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Biomedical subjects

M Navasa

Publications and source records attributed to M Navasa.

At least 91 records · Page 5Linked to original sources
PubMed1994

Spontaneous bacterial peritonitis in liver cirrhosis: treatment and prophylaxis.

Spontaneous bacterial peritonitis in liver cirrhosis is due to the passage of intestinal bacteria into intestinal lymph vessels, systemic circulation and ascitic fluid. It may occur in patients with severe portal hypertension and hepatic failure, impaired reticuloendothelial phagocytic activity and low ascitic fluid opsonic activity. Spontaneous bacterial peritonitis is a monomicrobial infection usually caused by gram-negative bacteria. The treatment of choice of spontaneous bacterial peritonitis is cefotaxime. Several subgroups of cirrhotic patients have been shown to be predisposed to develop spontaneous bacterial peritonitis, including cases with gastrointestinal hemorrhage, patients with high serum bilirubin and low ascitic fluid protein concentration (< 1 g/dl), and patients who had recovered from an episode of spontaneous bacterial peritonitis. Since spontaneous bacterial peritonitis is associated with a relatively high in-hospital mortality rate (20-40%), prophylactic measures to prevent this infection are required. Short-term and long-term selective intestinal decontamination with oral norfloxacin has proved highly effective in preventing bacterial infection and spontaneous bacterial peritonitis in bleeding cirrhotic patients as well as recurrence of spontaneous bacterial peritonitis.

Cefotaxime↗
PubMed1994

Cyclosporin A increases the biochemical markers of bone remodeling in primary biliary cirrhosis.

To assess whether cyclosporin A has any influence on the bones of patients with primary biliary cirrhosis, bone mineral density, vertebral fractures and biochemical and hormonal parameters of bone mineral metabolism were evaluated in 38 female patients with primary biliary cirrhosis who, 7 to 47 months previously, had been randomized to receive cyclosporin A (n = 18) or placebo (n = 20). Bone mineral density and vertebral fractures were reevaluated after 12 to 47 months in 19 of these patients (ten with cyclosporin and nine with placebo). Serum osteocalcin levels in patients taking cyclosporin (median, range: 7.8, 4.2-16 ng/ml) were similar to healthy female controls (6.0, 4.7-9.5 ng/ml), and significantly higher than in patients receiving placebo (5.4, 1.0-8.6 ng/ml, p < 0.02). Patients treated with cyclosporin showed a higher urinary hydroxyproline/creatinine ratio (0.097, 0.025-0.138) than patients with placebo (0.031, 0.022-0.044) (0.05 > p < 0.1), and healthy controls (0.032, 0.021-0.048) (p < 0.001). Urinary hydroxyproline was above normal levels in six of nine patients treated with cyclosporin. Circulating parathyroid hormone levels were also higher in patients treated with cyclosporin (4.3, 2.0-9.0 pmol/l) than in those with placebo (3.1, 1.1-5.1 pmol/l) (p < 0.001), and healthy controls (2.9, 1.1-6.9 pmol/l) (p < 0.001). In four patients treated with cyclosporin the parathyroid hormone levels were above normal values. No patient had renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Bone fractures in liver transplant patients.

Atraumatic bone fractures are a frequent complication in orthotopic liver transplantation (OLT). A retrospective study of 91 adult OLT patients was carried out to detect the prevalence of bone fractures, and to isolate predictive factors for their development. After OLT 22 patients (24%) developed 56 atraumatic bone fractures. All fractures occurred within the first 13 months following OLT. No predictive pre- or post-OLT risk factors for the development of bone fractures were identified.

Adult↗
PubMed1994

Predictive factors of in-hospital CNS complications following liver transplantation.

We prospectively evaluated 84 consecutive adult patients with chronic liver disease before and after liver transplantation to define the type and frequency of post-transplant neurologic complications, and to assess possible pretransplant and operative variables associated with in-hospital CNS complications. There were 25 patients (30%) who presented 23 neurologic complications of the central and six of the peripheral nervous system. Seventy-five percent of the complications occurred in the first month post-transplant. The most frequent CNS complications included anoxic (six patients) and septic (five) encephalopathy, as well as brain hemorrhage (five). Patients who presented CNS complications had a higher mortality rate than those who did not (55% versus 17%, p = 0.002). Multiple logistic regression analysis showed abnormal pretransplant neurologic examination suggestive of chronic hepatic encephalopathy (p = 0.007) and noncholestatic liver disease (p = 0.012) to be independently associated with in-hospital CNS complications. These data indicate that CNS neurologic complications following liver transplant are common in patients with noncholestatic liver disease and are associated with increased mortality. The pretransplant neurologic examination is an important predictor of CNS complications that occur in the immediate post-transplant period.

Adult↗
PubMed1993

On the reliability of clinical criteria for the diagnosis of hepatic veno-occlusive disease.

Among 217 patients who received an allogeneic (136 cases) or autologous (81 cases) bone marrow transplant, the diagnosis of hepatic veno-occlusive disease (VOD) was established in 38 according to Seattle clinical criteria. Thirty-two underwent a transjugular liver biopsy and measurement of the hepatic venous pressure gradient (HVPG). The study was completed in 30 patients with no serious complications. Hepatic VOD was histologically confirmed in 18 patients (60%); the remaining 12 were classified as non-VOD. An increased HVPG discriminated well between VOD and non-VOD cases. Thus, hemodynamic data can considerably reinforce the accuracy of histological diagnosis. The predictive value of two vs. three clinical data of the Seattle criteria was analyzed. Among the 19 cases fulfilling two clinical data VOD was confirmed in only eight (42%), whereas VOD was proved in ten of 11 cases (91%) (p = 0.02) suspected on the basis of three clinical data. When reliability of the Baltimore clinical criteria was analyzed, the result was identical to that observed when three Seattle clinical data were present. The specificity of the latter classification was high (92%) while its sensitivity was relatively low (56%). In conclusion, clinical criteria are not reliable for either recognizing or excluding the diagnosis of VOD. Thus, a transjugular liver biopsy, associated with hemodynamic evaluation, is strongly recommended when VOD is clinically suspected.

Adolescent↗
PubMed1993

Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites.

BACKGROUND: The aim of the study was to investigate the incidenc, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. METHODS: The study is a follow-up investigation in 234 nonazotemic patients with cirrhosis and ascites. Thirty-nine variables obtained at inclusion were analyzed as possible predictors of hepatorenal syndrome occurrence (Kaplan-Meier method, Mantel-Cox test, and step-wise Cox regression procedure). RESULTS: The probability of hepatorenal syndrome occurrence was 18% at 1 year and 39% at 5 years. Sixteen variables had predictive value for hepatorenal syndrome occurrence in the univariate analysis: history of ascites, hepatomegaly, nutritional status, blood urea nitrogen level, serum creatinine concentration, serum sodium and potassium concentration, serum and urine osmolality, urinary sodium excretion, free water clearance after a water load, glomerular filtration rate, arterial pressure, plasma renin activity, plasma norepinephrine concentration, and esophageal varices. Neither etiology (alcoholic vs. nonalcoholic) nor the Child-Pugh score had predictive value. A multivariate analysis disclosed only three independent predictors of hepatorenal syndrome occurrence: low serum sodium concentration, high plasma renin activity, and absence of hepatomegaly. CONCLUSIONS: The hepatorenal syndrome is a relatively frequent complication in cirrhotic patients with ascites that is associated with an extremely short survival. Liver size, plasma renin activity, and serum sodium concentration are predictors of hepatorenal syndrome occurrence in these patients.

Adult↗
PubMed1993

Cyclosporin A treatment in primary biliary cirrhosis: results of a long-term placebo controlled trial.

BACKGROUND: Effective treatment for primary biliary cirrhosis (PBC) resulting in slower progression and improved survival remains elusive. Cyclosporin A (CyA), which has been so effective in preventing human allograft rejection, has shown promise in small numbers of patients in early studies. METHODS: Three hundred forty-nine patients with PBC were randomized to receive CyA, 3 mg.kg-1.day-1, or placebo in a multicenter study with follow-up for 6 years. The end point was death or liver transplantation. RESULTS: Cox multivariate analysis showed time from entry to death or transplantation was significantly prolonged (by up to 50%) in the CyA-treated group. Liver-related mortality was also significantly lower. However, a univariate analysis of survival showed no statistical differences between the two groups. Biochemical liver indices deteriorated more slowly in the CyA-treated group, but serum creatinine concentration was elevated > 150 mumol/L in 9%, necessitating permanent discontinuation in half of these. A reduction in the dose of CyA was required in 11% because of hypertension. CONCLUSIONS: CyA has some therapeutic potential in primary biliary cirrhosis, providing blood pressure and renal function are closely monitored.

Adult↗
PubMed1993

Liver transplantation for acute liver failure: analysis of applicability.

BACKGROUND: Liver transplantation has emerged as the most important advance in the therapy of acute liver failure. To assess the applicability of liver transplantation in this setting, the outcome of 62 patients with acute liver failure consecutively admitted to hospital was analyzed. METHODS: Criteria for indicating liver transplantation were grade III-IV hepatic encephalopathy or progression of encephalopathy following a transient improvement. In subfulminant cases, liver transplantation was also indicated when no improvement was observed after a 3-day period of conservative treatment. RESULTS: Thirteen (21%) of the 62 patients never met criteria for transplant indication; all of them were discharged after receiving conventional therapy. Twenty-one (34%) patients with criteria for indicating liver transplantation could not receive the transplant because of either contraindications (17 patients; only 1 being discharged from hospital) or death before donor organ availability (4 patients). Finally, 28 (45%) patients received a liver transplant and 22 were discharged from hospital. CONCLUSIONS: The applicability of liver transplantation in acute liver failure is relatively low. Considering the high survival rate (79%) obtained in the patients with transplantations and the poor survival rate (6%) observed in those who could not be transplanted, efforts should be made to increase liver transplant applicability to improve the prognosis in acute liver failure.

Adolescent↗
PubMed1993

Sacral stress fracture after liver transplantation.

Sacral insufficiency fractures have been related to osteoporosis and steroid therapy, however only one case has been reported following liver transplantation. We describe three patients who developed insufficiency fractures of the sacrum following liver transplantation, these fractures could be overlooked or confused with inflammatory processes involving the sacrum.

Female↗
PubMed1993

Determinants of ethanol and acetaldehyde metabolism in chronic alcoholics.

We have studied the factors determining the rate of ethanol and acetaldehyde metabolism in a group of 25 alcoholics with varying degrees of liver lesion (from normal liver to cirrhosis) and in six nonalcoholic cirrhotics. In alcoholics the ethanol metabolic rate was related to hepatic function, estimated either by the aminopyrine breath test (r = 0.70, p < 0.001) or the indocyanine green clearance (r = 0.76, p < 0.01), and was independent of the activity of hepatic alcohol dehydrogenase and hepatic blood flow. In nonalcoholic cirrhotics blood acetaldehyde was always below the detection limit (0.5 microM), but elevated levels were found in 14 out of the 25 alcoholics. Alcoholics with elevated blood acetaldehyde showed a significantly higher ethanol metabolic rate than alcoholics with undetectable acetaldehyde (120 +/- 17 mg/kg/hr vs 104 +/- 11 mg/kg/hr, p < 0.02), but no differences were observed in the activities of alcohol and aldehyde dehydrogenases. Peak blood acetaldehyde levels were directly related to the ethanol metabolic rate (r = 0.48, p < 0.02), but not to activities of hepatic alcohol or aldehyde dehydrogenases. These results indicate that in chronic alcoholics the main determinant of the ethanol metabolic rate is hepatic function, while the rise of blood acetaldehyde is mainly dependent on the ethanol metabolic rate. Alcohol and aldehyde dehydrogenase activities do not seem to be rate-limiting factors in the oxidation of ethanol or acetaldehyde.

Acetaldehyde↗
PubMed1993

Treatment of small hepatocellular carcinoma in cirrhotic patients: a cohort study comparing surgical resection and percutaneous ethanol injection.

This study was intended to compare the survival rates of two contemporary cohorts of patients with solitary hepatocellular carcinomas < or = 4 cm subjected to surgical resection (n = 33) or percutaneous ethanol injection (n = 30). Outcomes in a third cohort, 21 patients with hepatocellular carcinoma who underwent orthotopic liver transplantation, were also assessed. Surgical and ethanol-treated patients were similar with regard to age and tumor stage, differing only in liver function; 30 of the 33 surgical patients were of Child-Pugh class A, whereas only 7 of the 30 ethanol-treated patients were of class A (p < 0.05). Surgical resection was successful in 30 cases; ethanol injection achieved initial success in 23 patients. Tumor recurrence rate at 2 yr was 45% in the surgical group and 66% in the ethanol group. The difference was significant only for cases with tumors between 3 and 4 cm. Despite poorer liver function, the 1-, 2-, 3- and 4-yr survival rates of ethanol-treated patients (83%, 66%, 55% and 34%, respectively) were not different from those of surgically treated patients (81%, 73%, 44% and 44%, respectively). The 1- and 2-yr survival rates of patients given liver transplants were 81% and 66%, without tumor recurrence, after 16-mo follow-up. These data confirm that ethanol injection is a useful treatment for patients with solitary small hepatocellular carcinomas and suggest that surgical resection and liver transplantation may achieve better results only after strict candidate selection to reduce mortality and tumor recurrence during follow-up.

Actuarial Analysis↗
PubMed1993

Spontaneous bacterial peritonitis in cirrhosis: predictive factors of infection resolution and survival in patients treated with cefotaxime.

Cefotaxime is the most commonly used antibiotic for initial therapy of spontaneous bacterial peritonitis in cirrhosis. However, since the introduction of cefotaxime no study has been performed to investigate factors influencing prognosis in cirrhotic patients with this type of infection. In this study, predictive factors for infection resolution and patient survival were investigated in 213 consecutive episodes of spontaneous bacterial peritonitis in 185 cirrhotic patients. All patients were initially treated with cefotaxime. One hundred sixty-five episodes (77%) resolved with cefotaxime alone, and two more episodes (1%), initially unresponsive to cefotaxime, were cured after modification of antibiotic therapy. In a multivariate analysis (stepwise logistic regression), only 4 of 51 clinical and laboratory variables obtained at the time of diagnosis of infection were identified as independent predictors of infection resolution: band neutrophils in white blood cell count, community-acquired vs. hospital-acquired peritonitis, blood urea nitrogen level and serum aspartate aminotransferase level. No patient experienced serious adverse effects related to cefotaxime. Eighty-two patients died during hospitalization (38% mortality rate in relation to the 213 episodes of peritonitis). In the multivariate analysis, six variables were independently correlated with survival: blood urea nitrogen level, serum aspartate aminotransferase level, community-acquired vs. hospital-acquired peritonitis, age, Child-Pugh score and ileus. No microbiological data had predictive value for infection resolution or survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Transjugular liver biopsy in BMT.

With the aim of evaluating liver disturbances after BMT in 76 patients, the hepatic venous pressure gradient was measured and a transvenous liver biopsy was performed through the jugular vein. Catheterization was successful in 71 patients (93%). In 11 cases the procedure was performed twice, yielding a total number of 82 studies. In five (6%) liver biopsies were non-evaluable. Complications were rare (7%), minor and reversible. As a result of this procedure, the diagnosis was modified in 45%, with both the diagnosis and treatment being modified in 30% of patients. Veno-occlusive disease (VOD) was histologically demonstrated in 15 out of 26 patients (58%) in whom this complication was suspected and in two out of 33 (6%) in whom it was not. Acute GVHD of the liver was confirmed in 15 out of the 35 patients (43%) in whom this complication was suspected and in four of 24 (17%) in whom it was not. The hepatic venous pressure gradient was significantly higher in VOD than in liver GVHD. Whereas 14/17 (82%) patients with VOD had a gradient pressure higher than 9 mmHg, no patient with GVHD had a gradient above this value. We conclude that transjugular liver biopsy is an effective, safe, and useful technique to evaluate BMT related liver dysfunction.

Biopsy↗
PubMed1993

Hemodynamic and humoral changes after liver transplantation in patients with cirrhosis.

Splanchnic and systemic hemodynamics and plasma levels of aldosterone, glucagon and plasma renin were investigated in 12 patients with advanced cirrhosis before and 2 wk (14.6 +/- 2.8 days) and 2 mo (60.8 +/- 10.5 days) after orthotopic liver transplantation. Liver transplant was followed by significant (p < 0.01) changes in systemic hemodynamics at 2 wk, with a marked reduction in cardiac index (4.9 +/- 0.8 vs. 3.7 +/- 0.7 L/min.m2) and increases in mean arterial pressure (79 +/- 8 vs. 101 +/- 11 mm Hg) and peripheral vascular resistance (721 +/- 149 vs. 1,274 +/- 253 dyn.sec.cm-5). Two months after liver transplant, we saw further significant increases in peripheral vascular resistance (1,700 +/- 341 dyn.sec.cm-5; p < 0.05) without changes in cardiac index. Hepatic venous pressure gradient, very high before transplantation, was normal 2 wk after liver transplant (18.7 +/- 3.0 vs. 2.1 +/- 0.8 mm Hg; p < 0.01). Hepatic blood flow rose markedly from 1.03 +/- 0.46 to 2.25 +/- 0.79 L/min (p < 0.01) and was still elevated at 2 mo (1.84 +/- 0.74 L/min). Azygos blood flow had not changed after 2 wk with respect to pretransplant values (0.65 +/- 0.26 vs. 0.69 +/- 0.39 L/min) but had decreased significantly at 2 mo (0.39 +/- 0.16 L/min; p < 0.05). The elevated aldosterone, plasma renin and glucagon levels found in our cirrhotic patients before transplantation decreased to near-normal values 2 wk after the procedure. These results suggest that most of the hemodynamic and humoral abnormalities characteristic of advanced cirrhosis are reversed after liver transplant.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamics↗
PubMed1992

[Prognostic value of hepatic clearance of indocyanine green in patients with liver cirrhosis and hemorrhage of esophageal varices].

BACKGROUND: The prognostic value of the quantitative tests of hepatocellular function are not clearly established. Although these tests have significantly correlated with the Child-Pugh classification, it has not been demonstrated that they are better than the same in regards to prognosis. METHODS: The present study was aimed at investigating the prognostic values of hepatic clearance and the intrinsic clearance of indocyanine green (ICG) in 91 cirrhotic patients who had presented hemorrhage due to rupture of the esophageal varices. The clinical and biochemical data, portal pressure determined during suprahepatic vein catheterization, and the clearance, intrinsic clearance, extraction and hepatic blood flow measured during continual infusion of ICG were included in the analysis. All these data were obtained following the stabilization of the patients once over the hemorrhagic episode. RESULTS: The mean survival of the series was 48 months. During follow up (25 +/- 17, interval 1-58 months) 3 of the 32 patients died (9%) of group A of the Child-Pugh classification, 17 of the 52 patients of group B (33%) and 6 of the 7 patients of group C (85%). The Child-Pugh classification was the only variable with an independent predictive value in the multivariate analysis in the Cox model. On exclusion of the 7 patients pertaining to group C, whose survival was clearly inferior to that of the rest of the series, the variables with independent predictive value were, hepatic clearance of less than 240 ml/min and the presence of ascites, while the Child-Pugh classification had no independent predictive value on survival. CONCLUSIONS: The results of the present study indicate that hepatic clearance of ICG and the presence of ascites may have prognostic value in patients of Child-Pugh classification A and B who have recovered from a hemorrhagic episode due to rupture of esophageal varices.

Adult↗