeutic paracentesis. Bacterial content was determined by terminal restriction fragment length polymorphism (T-RFLP) analysis, quantitative polymerase chain reaction (PCR) and 16S ribosomal clone sequence analysis. Bacterial signal was detected in all samples, compared to three out of ten using standard methods. Bacterial loads ranged from 5.5 × 10 2 to 5.4 × 10 7 cfu/ml, with a mean value of 1.9 × 10 6 cfu/ml (standard deviation± 9.6 × 10 6 cfu/ml). In all but one instance, bacterial species identified by culture were also confirmed by molecular analyses. Preliminary data presented here suggests that culture-independent, molecular analyses could provide rapid characterisation of the bacterial content of ascites fluid, providing a basis for the investigation of SBP development and allowing early and targeted antibiotic intervention.

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Management of adult patients with ascites due to cirrhosis: An update

Cited by 874 publications

References 166 publications

Short-Term Pretransplant Renal Replacement Therapy and Renal Nonrecovery after Liver Transplantation Alone

Short-Term Pretransplant Renal Replacement Therapy and Renal Nonrecovery after Liver Transplantation Alone

Outcomes of Locoregional Tumor Therapy for Patients with Hepatocellular Carcinoma and Transjugular Intrahepatic Portosystemic Shunts

Characterisation of bacteria in ascites—reporting the potential of culture-independent, molecular analysis

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