Introduction Obesity has been associated with worse outcomes in multiple medical conditions.Although obesity is clearly associated with the development of steatohepatitis, its impact on patients' mortality and other outcomes in liver cirrhosis has not been investigated to date.Therefore, the aim of this study is to explore the impact of obesity on mortality, morbidity and resource utilization among inpatients with hepatic cirrhosis.Methods This was a retrospective cohort study using the 2012 National inpatient sample, the largest publically available inpatient database in the United States.The inclusion criteria were age older than 18 years and an ICD-9 CM code for any diagnosis of liver cirrhosis.There were no exclusion criteria.The primary outcome was in-hospital mortality.The secondary outcomes were morbidity measured by intensive care unit (ICU) admission, shock, hepatic encephalopathy, spontaneous bacterial peritonitis (SBP) and hepato-renal syndrome, and resource utilization measured by paracentesis for patients with ascites, length of hospital stay (LOS) and total hospitalization charges.Odds ratios and means were adjusted for the following confounders using multivariate regression analysis models: compensated or decompensated cirrhosis (using Beveno V criteria), age, sex, race, median income in the patient's zip code, Charlson Comorbidity Index, hospital region, rural location, size and hospital teaching status.Results 568,895 patients with liver cirrhosis were included in the study, 61,610 (11%) of whom were obese.The mean age was 59 years and 39% of patients were female.The in-hospital mortality rate was 6%.All adjusted odds ratios, adjusted means and p values are shown in Table 1.On multivariate analysis, obese patients had lower odds of in-hospital mortality compared with non-obese patients.Looking at morbidity, obese patients had lower odds of hepatic encephalopathy compared with non-obese patients, but both groups had similar odds of shock, ICU admission, SBP and hepato-renal syndrome.When resource utilization was examined, obese patients had lower odds of paracentesis compared with non-obese patients.Further, obese patients had higher total hospitalization charges but shorter LOS compared with non-obese patients.ConclusionObesity is associated with lower mortality among hospitalized patients with cirrhosis.Obesity is similarly not a negative prognostic factor for morbidity; obese patients had lower hepatic encephalopathy and similar ICU admission, shock, SBP and hepato-renal syndrome rates compared with non-obese patients.Although unexpected, this finding is consistent with that of patients using chronic hemodialysis and some other chronic conditions.In terms of resource utilization, obesity is associated with higher total hospitalization charges despite lower paracentesis rates and shorter length of hospital stay.

respectively), about 5.8% (N=2319) received SLK (6, 9, and 5% in groups I-III respectively). Of LTA, 22%, 14%, and 64% were performed for group I-III respectively. Similar respective figures of all SLK were 23, 20, and 57% respectively (Figure). Frequency of SLK increased from about 4% in 2002 to about 7% in 2011. Trends for group I-III were 4 to 5.8%, 4 to 10%, and 4 to 8% respectively. SLK for NASH+CC (group II, n=477) compared to1842 non-NASH SLK (group II+III) were older, more likely to be females, diabetics, andCaucasians, and have higher body mass index. Five year respective outcomes after SLK comparing group I-III were 78 vs. 76 vs. 66% for liver graft, 79 vs. 72 vs. 65% for kidney graft, and 81 vs. 77 vs. 69% for patient survival, Log Rank P<0.0001 for all. Comparing groups I and II, outcomes were similar for liver graft (P=0.29) and patient survival (p=0.14) but worse for group II on kidney graft (P=0.01). Diabetics compared to non-diabetics had worse five year kidney survival for non-NASH SLK (67 vs. 71%, P=0.044). Similar respective figures among group II were 69 vs. 78%, P=0.017. Patients receiving SLK for NASH or CC (group II) were 29%more likely to lose kidney graft [1.29 (1.002-1.67]) compared to non-NASH transplants after controlling for recipient characteristics and kidney donor risk index. Other strong predictors were black race [1.32 (1.06-1.63] and dialysis [1.26 (1.07-1.49)]. Conclusion: Frequency of SLK transplants is increasing among NASH patients requiring liver transplantation. SLK recipients for NASH have worse renal outcomes independent of associated diabetes. Studies are needed to examine mechanisms of renal pathology in NASH and to develop strategies to improve renal outcomes in NASH patients receiving SLK.

Patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency are not represented in clinical trials for heart failure. Moreover, many of the recommended medications can cause haemolysis in this group of patients. We present the case of a 71-year-old woman with G6PD deficiency admitted for acute non-ischemic heart failure with reduced ejection fraction. Our experience showed that a combination of ethacrynic acid and spironolactone is safe and effective for relief of volume overload in this group of patients. Studies are needed to determine whether the morbidity and mortality benefits of established heart failure regimens extend to patients with G6PD deficiency.