End Stage Liver Disease
Romany TawfikGawrgyMoawed;
Abstract
Patients with cirrhosis who experience hepatic decompensation, such as the development of ascites, SBP, variceal hemorrhage, or hepatic encephalopathy, or who develop HCC, are at a higher risk of mortality. Significant strides have been made in the last few years in advancing our knowledge of the natural history of cirrhosis. This includes (1) a better understanding of the prognosis in compensated and decompensated cirrhosis, (2) improved estimates of the natural course of variceal bleeding in patients receiving standard of care therapy, (3) recognition of renal failure and infection as important determinants of the clinic course among cirrhotics, (4) realization of the importance of hepatic venous pressure gradient as a marker of prognosis, progression, and treatment response among cirrhotics, and (5) evolution of noninvasive studies of liver stiffness such as ultrasound-based transient elastography and magnetic resonance elastography as potential predictors of decompensated cirrhosis. We hope that studies evaluating the propensity to develop decompensated cirrhosis will be carried out in order to improve the natural history of cirrhosis.
Management should be focused on the prevention of recurrence of complications, and these patients should be referred for consideration of liver transplantation. Refinement in the clinical management strategies for patients with cirrhosis and its complications appear to continue to contribute to improved patient outcomes. Many recent studies have provided insight into the area of management of patients with CLD and in improving their outcomes. However, further research is still required, and in particular, in assessing the most cost-effective strategies. The best therapy for hepatic encephalopathy will require further study, particularly with regard to the emergence of rifaximin and its cost-effectiveness. Further studies, including prospective trials on the subject of the use of NSBBs in patients with ascites, are needed. Noradrenalin appears to be as effective as terlipressin for type 1 HRS, but we need to understand better which patients are most likely to respond. Survival is significantly reduced in patients with hemorrhagic ascites. PPI therapy appears to be important in patients with acute EVH.
Renal dysfunction is common in liver cirrhosis, especially in patients with refractory ascites and influences negatively their survival. Its precise assessment and early diagnosis before and after liver transplantation are of great significance for the therapeutic strategy and prognosis. This is especially important for the liver transplantation candidates, in whom the MELD index determines their priority. Bacterial infections continue to be a leading cause of mortality andacute-on-chronic liver failure in endstage liver disease (ESLD). The consequences of infection include prolonged hospitalisation, acute CV kidney injury (AKI), death, de-listing from liver transplant and susceptibility to further infections. Although SBEM is a rare complication of cirrhosis, the high mortality rate should increase physicians’ index of suspicion in cirrhotic patients with hydrothorax and prompt immediate diagnostic thoracentesis. The MELD-Na score rather than Child–Pugh score may be a strong predictor of in-hospital mortality of SBEM patients.
Prognosis is an essential part of the baseline assessment of any disease. For predicting prognosis of end-stage liver disease, many prognostic models were proposed. Child-Pugh score has been the reference for assessing the prognosis of cirrhosis for about three decades in end-stage liver disease. Despite of several limitations, recent large systematic review showed that Child-Pugh score was still robust predictors and it’s components (bilirubin, albumin and prothrombin time) were followed by Child-Pugh score. Recently, Model for end-stage liver disease (MELD) score emerged as a ‘‘modern’’ alternative to Child-Pugh score. The MELD score has been an important role to accurately predict the severity of liver disease and effectively assess the risk of mortality. Due to several weakness of MELD score, new modified MELD scores (MELD-Na, Delta MELD) have been developed and validated.
Screening for chronic liver disease can be performed inexpensively and easily with clinical history-taking, measurement of transaminase concentrations, upper abdominal ultrasonography, and transient elastography (where available). Abnormal findings should prompt specific diagnostic testing to determine the etiology of the underlying disease. In most patients, the dynamic process of progressive fibrosis, which could ultimately lead to cirrhosis, can be interrupted by the timely recognition of the risk, followed by appropriate treatment.
Numerous publications since have reported outcomes for MELD-based liver allocation in the United States and in many other areas around the world. Some of these reports have suggested changes to the MELD equation or other ways to adapt the system to more accurately reflect the need for transplant. The transparency that this type of system brings allows for much more rigorous assessment of results and for highlighting areas for improvement toward a more fair, equitable, and utilitarian system.
Management should be focused on the prevention of recurrence of complications, and these patients should be referred for consideration of liver transplantation. Refinement in the clinical management strategies for patients with cirrhosis and its complications appear to continue to contribute to improved patient outcomes. Many recent studies have provided insight into the area of management of patients with CLD and in improving their outcomes. However, further research is still required, and in particular, in assessing the most cost-effective strategies. The best therapy for hepatic encephalopathy will require further study, particularly with regard to the emergence of rifaximin and its cost-effectiveness. Further studies, including prospective trials on the subject of the use of NSBBs in patients with ascites, are needed. Noradrenalin appears to be as effective as terlipressin for type 1 HRS, but we need to understand better which patients are most likely to respond. Survival is significantly reduced in patients with hemorrhagic ascites. PPI therapy appears to be important in patients with acute EVH.
Renal dysfunction is common in liver cirrhosis, especially in patients with refractory ascites and influences negatively their survival. Its precise assessment and early diagnosis before and after liver transplantation are of great significance for the therapeutic strategy and prognosis. This is especially important for the liver transplantation candidates, in whom the MELD index determines their priority. Bacterial infections continue to be a leading cause of mortality andacute-on-chronic liver failure in endstage liver disease (ESLD). The consequences of infection include prolonged hospitalisation, acute CV kidney injury (AKI), death, de-listing from liver transplant and susceptibility to further infections. Although SBEM is a rare complication of cirrhosis, the high mortality rate should increase physicians’ index of suspicion in cirrhotic patients with hydrothorax and prompt immediate diagnostic thoracentesis. The MELD-Na score rather than Child–Pugh score may be a strong predictor of in-hospital mortality of SBEM patients.
Prognosis is an essential part of the baseline assessment of any disease. For predicting prognosis of end-stage liver disease, many prognostic models were proposed. Child-Pugh score has been the reference for assessing the prognosis of cirrhosis for about three decades in end-stage liver disease. Despite of several limitations, recent large systematic review showed that Child-Pugh score was still robust predictors and it’s components (bilirubin, albumin and prothrombin time) were followed by Child-Pugh score. Recently, Model for end-stage liver disease (MELD) score emerged as a ‘‘modern’’ alternative to Child-Pugh score. The MELD score has been an important role to accurately predict the severity of liver disease and effectively assess the risk of mortality. Due to several weakness of MELD score, new modified MELD scores (MELD-Na, Delta MELD) have been developed and validated.
Screening for chronic liver disease can be performed inexpensively and easily with clinical history-taking, measurement of transaminase concentrations, upper abdominal ultrasonography, and transient elastography (where available). Abnormal findings should prompt specific diagnostic testing to determine the etiology of the underlying disease. In most patients, the dynamic process of progressive fibrosis, which could ultimately lead to cirrhosis, can be interrupted by the timely recognition of the risk, followed by appropriate treatment.
Numerous publications since have reported outcomes for MELD-based liver allocation in the United States and in many other areas around the world. Some of these reports have suggested changes to the MELD equation or other ways to adapt the system to more accurately reflect the need for transplant. The transparency that this type of system brings allows for much more rigorous assessment of results and for highlighting areas for improvement toward a more fair, equitable, and utilitarian system.
Other data
| Title | End Stage Liver Disease | Other Titles | المرحله النهائيه لمرض الكبد | Authors | Romany TawfikGawrgyMoawed | Issue Date | 2015 |
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