Evolución clínica y pronóstico de la ascitis neutrocítica con cultivo negativo (ANCN) y la peritonitis bacteriana espontánea (PBE)

263 pacients cirròtics que van presentar la primera descompensació ascítica es van seguir de forma prospectiva. A tots els pacients se'ls va realitzar anàlisi del líquid ascític. 58 pacients van desenvolupar 83 episodis d'infecció del líquid ascític. En 44 episodis el cultiu va ser negatiu i en 37 va ser positiu. A l'ingrès, els pacients amb ANCN van presentar una funció hepàtica i renal millor que aquells amb ANCN. La infecció del líquid ascític es va resoldre més precoçment als pacients amb ANCN, amb una menor incidència d'insuficiència renal. Es va observar una tendència a presentar una menor mortalitat acumulada a l'any al grup de pacients amb ANCN. La ANCN apareix sobretoto en cirròtics amb una malaltia hepàtica menys evolucionada.263 pacientes cirróticos que presentaron la primera descompensación ascítica fueron seguidos de forma prospectiva. En todos los pacientes se realizó análisis del líquido ascítico. 58 pacientes desarrollaron 83 episodios de infección del líquido ascítico. En 44 episodios el cultivo fue negativo y en 37 fue positivo. Al ingreso, los pacientes con ANCN presentaban una función hepática y renal mejor que aquéllos con PBE. La infección del líquido ascítico se resolvió de forma más precoz en los pacientes con ANCN, con una menor incidencia de insuficiencia renal. Se observó una tendencia a presentar una menor mortalidad acumulada al año en el grupo de pacientes con ANCN. La ANCN acontece principalmente en cirróticos con una enfermedad hepática menos evolucionada

Effect of rifaximin on infections, acute-on-chronic liver failure and mortality in alcoholic hepatitis: A pilot study (RIFA-AH)

Background & aims: Alcoholic hepatitis (AH) is associated with a high incidence of infection and mortality. Rifaximin reduces bacterial overgrowth and translocation. We aimed to study whether the administration of rifaximin as an adjuvant treatment to corticosteroids decreases the number of bacterial infections at 90 days in patients with severe AH compared to a control cohort. Methods: This was a multicentre, open, comparative pilot study of the addition of rifaximin (1200 mg/day/90 days) to the standard treatment for severe AH. The results were compared with a carefully matched historical cohort of patients treated with standard therapy and matching by age and model of end-stage liver disease (MELD). We evaluated bacterial infections, liver-related complications, mortality and liver function tests after 90 days. Results: Twenty-one and 42 patients were included in the rifaximin and control groups respectively. No significant baseline differences were found between groups. The mean number of infections per patient was 0.29 and 0.62 in the rifaximin and control groups, respectively (p = .049), with a lower incidence of acute-on-chronic liver failure (ACLF) linked to infections within the treatment group. Liver-related complications were lower within the rifaximin group (0.43 vs. 1.26 complications/patient respectively) (p = .01). Mortality was lower in the treated versus the control groups (14.2% vs. 30.9, p = .15) without significant differences. No serious adverse events were associated with rifaximin treatment. Conclusions: Rifaximin is safe in severe AH with a significant reduction in clinical complications. A lower number of infections and a trend towards a lower ACLF and mortality favours its use in these patients

Evolución clínica y pronóstico de la ascitis neutrocítica con cultivo negativo (ANCN) y la peritonitis bacteriana espontánea (PBE)

263 pacients cirròtics que van presentar la primera descompensació ascítica es van seguir de forma prospectiva. A tots els pacients se'ls va realitzar anàlisi del líquid ascític. 58 pacients van desenvolupar 83 episodis d'infecció del líquid ascític. En 44 episodis el cultiu va ser negatiu i en 37 va ser positiu. A l'ingrès, els pacients amb ANCN van presentar una funció hepàtica i renal millor que aquells amb ANCN. La infecció del líquid ascític es va resoldre més precoçment als pacients amb ANCN, amb una menor incidència d'insuficiència renal. Es va observar una tendència a presentar una menor mortalitat acumulada a l'any al grup de pacients amb ANCN. La ANCN apareix sobretoto en cirròtics amb una malaltia hepàtica menys evolucionada.263 pacientes cirróticos que presentaron la primera descompensación ascítica fueron seguidos de forma prospectiva. En todos los pacientes se realizó análisis del líquido ascítico. 58 pacientes desarrollaron 83 episodios de infección del líquido ascítico. En 44 episodios el cultivo fue negativo y en 37 fue positivo. Al ingreso, los pacientes con ANCN presentaban una función hepática y renal mejor que aquéllos con PBE. La infección del líquido ascítico se resolvió de forma más precoz en los pacientes con ANCN, con una menor incidencia de insuficiencia renal. Se observó una tendencia a presentar una menor mortalidad acumulada al año en el grupo de pacientes con ANCN. La ANCN acontece principalmente en cirróticos con una enfermedad hepática menos evolucionada

Diabetes mellitus mortality in Spanish cities: Trends and geographical inequalities

Aim: To analyze the geographical pattern of diabetes mellitus (DM) mortality and its association with socioeconomic factors in 26 Spanish cities. Methods: We conducted an ecological study of DM mortality trends with two cross-sectional cuts (1996–2001; 2002–2007) using census tract (CT) as the unit of analysis. Smoothed standardized mortality rates (sSMR) were calculated using Bayesian models, and a socioeconomic deprivation score was calculated for each CT. Results: In total, 27,757 deaths by DM were recorded, with higher mortality rates observed in men and in the period 1996–2001. For men, a significant association between CT deprivation score and DM mortality was observed in 6 cities in the first study period and in 7 cities in the second period. The highest relative risk was observed in Pamplona (RR, 5.13; 95% credible interval (95%CI), 1.32–15.16). For women, a significant association between CT deprivation score and DM mortality was observed in 13 cities in the first period and 8 in the second. The strongest association was observed in San Sebastián (RR, 3.44; 95%CI, 1.25–7.36). DM mortality remained stable in the majority of cities, although a marked decrease was observed in some cities, including Madrid (RR, 0.67 and 0.64 for men and women, respectively). Conclusions: Our findings demonstrate clear inequalities in DM mortality in Spain. These inequalities remained constant over time are were more marked in women. Detection of high-risk areas is crucial for the implementation of specific interventions.This work was partially supported by FIS (PI0426, PI081488, PI080330, PI081017, PI081713), the DGA (PI126/08), FUNCIS (PI84/07), Fundación Caja Murcia (FFIS/CM10/27), and by CIBER Epidemiología y Salud Pública (CIBERESP)

The prognostic Role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery

Background & aims: Surgery in cirrhosis is associated with a high morbidity and mortality. Retrospectively reported prognostic factors include emergency procedures, liver function (MELD/Child-Pugh scores) and portal hypertension (assessed by indirect markers). This study assessed the prognostic role of hepatic venous pressure gradient (HVPG) and other variables in elective extrahepatic surgery in patients with cirrhosis. Methods: A total of 140 patients with cirrhosis (Child-Pugh A/B/C: 59/37/4%), who were due to have elective extrahepatic surgery (121 abdominal; 9 cardiovascular/thoracic; 10 orthopedic and others), were prospectively included in 4 centers (2002-2011). Hepatic and systemic hemodynamics (HVPG, indocyanine green clearance, pulmonary artery catheterization) were assessed prior to surgery, and clinical and laboratory data were collected. Patients were followed-up for 1 year and mortality, transplantation, morbidity and post-surgical decompensation were studied. Results: Ninety-day and 1-year mortality rates were 8% and 17%, respectively. Variables independently associated with 1-year mortality were ASA class (American Society of Anesthesiologists), high-risk surgery (defined as open abdominal and cardiovascular/thoracic) and HVPG. These variables closely predicted 90-, 180- and 365-day mortality (C-statistic >0.8). HVPG values >16 mmHg were independently associated with mortality and values ≥20 mmHg identified a subgroup at very high risk of death (44%). Twenty-four patients presented persistent or de novo decompensation at 3 months. Low body mass index, Child-Pugh class and high-risk surgery were associated with death or decompensation. No patient with HVPG 0.63 developed decompensation. Conclusions: ASA class, HVPG and high-risk surgery were prognostic factors of 1-year mortality in cirrhotic patients undergoing elective extrahepatic surgery. HVPG values >16 mmHg, especially ≥20 mmHg, were associated with a high risk of post-surgical mortality.Supported in part by grants from Ministerio de Educacion yCiencia (SAF-2016-75767-R), and from Instituto de Salud CarlosIII (PIE 15/00027). CIBERehd is funded by Instituto de Salud Car-los III. ER was recipient of a Río Hortega award (2012–2014),Instituto de Salud Carlos III

Further decompensation in cirrhosis: Results of a large multicenter cohort study supporting Baveno VII statements

Background: The prognostic weight of further decompensation in cirrhosis is still unclear. We investigated the incidence of further decompensation and its effect on mortality in patients with cirrhosis.Methods: Multicenter cohort study. The cumulative incidence of further decompensation (development of a second event or complication of a decompensating event) was assessed using competing risks analysis in 2028 patients. A four-state model was built: first decompensation, further decompensation, liver transplant, death. A cause-specific Cox model was used to assess the adjusted effect of further decompensation on mortality. Sensitivity analyses were performed for patients included before or after 1999. Results: In a mean follow-up of 43 months, 1192 patients developed further decompensation and 649 died. Corresponding 5-year cumulative incidences were 52% and 35%, respectively. The cumulative incidences of death and liver transplant after further decompensation were 55% and 9.7%, respectively. The most common further decompensating event was ascites/complications of ascites. Five-year probabilities of state occupation were: 24% alive with first decompensation, 21% alive with further decompensation, 7% alive with liver transplant, 16% dead after first decompensation without further decompensation, 31% dead after further decompensation, and <1% dead after liver transplant. The hazard ratio for death after further decompensation adjusted for known prognostic indicators, was 1.46 (95% CI 1.23-1-711) (p<0.001). The significant impact of further decompensation on survival was confirmed in patients included before or after 1999. Conclusion: In cirrhosis, further decompensation occurs in approximately 60% of patients, significantly increases mortality, and should be considered a more advanced stage of decompensated cirrhosis