Identification de facteurs pronostiques délétères dans la cirrhose compliquée d'ascite réfractaire

Cirrhosis is characterized by the progressive development of portal hypertension. Portal hypertension, associated with sodium retention, leads to the formation of ascites. Ascites may be difficult to treat and, thereby, become "refractory". To date, the mortality of patients with refractory ascites remains high. In order to offer patients adequate treatment, it is important to identify complications that may develop and the factors of good and poor prognosis affecting their survival. One can retain five specific complications of cirrhosis with ascites: hepatorenal syndrome, spontaneous bacterial peritonitis, paracentesis induced circulatory dysfunction, hepatic hydrothorax and dilutional hyponatremia. This thesis reported an update of pathogenesis, complications and treatment of refractory ascites. Our original clinical research has, meanwhile, focused on the identification of different prognostic factors in refractory ascites in direct relation to these five complications. We have focused on the effect of the administration of beta blockers in patients with refractory ascites: this treatment is widely prescribed for prevention of gastrointestinal bleeding. It is associated in these patients with higher mortality and a high incidence of paracentesis induced circulatory dysfunction. We specified that the severe hyponatremia, leading to withhold diuretic therapy, is a more accurate prognostic factor than the MELDNa score in refractory ascites. With regard to the hepatorenal syndrome of slow onset (type 2), we emphasized the high frequency of this syndrome in refractory ascites. We showed that there was an association between the level of portal hypertension and the incidence of spontaneous bacterial peritonitis. Furthermore, we demonstrated that the presence of bacterial DNA in ascites of outpatients suffering from refractory ascites was particularly low. The detection of this DNA is not a precursor to infection of ascites. In conclusion, with a systematic analysis of various prognostic factors related to complications of ascites in cirrhotic patients, this work gives a better understanding of their chances of survival. This will allow a more adequate stratification in the decision trees for a cure of the disease such as liver transplantation.Doctorat en Sciences médicalesinfo:eu-repo/semantics/nonPublishe

Sleep disturbances in patients with liver cirrhosis: Prevalence, impact, and management challenges

Sleep–wake disturbances are common in liver cirrhosis and associated with impaired quality of life. The most common abnormalities are insomnia (difficulties falling asleep and maintaining sleep, or unrefreshing sleep), excessive daytime sleepiness, and sleep–wake inversion (disturbances of circadian rhythmicity). The underlying pathophysiological mechanisms for sleep disturbances in cirrhosis are complex and may include disturbed metabolism of melatonin and glucose, alterations in thermoregulation, and altered ghrelin secretion profiles. Sleep–wake abnormalities are related to the presence of hepatic encephalopathy (HE) and improvement in sleep parameters can be observed when HE is properly managed. A few non-specific treatments for sleep–wake abnormalities have been tried with encouraging results for hydroxyzine and modafinil. However, due to the potential for medication toxicity in these disabled patients, further studies are needed to address the potential role of non-drug therapies in this population (eg, cognitive behavioral therapy, mindfulness, yoga) that have demonstrated usefulness in insomnia disorders.SCOPUS: re.jinfo:eu-repo/semantics/publishe

Ageing and the liver

SCOPUS: cp.jinfo:eu-repo/semantics/publishe

Reply to: “Prevalent acute-on-chronic liver failure and response to corticosteroids in alcoholic hepatitis”

SCOPUS: le.jinfo:eu-repo/semantics/publishe

Klebsiella and E. Coli liver abscess associated with aerobilia: A case report

SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Facteurs associés à l’hypovitaminose D dans une population de patients séropositifs pour le VIH: Etude d’une cohorte de 2044 patients

info:eu-repo/semantics/nonPublishe

Combination ledipasvir-sofosbuvir for the treatment of chronic hepatitis C virus infection: A and clinical perspective

Chronic hepatitis C treatment has continued to evolve, and interferon-free, oral treatment with direct-acting antiviral agents is the current standard of care. Recently, a new treatment, which is a combination of two direct-acting antiviral agents, ledipasvir 90 mg (anti-NS5A) and sofosbuvir 400 mg (anti-NS5B), has been approved in the US and the European Union for the treatment of chronic hepatitis C viral infection. In Phase III trials among chronic hepatitis C virus genotype 1 monoinfected (treatment-naïve, treatment-experienced, and with advanced liver disease or posttransplant) patients and HIV–hepatitis C virus coinfected patients, the ledipasvir-sofosbuvir fixed-dose combination is associated with a higher rate of sustained virologic response at 12 weeks after therapy has ceased. According to preliminary data, the ledipasvir-sofosbuvir combination also may be effective against hepatitis C genotype 4 virus infection. The ledipasvir-sofosbuvir combination taken orally is generally well-tolerated. Moreover, the combination treatment may suppress the effect of predictive factors of chronic hepatitis C that have historically been known to be associated with treatment failure. Thus, the fixed-dose single-tablet combination of ledipasvir-sofosbuvir offers a new era for the effective treatment of a variety of patients suffering from chronic hepatitis C virus infection.SCOPUS: re.jinfo:eu-repo/semantics/publishe

Factors associated with vitamin D deficiency in a population of 2044 HIV-infected patients

Background and aims: The high prevalence of vitamin D deficiency in HIV-infected patients has been demonstrated but there are still controversies regarding to the role of antiretroviral therapy (ART) in this setting. The aims of this study was to validate factors associated with vitamin D deficiency in a large cohort of HIV-infected patients. Methods: A retrospective analysis of 2044 consecutive patients from December 2005 to March 2011 was conducted. Factors independently associated with vitamin D deficiency (<30 ng/ml and <10 ng/ml) were analyzed. Vitamin D levels were compared according to CD4 count, viral load and ART modalities. Results: vitamin D was <30 ng/ml in 89.2% and <10 ng/ml in 32.4%. The median value was 13.8 ng/ml (4-102). Winter season, female sex, heterosexual acquisition of HIV, the need of second lines (complex and sequential treatment modalities) and a longer duration of ART were independently associated with vitamin D deficiency (<30 ng/ml). CD4 count <200/μl, advanced stages of disease and the current efavirenz use were independently associated with severe vitamin D deficiency (<10 ng/ml). Median vitamin D levels was 14.1 ng/dl when CD4 ≥200/μl, 11.5 ng/dl when CD4<200 (p = 0.0003). The ART modalities had a significant influence on vitamin D concentrations, the highest vitamin D level was observed in the absence of treatment. Conclusions: In HIV-infected patients, vitamin D deficiency is associated with ART modalities and duration. The most severe vitamin D deficiencies are associated with low CD4 count, the use of efavirenz and advanced stages of disease severity. © 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Factors Associated with Vitamin D Insufficiency in a Population of HIV-Infected Patients

info:eu-repo/semantics/nonPublishe