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Clinical decompensation and acute-on-chronic liver failure: evolving concepts
Prof. Dr. med Paolo Angeli, University of Padova, Department of Internal Medicine and Hepatology DIMED, Padova, Italy
Thursday, Dec. 6, 2018 · 6:54 p.m. · 44m 19s
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q. and the user to have have think you young francoise it is a really big pleasure to be
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here at the wrong or also and i'm very happy to to meet a old friends i have
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and uh so my two local will be a little beef a more uh
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the clinical because uh i really appreciate then the
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the fascinating a toll call uh you have um and well
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we give me a much more ideas uh in the relationship between uh
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for piper thing shown lever fey laura and the oregon
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fey laura known a category in favour but
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nevertheless i will start the same that they will follow be subject though
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the first part of is your job or could come crawling with a failure and that you the compensation
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between asian and pacific asian overcome chronically a favour probably knows you so but couldn't chronically
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buffet or the rule really but transplanting the management about two don't chronic liver failure
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and then some general aspect of the medical management probably if you don't currently
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buffeted let me move from big part of physiology because you know
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mm seems a five six years ago we all
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where thinking that uh well the story of the whole lucian of zeros he was
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related to that were progress increase the all powerful i perth ancient and so
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what progress a worsening the all the systemic circulation all the
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hyper dynamics to college this is for sure worked through
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but probably we should consider some other components in the part of physiology
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all the evolution of the liver disease and particularly all the the
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compensation and the the the moment double organ fatal so well
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what we we are thinking got up to five years ago with that uh
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the relationship uh between portal a potentially the pharaoh and
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this prank nick of the there was a violation
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was that almost naked mechanistic you know now we learned
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how complex so these relation maybe and the
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when we had the opportunity to jacket larger
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seniors operation we're allies for example
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that and it is not true that that is a progressively increasing the activation
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all that that's o. constrict don't install your thing in fact or a
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long the course a little that we buy this is this is true for
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the early stages of zeros this but now they are after innovation
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will the five six years ago that it a the stage all the chronically the disease a new
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scene dreamy develop that is that you don't chronic liver failure that is correct arrive by
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at your concert development of organ failures and the nine mortality rate at twenty a day
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and you're not and we realise that the actual don't chronic
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liver failure may develop in presence all but sorry
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even normal they you all plasma raining concentration
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baton never without an increase of pro inflammatory site okay
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more in detail we observe that that there is a revelation shape between
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uh the grey about you don't chronically buffet or any chronic inflammation
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but i won't play like one concert
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inflammation is still present in patient would be compensated sources
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not only patient with the organ failure so with that you don't running without fail here
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this c. r. p. level is a six seven for
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higher than that barely need all the normal range
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so there is another concert that we should take into account that the systemic inflammation uh you can
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see that systemic inclination you think losing going through
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the five classical stage all the liver disease
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another concert these uh boxy that the stress this in this tractor about when this is
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uh this this thing position thirty four that is capable to buy in the
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wrap the oxygen spaces
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but in doing so all in all i will mean is a boxy that is the
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in a very simple way that use the human normal kept the law booming one
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or in our they're simple phase that is a human normal
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kept allowable mean to and if you look at the
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global accountable to guys out when you can rely is that the user
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progressively increase the along the course of the liver disease so we
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have another concept to consider that these roxy that the stress and
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just play live these calls that i will introduce the most
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complex slightly my talk a bit these are the following i should take care of this okay
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bizarre patient that
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why are we haven't they compensate this rose without organ fate
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these are increasing level of boxes eyes are building and these are increasing level
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all plasma raining concentration shot you carry lies that the compensation may develop
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in presence all normal they your plasma raining concentration and also in
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presence all normal they you all the oaks it dies i'll
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but if we can see the patient without you punk wrongly buffet of you can see that a lot all that
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may develop are gonna fail in presence of normal they you
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all plasma rainy cause inflation but but if you
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in presence of normal they knew about it dies out so in other
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concept to consider in the pot of physiology all the compensation
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in particular the organ failure is roxy that extracts
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so we decided to to design and now the fe already according to which of
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the may concert was supported by potentially available is but the the others location
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that probably is responsible for the chronic inflammation in doc see that is less
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which is responsible for that matter circulatory this function and that it
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national says they it's over the effect the circulating will
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that is no other mechanism by which for fellow per patient named use
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the marker civil authorities faction and then like a civil authorities faction
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the way i waited inflammation and boxy that the stress probably through micro bicycle
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is capable to activate the the basil constrict sort of saudi
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retaining factor in doing uses that it's on one side
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then let me say that being polemical accuracy that these trace means star
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admitting a happy because you see a cool increasing puerto like birthday show
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labour for a low bacteria that's location and is made me laugh
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two in use of the onset about camp a lot with or without precipitate in fact
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so well what i think there's so we had that clinically
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chronic inflammation is relevant impatient would be compensated zeros
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well you can see that six master bible impatient now
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cool do not add the inflammation is much
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higher than inpatient habit trials yet information
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and overall then inpatient all have a a persistent information
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let me go on to the definition in classification of basic life and you know
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you're all that there are more than fifteen different definition of acute
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and chronic liver favourite and i should confess so that they
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have a big conflict of interest because it was a moan y'all towards that i'd that's all they can only study
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so for me the only the finnish don't use these are cleave consortium definition
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that is based on the following criteria the first is the
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patient should have a a the companies say that's rose
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the patient should develop organ fatal that should be defined on the basis of the place of a score
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that is the service corps adapted to patient with chronic liver disease so for example
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we remove the gravel score for the finish another set of fate
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or and we'll play replace it it uh with a
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a a new web then uh classification other part again give up what we produce
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barely pressing them on the bus oppressor and so and so and so
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so they blow lara repose and the organ fail
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renal failure is defined by its zero grad in equal or higher than two point zero meeting and yeah
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the third criteria user to have that it twenty eight
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day mortality way higher than fifty percent so
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you can say that this is true for patients who have three or two organ fatal
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for patients will have a single renal organ fail or not
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to patients who have a single no reno log off
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but then we should go see that that this patient may have something yes so for example
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every now these financial that is relevant is not the renal failure about is if even
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crap in in between one point five one point right or may have uh
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in mild to moderate the vatican careful but the that is
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not to say but i fail about these clinically relevant
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so if we add one of these two diagnostic categories to this scene
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goal no reno organ failure bad this revival at twenty eight they
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is that why it low and immortality desire them fifty percent but at the end of the day
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they are outboard already read read present what we think
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these are the new seen the remarkable chronic liver failure
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them already they get eight one one organ failure
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by a single renal organ fate or that i'd be seeing on or a lot of a lot class
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yeah there is zero great happening between one point five one point nine eleven yeah
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out or in monterey knee mild to moderate apart again can follow but
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great to to ward off a lot lately three or more than
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three organ failure and you can see that in this patient
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the mortality rate they way they they ranges from
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twenty two percent to more than seventy percent
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please take care that the mortality rate that twenty eight days in patient would compensate this zeros is
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without organ failure is the less than eighty per se so that they differences quite u. h.
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the prevalence of acute or chronic liver failure inflation why
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respect allies boardrooms they complain say that zero
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this is around the thirty thirty one percent let me move on now to probably knows
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i couldn't chronic liver failure isn't quite the dynamic single what does
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it me it means that if a patient as the
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in a coupon chronically the fatal great one it has a fifty five percent to recall
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if the patient as an a. c. l. f. grade till
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the patient as forty eight percent possibility to recall
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evaporation as a a may still have great three the possibility to recall there are
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thirty three to thirty two percent but in safety eighty percent of the cases
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the patient we'll have still an a. c. l. s. great tree after three seven days
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anything yeah what may it's the difference is the number of organ failure because the
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the number of organ failure in a patient with the seal at grade three
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he is the for more than for the probability to
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survive a twenty eight days is animals zero percent
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so it is clear that then then the robot can fail or is
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much more important in the prognosis operation with the c. left
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then the final mail soon be due to being the final they'll right in our
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the final they lose your room grabbing the final they've your students
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audio concentration you know word now them out saddam score
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so it is not surprising that a score that is likely see a
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few less core which include the number of organ fey or agent
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and they're off in the excel systemic inflammation works quite better
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then mel mel so audience for child pew that in predicting the
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mortality lay at twenty eight days and at three map
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this is true not only you know stop the way i mean at the
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diagnosis always us about these true in a dynamic way so ah the
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forty eight hours from the diagonal this ah the three seven days from
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the diagnoses are that age fifteen days for the bank is
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let me gone considering the rule only a transplant the in the
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management always yeah that that is quite they're not topic
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so in a necessity starting from the canonical we prove that the
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in nearly transplant that mean it transplantation within forty eight
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days uh from the diagnosis of basic left
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is associated that with it rebounds reliable berkeley is
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that eighty one percent versus ten percent
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that the was absurd that the impatient with the drop receive a trap
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i am not these data we have goal for now by a frames that be showing that that
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yeah well this revival like twenty out after the the
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transplantation impatient with basal effort was quite cool eighty
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four percent versus less than ten percent impatient would be not with
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a big raft you know they show they show where the
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then they get a job a c. l. f. at the time of transparent had not
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negatively that probably once yeah survival after liver transplantation that is quite a good point
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let me go on several of the study but they want to focus on this one why because
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that they start to show whether that that there is a new difference in three national bible
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impatient will had been a c. led to greatly at the time only the transportation
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and the study also elaborate a score that is a really
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bad france was survivor score that as you can see
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includes a lot of variables the the jane they're all they recipient the gender of the
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dawn or they need keychain to leave a transplant but for the first time
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eating close that presents all a. c. l. f. at the time or the the transparent h.
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and this started the the bay is the acute and chronic liver failure clinical condition
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for week show some signs believe liver
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transplant maybe potentially inappropriate that means
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and i probably to do that within three man after the
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the transplantation is the calls that a little bit different
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from to die liver transplant that these are be thirty the fine
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by a survival less than fifty percent after five years
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from leave it open page so this that they that rises to quest
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oh don't fail or similar for their impact on survival after the the transplantation
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is there are and then but all the organ failure bayonne
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we each liver transplantation should not be done in this
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the first point it as being a suggested that if it's incredibly fail or
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require two was oppressed so it should be considered a enough so contra indication to the trust
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likewise it best beagle say that uh that that a city or
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spirit or if a law requiring maximally relation or ask more
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ease again pick up sort of gunter indication to the the transplant the patient with that you don't
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chronically that fit but look this that be it will be probably shoe in the j. at
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there is no difference you when you have survival after
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liver transplantation according to the type of organ face
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so the second question than than we're all bargain fail it has been suggested
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that is the number of organ failure is four or higher than for
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the issue because see that an absolute contra indication to the transport again the study
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i work with before no difference in one yeah survival in liver transplant patient
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after the the confrontation uh according to the name bearable face
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what they think it is that the war situation he's uh to have uh
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the worse organ fails combine so you can see if you have a patient
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we have a a eh eh mm being
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getting more dynamic support we will the
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has that mechanical ventilation and we receive it in
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r. p. probably this will be a patient
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for whom a liver transplant may be considered it potentially in other
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way but this is a topic that need perspectives that
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let me go on because there is another study i want to show you because if
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we can in some way a wreck all over the condition all the patient
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with a c. left before the the transplant patient for example written using
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by one the number of organ fail we can recall or
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they sure bye bye re the battery math after leaving transplantation
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it's also all is a square or that the assault or the reply and you
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can see that they need to use the program and all the clinical condition
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before liver transplant patient that was defined by that at the action
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of the number of organ failure at least by one
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and they start the highlights the relevance all that management before
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the the transportation so i want all it too
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keep your attention on some points the first is a a general point of course so
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we should do our best uh during that three seven days after
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uh the onset publishing and the first thing to consider that
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is that the station uh offer require to be transparently nicely
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i'm sure that here you have no problem plus button
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several can't you know being basic care physicians
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refuse the transfer to the station because they think of
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that they are dying and they will surely die
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this is not true at all you can see here that we'll compare yeah
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the i. c. u. outcomes impatient with basic life impatient
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without the reverb disease and sepsis impatient without
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really the disease and the other than maybe got condition or acquiring the transferring nicely you
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there is no they play nicely use they off because they
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requiring that all mechanical ventilation in more dynamic supported
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but overall in i. c. u. mortality rate
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in all spiegel mortality rate paramount mortality rate so there is no result
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on we show any intensive care physician can refuse that the transfer
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probably patient with acute or chronic liver failure in i. c.
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the second constantly user prevention and treatment of infection because you know
00:21:04
in they can only 'cause periods main passion where precipitating event obey
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still left in them most one third of the patient
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and if you have the patient would develop basic left without
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a bacterial infection that probability to develop bacterial infection after the
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diagnosis so basically left is them of sixty percent
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so i think uh we should think about prevention and what we have we have processing already faxing
00:21:38
we need to control the clinical study obese because up to
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now we can always say that in child you see
00:21:47
patients with and i always to develop as b. p. they use on or processing is
00:21:53
associated with an improvement of survival but we're speaking about eight different type operation
00:22:00
and this is related to the fact that no flock to see is capable
00:22:04
to reduce the rate of infections was painted by gram negative bacteria
00:22:10
probably we should think about all the known antibiotic prevention in profit
00:22:16
axes and one me maybe up to me for example
00:22:21
because we now where answers that be that was performing
00:22:24
in patient with zeroes is an responsive outside the
00:22:29
they use allowable me was capable to reduce the rate of s.
00:22:33
b. b. a. l. b. faction other than s. p. p.
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uh in other point between the mental bacterial infection i have no time to go into the detail but
00:22:45
the first line antibiotic predicament is crucial if we want
00:22:50
to say the stations and this should be based on geographic data they
00:22:56
can't rearrange on off without war bayes microbiology you should know we
00:23:02
second point the environment where the infection is develop also call me l. o.
00:23:07
k. r. communicate why the type of infection the severity of infection
00:23:15
it is crucial to start with the it brought the spectrum first line antibiotic
00:23:20
treatment taking into account these data because if you're not you can
00:23:26
use it any predictors you want top mortality in hospital mortality
00:23:32
at three man but the most popular powerful one
00:23:36
use a bit and in fact the first line antibiotic treatment
00:23:40
is you if you are wrong in this choice
00:23:44
that probably a deal that patient to die will increase about silent fall
00:23:50
than in other important concert this study will probably i i'm not sure that tall
00:23:57
be published on castro and the is the first time that we prove the that the
00:24:04
in sixty percent at most also wrote the patient with the infection
00:24:08
you can have at least one positive catcher so please uh
00:24:14
dual de escalation all the treat them and they is the
00:24:18
on the positive catcher and on the eyes only
00:24:21
because of this can be doubts if you can see that the escalation
00:24:26
although antibiotic treatment is not associated with any negative
00:24:31
outcome in them our social when you fashion
00:24:34
development of organ failure development of set the shock and enough speed
00:24:38
them up that so let me go on briefly beta blockers
00:24:45
i don't want to comment so much of this point this is the
00:24:48
only study i have i mean a a good friend already
00:24:53
i believe to is they got that you're not yeah there is a a great
00:24:58
bias bit to group but not completely simulated the baseline and l. most uh
00:25:06
forty five percent operation on the beta blocker group stop but the
00:25:10
treatment during this that so we need perspective study on base
00:25:16
the last point three the menthol but a jurassic yeah yeah we had this all the
00:25:22
data you can say that they think i see all the repressing plus are booming
00:25:28
is the strongly affected by the great all but you don't chronically
00:25:34
the fit the higher grade about you don't chronically the
00:25:37
phase or the lower rate of response to the trick them but the of the clinical message is another one
00:25:46
the higher level of the baseline bail zero crowding at which you
00:25:50
will start the treatment the lower level over sparks so please
00:25:56
forgot the previews classification novel it but all in a single now with
00:26:02
a we don't speak anymore about type one h. r. s.
00:26:06
we speak about h. r. s. a. key i according to which are they are these no more capped off of a you
00:26:12
of zero k. acting at which we do all that bad you know
00:26:16
this then we start that retirement probably jurassic yeah the final concert
00:26:24
should that perspective in the tree tonight extra corporate support to the financial that
00:26:28
is the dream of the pathologist it it is still a dream
00:26:33
and regenerated maybe see we have some maybe thence on uh they use all the uh
00:26:39
grow fat or from mean yeah but we need the larger perspective control the clean guest
00:26:45
and so i want to finish with two slides i said that we should it be better in
00:26:52
place even the the treatment during the first three seven they that if the patient red colour
00:26:58
the patient should be assessed that fully but often they show regularly
00:27:03
innovation is not competent occasionally we'll enter into the waiting list that
00:27:08
if the patient escort medication you will go on with the medical treatment and
00:27:12
they blast libraries are viable at paramount in the spatial will be
00:27:18
p. p. three percent if after they take them in the patient's still had they sell
00:27:23
at great tool greatly you should be all gently assess the for the transplant
00:27:29
if the patient is not content occasionally will enter into the waiting list with
00:27:33
the probability of free transpose survival of thirty five percent at three months
00:27:39
if the patient responder indication big problem because of course is the number of
00:27:44
organ failure desire them for the probability to survive the zero percent
00:27:49
that twenty eight days and so probably it is that the case to
00:27:53
stop being fancy treatment and to start but yet the car
00:27:58
but this is the just the very critical decision so is on r. e. a.
00:28:04
c. l. f. b. is a a single quite common use our occupation uh
00:28:10
particularly those reading compensate that's roses uh that probably you know this is dependent
00:28:15
upon the great debased i left that that three seven they use it
00:28:19
so all the therapeutic measure should be applied during this period of time and in case all
00:28:25
no response yeah we liver transplant should because see that thank you very much for your
00:28:38
thank you very much for use a super state of the art it's
00:28:43
complicated topic which i'm sure that would be maybe it's because
00:28:48
it's not a a a nice to see
00:28:54
uh you have a lot of people that i know from long time yeah talk thank you thank you very much
00:29:02
so i question how cool it's like i'll call probably need to be as well and the
00:29:11
quite often i'll call this a resident factoring patients always acute alcoholic appetite
00:29:17
is but with a. c. l. f. and the there are some
00:29:21
little constraints to transplant these patients so how do you
00:29:25
deal with that problem if these patients need
00:29:28
uh in the transplant between a few months but that
00:29:32
we also have this restriction of six months okay
00:29:35
big western so i'll wear centre as being approve the the to go on with the protocol
00:29:44
that provides a liver transplant for patient with the acute alcoholic apartheid is
00:29:49
that often as you said is i couldn't chronically the fate
00:29:54
i realise that there are
00:29:57
many ethical problems yeah but uh we phase them
00:30:03
with a moot issue binary evaluation so
00:30:06
toxicology spike psychiatric psychology is the pathologies and
00:30:10
the the final we will decide that
00:30:14
taking into account the age of the beige and uh the the the a row of the patient before the
00:30:20
development about you don't chronicle buffeted or uh the family the social support and so and so and so
00:30:27
we do not follow the rule six man because it does not the
00:30:31
the then it for this type or by a green glass an area because of or the the
00:30:37
base you will die if we would do not respond to stairways within a one month
00:30:45
so we apply this there it's if the patient these enormous boundary will consider for early the trap
00:30:52
but
00:30:56
i can do the fantastic lecture oakwood iterations thank you i i have a
00:31:01
question because i only the bustle when you were critically assess impatiently cool
00:31:09
the advance complicated the buffer because sometimes some appreciating so mistake twos
00:31:16
it's quite difficult that way we kept almost about the the
00:31:20
chapel classification because it it was very subjective parameters
00:31:24
but when you are charging the number of organ players at us as if the page is equivalent but the
00:31:31
if you send that mechanical ventilation yeah it was very good with this it's it's almost impossible yeah
00:31:38
and one number one or number which you can change you show the change totally the probabilities
00:31:44
it's uh if you improve on what the d. e. i. have
00:31:49
don't give up but i gave three and you can do it through you improve the privilege
00:31:53
but for the present but i think probably we need more broad nutty that the backups
00:32:00
some of the organs various considered it so mixed in there is at least
00:32:04
important than others that they want you to come in it yeah yeah
00:32:08
uh my comment is why the period you know we are lacking because uh
00:32:14
the mm respiratory fate or require a mechanical ventilation is quite rare
00:32:20
in the experience of the can only get was quite rare
00:32:24
but this is a condition of course of the should be considering your comment is quite right
00:32:31
uh_huh yeah yeah yeah this is true for our county for example of absolutely
00:32:42
no no you you it is rare in general you know not in i. c. u.
00:32:51
your remote for a very this presentation and uh it's good to pay per use it
00:32:59
say that again or you showed that uh if the first choice
00:33:04
is wrong phone to that extent the risk of this is
00:33:07
from increased yeah what does the practical consequence do usage it
00:33:13
that first time treatment of patient resources should be very
00:33:18
large uh a spectrum i'll give it it's in all patients you all
00:33:22
the time not ill patient all the time but if you add
00:33:28
and also call the l. s. b. p. just to make an example we start
00:33:31
with the card up a name in our unit we had all soul
00:33:36
dot on my scene because we hadn't i rate all the interrupt
00:33:40
loci which are resistant to buy income i see you know
00:33:43
so we start in the this way what about community acquire
00:33:48
it for the interaction is not associated the two sepsis
00:33:52
you can use a peep doubts of for example health care and in the middle you know it will depend upon uh
00:33:59
the eh profile a bacterial resistant in your unit
00:34:03
it will depend upon the severity of infection
00:34:06
that's for sure you know the committee infection we are very very aggressive um hum maybe can right
00:34:15
i come maker should question i i yeah but i mean when you are on the word and you see
00:34:21
these patients there are lots of question arising one of them is when you don't find it see
00:34:28
a clear sign of infection or a hundred percent it's a specific
00:34:33
sign of infection but you haven't increased zero p. for instance
00:34:37
and the patient is in a condition of like you to chronically buffeted you
00:34:40
strongly suspect that even if you can read the patient is in fact
00:34:45
therefore i was wondering when you were presenting these data regarding the peak increase of uh
00:34:50
of c. o. p. at some point the top of the proposed actually vacation
00:34:55
to what extent do you think that most were largely the
00:34:58
scene do depends on known diagonals or some clinical infection
00:35:04
i suggest to my colleagues yeah and colleagues that that that is what the patient
00:35:09
who can to the hospital with that you the compensation as in infection
00:35:15
still it has been improved that this is the first concert the first concert he this
00:35:22
then if you want my opinion yeah that is right now i think also that
00:35:27
eh it barstow but the others location may be enough to
00:35:33
create a a systemic inflammation that in quantitative there um
00:35:38
can be similar to that in use by bacteria infection um you know so
00:35:46
hunter remote rudeness presentation so one a comment or question
00:35:51
is like i mean sometimes with this vicious circle
00:35:54
having the sort of person with us it is but also kidney failure and happen at remus alike
00:36:00
um with us it is going to have to literally would say
00:36:02
like soda restricted diets low volume at the same time
00:36:06
then you have the kidney failure what you would expect to give more volume so how do you
00:36:12
uh go on with this that the this is a big problem because we
00:36:16
have not the driver for the treatment of my point three well
00:36:20
yeah restriction of what that is not the solution course this patient up
00:36:25
first the first double sole usually we don't use that a
00:36:31
say the also the restriction and for the treatment although i pointed dream
00:36:35
yeah we use ah building in sometime in combination with the press
00:36:41
visit a it is not pro by a controller clean that's right yeah recently happier eh
00:36:48
a paper from about child the global buffy i'd show when that
00:36:53
uh the patient to receive our mean during those people decision uh have
00:36:57
a less frequently i pointed three yeah then patient with it now
00:37:01
but we have not the control ugly custody on this that all this
00:37:05
is that we're in the legal management type on the tree
00:37:09
maybe can ask another question regarding these because the reason pleasing mitzi
00:37:14
attention to nutritional states a status of our patients so
00:37:19
however when patients hours bitterness university condition there is no really
00:37:24
clearer guidelines on what should should be the one regarding to
00:37:28
teaching distinct what is your you read what to use
00:37:32
if we can avoid the parental nutrition uh we try to avoid it because it can be
00:37:38
it is being said then gyros in this patient that's sometime we should delete you know
00:37:44
sometime we should do it because the enter the nutrition is quite the less uh
00:37:50
it tolerated by the speech i don't like it so
00:38:02
see it's from to pay the question and cabinet union
00:38:06
also because when we use that depressing for the reading
00:38:11
you described that have yeah yeah uh active therapy was associated with technology yeah
00:38:17
and what is not effective therapy was not so when you have a policy needed to but uh still in
00:38:24
it uh it's just the quarter you can improve the yeah by improving the above the kidney function
00:38:30
just for the look at the it to get the other bistro absolutely true
00:38:34
absolutely though innovation whereas analysis ideas and uh
00:38:39
uh uh uh receive belly pressing for believing that
00:38:44
that we're not doing a medieval but if you have i pointed to him in the setting all of a a
00:38:49
jurassic yeah i uh used to repressing plus ah will make you can correct that poetry i think there
00:38:56
the the this equation in a patient with a jurassic guy from
00:39:00
it in more dynamic point of view is so severe
00:39:04
but probably the fact of belly pressing on the
00:39:07
human dynamics uh we'll uh uh uh mm
00:39:12
over cam the direct the fact of the lip resting on the hoop doris actor at
00:39:16
in the collective that is not the case with the patient is bleeding without aside
00:39:23
i thank you very much for your talk my question is we know that acute
00:39:28
and chronic liver failure is that i'm planetary staked anticipation usually have that
00:39:34
elevating talent keen seeks and not every man
00:39:39
and the yourself into looking and then
00:39:42
because see in this patient maybe in the first moment at
00:39:47
to the normal ted at b. ah known the later
00:39:52
today we should find them absolutely that them the most complex problem use this patient is at the
00:40:00
same time increase or bro inflammatory cycle going yeah anti inflammatory side okay so it is a
00:40:07
they they they if we could we may gene where we
00:40:10
can interfere with this uh in logical exciting no
00:40:17
it's quite complex mike question goes in the same direction button not uh
00:40:24
a recording acute but regarding the chronic inflammation i think this is
00:40:29
one of the concepts that or one of the driver of uh the development of c.
00:40:34
roses and my question is what do you think that treatment of chronic inflammation
00:40:39
would be something that emerges in the future as may
00:40:43
be stepped in so relevant and antique opulence
00:40:47
absolutely we are now the check in the combination of the staffing is with the re faxing
00:40:53
in the treatment out to compensate the source again you know it is
00:40:59
quite important how and where you put your hands in chronic inflammation
00:41:06
for sure well not all the not stared anti inflammatory badness paper
00:41:11
it's and so knowledge organic and being from not only agents
00:41:17
do not function is one of the main uh
00:41:20
factors deciding outcome disney situation at trinity isn't
00:41:25
quite different according to the scroll
00:41:28
scroll mouse shoe treat men and women different three your approach no
00:41:34
i like the i know your point uh in the eighties
00:41:38
quite relevant but practically we use the the same approach
00:41:44
and i hope so with the fully agree that that we are
00:41:46
measuring uh we are measuring a renal function with this plan
00:41:56
yeah
00:41:58
yeah
00:42:00
it's
00:42:08
uh_huh uh_huh
00:42:10
we're i have not data in all that is some papers on the
00:42:13
body don't yell dialysis all course the concern is about infections
00:42:19
no as far as uh or interrupt play therapy i think that the the indication maybe
00:42:27
c. k. the stage of four five but and in this setting all the
00:42:31
key i isn't that you two would run across this icky i
00:42:35
or in a jurassic yeah i without the response so to the pharmacological treatment
00:42:42
these are the main vacation and the timing should be almost
00:42:45
the same that in the general population with only one
00:42:48
exception that is the party can can follow but because our the ne low where the level of ammonium
00:42:56
so if you add the in and control of the party can can follow but
00:42:59
the notation with persistent ache yeah you you can start our of the
00:43:04
uh uh yeah we're then uh it is generally consider
00:43:11
uh yes uh_huh
00:43:15
thank you for what bothers me is and you know we don't use a gun might help you
00:43:22
yeah exactly mean and then maybe you should start it so what is the
00:43:26
quality that that became yeah giving your page and is actually don't
00:43:31
this is a good question i you show many a commercial products
00:43:36
and they can say that the lab a lot well
00:43:38
oxides outgoing don't ask me if reversible reversible we we have
00:43:43
no they that ranges for from twenty to thirty percent
00:43:48
so this is also a big problem for the pharmaceutical company no they should prove
00:43:54
produce the eh eh a better out when then they are producing now
00:44:04
i
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