We investigated the durability of the biochemical and virologic responses after adefovir (ADV) discontinuation in lamivudine-resistant (LMV-R) chronic hepatitis B (CHB) patients, and the outcomes of ADV discontinuation compared to that of ADV maintenance.The indication for ADV treatment cessation was an undetectable level of hepatitis B virus (HBV) DNA documented on two occasions at least 6 months apart. All patients received additional ADV for at least 12 months after the confirmation of undetectable HBV DNA (Cobas TaqMan PCR assay, <70 copies/mL). Of 36 patients who had a sufficient ADV therapeutic effect, 19 discontinued ADV treatment, while the others maintained it. A virologic rebound was arbitrarily defined as the redetection of HBV DNA at a level higher than 10(5) copies/mL.In the ADV discontinuation group, ADV treatment and additional therapy were administered for medians of 33 months (range, 12-47 months) and 18 months, respectively. The patients were followed for a median of 12 months (range, 3-30 months) after ADV cessation. During that period, 18 of 19 patients (95%) experienced viral relapse. Viral rebound was observed in six patients (32%). However, 12 of 18 patients (67%) exhibited serum HBV DNA levels of less than (5) copies/mL. Biochemical relapses were observed in four of the six patients with viral rebound. In the ADV maintenance group, patients were treated for a median of 53 months (range, 31-85 months), and 9 patients (53%) experienced viral breakthrough.During short-term follow-up after ADV discontinuation, most patients (95%) exhibited viral relapse, whereas and viral breakthrough occurred in about half of patients (53%) maintained on ADV therapy. Therefore, the durability of virologic response after ADV discontinuation in LMV-R patients was unsatisfactory. In addition, and viral breakthrough was not infrequent in the ADV continuation group.
See the Original "The efficacy of tenofovir-based therapy in patients showing suboptimal response to entecavir-adefovir combination therapy" on page 241.
Abdominal ultrasonography uses the transmission and reflection of ultrasound waves to observe the internal organs through the abdominal wall and can visualize various abdominal anatomical structures. Abdominal ultrasound examinations are performed by gastroenterologists or other specialists in internal medicine and radiologists trained for this procedure. Thus far, abdominal ultrasonography has not been included in the standard education of gastroenterologists in Korea. On the other hand, abdominal ultrasonography is being used increasingly, making it necessary to establish a training program in Korea. Abdominal ultrasonography was established as an essential part of education for the resident training program in 2017. In addition, an educational accreditation system for the trainers of ultrasonography in the field of internal medicine, including gastroenterology, was developed in 2018. This article describes the development process of the educational accreditation system for trainers of ultrasonography.
Background: Prognosis of patients with diverse chronic diseases is reportedly associated with 25-hydroxyvitamin D levels.In this study, we investigated the potential role of 25-hydroxyvitamin D3 (25[OH]D3) levels in improving the predictive power of conventional prognostic models for patients with liver cirrhosis.Methods: We investigated clinical findings, including serum 25(OH)D3 levels at admission, of 155 patients with cirrhosis who were followed up for a median of 16.9 months.Results: Median 25(OH)D3 levels were significantly different among patients exhibiting Child-Pugh grades A, B, and C. Mortality, including urgent transplantation, was significantly associated with 25(OH)D3 levels in univariate analysis.Severe vitamin-D deficiency (serum 25[OH]D3 level < 5.0 ng/mL) was significantly related to increased mortality, even after adjusting for Child-Pugh and Model for End-stage Liver Disease (MELD) scores.In particular, the presence of severe vitamin D deficiency clearly defined a subgroup with significantly poorer survival among patients with Child-Pugh scores of 5-10 or MELD scores ≤ 20.A new combination model of MELD score and severe vitamin D deficiency showed significantly more accurate predictive power for short-and long-term mortality than MELD scores alone.Additionally, serum 25(OH)D3 levels and new model scores were significantly associated with the development of spontaneous bacterial peritonitis, overt encephalopathy, and acute kidney injury.Conclusion: Serum 25(OH)D3 level is an independent prognostic factor for patients with liver cirrhosis and has a differential impact on disease outcomes according to MELD and Child-Pugh scores.
Aims: Development of acute kidney injury (AKI) is closely associated with mortality in patients with liver cirrhosis. Recently, several new definitions of AKI were published. This study was performed to compare the efficacy of several definitions of AKI for predicting prognosis in cirrhotic patients. Methods: Cirrhotic patients who hospitalized to our hospital were enrolled. Patients with hepatocellular carcinoma and parenchymal kidney disease were excluded. AKI was defined by conventional, RIFLE, and KDIGO criteria. Results: A total of 696 cirrhotic patients were enrolled. Age was 54.1±10.7 years and 526 patients (75.6%) were men. Child-Pugh and MELD scores were 8.7±2.4 and 15.5±6.9, respectively. During follow-up, 155 patients died. Six and 12 months mortality rates were 10.7% and 14.2%, respectively. Among all patients, 22 (3.2%), 29 (4.2%), and 52 (7.5%) patients fulfilled the criteria of AKI of conventional, RIFLE, and KDIGO definitions, respectively. Survival time differed significantly between patients without and with AKI according to the conventional (92.3±2.1 vs 18.7±6.2 months, P<0.001), RIFLE (92.3±2.2 vs 42.8±11.2 months, P<0.001), and KDIGO (94.0±2.2 vs 44.0±8.3 months, P<0.001) criteria. Both conventional and KDIGO criteria were fulfilled in 22 patients (3.2%), while 30 patients (4.3%) fulfilled only KDIGO criteria. There was a trend of worse prognosis in patients who fulfilled both conventional and KDIGO criteria than those who only fulfilled KDIGO criteria (18.7±6.2 vs 53.3±11.1 months, P=0.051). Both RIFLE and KDIGO criteria were fulfilled in 29 patients (4.2%), while 23 patients (3.3%) fulfilled only KDIGO criteria. Survival did not differ between patients who fulfilled both RIFLE and KDIGO criteria and those who fulfilled only KDIGO criteria (42.8±11.2 vs 30.1±7.7 months, P=0.106). Conclusions: KDIGO criteria for AKI predicted survival in cirrhotic patients more accurately compared to conventional and RIFLE criteria. Our results suggest that even subtle changes in the serum creatinine level requires close attention in these patients.
Abstract Background/Aims We retrospectively compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding. Methods Patients with acute cardiofundal variceal bleeding treated with EVO or RTO at two hospitals were included. Results Ninety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P = 0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P = 0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P = 0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P < 0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P = 0.005). The mortality rates were similar between two groups ( P = 0.597). Conclusions Both EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes.
A 58-year-old man presented with postprandial pain that radiated to the right shoulder and right flank. He had undergone a laparoscopy-assisted distal gastrectomy with Billroth II anastomosis 2 months previously for Borrmann type III advanced gastric cancer. The operation had been uneventful and he had been discharged without any complications. However, about a week after being discharged he developed abdominal discomfort that worsened after eating. Because of the progressive postprandial abdominal pain, which was unrelated to gastric dumping syndrome or blind loop syndrome, his oral intake had reduced and he had lost 6 kg since the time of the operation.
Background/Aims Several studies suggested that serum cystatin C (CysC) is more useful than serum creatinine (Cr) for the assessment of renal function in patients with liver cirrhosis. This study evaluated the clinical significance of CysC in patients with cirrhotic ascites and normal Cr level. Methods We enrolled patients with cirrhotic ascites and a normal serum Cr level (<1.2 mg/dL). GFR was measured by 99mTc-DTPA renal scan. Serum Cr, CysC, and Cr clearance (CCr) were measured on the same day. Significant renal impairment and severe renal impairment were defined as GFR <60 mL/min and GFR <30 mL/min, respectively. Results Eighty-nine patients with cirrhotic ascites were enrolled in the study (63 men and 26 women; age, 55±11 years). Forty-seven (52.8%) and 42 (47.2%) patients were in Child-Pugh grade B and C, respectively. Serum Cr and CysC levels and GFR were 0.8±0.2 mg/dL, 1.1±0.3 mg/L, and 73.4±25.5 mL/min, respectively. Significant and severe renal impairment were noted in 28 (31.5%) and 2 (2.2%) patients, respectively. GFR was well correlated with serum Cr, CysC, and e-GFRMDRD, while it was not correlated with e-GFRC&G. In multivariate analysis, only CysC was significantly correlated with GFR (β, 45.620; 95% CI, 23.042-68.198; P<0.001). Serum CysC level was the only independent predictor for significant renal impairment. Conclusions Significant renal dysfunction was not rare in patients with cirrhotic ascites, even their serum Cr level is normal. Serum CysC is a useful marker for detecting significant renal dysfunction in these patients. Keywords: Ascites; Creatitine; Cystatin C; Liver cirrhosis; Renal dysfunction
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