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INTRODUCTION:Critically ill patients with cirrhosis admitted to the intensive care unit (ICU) are usually on broad-spectrum antibiotics because of suspected infection or as a hospital protocol. It is unclear if additional rifaximin has any synergistic effect with broad-spectrum antibiotics in ICU patients with acute overt hepatic encephalopathy (HE).METHODS:In this double-blind trial, patients with overt HE admitted to ICU were randomized to receive antibiotics (ab) alone or antibiotics with rifaximin (ab + r). Resolution (or 2 grade reduction) of HE, time to resolution of HE, in-hospital mortality, nosocomial infection, and changes in endotoxin levels were compared between the 2 groups. A subgroup analysis of patients with decompensated cirrhosis and acute-on-chronic liver failure was performed.RESULTS:Baseline characteristics and severity scores were similar among both groups (92 in each group). Carbapenems and cephalosporin with beta-lactamase inhibitors were the most commonly used ab. On Kaplan-Meier analysis, 44.6% (41/92; 95% confidence interval [CI], 32-70.5) in ab-only arm and 46.7% (43/92; 95% CI, 33.8-63) in ab + r arm achieved the primary objective (P = 0.84).Time to achieve the primary objective (3.65 ± 1.82 days and 4.11 ± 2.01 days; P = 0.27) and in-hospital mortality were similar among both groups (62% vs 50%; P = 0.13). Seven percent and 13% in the ab and ab + r groups developed nosocomial infections (P = 0.21). Endotoxin levels were unaffected by rifaximin. Rifaximin led to lower in-hospital mortality (hazard ratio: 0.39 [95% CI, 0.2-0.76]) in patients with decompensated cirrhosis but not in patients with acute-on-chronic liver failure (hazard ratio: 0.99 [95% CI, 0.6-1.63]) because of reduced nosocomial infections.DISCUSSION:Reversal of overt HE in those on ab was comparable with those on ab + r.

Background and Objectives Human albumin (HA) solution is currently recommended only for patients with spontaneous bacterial peritonitis (SBP) and acute kidney injury (AKI). However, its use in hospitalized patients is quite frequent. The objective was to compare the outcomes of patients receiving HA in recommended (Gr. A) vs. non-recommended (Gr. B) indications. Methods In this prospective study, consecutive hospitalized patients who received HA were included. Apart from comparing the proportion of patients achieving resolution of hyponatremia, infection and hepatic encephalopathy among Gr. A and Gr. B, we also compared the in-hospital survival and performed a sub-group analysis of patients with the European Association for the Study of the Liver (EASL) acute-on-chronic liver failure (ACLF) and decompensated cirrhosis (DC). Results Of the 396 hospitalized patients who received HA, 180 had AKI and/or SBP (Gr. A), and 216 received albumin for non-recommended indications (Gr. B). The mean age, sex and etiology distribution were similar. The total dose of HA was higher (88 ± 61.62 g vs. 71.31 ± 488.17 g; p  = 0.003) and the duration longer (4 ± 2.37 vs. 3.4 ± 1.82 days; p  = 0.005) in Gr. A than B. The resolution of infection and HE was similar among both groups, while hyponatremia resolution was significantly higher in Gr. B (94.7%) than Gr. A (75.6%; p  < 0.001). On Kaplan-Meier analysis, survival was significantly higher in Gr. B (94%) than Gr. A (78.9%; p  < 0.001). The incidence of albumin-induced fluid overload was comparable (2.8% vs. 1.4%; p  = 0.32). Patients with ACLF were sicker with a higher incidence of microbiologically proven infection, hepatic encephalopathy (HE) and hyponatremia than in the DC group. Resolution of infection and hyponatremia and in-hospital survival was significantly lower in the ACLF group (72.5%) than in the DC group (92.7%; p  < 0.001). Eighty-six per cent of patients achieved resolution of ACLF. Conclusions HA infusion is safe and effective even in patients without AKI and SBP and leads to the resolution of infection, hyponatremia, HE and ACLF. Graphical abstract

BACKGROUND AND OBJECTIVESChronic kidney disease (CKD) is a worldwide public health problem, with adverse outcomes of kidney failure, cardiovascular disease (CVD), and premature death.Carotid intimal medial thickness is a direct measure of atherosclerotic process. Serum phosphorus levels have been implicated in development of atherosclerosis in CKD patients The aim of this study is to study the association of serum phosphate levels with carotid intimal medial thickness in CKD patients.METHODS100 patients meeting the inclusion criteria were selected based on random sampling technique. The stage of CKD was assessed by Cockroft Gault equation. CIMT was measured by B mode ultrasound and blood investigations were doneRESULTSThe present study included 100 subjects with a male preponderance of 73%. There was a statistically significant correlation (p=0.003; r=0.284) between CIMT and CKD stages. Mean age of the patients is 46 years. There was a statistical significance found between Hypertension (p=0.01), both Diabetes and Hypertension (p=0.016) and CIMT. Also the CIMT values were higher in diabetics (57.1%) compared to non-diabetics (42.9%) although the results were not statistically significant.High levels of triglycerides (p=0.004; r=0.184), total cholesterol (p=0.004; r=0.353) and LDL levels (p=0.001; r=0.338) showed statistical significance with CIMT levels and HDL levels showed a negative correlation(r-0.16) and statistically significance (p=0.001) with CIMT levels. Maximum number of patients with low serum calcium levels have been found in stage 4 (72%) and 5 (30%) CKD which is statistically significant (p=0.012) with a strong association (r=0.315). Calcium phosphate product showed strong correlation (r=0.331) with CIMT and the results were statistically significant (p<0.001). Serum phosphate levels had a strong positive correlation (r=0.35) and a highly statistically significant value with CIMT levels (p<0.001) and also CKD stages (p<0.001) with the highest values being in late stages of CKD.CONCLUSIONIn the present study, significant correlation was found between CIMT and CKD stages with CIMT being higher in the late stages of CKD. Also hypertension, both diabetes and hypertension, dyslipidemia and serum phosphate levels were found to increase carotid intima medial thickness in patients with chronic kidney disease. Hence, appropriate measures like phosphate binders, adequate control of diabetes and hypertension and dyslipidemia have to be taken to control the above mentioned cardiovascular risk factors in chronic kidney disease patients.