Seminars in respiratory and critical care medicine
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Bleeding from gastroesophageal varices is a frequent complication of cirrhosis. Mortality from a variceal bleeding episode has decreased in the last 2 decades from 40% to 15 to 20% due to the implementation of effective treatments and improvement in the general medical care. Initial treatment should include adequate fluid resuscitation and transfusion to maintain hemoglobin around 7 to 8 g/dL, and prophylactic antibiotics (norfloxacin or ceftriaxone). ⋯ In refractory variceal bleeding episodes, balloon tamponade may be used as a temporary bridge to TIPS. Identification of patients that are at high risk of treatment failure may guide new strategies to improve outcomes. Indeed, a recent trial has shown that placement of TIPS, using covered stents, within 72 hours of admission in patients at high risk of treatment failure (i.e., those Child B with active bleeding or Child C less than 14 points) markedly decreased rebleeding and improved survival.
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Semin Respir Crit Care Med · Feb 2012
ReviewInfectious complications of acute and chronic liver disease.
Acute and chronic liver diseases are frequently complicated by infections, which result in increased morbidity and mortality and place an economic burden on health care systems. This review discusses the epidemiology and the impact on prognosis of infections in liver cirrhosis, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, acute liver failure, and post-liver transplantation. ⋯ From a clinical viewpoint this article discusses problems in diagnosing infection. Established (vaccination, antibiotic prophylaxis, antiviral prophylaxis, and nutrition) and experimental (probiotic) prophylactic strategies as well as established (antibiotics) and experimental (liver support, albumin, toll-like receptor antagonists) strategies are also reviewed.
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Semin Respir Crit Care Med · Feb 2012
ReviewInfectious complications after orthotopic liver transplantation.
Advances in surgical technique, critical care, immunosuppression, donor and recipient screening, and prophylactic strategies have contributed to the evolving microbiology and epidemiology of infectious complications after liver transplantation. Although decreased overall, infections continue to be a major contributor to graft loss and patient morbidity. Bacterial and candidal infections are less frequent, but antimicrobial resistance has become more common and can potentially limit successful treatment of health care-acquired and surgical site infections. ⋯ Presentations of opportunistic respiratory infections may be atypical in the setting of immunosuppression. Although novel noninvasive diagnostic tools are available for some pathogens, bronchoscopic evaluation may be increasingly helpful in differentiating between certain respiratory pathogens when empirical therapy is plagued by drug interactions and drug toxicities. Knowledge about common postoperative infections and opportunistic respiratory pathogens such as cytomegalovirus and fungi is essential to improving the global care of the liver transplant recipient.
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Acute kidney injury (AKI) is common in cirrhotic patients with ascites. Although not the primary etiology of AKI in cirrhotic patients, hepatorenal syndrome (HRS) is a unique form of AKI that develops only in cirrhotic patients. Intense renal vasoconstriction is the hallmark of HRS. ⋯ Given its overall dismal prognosis, strategies to prevent HRS have been developed and proved to be effective in reducing HRS prevalence among cirrhotic patients. Liver transplantation is the ultimate treatment, but more than one treatment modality can be utilized as a bridge to transplantation. This review provides an update on our current understanding of HRS with emphasis on the underlying pathophysiological mechanisms involved, difficulties in diagnosis, and different treatment modalities.