Search

Purpose of Review Dietary interventions (DI) aimed at improving overweight and metabolic abnormalities in metabolic dysfunction-associated fatty liver disease (MAFLD) and at reducing malnutrition and sarcopenia in cirrhosis should become part of routine care in hepatology. This review focuses on recent advances in this field. Recent Findings In patients with MAFLD, a gradual reduction, respectively, of 7–10% of body weight if overweight or of 3–5% if lean, obtained by moderately reducing caloric intake, is effective to improve liver disease. Intermittent energy restriction might be an alternative to continuous energy restriction with higher adherence. Qualitative dietary adjustments should include increased intake of unprocessed foods including fruits and vegetables, whole grains, fiber, and unsaturated fatty acids (FAs), for example, through a Mediterranean diet. Refined carbohydrates (CHOs), saturated FA (SFAs), red meat, and processed meat should be limited. DI studies in HIV-infected subjects with MAFLD are very limited, and this is a field for future research. In patients with cirrhosis, DI should aim at correcting malnutrition and improving skeletal muscle mass. Daily diet contents should aim at achieving 30–35 kcal/kg of body weight, including 1.2–1.5 g/kg proteins, and oral or enteral supplementation might be used in patients unable to achieve these targets. In some studies, branched-chain amino acids (BCAAs) proved to be effective in improving muscle mass and were associated with a lower risk of hepatic encephalopathy. Obesity requires adjustment of the above-mentioned targets, and its management is challenging. Studies looking at the efficacy of DI recommended by the existing guidelines on clinical endpoints are a field for future research. Summary Dietary interventions are able to improve MAFLD and show potential to reduce complications in liver disease. Despite its key importance, there are many barriers limiting the implementation of DI in patients with chronic liver disease. Patients’ empowerment is crucial and should be the focus of specific educational programs. In addition, liver clinics would benefit from multidisciplinary teams involving experts in nutrition, physical exercise, primary care physicians, and psychologists when needed.

The development of autoimmune diseases has been reported after SARS-CoV-2 infection. Vaccination against SARS-CoV-2 could also trigger auto-immunity, as it has been described with other vaccines. An aberrant immune response induced by molecular mimicry and bystander activation, especially in predisposed individuals, is a potential mechanism. We report the case of a 76-year-old woman with Hashimoto thyroiditis and prior COVID-19 infection who developed severe autoimmune hepatitis (with typical features including strongly positive anti-smooth muscle antibody and markedly elevated immunoglobulins G, as well as typical histological findings) following SARS-CoV-2 vaccination (mRNA-1273 SARS-CoV-2 vaccine, Moderna®). The link between SARS-CoV-2 vaccination and the development of autoimmune diseases needs to be further investigated. Although a causality relationship cannot be proven, caution may be warranted when vaccinating individuals with known autoimmune diseases.

BACKGROUND & AIMS: Portal hypertension is the strongest predictor of hepatic decompensation and death in patients with cirrhosis. However, its discriminatory accuracy in patients with nonalcoholic fatty liver disease (NAFLD) has been challenged because hepatic vein catheterization may not reflect the real portal vein pressure as accurately as in patients with other etiologies. We aimed to evaluate the relationship between hepatic venous pressure gradient (HVPG) and presence of portal hypertension-related decompensation in patients with advanced NAFLD (aNAFLD). METHODS: Multicenter cross-sectional study included 548 patients with aNAFLD and 444 with advanced RNA-positive hepatitis C (aHCV) who had detailed portal hypertension evaluation (HVPG measurement, gastroscopy, and abdominal imaging). We examined the relationship between etiology, HVPG, and decompensation by logistic regression models. We also compared the proportions of compensated/decompensated patients at different HVPG levels. RESULTS: Both cohorts, aNAFLD and aHVC, had similar baseline age, gender, Child-Pugh score, and Model for End-Stage Liver Disease score. Median HVPG was lower in the aNAFLD cohort (13 vs 15 mmHg) despite similar liver function and higher rates of decompensation in aNAFLD group (32% vs 25%; P = .019) than in the aHCV group. For any of the HVPG cutoff analyzed (

The ability of identifying those patients at highest risk of developing clinical decompensation and hepatocellular carcinoma and at higher risk of death is key in clinical practice. Among patients with compensated advanced chronic liver disease (cACLD), risk stratification can take advantage of liver and spleen stiffness measurement. Liver stiffness measurement (LSM) has proven a robust predictor of clinical events in patients with cACLD, even beyond the identification of those with clinically significant portal hypertension. This chapter summarizes the existing data regarding the prognostic ability of liver stiffness and spleen stiffness measured by different ultrasound elastography techniques for predicting clinical decompensation, hepatocellular carcinoma and death in patients with cACLD.

Background Conventionally, topical anesthesia is applied to improve the tolerance of esophageal manometry (EM) and ambulatory pH monitoring (apH) but there is presently no evidence supporting this practice. We aimed to compare the tolerance of EM and apH with vs without topical lidocaine anesthesia. Methods A prospective study was conducted at our center between January 2017 and January 2019. All patients who underwent EM or apH and completed a systematically distributed standardized patient survey were included. From January 2017 to June 2018, all patients had a viscous lidocaine solution applied before EM and apH ("lidocaine" group). After June 2018, we ceased applying any topical anesthesia ("no lidocaine" group). Patient-reported adverse effects and satisfaction scores were compared between these two patient groups. Key results Two hundred forty-nine patient surveys were included. "Lidocaine" (n = 124) and "no lidocaine" (n = 125) groups were similar in age (56.9 ± 14.0 vs 56.0 ± 13.7; P = .77) and gender distributions (65.9% vs 63.3% female; P = .68). Patients in the "lidocaine" group were less likely to report pain during catheter insertion (33.6% vs 50.8%; P = .007, OR: 0.49 [95% CI 0.29-0.83]) and reported a lower overall pain score (2.82 ± 1.38 vs 3.20 ± 1.42 on 5; P = .04). There was a tendency toward increased global satisfaction with lidocaine application but that was not statistically significant (4.36 ± 1.05 vs 4.11 ± 1.13; P = .08). In subgroup analyses, female patients, younger patients, and patients who underwent EM were more likely to benefit from lidocaine application. Conclusions and inferences Application of topical lidocaine before esophageal motility tests reduces pain during catheter insertion and overall pain.

BACKGROUND: Clinicians have adopted a restrictive transfusion threshold (75-80 g/L) after major orthopedic surgery. Anemia may be associated with a decrease in postoperative vigor. We hypothesize that, in these patients, a threshold hemoglobin (Hb) concentration exists below which functional recovery and quality of life (QoL) become difficult. STUDY DESIGN AND METHODS: A prospective, observational cohort study in 305 patients 60 years or older undergoing a total hip or knee arthroplasty was conducted. Major outcome variables were distance walked in 6 minutes (6MWT), score on the Borg Scale for perception of effort, maximal dominant hand strength, and Short Form 36 (SF-36) QoL assessment in the preoperative and early postoperative periods. Patients were categorized according to their Hb level the day of the postoperative 6MWT (≤80, 81-90, 91-100, and >100 g/L). RESULTS: There was no difference between Hb groups in the decrease of the distance walked preoperatively versus postoperatively. For both moments of observation, the 6MWT was not significantly different between Hb groups (p = 0.190). Similar results were found with perception of effort, maximal dominant hand strength, and SF-36 QoL assessment scores. In a regression model, the decrease in Hb concentration could explain only 1.9% of the total variation observed in the 6MWT (p = 0.008). CONCLUSION: Moderate anemia is not associated with an impaired functional recovery or QoL in the immediate postoperative period after major arthroplasties. Further studies will be required to determine the long-term consequences of a restrictive transfusion strategy in these patients.

BACKGROUND: The indications for red blood cell (RBC) transfusions remain unclear despite published guidelines. Our hypothesis was that the transfusion practice varies inside the Centre hospitalier de l'Universite de Montreal (CHUM). STUDY DESIGN AND METHODS: A total of 701 charts of patients who underwent a knee or hip arthroplasty or prosthesis revision in three hospitals of the CHUM were reviewed. Demography, hemoglobin (Hb) concentrations, details on transfusions, and postoperative adverse events (AEs) were collected up until discharge. The primary outcome was the presence or absence of RBC transfusion. Secondary outcomes were the nadir Hb, number of units transfused, discharge Hb, blood losses, and postoperative AEs. RESULTS: The rate of postoperative transfusion was 29%. We found no significant difference between odds ratios of each site for sex, coronary artery disease, chronic heart failure, type of procedure, American Society of Anesthesiologists physical status, weight, height, body mass index, body surface area, and estimated blood volume. Overall, patients were transfused at a Hb between 75 and 80 g/L. Eighty-five percent of postoperative transfusions could be predicted using only nadir Hb and adding patient characteristics did not substantially improve the model (86.1%). Discharge Hb was below 100 g/L in 66% of patients. CONCLUSIONS: There was no difference among hospitals regarding the way RBC transfusions are used. Our data suggest that physicians mainly based their decision to transfuse on a single variable, the Hb concentration, with the use of a restrictive strategy. Future trials should focus on the optimal transfusion trigger to adopt in major orthopedic surgery.