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| Dr Sahhar, Dr Ha, Professor Sievert and Dr Le |
While other chronic diseases such as heart failure are well
managed by a range of health professionals and a dedicated ambulatory care
service, there is no comprehensive model of care for people living with
cirrhosis.
Published recently in the prestigious American Journal of
Gastroenterology, a team of researchers at Monash University and Monash
Health have shown for the first time that early intervention using diuretic
therapy or paracentesis (removing fluid from the abdomen) for patients with
cirrhosis and ascites significantly reduces hospital readmission and mortality.
“Cirrhosis, or scarring of the liver, is commonly caused by
alcohol and viral hepatitis. 50% of cirrhosis patients develop ascites, the
most common complication of this debilitating disease” said gastroenterologist
and lead researcher Dr Suong Le.
Ascites is the build-up of fluid in the abdomen and results
from scarred liver tissue unable to filter substances in the body.
“Some of our patients present in the emergency department
looking like they’re nine months pregnant; they can’t breathe; they can’t walk
and they’re extremely sick,” said Dr Le.
“We often drain 5 to 10 litres of fluid from their abdomen.”
While there is no cure for cirrhosis related ascites other
than liver transplantation, it can be managed to improve quality of life.
“Our study found that giving patients diuretics as early as
possible lowers 90-day mortality, and early paracentesis lowers 30-day hospital
admission rates,” said Dr Le.
Senior author and Monash University Professor of Medicine William Sievert said 70%
of patients initially hospitalised for new onset cirrhotic ascites were being
readmitted within 90 days because of recurrent ascites.
“People
with cirrhotic ascites have a higher mortality rate than those with cirrhosis
who have never developed ascites, and 30 day readmission was a very strong
predictor of 90 day mortality,” said Professor Sievert, who is also Director,
Gastroenterology and Hepatology Unit at Monash Health.
“We found that if patients had a paracentesis within 30 days
of the diagnosis of ascites or during their initial hospitalization then those
patients were significantly less likely to be readmitted for recurrent ascites
and that early initiation of diuretics significantly lowered the risk of
mortality at 90 days.”
“Adherence to these two quality of care indicators had the
greatest benefit for patients, which was especially important given that 40% of
the unplanned 30-day readmissions were to the ICU,” said Professor Sievert. Dr
Le said there’s a lack of awareness in the community about cirrhosis and patients
and medical staff need to be educated that these simple and early interventions
will extend and significantly improve quality of life.
“One of the most shocking findings of our study was that 58%
of patients did not even know they had liver disease until they presented to
hospital with ascites,” said Dr Le.
“These patients have previously had no formal
diagnosis—cirrhosis is a long process, taking 10 to 20 years to develop and
progress.”
More than 300 patient records were analysed for the research
study, revealing that most patients with the disease were men who lived alone,
with a mean age of 57 years.
The Monash research team included Dr Phil Ha, Dr Lukas
Sahhar, Dr Julian Lim and Dr Tony He, all of whom were medical students when
the project commenced.
Dr Tony He said he had a particular interest in
gastroenterology and was keen to help facilitate better management of patients
with chronic liver disease and their complications.
Of the research project, Dr Lukas Sahhar said he’d learnt
about the conduct and application of real-world medical research.
“It was a very satisfying experience working with doctors
and researchers at Monash Health and Monash University and we are all grateful
to Dr Le and Professor Sievert for the opportunity,” said Dr Sahhar.
Monash Health intern Dr Phil Ha said it was a fascinating
project that assessed the degree to which current practices had followed best
practice guidelines.
“Investigating whether higher adherence to evidence-based
medicine translates into better outcomes for patients with advanced liver
disease was a fantastic learning experience,” said Dr Ha.
In 2014, then medical student Phil Ha undertook at Bachelor
of Medical Science (Honours) under the supervision of Professor Sievert to
investigate the use of a smartphone app to improve outpatient care for patients
with cirrhotic ascities.
“In Dr Le’s
research project, we found there was a particularly high readmission and
mortality rate for patients with advanced liver disease, and strategies to
identify outpatients at risk of deteriorating could improve these outcomes,”
said Dr Ha.
“For my BMedSc
research project, I developed and implemented a remote monitoring system for
outpatients with cirrhotic ascites using a smartphone app, enabling the
transmission of real-time information to the treating team.”
Simple indicators
such as weight and symptoms suggestive of decompensation were transmitted via
the smartphone app to the liver team, and abnormal values were automatically
flagged, and prompted a telephone consultation with the patient.
Dr Ha said they
trialled the system with nine patients and found some promising results.
“Future studies
will evaluate the potential benefits of using this technology to improve
patient outcomes.”
