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Introduction Although serum creatinine is a well-recognised marker of prognosis in cirrhosis, it is only an indirect marker of renal function as it is affected by various extra-renal factors. The measurement of glomerular filtration rate (GFR) by the plasma clearance Cr-EDTA is an acceptable substitute of the gold standard of inulin clearance. We assessed the correlations of serum creatinine with GFR measured by Cr-EDTA in patients with cirrhosis in comparison with patients with renal disease. Method We analysed data from 298 consecutive patients who underwent GFR assessment by Cr-EDTA as part of their liver transplant work-up. We collected similar data on 187 consecutive non-cirrhotic patients who attended the renal outpatient clinic. GFR was assessed by bolus infusion of Cr-EDTA and single or serial serum measurements after 2, 4, 6 and 24 h. Spearman test was used to correlate serum creatinine and GFR in renal and liver patients. The significance of the difference between the correlations from the two groups was calculated by transforming the Spearman's r to Fischer's z-score, estimating the SE of difference between the two correlations and finally dividing the differences between the two z-scores by the SE. If the result was 1.96 or higher, then the difference in the correlation was considered significant in the 0.05 level. Results Serum creatinine significantly and inversely correlated with GFR in patients with cirrhosis (r=−0.702, p<0.001) and renal disease (r=−0.856, p<0.001), however the difference of the correlation was significant between patients with renal disease and patients with cirrhosis (p<0.05). When analysis was performed according to gender, there were significant correlations of serum creatinine and GFR in patients with cirrhosis (males r=−0.806 and females r=−0.699) and renal disease (males r=−0.877 and females r=−0.890). Moreover, the difference of the correlation was again significant among male and female patients with renal disease and cirrhosis and notably in male compared to female patients with cirrhosis (p<0.05). Therefore, for a given GFR, patients with cirrhosis have lower serum creatinine values than patients with renal disease. Moreover, female patients with cirrhosis have lower serum creatinine values than male patients with the same GFR. Conclusion Serum creatinine underestimates renal function in patients with cirrhosis compared to patients with renal disease. Serum creatinine cut-offs used to define renal failure in the general population are not applicable to patients with cirrhosis and should be re-evaluated as they systematically underestimate renal function. [ABSTRACT FROM PUBLISHER]

Introduction Accurate prognostic indicators of patient survival in an intensive care unit (ICU) help guide clinical decision-making. Factors known to portend poor prognosis in acutely ill cirrhotics in ICU include the need for mechanical ventilation, development of shock, renal failure and sequential increase in the number of failing organs. While serum lactate is now an established marker of survival and/or the need for transplantation in fulminant liver failure, its impact on critically ill cirrhotics is less well known. Method We retrospectively studied 133 consecutive acutely ill cirrhotics admitted to the ICU between 2005 and 2008 at the Royal Free Hospital, a tertiary referral centre in liver diseases and transplantation. Data were collected on demographic variables, aetiology of liver disease, liver-specific prognostic scores (Child–Turcotte–Pugh (CTP), model for end-stage liver disease (MELD), UK model for end-stage liver disease (UKELD)), and acute illness scores (acute physiological score and chronic health point (APACHE II), sequential organ failure assessment score (SOFA)). In addition, serum lactate levels at 0, 24 and 48 h were also recorded. Multivariable logistic regression analysis was performed, and the discrimination ability of each of the above-mentioned scoring models in predicting ICU and hospital survival of these patients was evaluated using the area under the receiver operating characteristic (ROC) curve. Results The ICU and hospital non-survivors—43/133 (32.3%) and 57/133 (43.4%) respectively—had similar demographic features as the survivors, but had significantly higher mean admission MELD, UKELD, SOFA and APACHE II scores, as well serum lactate levels on admission. Serum lactate at admission and particularly at 24 h had a better discriminative accuracy for mortality (AUC=0.737 and 0.764) compared with liver-specific prognostic scores, MELD (AUC=0.732 and 0.720), MELD-Na (AUC=0.338 and 0.554) and UKELD (AUC=0.698 and 0.695). Acute illness scores exhibited a rather poorer predictive power, both APACHE II (AUC=0.632 and 0.571) and SOFA (AUC=0.688 and 0.716). Adding lactate to MELD and UKELD scores further improved their outcome prediction potential (AUC MELD-lactate=0.737 and UKELD-lactate=0.717). Conclusion Serum lactate is a powerful independent tool in predicting survival of acutely ill cirrhotics on ICU. Persistent hyperlactataemia after aggressive resuscitation for 24 h may reflect native liver's inability to metabolise it. In that case, should lactate not be incorporated in the liver function scoring models such as CTP, MELD or UKELD? [ABSTRACT FROM PUBLISHER]

Introduction Hepatocellular carcinoma (HCC) is the main indication for 15% of liver transplants. Currently the criteria used for listing patients are the Milan criteria. However, as waiting time is increasing, patients may fall out these criteria while on the waiting list. Aim We retrospectively evaluated the effect of neo-adjuvant transarterial chemoembolization (TACE) in consecutive patients transplanted for HCC. Method We analysed data from consecutive patients who were transplanted for HCC between 1990 and 2010 as main indication in our unit. Laboratory, epidemiological, radiological and histological data were analysed. Survival was evaluated using multiple regression analysis. Results In total 148 patients were transplanted for HCC, of which 74 had TACE as neo-adjuvant therapy. Mean follow-up post-transplant was 31±29 months (range 1–145). Patients had a mean of 1.6±0.9 (range 1–5) TACE sessions and had a mean waiting list time of 2.5±2.4 months (range 0.5–12.3). TACE response was evaluated in explanted livers as follow: no response in 10 (16%), partial tumour necrosis in 35 (55%) and complete tumour necrosis in 19 (30%). Tumour recurred in 21 (14%) patients in a mean time of 5.1±14 months. Recurrence happened in 2/10 patients who did not respond to TACE, 1/35 who had a partial response and 0/19 who had a complete response (p=0.040). TACE as neo-adjuvant therapy was associated with less recurrence irrespective of histological response (18.3% recurrence in patients who did not have TACE vs 5.6% in patients who had, p=0.037). No serious adverse effects of TACE were noted. Conclusion TACE is an effective neo-adjuvant therapy in patients listed for liver transplantation, as it is associated with significantly less post-transplantation tumour recurrences. As waiting lists are getting longer, its use as a standard neo-adjuvant therapy should be further explored. [ABSTRACT FROM PUBLISHER]