Related Articles

Protein-calorie malnutrition as a prognostic indicator of mortality among patients hospitalized with cirrhosis and portal hypertension.

Liver Int. 2009 Oct;29(9):1396-402

Authors: Sam J, Nguyen GC

BACKGROUND: We conducted a nationwide analysis of the prevalence of protein-calorie malnutrition (PCM) in patients with cirrhosis and portal hypertension (PHTN) and to determine its mortality and economic impact. METHODS: We used the Nationwide Inpatient Sample (NIS) to identify admissions throughout the US with cirrhosis and PHTN between 1998 and 2005 using the International Classification of Diseases, 9th Revision diagnostic codes. Prevalence of PCM in this group of patients with cirrhosis was compared with that of general medical inpatients. The impact of PCM on in-hospital mortality was quantified using multiple logistic regression analysis. RESULTS: There were 114 703 admissions with cirrhosis and PHTN in the NIS between 1998 and 2005. The prevalence of PCM was substantially higher among patients with cirrhosis and PHTN compared with general medical inpatients (6.1 vs. 1.9%, P<0.0001), with an adjusted odds ratio of 1.55 (95% CI: 1.4-1.7). There was greater prevalence of ascites (64.6 vs. 47.8%, P<0.0001) and hepatorenal syndrome (5.1 vs. 2.8%, P<0.0001) among those with PCM and cirrhosis. In-hospital mortality was two-fold higher among patients with cirrhosis and PCM (14.1 vs. 7.5%, P<0.0001), with an adjusted mortality of 1.76 (95% CI: 1.59-1.94). PCM was associated with greater length of stay (8.7 vs. 5.7 days, P<0.0001) and hospital charges (US$36 818 vs. US$22 673; P<0.0001) among patients with cirrhosis. CONCLUSIONS: PCM is more common among patients with cirrhosis and PHTN than the general medical population, and is associated with higher in-hospital mortality and resource utilization. PCM may be an indicator of greater disease severity and should be routinely assessed on admission.

PMID: 19602136 [PubMed - indexed for MEDLINE]

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The effect of 1 month of therapy with midodrine, octreotide-LAR and albumin in refractory ascites: a pilot study.

Liver Int. 2008 May 19;

Authors: Tandon P, Tsuyuki RT, Mitchell L, Hoskinson M, Ma MM, Wong WW, Mason AL, Gutfreund K, Bain VG

Background: The pathogenesis of refractory ascites (RA) is linked to splanchnic vasodilation. We hypothesized that a combination of midodrine, octreotide long-acting release (LAR) and albumin would result in increased natriuresis, better control of ascites and an improvement in renal function in patients with RA+/-Type 2 hepatorenal syndrome. Methods: A prospective pilot study in patients with RA as defined by the International Ascites Club. Consecutive patients received an intramuscular injection of octreotide-LAR, 50 g of albumin three times per week and midodrine titrated to increase the systolic blood pressure for 1 month. Results: Ten patients with RA were enrolled and eight with complete data to 1 month post-treatment were included in the analysis. There was no change in renal function but there was a trend towards a reduction in the volume of ascites removed by paracentesis (P=0.08) and a significant reduction in the plasma renin (P=0.01) and aldosterone concentrations (P=0.01). Interestingly, there was a transient worsening in the model for end-stage liver disease (MELD) score (P=0.01). The deterioration in MELD was completely reversible after discontinuation of therapy. Conclusions: To our knowledge, this is the first study of prolonged midodrine, octreotide and albumin therapy in RA. We observed a significant reduction in the plasma renin and aldosterone concentrations and a trend towards a reduction in the volume of ascites removed by paracentesis without an effect on renal function. The beneficial effects are at the expense of a reversible deterioration in the MELD score. Large controlled trials are needed before this therapy can be routinely recommended.

PMID: 18492024 [PubMed - as supplied by publisher]

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Prevention of paracentesis-induced circulatory dysfunction: midodrine vs albumin. A randomized pilot study.

Liver Int. 2008 Apr 10;

Authors: Appenrodt B, Wolf A, Grünhage F, Trebicka J, Schepke M, Rabe C, Lammert F, Sauerbruch T, Heller J

Background/Aims: Large-volume paracentesis in patients with cirrhosis and ascites induces arterial vasodilatation and decreases effective arterial blood volume, termed paracentesis-induced circulatory dysfunction (PICD), which can be prevented by costly intravenous albumin. Vasoconstrictors, e.g. terlipressin, may also prevent PICD. The aim was to compare the less expensive vasoconstrictor midodrine, an alpha-adrenoceptor agonist, with albumin in preventing PICD. Methods: Twenty-four patients with cirrhosis and ascites were randomly assigned to be treated with either midodrine (n=11) (12.5 mg three times per day; over 2 days) or albumin (n=13) (8 g/L of removed ascites) after large-volume paracentesis. Effective arterial blood volume was assessed indirectly by measuring plasma renin and aldosterone concentration on days 0 and 6 after paracentesis; renal function and haemodynamic changes were also measured. PICD was defined as an increase in plasma renin concentration on day 6 by more than 50% of the baseline value. Results: PICD developed in six patients of the midodrine group (60%) and in only four patients (31%) of the albumin group. Six days after paracentesis, the aldosterone concentration increased significantly in the midodrine group, but not in the albumin group. Conclusions: This pilot study suggests that midodrine is not as effective as albumin in preventing circulatory dysfunction after large-volume paracentesis in patients with cirrhosis and ascites.

PMID: 18410283 [PubMed - as supplied by publisher]

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