EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis

Angeli, Paolo; Bernardi, Mauro; Villanueva, Càndid; Francoz, Claire; Mookerjee, Rajeshwar P.; Trebicka, Jonel; Krag, Aleksander; Laleman, Wim; Ginès, Pere

doi:10.1016/j.jhep.2018.03.024

Cited by 2,053 publications

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References 616 publications

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“…1 Due to increased permeability of the intestinal wall in cirrhotic patients, pathogens translocate from the intestinal lumen into the peritoneal cavity and may cause SBP. 1 Due to increased permeability of the intestinal wall in cirrhotic patients, pathogens translocate from the intestinal lumen into the peritoneal cavity and may cause SBP.…”

Section: Introductionmentioning

confidence: 99%

Patients with cirrhosis and SBP: Increase in multidrug‐resistant organisms and complications

Zhang

Liss

et al. 2020

Eur J Clin Investigation

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Background: Spontaneous bacterial peritonitis (SBP) is a serious complication in patients with liver cirrhosis. In recent years, it has been postulated that the rate of multidrug-resistant organisms (MDROs) is increasing, especially in nosocomial SBP patients. Aim of the present work was to investigate this hypothesis and its possible clinical consequences. Materials and methods: One hundred and three culture-positive patients between 2007 and 2014 were compared with 81 patients between 2015 and 2017, to study the change of microbiological profiles and their clinical consequences. The cirrhosis patients with bacterascites requiring treatment were included as well. Results: The most prevalent Gram-negative bacteria isolated from ascites were Enterobacterales (31.6%) and in Gram-positive pathogens Staphylococci (22.8%).There was a significant increase in MDROs (22.3% ICU 40.7%, P = .048), accompanied by an increased incidence of sepsis (from 21.4% to 37.0%, P = .021), hepatorenal syndrome (from 40.8% to 58.0%, P = .007) and the need of catecholamine therapy (from 21.4% to 38.8%, P = .036). Nosocomial origin correlated with higher MDRO proportion, more complications and lower antimicrobial susceptibility rates in 12 commonly used antibiotics. MDROs were confirmed as an isolated predictor for inpatient mortality and complications in multivariable logistic regression. Conclusions: The feeling in clinical practice that MDROs have increased in the last 11 years could be confirmed in our study in Munich, Germany. Nosocomial SBP correlated with significantly higher MDRO rates (nearly 50%) and complication rates.In our opinion, an antibiotic combination with comprehensive effect should be taken into account in nosocomial SBP patients in this region. K E Y W O R D Santimicrobial susceptibility, liver cirrhosis, microbiological profile, multidrug-resistant organism, spontaneous bacterial peritonitis 2 of 8 | LI et aL.

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Section: Introductionmentioning

confidence: 99%

Patients with cirrhosis and SBP: Increase in multidrug‐resistant organisms and complications

Zhang

Liss

et al. 2020

Eur J Clin Investigation

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“…1). These recommendations are summarized in the German Guidelines and the European Clinical Practice Guidelines of the European Association of the Study of the Liver [22,23]. …”

Section: Clinical Managementmentioning

confidence: 99%

“…The first choice is the administration of a vasoconstrictive drug in combination with albumin. Vasoconstrictive drugs counteract splanchnic vasodilatation, and renal vasoconstriction decreases with improved renal perfusion [22,23]. …”

Section: Medical Treatmentmentioning

confidence: 99%

“…bolus with an initial dose of 0.5-1 mg every 4-6 h. The dose can be increased to a maximum of 2 mg every 4-6 h, with a daily maximum of 12 mg [22,23]. Improvement of kidney function during treatment is defined as a decrease of serum creatinine of more than 25% of the baseline value prior to treatment.…”

Section: Dosage and Application Of Terlipressin And Albuminmentioning

confidence: 99%

“…Albumin solution (20%) should be administered at a dose of 1 g/kg body weight on the first day followed by a dose of 20-40 g per day [22,23]. However, the exact dose of albumin in the treatment of type-1 HRS has not been well examined.…”

Section: Albuminmentioning

confidence: 99%

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Renal Failure in Patients with Liver Cirrhosis: Novel Classifications, Biomarkers, Treatment

Appenrodt

Lammert²

2018

Visc Med

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Renal failure is a severe complication in patients with liver cirrhosis. It is associated with increased mortality and morbidity. Diagnosis is a challenge because it is mainly based on serum creatinine, which does not seem to be an ideal measure of renal function in cirrhosis. The definition of renal failure in these patients has been changed for optimizing treatment and for improving outcome and prognosis. The new criteria are based on the adapted KDIGO (Kidney Disease: Improving Global Outcomes) staging system. The diagnosis of acute kidney injury (AKI) is based on an absolute increase of serum creatinine of >0.3 mg/dl from baseline within 48 h or an increase of >50% from baseline. This means smaller changes in serum creatinine in a shorter time frame which may lead to an early identification of renal failure in cirrhotic patients. The former cirrhotic-specific term hepatorenal syndrome (HRS) is now part of the new diagnostic criteria and is called HRS-AKI. The diagnostic criteria of HRS have changed due to the new criteria for AKI. Due to these criteria for HRS, the medical treatment will be started earlier. First-line treatment for renal AKI-HRS is the combination of a vasoconstrictor and albumin. Most data exist for terlipressin, a vasopressin analog, as vasoconstrictor. Besides this medical treatment, there are other options like the placement of a transjugular intrahepatic portosystemic shunt, renal replacement, and artificial extracorporeal liver support systems. However, these alternative treatment options have limitations. Liver transplantation is the treatment of choice for these patients and represents the definitive treatment. Using new biomarkers like urinary neutrophil gelatinase-associated lipocalin or interleukin-18 for renal failure in cirrhosis should help to differentiate the causes of renal failure and provide an indication regarding the prognosis.

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Daily Low-Volume Paracentesis and Clinical Complications in Patients With Refractory Ascites

et al. 2023

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ImportanceThe potential association of low-volume paracentesis of less than 5 L with complications in patients with ascites remains unclear, and individuals with cirrhosis and refractory ascites (RA) treated with devices like Alfapump or tunneled-intraperitoneal catheters perform daily low-volume drainage without albumin substitution. Studies indicate marked differences regarding the daily drainage volume between patients; however, it is currently unknown if this alters the clinical course.ObjectiveTo determine whether the incidence of complications, such as hyponatremia or acute kidney injury (AKI), is associated with the daily drainage volume in patients with devices.Design, Setting, and ParticipantsThis retrospective cohort study of patients with liver cirrhosis, RA, and a contraindication for a transjugular intrahepatic portosystemic shunt who received either device implantation or standard of care (SOC; ie, repeated large-volume paracentesis with albumin infusion), and were hospitalized between 2012 and 2020 were included. Data were analyzed from April to October 2022.InterventionsDaily ascites volume removed.Main outcomes and MeasuresThe primary end points were 90-day incidence of hyponatremia and AKI. Propensity score matching was performed to match and compare patients with devices and higher or lower drainage volumes to those who received SOC.ResultsOverall, 250 patients with RA receiving either device implantation (179 [72%] patients; 125 [70%] male; 54 [30%] female; mean [SD] age, 59 [11] years) or SOC (71 [28%] patients; 41 [67%] male; 20 [33%] female; mean [SD] age, 54 [8]) were included in this study. A cutoff of 1.5 L/d or more was identified to estimate hyponatremia and AKI in the included patients with devices. Drainage of 1.5 L/d or more was associated with hyponatremia and AKI, even after adjusting for various confounders (hazard ratio [HR], 2.17 [95% CI, 1.24-3.78]; P = .006; HR, 1.43 [95% CI, 1.01-2.16]; P = .04, respectively). Moreover, patients with taps of 1.5 L/d or more and less than 1.5 L/d were matched with patients receiving SOC. Those with taps of 1.5 L/d or more had a higher risk of hyponatremia and AKI compared with those receiving SOC (HR, 1.67 [95% CI, 1.06-2.68]; P = .02 and HR, 1.51 [95% CI, 1.04-2.18]; P = .03), while patients with drainage of less than 1.5 L/d did not show an increased rate of complications compared with those receiving SOC.Conclusions and RelevanceIn this cohort study, clinical complications in patients with RA performing low-volume drainage without albumin infusion were associated with the daily volume drained. Based on this analysis, physicians should be cautious in patients performing drainage of 1.5 L/d or more without albumin infusion.

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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis

Cited by 2,053 publications

References 616 publications

Patients with cirrhosis and SBP: Increase in multidrug‐resistant organisms and complications

Patients with cirrhosis and SBP: Increase in multidrug‐resistant organisms and complications

Renal Failure in Patients with Liver Cirrhosis: Novel Classifications, Biomarkers, Treatment

Daily Low-Volume Paracentesis and Clinical Complications in Patients With Refractory Ascites

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