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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 4  |  Page : 587-592
Impact of Renal Failure on Survival of African Patients with Cirrhosis


1 Service of Hepatology and Gastroenterology, Yopougon Teaching Hospital, Abidjan, Ivory Coast
2 Service of Nephrology, Dialysis and Hypertension, Yopougon Teaching Hospital, Abidjan, Ivory Coast

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   Abstract 

To assess the effect of renal failure on the survival of black African patients with cirrhosis, we studied 132 (82 males, 50 females) cirrhotic black African patients with mean age of 47.5 ±14.4 years and mean follow-up period of 373 ± 194 days. The edema and ascitis were the main reasons for admission to hospital. Renal failure was present in 30 (22.7%) patients, and it was positively correlated to the severity of the stage of the liver disease, and associated with severe hyponatremia. Survival at 1 year was 60.1% and 37.6% in the absence or presence of renal failure, respectively (p< 0.001)). The stage of the liver disease was significantly inversely corre­lated with survival, which was further diminished in the presence of renal failure:23.7% versus 12.5% for Child-Pugh-Turcote (CPT) A-B in the absence or presence of renal failure, respectively (p= 0.67), 30.2% versus 81.8% for CPT C in the absence or the presence of renal failure respectively (p< 0.001). Hyponatremia has also appeared detrimental to survival, since mortality was 38.4% versus 81.8% in the absence or the presence of hyponatremia respectively (p< 0.001). By multivariate analysis, renal failure, CPT stage C, and hyponatremia independently significantly correlated to mortality in patients with cirrhosis. We conclude that renal failure is frequently associated with decompensated cirrhosis. The presence of renal failure in this setting often results in high mortality. Renal failure that occurs in the setting of a severe liver disease and hyponatremia may be part of hepatorenal syndrome.

Keywords: Cirrhosis, Renal failure, Mortality

How to cite this article:
Attia K A, N’dri Yoman A T, Mahassadi A K, Ackoundou-N’Guessan K C, Kissi H Y, Bathaix Y F. Impact of Renal Failure on Survival of African Patients with Cirrhosis. Saudi J Kidney Dis Transpl 2008;19:587-92

How to cite this URL:
Attia K A, N’dri Yoman A T, Mahassadi A K, Ackoundou-N’Guessan K C, Kissi H Y, Bathaix Y F. Impact of Renal Failure on Survival of African Patients with Cirrhosis. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2018 Aug 15];19:587-92. Available from: http://www.sjkdt.org/text.asp?2008/19/4/587/41319

   Introduction Top


The prevalence of renal failure in cirrho­tic patients varies from 7-65%. [1],[2],[3] About 20% of the cirrhotic patients who present with edema and ascitis are likely to reveal acute prerenal azotemia. This value has been reported to exceed 50% when end stage-liver disease is present. [4] The Child-Pugh-Turcote (CPT) score is usually used to assess the prognosis of patients with cirrhosis, [5] since it is related to the severity of the liver di­sease. However, the CPT score does not include in its determination the renal func­tion, which is widely reported to indepen­dently influence survival in patients with cirrhosis. [6],[7],[8].

The aim of the present study is to evaluate the effect of the renal function on the sur­vival of black African patients with cirrhosis.


   Patients and Methods Top


We studied retrospectively a cohort of cirrhotic black African patients who were hospitalized in the hepatology unit of the University hospital of Yopougon (Abidjan) from January the 1 st , 1991 to December the 31 st , 2001. Of 307 patients recruited over this period, 135 were excluded because of missing data, and 172 patients were consi­dered for analysis.

Child-Pugh-Turcote (CPT) (CPT) score that uses 5 parameters: hepatic encephalo­pathy, ascitis, prothrombin time, serum al­bumin in g/L, and bilirubin in mg/L, is widely applied to classify cirrhotic patients.

We defined the time of follow-up as the time from the date of first admission for cirrhosis to the date of last visit or the date of death for deceased patients, and time of survival as the time from the date of the first symptoms of decompensated cirrhosis as reported by the patient to the date of last visit for the patients who lost to follow-up or still alive, or the date of death for the deceased patients.

Statistical analysis

Parameters were expressed in percentage (%). Survival curves were determined using the Kaplan-Meier method. Analysis of sur­vival prognostic factors was performed using the chi-square test or the Fisher exact test (univariate and stratified analysis), a step­wise regression analysis (multivariate ana­lysis), and the log rank test (for compa­rison between survival curves). A p value < 0.05 was considered as significant.


   Results Top


The different reasons for admission of pa­tients with cirrhosis were: edema and as­citis (68.6%), jaundice (25.2%), hematemesis or melena (15.1%), and hepatic encephalolopathy (3.8%). Ascitis was present in 108 out of 132 (81.8%) patients, and it was severe in 53.7%. Fifteen (11.36%) patients presented with a CPT score stage A, 52 (39.39%) with stage B, and 65 (49.24%) with stage C.

Renal failure was present in 30 (22.7%) patients. It was significantly proportionally related to the stage of the liver disease as renal failure was present in 6.7% of pa­tients with CPT score stage A, 13.5% in patients with stage B and 33.9% in patients with stage C (p= 0.01). There was 16.5% of renal failure patients with sodium blood level more than 130 mmol/L, and 34.4% with sodium blood level was less than 130 mmol/L, (p= 0.038).

The mean time of follow-up of patients was 373 ± 194 days with a median of 224 days, and the overall mortality was 34.9%. The median survival time was 865 days (30 months). The main cause of death was hepatic encephalopathy (51.5%). This was generally triggered by hemorrhage in the digestive tract, the use of diuretics, general infection, of infection of ascitis.

The overall survival curve is shown in [Figure 1], and survival according to renal function is shown in [Figure 2]. Factors likely to influence mortality are summarized in [Table 1] and [Table 2].


   Discussion Top


Prognosis of cirrhosis is intimately linked to the occurrence of complications. Half of the patients with cirrhosis who are for­merly compensated will develop an ascitis within the first 10 years of evolution. [9] The development of ascitis usually represents a turning point in the natural history of the disease, since survival with ascitis is 50% and 30% respectively at 1 and 5 years. Survival is only 20% at 1 year when ascitis is refractory to treatment. [9],[10]

The CPT score has usually been used to assess prognosis in patients with cirrhosis. It has a good predictive value. [5] However, factors such as renal failure or hepato-renal syndrome, which are currently associated with the severity of the liver disease [6],[7],[8],[11],[12] were often overlooked, and the CPT score could not reflect in these cases the true status of the patient. In our study 1/5 of our patients presented with a renal failure. The prevalence of renal failure was proportion­nally related to the stage of the liver di­sease. Moreover, this prevalence was much higher when severe hyponatremia was su­perimposed. Whether hyponatremia was part of hepatorenal syndrome [13] could not be substantiated because of the retrospective nature of the study.

Three parameters have been found inde­pendently related to mortality: the CPT score, renal failure, and severe hypona­tremia. Furthermore, in patient with CPT score stage C, mortality was significantly higher in case of renal failure as compared to when renal dysfunction is absent. Survi­val was significantly less in the presence of renal failure at 3, 6, 12 and 24 months.

The deleterious impact of renal failure on the survival of patient with cirrhosis has resulted in the development of a new equation, abbreviated as the MELD (Model for End-stage Liver Disease) score [11] that has been used so far for graft allocation to patients on the liver transplantation waiting list. The performance of the two scores has been compared in several studies with conflicting results: some studies [11],[12],[14],[15],[16],[17],[18] have demonstrated superiority of the MELD score over the CPT score in predicting survival in patients on the transplantation waiting list or in patients awaiting transjugular intrahepatic portosystemic shunt (TIPS) or even in patients with acute alcoholic hepa­titis; others have found the two scores to be comparable. [19],[20],[21],[22],[23]

In any case, renal function must be appre­ciated in any patient with cirrhosis because of its high prevalence in this setting and also to rule out hepatorenal syndrome. [13] Pre­vention and early treatment of the trigge­ring factors (severe infection, anti-inflam­matory drugs, hemorrhage of the digestive tract, vasodilators, iterative paracentesis, abuse of diuretics) may help in decreasing mortality related to hepatorenal syndrome. This attitude is of an outmost importance since liver transplantation, TIPS and vaso­constrictors such as vasopressin and its analogues which represent majors treatment of this syndrome are not available in our daily practice.

We conclude that renal failure represents a frequent complication of decompensated cirrhosis, and was an independent risk factor of mortality as was the CPT score in our study. Renal function was proportio­nally related to the severity of the liver disease and frequently associated with se­vere hyponatremia suggesting the likelihood of hepatorenal syndrome. The present study could not confirm the presence of hepato­renal syndrome because of its retrospective nature.

 
   References Top

1.Vinel JP. Nephropathy in liver disease. Hepatology Encycl Med Chir 1995;7:34-95.  Back to cited text no. 1    
2.Moreau R, Lebrec D. Acute renal failure in patients with cirrhosis: perspectives in the age of MELD. Hepatology 1998;37(2): 233-43  Back to cited text no. 2    
3.Rodes J. The hepatorenal syndrome. Hepa­tology Encycl Med Chir 1999;7:34-60.  Back to cited text no. 3    
4.Gines A, Rodes J. Clinical physiopathology and treatment of ascitis in patients with cirrhosis. Hepatology Encycl Med Chir 996;7:34-40.  Back to cited text no. 4    
5.Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, William R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60(8):646-9.  Back to cited text no. 5    
6.Gines P, Guevara M, Arroyo V, Rodes J. Hepatorenal syndrome. Lancet 2003;362 (9398):1819-27.  Back to cited text no. 6    
7.Epstein M. Hepatorenal syndrome: emerging perspectives of pathophysiology and the­rapy. J Am Soc Nephrol 1994;4:1735-53  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Gines P, Cardenas A, Arroyo V, Rodes J. Management of cirrhosis and ascites. N Engl J Med 2004;350(16):1646-54.  Back to cited text no. 8    
9.Gines P, Quintero E, Arroyo V, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987;7(1): 122-8.  Back to cited text no. 9    
10.Guardiola J, Balliellas C, Xiox X, et al. External validation of a prognostic model for predicting survival of cirrhotic patients with refractory ascites. Am J Gastroenterol 2002;97(9):2374-8.  Back to cited text no. 10    
11.Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients under­going transjugular intrahepatic portosystemic shunts. Hepatology 2000;31(4):864-71.  Back to cited text no. 11    
12.Wiesner R, Edwards E, Freeman R, et al.Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroente­rol 2003;124(1):91-6.  Back to cited text no. 12    
13.Pariente A. Ascitis decompensation. Gastroenterol Clin Biol 2006;30(6-7):870-4.  Back to cited text no. 13    
14.Salerno F, Merli M, Cazzaniga M, et al. MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt. J Hepatol 2002;36 (4):494-500.  Back to cited text no. 14    
15.Ferral H, Gamboa P, Postoak DW, et al. Survival after elective transjugular intra­hepatic portosystemic shunt creation: pre­diction with model for end-stage liver disease score. Radiology 2004;231(1):231-6.  Back to cited text no. 15    
16.Giannini E, Botta F, Fumagalli A, et al. Can inclusion of serum creatinine values improve the Child-Turcotte-Pugh score and challenge the prognostic yield of the model for end-stage liver disease score in the short-term prognostic assessment of cirrhotic patients? Liver Int 2004;24(5): 465-70.  Back to cited text no. 16    
17.Zhang JY, Zhang FK, Wang BE, Jia JD, Zhang ST. The prognostic value of end­stage liver disease model in liver cirrhosis. Zhonghua Nei Ke Za Zhi 2005;44(11): 822-4.  Back to cited text no. 17    
18.Fejfar T, Safka V, Hulek P, Vanasek T, Krajina A, Jirkovsky V. MELD score in prediction of early mortality in patients suffering refractory ascites treated by TIPS. Vnitr Lek 2006;52(9):771-6.  Back to cited text no. 18    
19.Botta F, Giannini E, Romagnoli P, et al. MELD scoring system is useful for pre­dicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study. Gut 2003;52(1):134-9.  Back to cited text no. 19    
20.Angermayr B, Cejna M, Karnel F, et al. Child-Pugh versus MELD scores in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt. Gut 2003;52(6):879-85.  Back to cited text no. 20    
21.Papatheodoridis GV, Cholongitas E, Dimitriadou E, Touloumi G, Sevastianos V, Archimandritis AJ. MELD vs Child­Pugh and creatinine modified Child-Pugh score for predicting survival in patients with decompensated cirrhosis. World J Gastroenterol 2005;11(20):3099-104.  Back to cited text no. 21    
22.Cholongitas E, Marelli L, Shusang V, et al. A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplan­tation. Liver Transpl 2006;12(7):1049-61.  Back to cited text no. 22    
23.Cesbron E, Tropet A, Boursier J, Pillette C. Is the predictive value of the MELD score over mortality superior than the Child Pugh score and can it be improved? A prospective analysis of 309 patients from a secondairy care hospital of France. Gastoenterol Clin Biol 2006;30:A96(Abst).  Back to cited text no. 23    

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Correspondence Address:
K A Attia
Service of Hepatology and Gastroenterology, Yopougon Teaching Hospital, P. O. Box 632, Abidjan 21, Abidjan
Ivory Coast
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PMID: 18580018

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

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