Direct-Acting Antivirals in Chronic Hepatitis C Infection with Liver Cirrhosis

Chronic hepatitis C infection is a common cause of liver morbidity and mortality across the world, in part due to complications including cirrhosis and hepatocellular carcinoma. The advent of Direct-acting antiviral (DAA) therapy has the potential to change the outcome of HCV infection in the vast majority of patients. Unfortunately, the chronic nature of HCV infection means that many patients requiring direct-acting antiviral (DAA) therapy have already developed compensated cirrhosis. This chapter reviews the importance of DAAs in the treatment of HCV infection, particularly in patients with existing compensated cirrhosis. Both efficacy and safety are discussed as essential endpoints of DAA therapy. Decompensated cirrhosis, treatment failures, vitamin-D deficiency, HIV co-infection, and ethnic differences in the context of treatment response are also discussed in this chapter

Liver Assist Devices for Liver Failure

Historically, mortality rates for liver failure have been high, regardless of the type. With new advancements in liver transplantation (LTx), 1-year survival rates have improved up to 95% in most recent estimates. While some patients may live past the critical period, the majority of patients do not survive the interval period for awaiting LTx or liver regeneration. The function of the liver to detoxify and correct several biochemical parameters has been achieved to some extent through artificial liver support technology, although constant innovations are still being developed for the most optimal liver support device. The complex function of the liver makes it challenging since it does not only detoxify toxic by-products but also participates in numerous other synthetic and metabolic functions of the body. Liver support systems are divided into an artificial liver assist device (ALD) and a bioartificial liver assist device (BLD). ALDs include molecular adsorbent recirculating system (MARS), Prometheus, single-pass albumin dialysis, and selective plasma filtration therapy. These devices work as a blood purification system of the liver. On the other hand, BLD has hepatic cell lines incorporated in its equipment, which aims to function as a complex biological liver system providing support to its biochemical processes. Several clinical and randomized trials have conflicting results on the survival of the patients with acute liver failure (ALF), and the ideal liver support system still seems a far-off goal

End-Stage Renal Disease and Lower Gastrointestinal Bleeding—a Propensity-Matched Analysis of Nationwide Inpatient Sample

Aims: We aim to determine the influence of lower gastrointestinal bleeding (LGIB) on mortality, morbidity, length of hospital stay and resource utilisation in end-stage renal disease (ESRD) patients. Material and Methods: The National Inpatient Sample database (2016 &2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of ESRD and LGIB. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS) and total costs between propensity-matched groups of ESRD patients with LGIB versus ESRD patients. Results: We identified 2 187 954 ESRD patients, of whom 242 075 has LGIB, and 1 945 879 were ESRD patients. The in-hospital mortality was higher in ESRD with LGIB (OR 2.5, 95% CI 1.5-2.2; P =.00). ESRD with LGIB has higher odds of mechanical ventilation (OR 1.4, 95% CI 6.4-16.4; P =.00), and shock requiring vasopressor (OR 1.2, 95% CI 4.9-5.4; P =.002). Advanced age (OR 1.02 CI 1.02-1.03 P =.00), anaemia (OR 1.04 CI 1.59-1.91 P =.006), acute coronary syndrome (OR 1.8 CI 1.6-2.1, P =.00), acute respiratory failure (OR 1.29 CI 2.0-2.6, P =.00), mechanical ventilation (OR 1.9, CI 3.5-4.4, P =.00) and sepsis (OR 1.5, CI 4.1-5.08, P =.00) were identified as predictors of mortality in ESRD with LGIB. Mean LOS (10.8 ± 14.9 vs 6.3 ± 8.5, P \u3c.01) and mean total charges (37 054 $vs 18 080$, P \u3c.01) were also higher. Conclusions: In this propensity-matched analysis, ESRD with LGIB was associated with higher odds of in-hospital mortality, mechanical ventilation and shock requiring vasopressor. Mean LOS and resource utilisation were also higher

Moderate Hypertriglyceridemia Causing Recurrent Pancreatitis: A Case Report and the Literature Review

Recurrent acute pancreatitis secondary to hypertriglyceridemia (HTG) with levels below 1000 mg/dL has been rarely reported in the literature. HTG is the third most common cause of acute pancreatitis and has been established in the literature as a risk factor when levels are greater than 1000 mg/dL. A 43-year-old patient presented to the hospital with severe epigastric abdominal pain. Initial laboratory investigations were significant for a lipase level of 4143 U/L and a triglyceride level of 600 mg/dL. Computed tomography (CT) of the abdomen showed diffuse enlargement of the pancreas consistent with pancreatitis. A diagnosis of severe acute pancreatitis secondary to high triglycerides was made based on the revised Atlanta classification 2012. The patient was initially managed with intravenous boluses of normal saline followed by continuous insulin infusion. Diabetic Ketoacidosis (DKA) was ruled out due to a past medical history of diabetes. Her clinical course was complicated by acute respiratory distress syndrome requiring intubation and mechanical ventilation. During the course, she improved symptomatically and was extubated. She was started on nasogastric feeding initially and subsequently switched to oral diet as tolerated. After initial management of HTG with insulin infusion, oral gemfibrozil was started for long-term treatment of HTG. Emerging literature implicates HTG as an independent indicator of poor prognosis in acute pancreatitis (AP). Despite the paucity of data, the risk of developing AP must be considered even at triglyceride levels lower than 1000 mg/dL

Valproic acid induced acute liver injury resulting in hepatic encephalopathy- a case report and literature review

Valproic acid (VPA) is a commonly used agent in the management of seizures and psychiatric disorders. Hyperammonemia is a common complication of VPA with 27.8% of patients having elevated levels – that is unrelated to hepatotoxicity and normal transaminases. Common side effects include obesity, insulin resistance, metabolic disorder and severe forms of hepatotoxicity. Other rare and idiosyncratic reactions have been reported, one of which is presented in our case. A 27-year old patient presented with hyperammonemia and encephalopathy as a consequence of idiosyncratic VPA reaction causing drug-induced liver injury (DILI) with severely elevated transaminases. DILI is commonly overlooked when investigating encephalopathy in the setting of VPA. Physicians should consider DILI in the context of hyperammonemia and transaminitis

Clozapine-Induced Cardiotoxicity Presenting as Sepsis: A Case Report and Literature Review

Clozapine is an atypical antipsychotic agent indicated in the treatment of medication-resistant schizophrenia. It is often reserved as a last line of treatment owing to the potential for serious and potentially life-threatening side effects, the most serious being agranulocytosis requiring close hematological monitoring and possible discontinuation of the medication from further use in the patient even when the agranulocytosis resolves. Other complications of clozapine include sedation, weight gain, elevated triglyceride levels, postural hypotension, and tachycardia. However, the potentially serious complication of myocarditis, though rare (with an incidence of 3%), may lead to cardiomyopathy as described in our present case. We present a 21-year-old patient who was started on clozapine for management of schizophrenia. He developed fever and tachycardia and was admitted to the medical unit on intravenous antibiotics for management of sepsis as he met the criteria for systemic inflammatory response syndrome. His labs revealed an elevated troponin and trending eosinophilia, which, in the context of clozapine use, raises the suspicion of clozapine cardiotoxicity. Echocardiogram showed reduced systolic function (45%). Clozapine was immediately discontinued, and his repeat echocardiogram showed normalization of his systolic function. In view of the increased prevalence of psychiatric illnesses, internists should be aware of rare but potentially life-threatening side effects

A Rare Case of Acute Pancreatitis Due to Very Severe Hypertriglyceridemia (>10 000 mg/dL) Successfully Resolved With Insulin Therapy Alone: A Case Report and Literature Review

A 48-year-old male presented to the psychiatric emergency room for dysmorphic mood. He was admitted to medical service for the management of hyponatremia, which was discovered in his initial laboratory workup. After the first day of admission, he developed abdominal pain and fever, and subsequent laboratory work revealed a triglyceride level of 10 612 mg/dL (reference range = 0-194 mg/dL). Computed tomography scan of the abdomen and pelvis revealed a hypodense lesion in the pancreas surrounded by a moderate amount of peripancreatic fluid suggestive of hemorrhagic pancreatitis. Based on the laboratory findings and imaging, we diagnosed acute pancreatitis (AP) secondary to hypertriglyceridemia. The patient was initiated on intravenous fluids and insulin to help decrease the triglyceride level with the plan to initiate apheresis. However, the patient improved on insulin therapy alone, which negated the need for apheresis, and the patient was discharged with fenofibrate with no further complications. While elevated triglycerides are a well-known cause of AP, we sought to assess various treatment options in management, especially considering a severely elevated triglyceride level of >10 000 mg/dL. Along with supportive care in AP, there are additional options in hypertriglyceridemia AP, including heparin, insulin, apheresis, antioxidants, and fibrates. Currently, there are no clear guidelines favoring one therapeutic option over the other