Assessment of the Predictors and Mortality in Patients of Acute on Chronic Liver Failure; A Prospective Study

Objective: To evaluate the predictors of short-term mortality in patients with acute-on-chronic liver failure (ACLF). Methodology: This prospective study was conducted at the gastroenterology department of the Asian Institute of Medical Sciences Sindh, Pakistan from January 2018 to December 2018. All the patients with acute-on-chronic liver failure (ACLF) aged more than 25 years and of either gender were included. A complete history was obtained including demographic profile and specifics on clinical characteristics (jaundice, ascites, gastro-intestinal bleed, grade of encephalopathy, records of vital parameters etc.). Serum electrolytes, viral serology, autoimmune profile, liver function tests, serum creatinine, prothrombin time, and INR were among the laboratory tests performed on each patient. Results: A total of 99 patients were studied; their average age was 40.90+13.93 years; and there was a male predominance (73.5%). HCV and HBV+HDV were the most common etiological factors. According to the frequency of organ failure, hepatic failure was in 59.8% of the cases, renal failure was in 43.6% of the cases, CNS failure was in 38.5% of the cases, 41.0% of the cases had circulatory failure, coagulation failure was in 55.6% of the cases, and respiratory failure was seen in 17.1% of the cases. Overall, the 30-day mortality rate was 61.5%. Hepatic failure, renal failure, CNS failure, coagulation failure, SBP, and grading of ACLF were significantly associated with short-term survival rate (p= <0.05). While gender, etiology, circulatory failure and respiratory failure were statistically insignificant (p= >0.05). MELD score >28, CTP score >13, organ failure >3 and ACLF grade II and III were also highly significantly linked to short term survival rate (p-0.0001). Conclusion: According to the study's findings, hepatic failure, renal failure, CNS failure, coagulation failure, and ACLF grading, CTP score > 13, MELD score > 28, and the presence of hepato-renal syndrome were found to be significant predictors of short-term mortality in patients with Acute On-Chronic Liver Failure (ACLF)

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

Frequency of hepatocellular carcinoma in patients with hepatitis C received treatment with directly antiviral agents

Background and Aims: Hepatitis C infection is one of leading causes of liver cirrhosis and a considerable proportion of hepatocellular carcinoma worldwide. Despite the very high efficacy of Directly Acting Viral Agents (DAAs) on clearance of hepatitis C their role remains controversial on development of Hepatocellular Carcinoma. The Aim of this study is to analyze hepatocellular occurrence in hepatitis C patients after achieving Sustained virologic response on directly acting viral agent. Methods and Material: It is prospective study conducted on outpatients in the Hepato-gastroenterology department of Asian Institute of Medical Science Hospital Hyderabad from 21-10-2018 to 20-04-2019. All patients who fulfilled the criteria were enrolled, their baseline demographic characteristics, Child Pugh Class, MELD score, alpha-fetoprotein level and Ultrasound liver before and after treatment collected. Duration of DAAs treatment and type of DAAs used also noted. Hepatocellular carcinoma labelled when Triphasic CT scan liver shows typical characters of hepatocellular carcinoma i.e. arterial phase hyperenhancement and delayed washout on portal and venous phase or ultrasound liver shows focal liver lesion with alpha-fetoprotein level more than 300ng/ml. Results: One hundred fifty-seven patients of chronic hepatitis C enrolled in the study after exclusion criteria.&nbsp

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

BackgroundTranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding.MethodsWe did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124.FindingsBetween July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98).InterpretationWe found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial.</div