BACKGROUND For compensated advanced chronic liver disease(cACLD)patients,the first decompensation represents a dramatically worsening prognostic event.Based on the first decompensation event(DE),the transition to deco...BACKGROUND For compensated advanced chronic liver disease(cACLD)patients,the first decompensation represents a dramatically worsening prognostic event.Based on the first decompensation event(DE),the transition to decompensated advanced chronic liver disease(dACLD)can occur through two modalities referred to as acute decompensation(AD)and non-AD(NAD),respectively.Clinically Significant Portal Hypertension(CSPH)is considered the strongest predictor of decompensation in these patients.However,due to its invasiveness and costs,CSPH is almost never evaluated in clinical practice.Therefore,recognizing noninvasively predicting tools still have more appeal across healthcare systems.The red cell distribution width to platelet ratio(RPR)has been reported to be an indicator of hepatic fibrosis in Metabolic Dysfunction-Associated Steatotic Liver Disease(MASLD).However,its predictive role for the decompensation has never been explored.AIM In this observational study,we investigated the clinical usage of RPR in predicting DEs in MASLD-related cACLD patients.METHODS Fourty controls and 150 MASLD-cACLD patients were consecutively enrolled and followed up(FUP)semiannually for 3 years.At baseline,biochemical,clinical,and Liver Stiffness Measurement(LSM),Child-Pugh(CP),Model for End-Stage Liver Disease(MELD),aspartate aminotransferase/platelet count ratio index(APRI),Fibrosis-4(FIB-4),Albumin-Bilirubin(ALBI),ALBI-FIB-4,and RPR were collected.During FUP,DEs(timing and modaities)were recorded.CSPH was assessed at the baseline and on DE occurrence according to the available Clinical Practice Guidelines.RESULTS Of 150 MASLD-related cACLD patients,43(28.6%)progressed to dACLD at a median time of 28.9 months(29 NAD and 14 AD).Baseline RPR values were significantly higher in cACLD in comparison to controls,as well as MELD,CP,APRI,FIB-4,ALBI,ALBI-FIB-4,and LSM in dACLD-progressing compared to cACLD individuals[all P<0.0001,except for FIB-4(P:0.007)and ALBI(P:0.011)].Receiving operator curve analysis revealed RPR>0.472 and>0.894 as the best cut-offs in the prediction respectively of 3-year first DE,as well as its superiority compared to the other non-invasive tools examined.RPR(P:0.02)and the presence of baseline-CSPH(P:0.04)were significantly and independently associated with the DE.Patients presenting baseline-CSPH and RPR>0.472 showed higher risk of decompensation(P:0.0023).CONCLUSION Altogether these findings suggest the RPR as a valid and potentially applicable non-invasive tool in the prediction of timing and modalities of decompensation in MASLD-related cACLD patients.展开更多
For individuals with decompensated advanced chronic liver disease(dACLD),the onset of refractory ascites(RA)represents a dramatic event.In this setting,a relevant proportion of RA patients develop kidney dysfunction,a...For individuals with decompensated advanced chronic liver disease(dACLD),the onset of refractory ascites(RA)represents a dramatic event.In this setting,a relevant proportion of RA patients develop kidney dysfunction,as well as hepatorenal syndrome-acute kidney injury,with limited therapeutic and survival chances.An 81-year-old woman with dACLD-RA was admitted with severe ascites and stage Ⅳ chronic kidney dysfunction.On the second day,hepatorenal syndrome-acute kidney injury occurred,requiring standard medical therapy.Intravenous human albumin(HA)and terlipressin administration were compromised by poor venous access and severe respiratory dysfunction.After excluding transjugular intrahepatic portosystemic shunt and transplantation due to age and comorbidities,peritoneal dialysis(PD)was initiated,leading to renal recovery and ascites resolution.Two weeks later,she was readmitted due to the unfeasibility of accessing peripheral veins for the intravenous administration of HA,which was essential to support circulatory function,preserve oncotic balance,and properly manage both RA and chronic kidney dysfunction.A novel PD+HA protocol was therefore started,with intraperitoneal infusion of HA-enriched dialysate to allow a positive albumin gradient from dialysate to blood.Over 12 months,serum albumin levels increased,and clinical stability and improved nutritional status were observed,with no additional hospitalizations or complications.This is the first case describing the application of HA-enriched PD in managing a dACLD patient with RA and kidney dysfunction.HA-enriched PD may represent a promising strategy in complex dACLD care by guaranteeing frequent and small-volume paracentesis and preservation of oncotic pressure without dialytic albumin loss.展开更多
文摘BACKGROUND For compensated advanced chronic liver disease(cACLD)patients,the first decompensation represents a dramatically worsening prognostic event.Based on the first decompensation event(DE),the transition to decompensated advanced chronic liver disease(dACLD)can occur through two modalities referred to as acute decompensation(AD)and non-AD(NAD),respectively.Clinically Significant Portal Hypertension(CSPH)is considered the strongest predictor of decompensation in these patients.However,due to its invasiveness and costs,CSPH is almost never evaluated in clinical practice.Therefore,recognizing noninvasively predicting tools still have more appeal across healthcare systems.The red cell distribution width to platelet ratio(RPR)has been reported to be an indicator of hepatic fibrosis in Metabolic Dysfunction-Associated Steatotic Liver Disease(MASLD).However,its predictive role for the decompensation has never been explored.AIM In this observational study,we investigated the clinical usage of RPR in predicting DEs in MASLD-related cACLD patients.METHODS Fourty controls and 150 MASLD-cACLD patients were consecutively enrolled and followed up(FUP)semiannually for 3 years.At baseline,biochemical,clinical,and Liver Stiffness Measurement(LSM),Child-Pugh(CP),Model for End-Stage Liver Disease(MELD),aspartate aminotransferase/platelet count ratio index(APRI),Fibrosis-4(FIB-4),Albumin-Bilirubin(ALBI),ALBI-FIB-4,and RPR were collected.During FUP,DEs(timing and modaities)were recorded.CSPH was assessed at the baseline and on DE occurrence according to the available Clinical Practice Guidelines.RESULTS Of 150 MASLD-related cACLD patients,43(28.6%)progressed to dACLD at a median time of 28.9 months(29 NAD and 14 AD).Baseline RPR values were significantly higher in cACLD in comparison to controls,as well as MELD,CP,APRI,FIB-4,ALBI,ALBI-FIB-4,and LSM in dACLD-progressing compared to cACLD individuals[all P<0.0001,except for FIB-4(P:0.007)and ALBI(P:0.011)].Receiving operator curve analysis revealed RPR>0.472 and>0.894 as the best cut-offs in the prediction respectively of 3-year first DE,as well as its superiority compared to the other non-invasive tools examined.RPR(P:0.02)and the presence of baseline-CSPH(P:0.04)were significantly and independently associated with the DE.Patients presenting baseline-CSPH and RPR>0.472 showed higher risk of decompensation(P:0.0023).CONCLUSION Altogether these findings suggest the RPR as a valid and potentially applicable non-invasive tool in the prediction of timing and modalities of decompensation in MASLD-related cACLD patients.
文摘For individuals with decompensated advanced chronic liver disease(dACLD),the onset of refractory ascites(RA)represents a dramatic event.In this setting,a relevant proportion of RA patients develop kidney dysfunction,as well as hepatorenal syndrome-acute kidney injury,with limited therapeutic and survival chances.An 81-year-old woman with dACLD-RA was admitted with severe ascites and stage Ⅳ chronic kidney dysfunction.On the second day,hepatorenal syndrome-acute kidney injury occurred,requiring standard medical therapy.Intravenous human albumin(HA)and terlipressin administration were compromised by poor venous access and severe respiratory dysfunction.After excluding transjugular intrahepatic portosystemic shunt and transplantation due to age and comorbidities,peritoneal dialysis(PD)was initiated,leading to renal recovery and ascites resolution.Two weeks later,she was readmitted due to the unfeasibility of accessing peripheral veins for the intravenous administration of HA,which was essential to support circulatory function,preserve oncotic balance,and properly manage both RA and chronic kidney dysfunction.A novel PD+HA protocol was therefore started,with intraperitoneal infusion of HA-enriched dialysate to allow a positive albumin gradient from dialysate to blood.Over 12 months,serum albumin levels increased,and clinical stability and improved nutritional status were observed,with no additional hospitalizations or complications.This is the first case describing the application of HA-enriched PD in managing a dACLD patient with RA and kidney dysfunction.HA-enriched PD may represent a promising strategy in complex dACLD care by guaranteeing frequent and small-volume paracentesis and preservation of oncotic pressure without dialytic albumin loss.
