Third-spacing of fluid is a common complication in hospitalized patients with decompensated cirrhosis. In addition to ascites, patients with advanced cirrhosis may develop significant peripheral edema, which may limit mobility and exacerbate debility and muscle wasting. Concomitant kidney failure and cardiac dysfunction may lead to worsening hypervolemia, which may ultimately result in pulmonary edema and respiratory compromise. Diuretic use in such patients may be limited by kidney dysfunction and electrolyte abnormalities, including hyponatremia and hypokalemia. A slow, continuous form of ultrafiltration known as aquapheresis is a method of extracorporeal fluid removal whereby a pump generates a transmembrane pressure that forces an isotonic ultrafiltrate across a semipermeable membrane. This leads to removal of an ultrafiltrate that is isotonic to blood without the need for dialysate or replacement fluid as is necessary in other forms of continuous kidney replacement therapy. This technique has been utilized in other conditions including acute decompensated heart failure, with trials showing mixed, but generally favorable results. Herein, we present a series of our own experience using aquapheresis among patients with cirrhosis, review the literature regarding its use in other hypervolemic states, and discuss how we may apply lessons learned from use of aquapheresis in heart failure to patients with end-stage liver disease.

Patients with end-stage renal disease (ESRD) receive dialysis through either hemodialysis (HD) or peritoneal dialysis (PD). HD has challenges associated with vascular access and catheter-associated complications. The development of a fibrin sheath is a common complication with tunneled catheters. However, infection of the fibrin sheath is not usually encountered. We discuss the case of a 60-year-old female with ESRD and heart failure with reduced ejection fraction (HFrEF) receiving HD via tunneled right internal jugular (RIJ) Permcath who was diagnosed with an infected fibrin sheath located in the cavoatrial junction via a transesophageal echocardiogram (TEE). Compared to a transthoracic echocardiogram (TTE), a transesophageal echocardiogram provides a much more accurate diagnosis of this rare condition. Treatment primarily involves administering antibiotics based on sensitivity cultures and closely monitoring for any potential complications.

BACKGROUND: To assess the association between exposure to micafungin, other echinocandins, or azoles and the development of short-term liver injury (STLI) or long-term liver injury (LTLI) in patients with Child-Pugh B or C liver disease.
METHODS: Multicenter case-control study of patients with Child-Pugh B or C liver disease who received antifungals (AF) for ≥ 72 h (May 2009-May 2015) in six Spanish and Italian hospitals. All micafungin patients were randomly matched with one patient who received another echinocandin and with one patient who received azole treatment. Primary outcome was development of STLI or LTLI (development of any type of liver tumor during the follow-up period).
RESULTS: Of 2335 patients with chronic liver disease admitted to the six centers, 20 (0.85%) were found to have Child-Pugh B or C liver disease and received micafungin for ≥ 72 h. During AF treatment, the frequency of STLI was 10% in each group. Most cases of STLI were asymptomatic, and AFs had to be switched to another class of AF in only two patients (one micafungin and one azole). No patients developed acute liver insufficiency, were admitted to the ICU, or had to undergo transplantation. Follow-up data (median of 1.3 years) were available for 30 patients. LTLI was observed in only one patient, who had previously received treatment with azoles.
CONCLUSIONS: Our study suggests that the administration of micafungin to patients with end-stage liver disease does not imply a higher risk of developing STLI or LTLI.

UNASSIGNED: Sublingual buprenorphine is indicated for opioid dependence. It comes in 2 formulations: a mono buprenorphine product (BUP) and a combination product containing naloxone (BUP-NAL), which functions as an abuse deterrent. Sublingual naloxone does not reach clinically significant levels except in cases of hepatic impairment, where its metabolism can be impaired. Substantial naloxone accumulation could block the therapeutic effects of buprenorphine. The risk of hepatic impairment is elevated in the opioid dependence population, and our case highlights the need for careful evaluation of hepatic function and consideration of BUP.
UNASSIGNED: We report a patient with end-stage liver disease who began BUP-NAL induction with modest improvement on treatment day 1 followed by sustained withdrawal after receiving an observed dose on day 2. He returned to the clinic 2 days after his second successive day of BUP-NAL, vomiting and complaining of persistent withdrawal. To avoid potential accumulation of naloxone, the patient was eventually switched to and stabilized on BUP with good response.
UNASSIGNED: The clinical course this patient experienced during induction makes a case that naloxone can accumulate and interfere with the effectiveness of buprenorphine in the presence of liver dysfunction. Our case highlights the need for consideration of BUP in circumstances where patient safety and effective treatment outweigh the risks of prescribing a product with abuse deterrent properties.

BACKGROUND: Ascites, the commonest complication of cirrhosis, leads to frequent hospitalisations. Refractory ascites confers a median survival of 6 months without liver transplantation. In many, the management remains palliative (large-volume paracentesis). Despite calls for improvement, palliative and end-of-life care is not yet integrated into end-stage liver disease. Long-term abdominal drains are a palliative strategy in malignant ascites, but not end-stage liver disease.
METHODS: A retrospective, single centre, case series review was performed of patients undergoing long-term abdominal drain placement for refractory ascites secondary to end-stage liver disease at a large teaching hospital between August 2011 and March 2013. Case management: Patients with end-stage liver disease and refractory ascites, where liver transplantation was not an option, were considered for long-term abdominal drains. Seven patients underwent successful long-term abdominal drain insertion after multi-professional assessment. Case outcome: Following long-term abdominal drain insertion, mean hospital attendances reduced to 1 (0-4) from 9 (4-21), with none for ascites management. Median survival after long-term abdominal drain insertion was 29 days (8-219). The complication rate was low and none life threatening.
CONCLUSIONS: Palliative and end-of-life care needs in end-stage liver disease remain under-addressed. Our data suggest that long-term abdominal drains may be a safe and effective palliative intervention in end-stage liver disease. Prospective randomised controlled trials comparing large-volume paracentesis versus long-term abdominal drains in refractory ascites secondary to end-stage liver disease are warranted.

BACKGROUND: Liver transplantation (LT) accompanied by jejunectomy to treat patients with acute or chronic hepatic cirrhosis with thrombosis in the portal system is extremely rare.
METHODS: A 47-year-old man presented with hematemesis and melena, and a diagnosis of decompensated cirrhosis, chronic portal vein thrombosis (PVT) and secondary gastro-esophageal variceal hemorrhage was made. Coagulants were administered, but portal vein thrombi occurred rapidly, and gastrointestinal bleeding recurred shortly thereafter. The patient underwent LT, phlebothrombectomy and a partial jejunectomy. His recovery from a fistula was uneventful, and follow-up visits over 70 months were unremarkable.
CONCLUSIONS: Liver transplantation and partial jejunectomy is a feasible and effective surgical option for select patients with end-stage liver disease accompanied by acute portal venous thrombosis.