Functional renal failure and haemorrhagic gastritis associated with endotoxaemia in cirrhosis

Forty-three patients with cirrhosis and ascites, 21 with normal renal function, 10 with a progressive functional renal failure (FRF), and 12 with a steady FRF, were investigated for the presence of endotoxaemia by the Limulus lysate test. Endotoxaemia was found in nine patients with FRF and in none of the 21 with normal renal function (P less than 0-01). A positive Limulus test was almost exclusively associated with a progressive FRF (eight of 10 patients) and all but one of them died. Renal function improved as endotoxaemia disappeared in the survivor. Endotoxaemia was also associated with haemorrhage due to acute erosions of the gastric mucosa, being present in six of the seven patients who had this complication. Intravascular coagulation was not found in any patient. The Limulus test was positive in the ascitic fluid in 18 of 21 patients tested, although only two of them had peritonitis. These results suggest that endotoxaemia may play a critical role in the development of progressive renal failure and haemorrhagic gastritis in cirrhosis, and emphasise the potential risk of procedures involving reinfusion of ascitic fluid.

Prognostic Importance of the Cuse of Renal Failure in Patients With Cirrhosis

BACKGROUND & AIMS: The prognostic value of the different causes of renal failure in cirrhosis is not well established. This study investigated the predictive value of the cause of renal failure in cirrhosis. METHODS: Five hundred sixty-two consecutive patients with cirrhosis and renal failure (as defined by serum creatinine 1.5 mg/dL on 2 successive determinations within 48 hours) hospitalized over a 6-year period in a single institution were included in a prospective study. The cause of renal failure was classified into 4 groups: renal failure associated with bacterial infections, renal failure associated with volume depletion, hepatorenal syndrome (HRS), and parenchymal nephropathy. The primary end point was survival at 3 months. RESULTS: Four hundred sixty-three patients (82.4%) had renal failure that could be classified in 1 of 4 groups. The most frequent was renal failure associated with infections (213 cases; 46%), followed by hypovolemia-associated renal failure (149; 32%), HRS (60; 13%), and parenchymal nephropathy (41; 9%). The remaining patients had a combination of causes or miscellaneous conditions. Prognosis was markedly different according to cause of renal failure, 3-month probability of survival being 73% for parenchymal nephropathy, 46% for hypovolemia-associated renal failure, 31% for renal failure associated with infections, and 15% for HRS (P .0005). In a multivariate analysis adjusted for potentially confounding variables, cause of renal failure was independently associated with prognosis, together with MELD score, serum sodium, and hepatic encephalopathy at time of diagnosis of renal failure. CONCLUSIONS: A simple classification of patients with cirrhosis according to cause of renal failure is useful in assessment of prognosis and may help in decision making in liver transplantation.

Experimental thermal hydraulic studies on the enhancement of safety of LWRs

The safe use of nuclear power plants (NPPs) requires a deep understanding of the functioning of physical processes and systems involved. Studies on thermal hydraulics have been carried out in various separate effects and integral test facilities at Lappeenranta University of Technology (LUT) either to ensure the functioning of safety systems of light water reactors (LWR) or to produce validation data for the computer codes used in safety analyses of NPPs. Several examples of safety studies on thermal hydraulics of the nuclear power plants are discussed. Studies are related to the physical phenomena existing in different processes in NPPs, such as rewetting of the fuel rods, emergency core cooling (ECC), natural circulation, small break loss-of-coolant accidents (SBLOCA), non-condensable gas release and transport, and passive safety systems. Studies on both VVER and advanced light water reactor (ALWR) systems are included. The set of cases include separate effects tests for understanding and modeling a single physical phenomenon, separate effects tests to study the behavior of a NPP component or a single system, and integral tests to study the behavior of the whole system. In the studies following steps can be found, not necessarily in the same study. Experimental studies as such have provided solutions to existing design problems. Experimental data have been created to validate a single model in a computer code. Validated models are used in various transient analyses of scaled facilities or NPPs. Integral test data are used to validate the computer codes as whole, to see how the implemented models work together in a code. In the final stage test results from the facilities are transferred to the NPP scale using computer codes. Some of the experiments have confirmed the expected behavior of the system or procedure to be studied; in some experiments there have been certain unexpected phenomena that have caused changes to the original design to avoid the recognized problems. This is the main motivation for experimental studies on thermal hydraulics of the NPP safety systems. Naturally the behavior of the new system designs have to be checked with experiments, but also the existing designs, if they are applied in the conditions that differ from what they were originally designed for. New procedures for existing reactors and new safety related systems have been developed for new nuclear power plant concepts. New experiments have been continuously needed.

Derivation of traceable and transplantable photoreceptors from mouse embryonic stem cells.

Retinal degenerative diseases resulting in the loss of photoreceptors are one of the major causes of blindness. Photoreceptor replacement therapy is a promising treatment because the transplantation of retina-derived photoreceptors can be applied now to different murine retinopathies to restore visual function. To have an unlimited source of photoreceptors, we derived a transgenic embryonic stem cell (ESC) line in which the Crx-GFP transgene is expressed in photoreceptors and assessed the capacity of a 3D culture protocol to produce integration-competent photoreceptors. This culture system allows the production of a large number of photoreceptors recapitulating the in vivo development. After transplantation, integrated cells showed the typical morphology of mature rods bearing external segments and ribbon synapses. We conclude that a 3D protocol coupled with ESCs provides a safe and renewable source of photoreceptors displaying a development and transplantation competence comparable to photoreceptors from age-matched retinas.

Actinobaculum schaalii: clinical observation of 20 cases.

Actinobaculum schaalii is a new species that has so far been isolated from human blood, urine and pus. Its importance has probably been underestimated and other Actinobaculum spp. may also have been underdiagnosed. This retrospective study comprises all known cases of A. schaalii infections identified since 2004 in the canton of Neuchâtel (170,000 inhabitants), Switzerland. Strains were cultivated and isolated in the bacteriology laboratory using its routine procedure. Identification included a Rapid ID 32 A strip (bioMérieux) and 16S rRNA gene sequencing. Twenty-one positive samples were found in 19 patients (11 male, 8 female) of all ages (range 16-91 years): 10 from urine (50%), six from blood (30%), one from both blood and urine (5%), and three from pus (15%). Thirteen out of 17 (76%) cases with either blood or urine specimens had underlying genitourinary tract pathologies. When urine cultures were positive for A. schaalii, leucocytes were found in all samples (10/10, 100%) but all nitrite tests were negative (10/10, 100%). The onset of appropriate treatment was delayed due to the diminished sensitivity of A. schaalii to the antibiotics commonly used for UTIs (i.e. ciprofloxacin and trimethoprim/sulfamethoxazole) and to the delay in microbiological diagnosis. A. schaalii should specifically be searched in all cases of leukocyturia with a negative nitrite test but with Gram-positive rods in the Gram stain, in patients with underlying genitourinary tract pathology, instead of dismissing these findings as clinically irrelevant colonization by coryneform bacteria. This infection may be much more common than previously thought.

The Paleozoic magmatic history of the Maggia and Sambuco nappes, Lower Penninic, Central Lepontine Alps

Résumé : Les corps magmatiques sont des indicateurs essentiels dans toute reconstitution paléogéographique et/ou géodynamique d'un cycle orogénique, en particulier en contexte polycyclique, où la plupart des autres indices ont été oblitérés. Ils sont aisément datables et leurs caractéristiques géochimiques permettent de contraindre leur contexte tectonique de mise en place. Cette approche a été appliquée aux socles pré-mésozoïques des nappes penniques inférieures de Sambuco et de la Maggia, dans les Alpes centrales lepontines. Plusieurs événements magmatiques ont été identifiés dans le socle de Sambuco et datés par la méthode U-Pb sur zircon couplée à la technique LA-ICPMS. La suite calco-alcaline mafique rubanée de Scheggia est datée du Cambrien inférieur à 540-530 Ma ; le métagranite alumineux oeillé de Sasso Nero a un âge de 480-470 Ma, tout comme bien d'autres «older orthogneisses» des socles alpins. Il contient des zircons hérités d'âge panafricain à 630-610 Ma, indicateur d'une affiliation gondwanienne de ces terrains. Le pluton calco-alcalin du Matorello est daté à environ 300-310 Ma, et les filons lamprophyriques qu'il abrite à 300 Ma. La granodiorite de Cocco et le leucogranite de Ruscada, tous deux intrudés dans le socle de la nappe adjacente de la Maggia, ont des âges similaires à celui du Matorello. Ceci ajouté aux similitudes magmatiques observées entre Cocco et Matorello suggère une proximité paléogéographique des deux nappes au Permien-Carbonifère. Or ces dernières sont actuellement considérées appartenir à deux domaines paléogéographiques mésozoïques distincts : helvétique pour Sambuco et briançonnais pour Maggia, séparés par un bassin océanique. Si tel fut le cas, aucun mouvement décrochant ne doit avoir décalé les marges continentales de l'océan, retrouvées en parfaite coïncidence lors de sa fermeture. Le Matorello est un pluton recristallisé en faciès amphibolite et plissé par cinq phases successives de déformation non-coaxiales, qui ont conduit à son renversement complet, attesté par des indicateurs de paléogravité. Il préserve de spectaculaires phénomènes de coexistence liquide de magmas (essaims d'enclaves et Bills composites). Ce pluton était originellement tabulaire, construit par l'accumulation de multiples injections de magma en feuillets d'épaisseur métrique à décamétrique. Suivant le rythme de mise en place, les injections successives ont rapidement cristallisé avec des contours nets et bien définis (Bills composites) ou se sont mélangées avec les précédentes pour former une couche non consolidée de plusieurs dizaines de mètres d'épaisseur (granodiorite principale). Les injections individuelles sont délimitées par de subtils contrastes en granulométrie, proportions modales ou ségrégation de minéraux (schlieren), ou par des phénomènes d'érosion le long des surfaces de contact. Deux couches métriques à contour sinueux consistent en une accumulation compacte d'enclaves mafiques arrondies dans une matrice granodioritique fine. Le granoclassement des enclaves, la présence de figures de charge et de phénomènes érosifs en base de couche, ainsi que des schlieren de biotite entrecroisés évoquent l'injection de coulées de magma chargé d'enclaves et de faible viscosité en régime hydrodynamique turbulent dans un encaissant granodioritique encore largement liquide. La nature hybride des roches implique une chambre magmatique sous-jacente, en cours de différenciation et périodiquement réalimentée. Les magmas sont des liquides mafiques dérivés du manteau et des liquides anatectiques d'origine crustale, comme l'indique la gamme mesurée des rapports isotopiques initiaux du Sr (0.704 à 0.709) et des valeurs epsilon Nd (-2.1 à -4.7). Ces données montrent également que la contribution crustale est dominante, en accord avec les isotopes du plomb. Les phénomènes d'hybridation ont vraisemblablement eu lieu en base de croûte et dans la chambre magmatique sous-jacente au laccolite du Matorello. Les indicateurs de paléogravité du Matorello contribuent accessoirement à la compréhension de l'architecture actuelle de la nappe de Sambuco. Des plis isoclinaux à surface axiale verticale peuvent être mis en évidence par le contact entre les faciès dioritique et granodioritique. L'antiforme dont le Matorello forme le coeur est un synclinal, ce qui le positionne dans le Flanc inverse du grand pli couché que forme la nappe de Sambuco. Par ailleurs, des blocs de gneiss retrouvés dans le wildflysch sommital de la couverture de la nappe d'Antigorio ont été affiliés dans cette étude au pluton du Matorello. Ceci implique que le front de la nappe de Sambuco chevauchait déjà la partie est du bassin d'Antigorio au moment de sa fermeture. Par conséquent, ce n'est qu'en position externe que la nappe du Lebendun chevauche directement la nappe d'Antigorio. Abstract Magmatic bodies are important markers in paleo-geographic or geodynamic reconstructions of orogenic cycles, even more so in the case of polycyclic events where many of the other markers have been overwritten or destroyed. Plutons are relatively easy to date and their geochemical properties help constrain the tectonic context in which they were emplaced. This study focuses on the pre-mesozoic basement in the Sambuco and Maggia lower Penninic nappes located in the central Lepontine domain of the Alps. A number of magmatic events have been identified in the Sambuco basement. These events were dated using LA-ICPMS U/Pb on zircon grains. The mafic calc-alkaline banded Scheggia suite is dated as lower Cambrian, 540-530 Ma. The Al-rich Sasso-Nero lenticular gneiss is 480-470 Ma old (similarly to many older orfhogneisses of the Alpine basement) and contains 630-610 Ma old pan-African inherited zircons that illustrate the Gondwanian origin of these terranes.The calc-alkaline Matorello pluton is dated as 310-300 Ma whereas the lamprophyric bodies it contains are of 300 Ma. The Cocco granodiorite and the Ruscada leucogranite both intrude the basement of the adjacent Maggia nappe and are of similar ages to the Matorello. The ages as well as the geochemical similarities between the Cocco, Rucada and Matorello plutons suggest their paleo-geographic proximity at the Permian-Carboniferous boundary. However, these nappes are currently considered as belonging to two different Mesozoic paleo-geographic domains. Indeed, the Sambuco is considered as Helvetic whereas the Maggia is said to be Briançonnais, both separated by an oceanic basin. If this is the case, then it is essential that nostrike-slip movement has misaligned both continental margins since these coincide perfectly now that the oceanic domain closed. The Matorello pluton was originally a tabular intrusion, built up by the accumulation of multiple, several meter-thick, subhorizontal sheet-like injections of magma. Depending on their emplacement rate, the successive magma injections either solidified rapidly with sharp and rather well-defined boundaries (like the composite sills) or mingled with previous injections generating a thick molten layer up to several tens to hundred meters thick, like in the main granodioritic facies. These coalesced injections are hardly distinguishable, however subtle contrasts in granulometry, mineral modal proportions or mineral sorting (cross-bedded biotite-rich schlieren), as well as erosional features and/or crystal entrapment along contact surfaces allow to distinguish between the different injections. Two exceptional meter-thick layers display sinuous boundaries with the host granodiorite and consist of a densely packed accumulation of mafic enclaves in a granodioritic matrix. Gravitational sorting of the enclaves with load cast features at the base of the layers and sinuous biotite schlieren point to injection of low viscosity turbulent composite magma flows in the still largely molten granodiorite host. The hybrid nature of these rocks implies the existence of á periodically replenished and differentiated underlying magma chamber. Magmas are mafic liquids derived from the mantle and anatectic liquids of crustal origin, as shown by the (87Sr/86Sr), and epsilon Nd values (0.704-0.709 and -2.1 to -4.7 respectively. These data show that the crustal contribution is important, as confirmed by the Pb isotopes. The hybridisation processes seem to have occurred in the lower crust in magma chambers underlying the Matorello laccolith. The paleo-gravity markers in the Matorello help understand the architecture of the Sambuco nappe. Isoclinal folds with a vertical axial plane can be seen at the contact between dioritic and granodioritic facies. The antiform structure of which the Matorello is the heart is in fact a syncline. This places it in the inverse flanc of the large recumbent fold that constitutes the Sambuco nappe. The gneiss blocs found in the summital wildflysh cover of the Antigorio nappe have been linked to the Matorello pluton. This means that the front of the Sambuco nappe already overlapped the Antigorio basin when it closed. This implies that the Lebendun nappe can only overlap the Antigorio nappe in it's external position. Résumé grand public La chaîne alpine est la conséquence de la collision tertiaire entre deux masses continentales, l'Europe au nord et la péninsule apulienne africaine au sud, originellement séparées par l'océan mésozoïque téthysien. Cette collision a fermé un espace large de plusieurs centaines de km avec pour résultat l'écaillage de la croûte terrestre en unités tectoniques de dimensions variables, qui se sont empilées, imbriquées, éventuellement replissées en nappes de géométrie complexe. Cet amoncellement de 40 km d'épaisseur a vu sa température et sa pression lithostatique internes augmenter jusqu'à des valeurs de l'ordre de 680 °C et 6000 bars, induisant une recristallisation métamorphique des roches. L'un des objectifs de la géologie alpine est de reconstituer la géographie de la région aux temps mésozoïques de l'océan téthysien, en d'autres termes, de replacer chacune des unités tectoniques identifiées au sein de l'empilement alpin dans sa position originelle. Le défi est de taille et peut être comparé à celui de la reconstitution d'un vaste puzzle, dont certaines pièces seraient endommagées au niveau de leur contour ou leurs couleurs (métamorphisme), dissimulées par d'autres (enfouissement), voire tombées de la table de jeu (subduction, échappement latéral). Plusieurs approches ont été mises en oeuvre au cours du siècle écoulé. On citera en particulier la stratigraphie, la tectonique et le paléomagnétisme. Dans ce travail, nous avons essentiellement utilisé des techniques de datation isotopique absolue des roches (U/Pb sur zircon) qui, sur la base des connaissances acquises par l'ensemble des autres disciplines géologiques, nous ont permis de mieux contraindre ta paléogéographie mésozoïque du domaine «pennique inférieur » des Alpes centrales lépontines. Et au-delà? Nous savons tous que la disposition des continents à la surface de la Terre évolue constamment. Il est donc tentant d'essayer de remonter plus loin encore dans le temps et de reconstituer la physionomie de la marge sud européenne, tout au moins certains éléments de son histoire, au cours de l'ère paléozoïque. Les traces de ces événements très anciens sont naturellement ténues et dans ce contexte, les techniques de datation mentionnées ci-dessus deviennent les outils les plus performants. Ainsi, des datations u/Pb sur zircon nous ont permis de recenser plusieurs intrusions magmatiques, attribuées à quatre événements orogéniques anté-alpins. Des âges néoprotérozoïques (630-610 millions d'années ou Ma), cambrien inférieur (540-530 Ma), ordovicien inférieur (480-470 Ma) et carbonifère supérieur-permien inférieur (310-285 Ma) ont été obtenus dans le socle de la nappe de Sambuco. Des âges similaires à 300 Ma ont été obtenus dans la nappe voisine de la Maggia, qui permettent de relier ces deux unités. Aujourd'hui côte à côte, ces deux nappes devaient également se trouver proches l'une de l'autre il y a 300 Ma, lors de l'extension post-varisque. Les structures magmatiques spectaculaires préservées dans le pluton du Matorello (300 Ma) contraignent la géométrie actuelle de la nappe de Sambuco dans laquelle l'intrusion s'est mise en place. La forme originelle du pluton, aujourd'hui retourné et replissé plusieurs fois, s'avère être tabulaire, faite d'intrusions de faible épaisseur (1-300 m) s'étalant en forme de disque (30m à 2 km de diamètre). Les injections successives de magma se sont accumulées sous un toit dioritique précoce; elles sont issues, par le refais de fractures, d'une chambre magmatique plus profonde, périodiquement réalimentée par des magmas calco-alcalins d'origine mantellique contaminés parla croûte continentale profonde (εNd = -2.1 à -4.7). Des accumulations d'enclaves magmatiques arrondies et granoclassées dans des paléo-chenaux à fond érosif témoignent de conditions de mise en place hydrodynamiques à haute énergie. Ces enclaves sont emmenées de la chambre magmatique sous-jacente à la faveur d'épisodes de fracturation hydraulique liés à l'injection de magmas matelliques chauds dans des liquides différenciés riches en eau. Cette hypothèse est étayée par l'existence de filons composites. Une paléohorizontale a pu être déduite au sein du pluton, indiquant que cette partie de la nappe de Sambuco est verticalisée et isoclinalement replissée par la déformation alpine. Finalement, des blocs érodés du socle Sambuco ont été retrouvés dans le wildflysch sommital de la couverture sédimentaire mésozoïque de la nappe d'Antigorio sous-jacente. Ceci suggère que les blocs ont été fournis parle front de la nappe de Sambuco en train de chevaucher sur la nappe d'Antigorio au moment de la fermeture du bassin sédimentaire de cette dernière.

El soporte de tela en la Pintura Europea de los siglos XVI, XVII y XVIII

El objetivo de este trabajo es analizar el origen y consolidación del soporte de lienzo en la pintura europea de los siglos XVI, XVII y XVIII. Identificar las principales fibras que lo componen y realizar una clasificación de los distintos ligamentos empleados por los pintores del momento, con la ayuda de imágenes y fotografías de obras de arte. Así mismo, trataremos de analizar, a través de la bibliografía consultada, cuáles eran los diferentes modelos de bastidores utilizados y definir sus posibles alteraciones. De este modo, podremos ver la gran relevancia que tuvieron los diferentes tipos de telas en el campo de las técnicas artísticas, especialmente desde que se generalizó su uso en los siglos XV y XVI.

Prevalence and clinical significance of isotype specific antinuclear antibodies in primary biliary cirrhosis.

with specific ANA, in particular of the IgG3 isotype, had significantly more severe biochemical and histological disease compared with those who were seronegative. None of the controls was positive.Conclusions: Disease specific ANA are present in the majority of patients with PBC when investigated at the level of immunoglobulin isotype. PBC specific ANA, in particular of the IgG3 isotype, are associated with a more severe disease course, possibly reflecting the peculiar ability of this isotype to engage mediators of damage.

Comblike poly(a-alkyl g glutamate)s: computer simulation studies of an intermediate thermal phase.

Monte Carlo (MC) simulations have been used to study the structure of an intermediate thermal phase of poly(R-octadecyl ç,D-glutamate). This is a comblike poly(ç-peptide) able to adopt a biphasic structure that has been described as a layered arrangement of backbone helical rods immersed in a paraffinic pool of polymethylene side chains. Simulations were performed at two different temperatures (348 and 363 K), both of them above the melting point of the paraffinic phase, using the configurational bias MC algorithm. Results indicate that layers are constituted by a side-by-side packing of 17/5 helices. The organization of the interlayer paraffinic region is described in atomistic terms by examining the torsional angles and the end-to-end distances for the octadecyl side chains. Comparison with previously reported comblike poly(â-peptide)s revealed significant differences in the organization of the alkyl side chains.

Differential Dimerization of Variants Linked to Enhanced S-Cone Sensitivity Syndrome (ESCS) Located in the NR2E3 Ligand-Binding Domain.

NR2E3 encodes the photoreceptor-specific nuclear hormone receptor that acts as a repressor of cone-specific gene expression in rod photoreceptors, and as an activator of several rod-specific genes. Recessive variants located in the ligand-binding domain (LBD) of NR2E3 cause enhanced short wavelength sensitive- (S-) cone syndrome (ESCS), a retinal degeneration characterized by an excess of S-cones and non-functional rods. We analyzed the dimerization properties of NR2E3 and the effect of disease-causing LBD missense variants by bioluminescence resonance energy transfer (BRET(2) ) protein interaction assays. Homodimerization was not affected in presence of p.A256V, p.R039G, p.R311Q, and p.R334G variants, but abolished in presence of p.L263P, p.L336P, p.L353V, p.R385P, and p.M407K variants. Homology modeling predicted structural changes induced by NR2E3 LBD variants. NR2E3 LBD variants did not affect interaction with CRX, but with NRL and rev-erbα/NR1D1. CRX and NRL heterodimerized more efficiently together, than did either with NR2E3. NR2E3 did not heterodimerize with TLX/NR2E1 and RXRα/NR2C1. The identification of a new compound heterozygous patient with detectable rod function, who expressed solely the p.A256V variant protein, suggests a correlation between LBD variants able to form functional NR2E3 dimers and atypical mild forms of ESCS with residual rod function.

Brief cognitive assessment instruments in schizophrenia and bipolar patients, and healthy control subjects: A comparison study between the Brief Cognitive Assessment Tool for Schizophrenia (B-CATS) and the Screen for Cognitive Impairment in Psychiatry (SCIP)

Cognitive impairment in schizophrenia and psychosis is ubiquitous and acknowledged as a core feature of clinical expression, pathophysiology, and prediction of functioning. However, assessment of cognitive functioning is excessively time-consuming in routine practice, and brief cognitive instruments specific to psychosis would be of value. Two screening tools have recently been created to address this issue, i.e., the Brief Cognitive Assessment Tool for Schizophrenia (B-CATS) and the Screen for Cognitive Impairment in Psychiatry (SCIP). The aim of this research was to examine the comparative validity of these two brief instruments in relation to a global cognitive score. 161 patients with psychosis (96 patients diagnosed with schizophrenia and 65 patients diagnosed with bipolar disorder) and 76 healthy control subjects were tested with both instruments to examine their concurrent validity relative to a more comprehensive neuropsychological assessment battery. Scores from the B-CATS and the SCIP were highly correlated in the three diagnostic groups, and both scales showed good to excellent concurrent validity relative to a Global Cognitive Composite Score (GCCS) derived from the more comprehensive examination. The SCIP-S showed better predictive value of global cognitive impairment than the B-CATS. Partial and semi-partial correlations showed slightly higher percentages of both shared and unique variance between the SCIP-S and the GCCS than between the B-CATS and the GCCS. Brief instruments for assessing cognition in schizophrenia and bipolar disorders, such as the SCIP-S and B-CATS, seem to be reliable and promising tools for use in routine clinical practice.

Prognostic Importance of the Cuse of Renal Failure in Patients With Cirrhosis

BACKGROUND & AIMS: The prognostic value of the different causes of renal failure in cirrhosis is not well established. This study investigated the predictive value of the cause of renal failure in cirrhosis. METHODS: Five hundred sixty-two consecutive patients with cirrhosis and renal failure (as defined by serum creatinine 1.5 mg/dL on 2 successive determinations within 48 hours) hospitalized over a 6-year period in a single institution were included in a prospective study. The cause of renal failure was classified into 4 groups: renal failure associated with bacterial infections, renal failure associated with volume depletion, hepatorenal syndrome (HRS), and parenchymal nephropathy. The primary end point was survival at 3 months. RESULTS: Four hundred sixty-three patients (82.4%) had renal failure that could be classified in 1 of 4 groups. The most frequent was renal failure associated with infections (213 cases; 46%), followed by hypovolemia-associated renal failure (149; 32%), HRS (60; 13%), and parenchymal nephropathy (41; 9%). The remaining patients had a combination of causes or miscellaneous conditions. Prognosis was markedly different according to cause of renal failure, 3-month probability of survival being 73% for parenchymal nephropathy, 46% for hypovolemia-associated renal failure, 31% for renal failure associated with infections, and 15% for HRS (P .0005). In a multivariate analysis adjusted for potentially confounding variables, cause of renal failure was independently associated with prognosis, together with MELD score, serum sodium, and hepatic encephalopathy at time of diagnosis of renal failure. CONCLUSIONS: A simple classification of patients with cirrhosis according to cause of renal failure is useful in assessment of prognosis and may help in decision making in liver transplantation.