Use of albumin infusion for cirrhosis-related complications: An international position statement

BACKGROUND & AIMS: Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. METHODS: Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. RESULTS: Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. CONCLUSIONS: Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. IMPACT AND IMPLICATIONS: Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion

A Viral Outcome

Lichen planus is a muco-cutaneous inflammatory disease of unknown origin which affects various regions of the body, mostly skin and oral mucosa. The association of lichen planus with chronic hepatitis C infection is well known, but a primary presentation of chronic hepatitis C infection with lichen planus is quite rare. In this report, a middle aged woman is presented, who had features of isolated severe ulcerating lichen planus of the tongue in whom an eventual diagnosis of chronic hepatitis C infection was made; one which responded to antiviral therapy. [Med-Science 2015; 4(3.000): 2589-92

Diagnosing cirrhosis – comprehension in a nut shell

Cirrhosis is a dynamic process that leads to progressive liver failure with development of portal hypertension and associated complications. Our current understanding of cirrhosis has come a long way from the time Rene Laennec first coined the term. Cirrhosis can be diagnosed with conformity utilizing histology, a trend that is changing in the current era of hemodynamic studies. To understand cirrhosis and its evolutionary stages, we must first understand fibrosis and the subsequent changes that occur, leading to cirrhosis at the histological level, correlate this with the investigational changes, and ultimately, know regarding hemodynamic progression. In this review, we discuss stages of cirrhosis from an investigational, imaging, histological and hemodynamic point of view; discuss the diagnosis of cirrhosis within the same aspects and in keeping with current changing scenarios

Hemostasis, Disorders of Coagulation and Transfusion in Cirrhosis

Coagulation disorders in liver diseases, especially cirrhosis occurs due to a complex play between procoagulant and anticoagulant factors. The understanding of bleeding and thrombosis in liver disease is fundamental to management and diagnosis of both these conditions that can occur in liver cirrhosis. In contrast to earlier teaching that considered cirrhosis to be an auto anticoagulated state, the current approach to considering it as a state of rebalanced hemostasis which can tip to either bleeding profile or thrombotic profile in the same patient has made way to considerable improvements in management and diagnosis of hemostatic and coagulation abnormalities in cirrhosis patients. The liver plays a central role in the four phases of clotting which includes platelet plug initiation and formation, coagulation cascade activity, clotting termination and clot removal by fibrinolysis. Multiple factors such as portal hypertension, decreased thrombopoetin production, endothelial dysfunction and thrombocytopenia and thrombocytopathy in cirrhosis pave way for coagulation abnormalities in this group of patients. Newer modalities like thromboelastography and thrombography have helped in making point of care reliable by improving assessment of coagulation processes globally and further studies and evidence point towards imparting a much better knowledge into this complex situation that is hemostasis/coagulation and liver disease. [Med-Science 2015; 4(3.000): 2610-49

Transjugular Intrahepatic Portosystemic Shunt in Chronic Portal Vein Thrombosis—From Routine Recommendations to Demanding Scenarios

Portal vein thrombosis (PVT), particularly the presence of portal cavernoma, was traditionally considered a relative contraindication for transjugular intrahepatic portosystemic shunting (TIPS) due to the technical difficulties in accessing and maneuvering the portal vein and avoiding the high risk for bleeding periportal collaterals. However, the last decade has seen a surge in the number of studies—mostly case reports and small series of patients—demonstrating that TIPS is not only technically feasible in the vast majority of these patients but also provides effective and long-term control of symptoms associated with portal hypertension in cases refractory to the standard line of therapy. The present article aims to provide a concise but exhaustive overview of the role and the standard and technically difficult TIPS placement scenarios in patients with chronic non-malignant PVT and with and without underlying liver disease. The review is strategically punctuated by exemplary instances from the authors’ experience

THE HEPATITIS B FLARE THAT WAS NOT

Background: Acute exacerbation of chronic hepatitis B virus occurs as either a flare of HBV in immune clearance phase or as a reactivation of HBV in patients with inactive or resolved HBV infection. In rare situations, HBV causes systemic autoimmunity that improves with antiviral therapy. However, in certain patients, puritan forms of autoimmune hepatitis develop independent of HBV that requires immunosuppressive therapy. Report: We present the case of a religious nun, who presented with suspected reactivation of HBV leading to jaundice and grade 2 hepatic encephalopathy not responding to 3 weeks of antiviral therapy with fluctuating jaundice and elevated transaminases. A timely liver biopsy based on a strong clinical suspicion led to a final diagnosis. We also briefly discuss the importance of liver biopsy in this scenario. Conclusion: We present the case of a patient who was incidentally detected to have HBV infection during work up of a flare of AIH. Treating physicians must be astute in analysing blood tests in the light of clinical symptoms and signs for comprehensive diagnosis of multiple insults that could occur in the liver

Sarcoidosis Presenting as Acute on Chronic Liver FailureReport of the First Case

Sarcoidosis is a multi system disease with different clinical presentations. Asymptomatic presentation is the commonest, but others include jaundice with chronic cholestasis, cirrhosis, portal hypertension, hepatic venous outflow tract obstruction and extrahepatic biliary obstruction. Cirrhosis and portal hypertension are the rarest manifestation of hepatic sarcoid and represent less than 1% of all cases. Acute on chronic liver failure as a presentation of sarcoidosis has never been reported before. Here we present a patient of sarcoidosis presenting with acute on chronic liver failure, and in whom, steroid therapy improved liver failure with a good outcome. [Med-Science 2016; 5(2.000): 655-65