Siriraj Medical Journal

The Role of Lactate-based Serum Tests for Prediction of 30-day Mortality in Hospitalized Cirrhotic Patients with Acute Decompensation: A Prospective Cohort Study

2024-03-16T12:46:35+07:00

Objective: Cirrhotic patients with acute decompensation are associated with high short-term mortality. The prognostic performance of venous lactate (VLAC) for mortality prediction in these patients has not been well established. This study aimed to evaluate the role of several lactate-based serum tests for prediction of 30-day mortality in these patients.

Materials and Methods: Cirrhotic patients with acute decompensation were prospectively enrolled. VLAC on admission and at 6, 12, and 24 hours were determined. Lactate clearance (LAC-Cl), MELD-lactate, and MELD-lactate clearance (MELD-ΔLA) at each timepoint were calculated and compared between 30-days survivors and non-survivors.

Results: 74 patients were included (age 69±13 years, 66.2% male, MELD 18.3±7). The main indications for admission were infection (67.6%) and gastrointestinal bleeding (18.9%). The 30-day mortality rate was 29.7%. Initial VLAC was significantly higher in non-survivors (9.7±8 vs. 3.61±1.79 mmol/L, P<0.001). In addition, VLAC at 6, 12, 24 hours, MELD-Lactate and MELD-ΔLA scores were significantly higher in non-survivors. Based on ROC analysis, the VLAC, MELD-Lactate, and MELD-ΔLA at 6 hours were reliable predictors of 30-day mortality (AUROC 0.79, 0.86, and 0.86, respectively). However, compared to MELD score (AUROC 0.81), no significant difference was found.

Conclusion: In hospitalized cirrhotic patient with acute decompensation, VLAC, MELD-Lactate and MELD-ΔLA at 6 hours are simple, and reliable predictors for 30-day mortality.

Urine Liver-Type Fatty Acid Binding Protein; Biomarker for Diagnosing Acute Kidney Injury and Predicting Mortality in Cirrhotic Patients

2024-03-19T09:34:38+07:00

Objective: To determine impact of urine liver-type fatty acid binding protein (uL-FABP) and urine neutrophil gelatinase-associated lipocalin (uNGAL), which were biomarkers linked to acute kidney injury (AKI), in AKI diagnosis and prediction of 28-day mortality among hospitalized cirrhotic patients.

Materials and Methods: We prospectively enrolled hospitalized cirrhotic patients at a tertiary care university hospital between June 2018 and November 2019. The uL-FABP, uNGAL, and plasma NGAL (pNGAL) were collected within 48 hours of admission. Cutoff values of biomarkers for diagnosing AKI derived from receiver operating characteristic (ROC) curve. Logistic regression analysis was used to identify independent factors for 28-day mortality.

Results: We enrolled 109 cirrhotic patients in derivative cohort, 41.3% had AKI. Median uL-FABP, uNGAL, and pNGAL levels in AKI group were higher than non-AKI group: 8.1 vs. 2.8 ng/mL (p=0.002), 40.5 vs. 10.1 ng/mL (p<0.001), and 195.7 vs 81.4 ng/mL (p=0.001), respectively. Areas under the ROC curve of uL-FABP, uNGAL, and pNGAL for AKI diagnosis were 0.68, 0.73 and 0.68, respectively. Also, all biomarkers were significantly higher in mortality group. Multivariate analysis showed that the only independent predictor for 28-day mortality was uL-FABP ≥ 4.68 ng/mL (odd ratio 4.15, p=0.02).

Conclusion: UL-FABP, uNGAL, and pNGAL are associated with AKI in hospitalized cirrhotic patients. Moreover, uL-FABP ≥ 4.68 ng/mL was a significant independent predictor for 28-day mortality.

Navigating the Nomenclature of Liver Steatosis: Transitioning from NAFLD to MAFLD and MASLD - Understanding Affinities and Differences

2024-03-22T12:54:11+07:00

The escalating prevalence of non-alcoholic fatty liver disease (NAFLD) represents a significant challenge to public health, with an increasing impact observed across various demographics. This review delivers a comprehensive evaluation of the evolving terminology in steatotic liver disease (SLD), documenting the transition from NAFLD to metabolic dysfunction-associated fatty liver disease (MAFLD), and progressing to the latest terms, metabolic dysfunction-associated fatty liver disease (MASLD) and MASLD with increased alcohol intake (MetALD). We conducted a comprehensive review of literature discussing the benefits and drawbacks of these nomenclatural changes. Clinical evidence supporting MASLD and MetALD, including the implications of alcohol consumption thresholds on disease classification and outcomes, was analyzed. The “MAFLD” and “MASLD” labels align with the pathophysiology of metabolic diseases, afford a positive disease connotation, and facilitate the identification of more severe diseases, such as significant fibrosis or advanced liver disease. However, the MAFLD criteria may underdiagnose lean, non-overweight, or non-obese individuals with MAFLD. The review underscores the understanding of liver diseases linked to metabolic dysfunction and alcohol use. The shift in terminology marks progress towards a clinical diagnosis that reflects underlying pathophysiology. However, additional studies are necessary to assess the longterm effects of these changes and their efficacy in enhancing patient care and health outcomes.

Current Perspectives on Small Bowel Tumors: Overview of Prevalence, Clinical Manifestations, and Treatment Approaches

2024-02-20T09:30:53+07:00

Small bowel tumors (SBTs) constitute a rare yet increasingly recognized group of gastrointestinal neoplasms, accounting for less than 5% of all gastrointestinal cancers. Despite their infrequency, the incidence of SBTs has exhibited a notable upward trend, underscoring the importance of understanding these diverse and complex tumors. This review consolidates current knowledge on SBTs, encompassing epidemiology, risk factors, clinical manifestations, diagnostic advancements, and treatment modalities. Data from various sources are analyzed to present a comprehensive overview of the evolving landscape of SBTs. Our findings indicate that adenocarcinomas, carcinoid tumors, lymphomas, and gastrointestinal stromal tumors (GISTs) are the common SBTs. While adenocarcinoma and neuroendocrine tumors are the common types of SBTs in the West, GIST and lymphoma are more common in Asia. Common risk factors include genetic syndromes and inflammatory bowel diseases. There is variability in clinical presentations depending on the type of tumors. Although diagnostic challenges persist, advancements in imaging and endoscopic techniques have improved detection rates. Treatment strategies are evolving; surgical resection remains the mainstay for localized disease, augmented by systemic therapies and targeted agents for advanced stages. This review emphasizes the importance of early detection and individualized treatment approaches in improving outcomes for SBT patients. It addresses the need for ongoing research and innovation in managing these tumors.

Effect of Delayed Endoscopic Retrograde Cholangiopancreatography after Diagnosis of Acute Cholangitis; A Real-life Experience

2024-03-12T11:56:30+07:00

Objective: Acute cholangitis is a potentially life-threatening condition. Its main treatments include antibiotics and biliary drainage, but longer waiting times for endoscopic biliary drainage may be unavoidable in some limited-resource settings.

Materials and Methods: All patients who presented with cholangitis and received ERCP during the 3-year study period were included. The associations between waiting time from the diagnosis of acute cholangitis to the endoscopic drainage and the clinical outcomes, including 30-day all-course mortality and 30-day rehospitalization rates, were compared in patients who received ERCP within 24 hours, 48 hours, 72 hours, 7 days, and later than 7 days.

Results: Overall, 300 patients were included. The 30-day all-course mortality rate was 5%, with 9% overall rehospitalization rate, and median waiting time for ERCP of 5 days (1 -50 days). There was no significant difference between 30-day mortality rates in patients who received ERCP within 24 hours, 48 hours, 72 hours and over 7 days (p > 0.05). The mortality rate was significantly higher in those with severe cholangitis and with pancreatobiliary malignancy (p < 0.05).

Conclusion: In real life situation when resources are limited, delayed ERCP did not increased the 30-day mortality rate in patients with cholangitis.