Association between early antibiotic treatment after admission and mortality of acute-on-chronic liver failure patients with bacterial infection: A multicenter retrospective study

Bacterial infection is a significant risk factor in the onset and development of acute-on-chronic liver failure (ACLF). Although early broad-spectrum antibiotic treatment is recommended, the optimal time to initiate antibiotic therapy remains unclear. This study aimed to investigate the relationship between the timing of antibiotic treatment and the prognosis of ACLF patients with bacterial infection. Patients with ACLF and bacterial infections upon admission were retrospectively evaluated. The predictors of 28-day mortality were identified using univariate, least absolute shrinkage and selection operator regression analysis, and multivariate logistic regression analyses. The "survminer" R package was used to categorize patients into two groups based on a 6-h threshold: early antibiotic administration (<6 h of admission) and later antibiotic administration (≥6 h after admission). A total of 295 patients were evaluated. The lungs were the most common site of infection (61.7% of patients had lung infections), followed by the peritoneum (25.4% of patients had spontaneous bacterial peritonitis). The time to first antibiotic administration was an independent predictor of 28-day mortality, and the odds of mortality increased by 2% for each hourly delay in antibiotic administration after admission. In Kaplan-Meier survival analysis, both 28-day and 90-day mortality rates were significantly lower in the early antibiotic group than in the later antibiotic group (both p < 0.0001). In conclusion, early antibiotic treatment is an independent predictor of 28-day mortality in ACLF patients with bacterial infections. Patients who received antibiotics less than 6 hours after admission exhibited lower 28- and 90-day mortality rates.

Extracorporeal therapies for post-liver transplant recipient: The road less traveled

Extracorporeal therapies have a definite role in patients with acute liver failure, acute on-chronic liver failure, and progressive chronic liver disease. They act as a bridge-to-transplant in these patients. With the increasing success of liver transplantation, the immediate postoperative complication spectrum continues to expand. Extracorporeal therapies can play an important role in managing these complications. However, the literature on extracorporeal therapies in the post-liver transplant period is limited. This review article discussed various extracorporeal therapies that are still evolving or marred by limited evidence but can improve patient outcomes. These extracorporeal therapies can be divided into two subgroups: (1) Therapies for infective complications. Endotoxin and cytokine adsorption columns; and (2) Therapies for noninfective complications like small for size syndrome, primary allograft nonfunction, early allograft dysfunction, hyperacute rejection, hepatopulmonary syndrome, etc. (plasma exchange, double plasma molecular adsorption, molecular adsorbent recirculation system, and extracorporeal membrane oxygenation, among others).

Indian National Association for the Study of Liver (INASL) Guidance Statements for Determining Futility in Liver Transplantation

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease; however, with the growing shortage of organ donors, the need to identify futile transplants has become increasingly urgent. Futility in liver transplantation refers to situations where the expected post-transplant survival or quality of life is poor, making the procedure unlikely to yield a meaningful benefit. Various definitions of futility are used across different countries and transplant centers, with criteria often based on clinical factors such as age, comorbidities, MELD score, and functional status. For hepatologists and transplant surgeons, clearer guidelines are essential to make informed decisions and avoid unnecessary transplants that may place patients at risk without improving their prognosis. While some studies have proposed futility scores, there is currently no universal consensus on a standardized definition or set of criteria. This highlights the need for further prospective trials to evaluate the predictors of futility in liver transplantation, aiming to refine decision-making processes, optimize organ allocation, and improve patient outcomes. Future research should focus on the development of universally accepted futility criteria and explore interventions to mitigate the factors contributing to transplant futility.

Sepsis in liver failure patients: Diagnostic challenges and recent advancements

Acute liver failure (ALF) and acute-on-chronic LF (ACLF) are prevalent hepatic emergencies characterized by an increased susceptibility to bacterial infections (BI), despite significant systemic inflammation. Literature indicates that 30%-80% of ALF patients and 55%-81% of ACLF patients develop BI, attributed to immunological dysregulation. Bacterial sepsis in these patients is associated with adverse clinical outcomes, including prolonged hospitalization and increased mortality. Early detection of bacterial sepsis is critical; however, distinguishing between sterile systemic inflammation and sepsis poses a significant challenge due to the overlapping clinical presentations of LF and sepsis. Conventional sepsis biomarkers, such as procalcitonin and C-reactive protein, have shown limited utility in LF patients due to inconsistent results. In contrast, novel biomarkers like presepsin and sTREM-1 have demonstrated promising discriminatory performance in this population, pending further validation. Moreover, emerging research highlights the potential of machine learning-based approaches to enhance sepsis detection and characterization. Although preliminary findings are encouraging, further studies are necessary to validate these results across diverse patient cohorts, including those with LF. This article provides a comprehensive review of the magnitude, impact, and diagnostic challenges associated with BI in LF patients, focusing on novel advancements in early sepsis detection and characterization.

Immune Dysfunction and Infection Risk in Advanced Liver Disease

The risk of microbial infections is increased in cirrhosis and other forms of advanced liver disease such as alcohol-associated hepatitis. Such infections may precipitate new or further decompensation and death, especially in patients with clinical features of acute-on-chronic liver failure. The severe immune dysfunction or "immune paralysis" caused by advanced liver disease is associated with high short-term mortality. However, the pathogenic mechanisms underlying immune dysfunction and immunodeficiency are incompletely understood. Evidence to date suggests a complex, dynamic process that perturbs the physiological roles of the liver as a master regulator of systemic immunity and protector against noxious effects of exogenous molecules in the portal vein flowing from the gut. Thus, in cirrhosis and severe alcohol-associated hepatitis, the ability of hepatocytes and intrahepatic immune cells to balance normal context-dependent dichotomous responses of tolerance vs immune activation is lost. Contributing factors include loss of the gut barrier with translocation of microbial products through the portal vein, culminating in development of functional defects in innate and adaptive immune cells, and generation of immune-regulatory myeloid cells that permit microbial colonization and infection. This review addresses key evidence supporting the paradigm of immune dysfunction as a risk for microbial infections and identifies potential therapeutic targets for intervention. The primary focus is on cirrhosis-associated immune dysfunction and alcohol-associated liver disease, because the bulk of available data are from these 2 conditions.

Soluble Urokinase Plasminogen Activator Receptor Predicts Survival and Hepatic Decompensation in Advanced Hepatocellular Carcinoma

BACKGROUND AND AIMS

The introduction of immune checkpoint inhibitor (ICI) based therapies has significantly improved the prognosis of patients with unresectable hepatocellular carcinoma (HCC). However, the variable treatment response and the uncertain benefit in patients with advanced liver cirrhosis emphasise the urgent need for prognostic and predictive biomarkers guiding patient selection. The soluble urokinase plasminogen activator receptor (suPAR) is strongly associated with inflammation, liver cirrhosis and various types of cancer. In this study, we investigated suPAR as a potential novel biomarker in patients with unresectable HCC.

METHODS

This multicenter retrospective study, conducted at three German tertiary care centers, included 90 patients with unresectable HCC and suPAR measurements prior to and during atezolizumab/bevacizumab therapy. Patients with liver cirrhosis without HCC (n = 235) and non-cirrhotic patients with other gastrointestinal tumours (n = 155) were selected as control cohorts.

RESULTS

Median suPAR levels were significantly higher in patients with liver cirrhosis compared to non-cirrhotic cancer patients. A strong association with parameters of liver function, but not with HCC characteristics, was observed. In patients with HCC receiving atezolizumab/bevacizumab, suPAR was the most accurate independent predictor of hepatic decompensation and overall survival (OS). In addition, suPAR was able to stratify the risk of hepatic decompensation within the different Child-Pugh classes.

CONCLUSIONS

SuPAR represents a promising novel biomarker in patients with HCC treated with ICI-based therapies and bears the potential to guide the selection of antitumoral systemic therapies in patients with advanced liver cirrhosis.

Prognostic value of relative adrenal insufficiency in patients with severe alcohol-associated hepatitis-A prospective clinical study

BACKGROUND/AIMS

Relative adrenal insufficiency (RAI) is frequent in patients with liver cirrhosis and affects their prognosis. Scarce data on RAI in patients with alcohol-associated hepatitis (AAH) exists. This study aimed to document the prevalence and prognostic implication of RAI in patients with severe AAH.

PATIENTS AND METHODS

Adults with a first episode of AAH were selected. The delta cortisol level was the difference between the serum basal cortisol and 60min after ACTH stimulation. Cox proportional-hazard regression model was used for univariate analysis of prognostic factors with 95% confidence intervals. The Kaplan-Meier and log-rank tests were applied for survival analysis between patients with RAI and without RAI.

RESULTS

Twenty-five subjects with a first episode of AAH were included. Eight (32.0%) deaths occurred in our cohort. Univariate analysis showed that presence of RAI (p=0.049) had a significant impact on 90-day Overall Survival (OS). Serum albumin (p=0.991), serum creatinine (p=0.954), sodium (p=0.986) and international normalized ratio (p=0.073) did not show a significant impact on 90-day OS. Ninety-day overall survival for patients with RAI was 50.0% vs. 90.9% in those without RAI, (p=0.040).

CONCLUSIONS

The presence of RAI seems to be a fair predictor of intermediate-term survival in AAH patients.

Prevalence of bacterial infections and factors associated with death related to these infections in two medical departments of a tertiary hospital in Dakar, Senegal

Objectives

This study aimed to estimate the prevalence of bacterial infections and identify the factors associated with death related to these infections in the internal medicine (Brévié) and infectious diseases departments (Boufflers) of Dakar Principal Hospital.

Methods

This cross-sectional study was carried out from January 1 to December 31, 2023, including patients with bacterial infections hospitalized in Boufflers and Brévié. Multivariate logistic regression was used to identify factors associated with death.

Results

Out of 1,085 hospitalized patients, 181 (16.7%) had bacterial infections. The mean age was 60±18 years, with a sex ratio of 1.08. Urinary tract infection (37%) was the most represented clinical presentation. Bacteria were isolated in 123 patients (68%), with Escherichia coli (39%), Staphylococcus aureus (12%), and Klebsiella pneumoniae (12%) as the most represented species. Of the 140 identified bacteria, 78 (55.7%) were multidrug-resistant. The death rate was 15%. Multivariate analysis showed that age ≥ 65 years (odds ratio [OR] = 3.2; 95% confidence interval [CI] 1.2-9.5), prior hospitalization (OR = 2.9; 95% CI 1.1-8.5), and hemoglobin levels between 3.4 g/dl and 7 g/dl (OR = 11.7; 95% CI 2.5-60) or between 8 g/dl and 11 g/dl (OR = 4.9; 95% CI 1.6-18.4) compared with levels ≥11 g/dl were associated with death.

Conclusions

This study showed a high prevalence and mortality rate of bacterial infections in the internal medicine and infectious diseases departments, particularly among older adult patients, those with a history of hospitalization, or those with low hemoglobin levels.

Mitochondrial Membrane Potential of CD8+ T Cells Predicts Bacterial Infection and Rapid Development of Acute-on-chronic Liver Failure in Cirrhotic Patients

Background and Aims

Patients with cirrhosis are at an increased risk of bacterial infection (BI), which is the most common precondition for acute-on-chronic liver failure (ACLF). In this study, we aimed to evaluate the ability of mitochondria-related indicators (mitochondrial mass and mitochondrial membrane potential (MMP)) of T cells in peripheral blood to predict BI and ACLF within 90 days in cirrhotic patients.

Methods

We prospectively studied mitochondria-related indicators in various T cells from 235 cirrhotic patients at the Second Hospital of Nanjing. The outcomes of interest were BI and ACLF.

Results

The restricted cubic spline analysis showed that the MMP of CD8+ T cells had a linear relationship with the risk of BI and ACLF (both P < 0.001). Multivariable Cox regression analysis demonstrated that the MMP of CD8+ T cells was an independent risk factor for both BI and ACLF (BI: hazard ratio 0.96, 95% confidence interval 0.94-0.98; P < 0.001; ACLF: hazard ratio 0.94, 95% confidence interval 0.90-0.97; P < 0.001). The MMP of CD8+ T cells exhibited better diagnostic efficacy than traditional indices in predicting BI (C index: 0.75). The MMP of CD8+ T cells, when combined with traditional models (Child-Turcotte-Pugh and model for end-stage liver disease score), improved their diagnostic efficiency in predicting both BI and ACLF. Additionally, the MMP of CD8+ T cells showed a significant negative correlation with inflammation-related markers (P < 0.05). Mitochondrial damage and abnormally activated mitochondrial autophagy were observed in CD8+ T cells from cirrhotic patients with low MMP.

Conclusions

The MMP of CD8+ T cells could serve as a valuable predictor of BI and ACLF within 90 days in cirrhotic patients.

Infection risk and management in patients with cirrhosis: A critical overview

In this paper, we analyze the article published by El Labban et al, which explores the impact of cirrhosis on patients with necrotizing fasciitis. The authors conclude that cirrhosis is a significant risk factor for increased in-hospital morbidity and mortality in this patient population. Building upon their final observation regarding the importance of understanding this association, we will delve into the topic of infections in patients with liver cirrhosis. These patients exhibit intrinsic characteristics that make them particularly susceptible to infections, both bacterial and fungal. This heightened risk not only increases the likelihood of severe infections but also makes them a common trigger for acute decompensations, including the development of acute-on-chronic liver failure, which markedly worsens prognosis and mortality. Infections in patients with cirrhosis often require a more aggressive and rapid diagnostic and therapeutic approach due to the higher risk of nosocomial infections, multidrug-resistant organisms, and atypical clinical presentations. Delayed or inadequate management can lead to unfavorable outcomes, further complicating the course of their underlying liver disease. The aim of this article is to emphasize the importance of early and appropriate management in patients with cirrhosis with infections. Evidence supports that timely and tailored interventions not only improve clinical outcomes but also reduce mortality. By raising awareness among clinicians about the complexity of these cases, we hope to contribute to optimizing the care of this high-risk population.

A model predicting the 6-year all cause mortality of patients with advanced schistosomiasis after discharge: Derived from a large population-based cohort study

BACKGROUND

Advanced schistosomiasis imposed a heavy economic burden on society and had a high rate of mortality and disability. However, methods for assessing its long-term prognosis were currently insufficient, and there was a lack of predictive tools to aid clinical decision-making and personalized follow-up plans for patients. We sought to determine risk factors associated with six-year all-cause mortality in advanced schistosomiasis, deriving and validating a six-year all-cause mortality prediction model through a retrospective cohort study based on a large population-based cohort.

METHODOLOGY

We collected information from 4,136 patients with advanced schistosomiasis who were discharged between December 2014 and January 2015. After excluding 17 patients with the less common subtypes of colonic tumoroid proliferation and dwarfism, as well as 92 patients who were lost to follow-up or had incomplete information, data from 4,027 patients were included in the study. These patients were randomly assigned to the derivation cohort and the external validation cohort in a 7:3 ratio, with 1,400 patients randomly selected from the derivation cohort for internal validation. Sixteen candidate variables were collected: age, gender, nutritional status, splenectomy history, presence of other conditions (such as cardiovascular and digestive diseases), clinical classification, disease duration, ascites occurrence frequency, levels of serum total bilirubin (TBil), direct bilirubin (DBil), aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin (ALB), alkaline phosphatase (ALP), Hepatitis B surface antigen (HBsAg), and alpha-fetoprotein (AFP). High-risk factors associated with the 6-year mortality outcome were identified through univariate and multivariate Cox proportional hazards regression analyses. The predictive value of different models was evaluated and compared using the receiver operating characteristic (ROC) curves, Akaike information criterion (AIC), net reclassification improvement (NRI), C statistic, and integrated discrimination improvement (IDI).

FINDINGS

The derivation cohort comprised 2819 patients and we randomly selected 1400 cases from this cohort for internal validation. The external cohort consisted of 1208 patients. The mortality rate for three groups was around 27%-28%. We identified ten variables associated with increased risk of death, including age, course of disease, frequence of ascites, hepatitis B co-infection, and levels of DBil, ALT, AST, ALP, ALB, and AFP at baseline. Using these variables, we developed a ten-variable model and three simpler models. In the derivation cohort, the ten-variable model showed the highest C statistic (0.759; 95% CI, 0.739-0.778) and the lowest AIC (2834.2). ROC curves indicated an AUC of 0.759 for the ten-variable model, outperforming the simpler models. External validation also demonstrated superior performance of the ten-variable model with a higher C statistic (0.774; 95% CI, 0.749-0.797). This model consistently showed better results in ROC curves, IDI, continuous NRI, and categorical NRI analyses compared to the reduced models in external validation cohort.

CONCLUSIONS

This study developed a multivariate model to predict the 6-year all-cause mortality rate in patients with advanced schistosomiasis, which demonstrated good performance. This convenient tool may potentially assist clinicians in formulating patient follow-up plans.

A novel prognostic model based on portal vein diameter for patients with acute-on-chronic liver failure

The prompt and accurate prognostication of acute-on-chronic liver failure (ACLF) patients is crucial for clinical intervention and reducing mortality. This study aimed to develop a novel prognostic model based on pathological changes, with a specific focus on portal vein which is correlated with hepatic pathology. A cohort of 127 ACLF patients was enrolled to develop the prognostic model for 90-day mortality, which was validated in a prospective cohort of 105 ACLF patients. Demographic characteristics, laboratory indicators, and imaging factor portal vein diameter (PVD) were screened, and a nomogram prognostic model was developed using logistic regression. Patients with PVD ≥ 13.4 mm had significantly higher mortality (P = 0.047). PVD, age, neutrophil percentage, sex and total bilirubin were identified as independent predictors for the new PVD-based nomogram prognostic model, PANST. The C-index (0.878) of PANST score was higher than Chronic Liver Failure-Consortium-ACLF (CLIF-C ACLF), end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores (0.691, 0.687, 0.639, respectively; P < 0.001). The ROC and decision curves demonstrated that the PANST score was superior to CLIF-C ACLF, MELD and CTP scores. Furthermore, after subgroup analysis, the C-indices of PANST score for hepatitis B virus-related ACLF (HBV-ACLF) and non-HBV-ACLF patients (0.842,0.950) were significantly higher than those of CLIF-C ACLF score (0.772, 0.750; P < 0.05), MELD score (0.730, 0.608; all P < 0.05) and CTP score (0.701,0.513; all P < 0.05). These results were confirmed in the validation cohort. PVD was an independent predictor, and the PANST score, a novel prognostic model based on PVD can accurately predict 90-day mortality in ACLF patients.

EASL-CLIF, NACSELD and APASL definitions for identification of acute-on-chronic liver failure and its outcome in a non-transplant setting

BACKGROUND AND OBJECTIVES

Chronic liver diseases (CLD) may progress to cirrhosis, decompensation and death. An intervening insult may lead to acute decompensation (AD); patients with AD may fulfil criteria for acute-on-chronic liver failure (AD-ACLF). While the outcome of ACLF and priority for liver transplantation have been studied, data on outcome in a non-transplant setting is sparse. We evaluated three international consensus criteria for definition of ACLF to determine the number of patients satisfying these definitions and their accuracy in predicting mortality and compare mortality in a non-transplant setting.

METHODS

Total 341 consecutive patients with CLD of any etiology were enrolled and followed up. All significant clinical events and changes in laboratory data were noted to classify patients into no AD, AD-ACLF and AD-non-ACLF.

RESULTS

Total 150 (44%) patients had non-alcoholic fatty liver disease as etiology. As many as 197 (57.8%) patients had AD; of these, 54 (27.4%) met at least one definition of ACLF: 50 (92.6%) fulfilled EASL-CLIF criteria, 31 (57.4%) NACSELD and 22 (40.7%) APASL. The most common precipitating event (59.2%) was infection. Forty-six (13.5%) patients died during the study period - 52% of those with AD-ACLF and 12.6% with AD-non-ACLF (p < 0.00001). The accuracy of EASL-CLIF, NACSELD and APASL definitions in determining mortality was 79.7%, 86.3% and 77.7%, respectively.

CONCLUSION

Total 16% of patients with CLD developed AD-ACLF by any definition; one-half of them died. EASL-CLIF criteria identified maximum number of patients with AD-ACLF, but NACSELD criteria had highest accuracy for predicting mortality in AD-ACLF. These findings may help prioritize patients with ACLF for intensive care in the absence of easy access to liver transplantation.

In Vitro Immune Response of Mononuclear Cells to Multidrug-Resistant Escherichia coli

Infections caused by multidrug-resistant organisms (MDRO) are linked to poor outcomes, particularly in patients with cirrhosis. The underlying mechanisms are not fully understood and may involve a different immune response against MDRO. This study aimed to compare the in vitro immune response between multidrug-resistant (MDR) Escherichia coli and antibiotic-susceptible E. coli strains. Surface protein extract and DNA extract were obtained from MDR E. coli (n = 6) and antibiotic-susceptible E. coli (n = 6) strains isolated from infected patients with cirrhosis. The extracts were used to stimulate in vitro peripheral blood mononuclear cells from healthy donors. After 48 h, cytokine levels (IFN-γ, IL-1β, IL-10, IL-12p70, MCP-1, IL-8, IL-6, MIP-1α, and MIP-1β) were measured. We observed no significant differences in cytokine production between MDR and susceptible strains. However, we identified notable interindividual variability in cytokine production for most of the cytokines studied. Only IFN-γ and IL-6 in surface extract and MCP-1 in DNA extract showed similar levels across all donors. We conclude that the cytokine profiles induced by MDR E. coli in vitro were similar to those in susceptible strains. These findings suggest that the poor prognosis associated with MDR E. coli infections is not due to a differential immune response but rather to other factors.

Recognition of Transfusion-Related Acute Lung Injury in a Patient With End-Stage Liver Disease and Sepsis

A man in his 40s with history of decompensated cirrhosis presented with acute leg pain. On presentation, he was febrile, tachycardic, and jaundiced. Laboratory findings included leukocytosis with bandemia, anemia, elevated creatinine, hyponatremia, lactic acidosis, hyperbilirubinemia, and elevated INR. His model for end-stage liver disease-sodium (MELD-Na) score was 32. Diagnostic paracentesis did not suggest spontaneous bacterial peritonitis, but blood cultures revealed Escherichia coli. He received intravenous fluids, broad-spectrum antibiotics, and packed RBC. He became acutely dyspneic, 1 h into the transfusion. Over the next 36 h, he developed worsening hypoxia with infiltrates on serial chest x-rays despite adequate diuresis. He required intubation for respiratory failure and his hospital course was complicated by hepatic encephalopathy. Ultimately, he was discharged on hospital Day 18 and was retrospectively diagnosed with transfusion-related acute lung injury (TRALI) Type II. This case focuses on management of TRALI in sepsis and highlights the elevated risk of transfusion-associated reactions in liver failure patients and its mortality and morbidity.

Beyond the Limits of Conventional Coagulation Tests: A Comprehensive Overview of ACLF-Related Coagulopathies

Acute-on-chronic liver failure (ACLF) is a complex and severe condition marked by multiple organ failure and high short-term mortality. Coagulopathy, a key component of ACLF, is characterized by rebalanced hemostasis with both hypo- and hypercoagulable features, increasing the risk of bleeding and thrombosis. Conventional coagulation tests, including prothrombin time (PT) and platelet count, fail to fully capture the complexity of coagulation dysfunction in ACLF. Advanced diagnostic tools, like viscoelastic tests (VETs), offer a more comprehensive assessment, yet they remain limited in evaluating endothelial dysfunction and fail to account for reduced levels of anticoagulant factors. Emerging therapeutic strategies targeting coagulopathies in ACLF hold promise, but their clinical efficacy remains unclear. A more nuanced approach to diagnosing and managing coagulopathy in ACLF is needed, incorporating advanced hemostatic profiling to better inform prognosis and guide treatment decisions.

Fecal carriage of multidrug-resistant organisms increases the risk of hepatic encephalopathy in patients with cirrhosis: insights from gut microbiota and metabolite features

BACKGROUND

The impact of the fecal multidrug-resistant organism (MDRO) carriage on the gut microbiota, metabolite alterations, and cirrhosis-related complications remains unclear.

METHODS

Eighty-eight patients with cirrhosis and 22 healthy volunteers were analyzed for plasma metabolites, fecal MDROs, and microbiota composition. The fecal bacterial and fungal composition was assessed using 16S ribosomal RNA and internal transcribed spacer sequencing, whereas plasma metabolomic analysis was evaluated via untargeted liquid chromatography-mass spectrometry. Predictors of cirrhosis-related outcomes, risk factors for MDRO carriage, and microbiota-metabolite correlations were analyzed.

RESULTS

Fecal MDRO carriage was detected in 33% of patients with cirrhosis. MDRO carriers had a higher risk of hepatic encephalopathy (HE) compared to non-carriers (20.7% vs. 3.2%, p = 0.008). Patients carrying MDROs had higher plasma lipopolysaccharide (LPS) levels, and both elevated LPS and MDRO carriage independently predicted HE occurrence within 1 year. Compared with non-carriers, MDRO carriers had higher fecal bacterial and fungal burdens and exhibited different gut microbiota compositions, characterized by increased Streptococcus salivarius and enrichment of Saccharomycetes and Candida albicans. Thirty-one metabolites differed significantly among healthy controls, and patients with cirrhosis, with and without MDRO carriage. Six metabolites were significantly correlated with specific microbial taxa in MDRO carriers. Isoaustin, a fungal-derived metabolite, was significantly elevated in MDRO carriers with HE.

CONCLUSIONS

Fecal MDRO carriage was associated with endotoxemia, altered gut microbiota, metabolic changes, and a higher risk of HE. It's worthy to monitor fecal MDRO colonization in cirrhosis.

Immunological Mechanisms and Effects of Bacterial Infections in Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome characterized by high morbidity and mortality rates. Bacterial infection is a frequent precipitating factor and complication in ACLF patients, significantly worsening patient outcomes. Elucidating the mechanisms underlying bacterial infections and their impact on ACLF pathophysiology is crucial for developing effective therapies to reduce infection rates and mortality. Current research highlights that immune suppression in ACLF increases susceptibility to bacterial infections, which in turn exacerbate immune dysfunction. However, a comprehensive review summarizing the emerging mechanisms underlying this immunosuppression is currently lacking. This review aims to provide an overview of the latest research, focusing on alterations in the immune responses of innate immune cells-including monocytes, macrophages, and neutrophils-as well as adaptive immune cells such as T and B lymphocytes during the onset and progression of bacterial infections in ACLF. In addition, recent advances in immunomodulatory therapies, including stem cell-based interventions, will also be discussed.

Alcoholic cirrhosis-associated immune dysfunction: What does it imply for us?

Alcoholic cirrhosis is a leading cause of chronic advanced liver disease. With the gradual eradication of viral hepatitis and the rising levels of alcohol consumption, the incidence of alcoholic cirrhosis is expected to increase steadily. Alcohol is primarily metabolized in the gastrointestinal tract, producing toxic metabolites that enter the portal vein circulation and are subsequently transported to the liver. Excessive alcohol intake activates the microsomal ethanol oxidation system and disrupts the intestinal microbiota-driven microenvironment dictated by intestinal microbiota, and increase intestinal permeability, all of which trigger severe systemic inflammatory responses and impaired immune function. This phenomenon, known as cirrhosis-associated immune dysfunction (CAID), is closely linked to the severity of cirrhosis and can significantly influence disease progression, potentially leading to multi-organ failure. This narrative review sheds light on the relationship between alcoholic cirrhosis and CAID, focusing on tailored interventions to modify immune response and modulate gut microbiota composition in hopes of mitigating the development and deterioration of alcoholic cirrhosis.

Influence of Familial Inflammatory Bowel Disease History on the Use of Immunosuppressants, Biological Agents and Surgery in Patients with Pediatric-Onset of the Disease in the Era of Biological Therapies. Results from the ENEIDA Registry

Background: Pediatric-onset familial inflammatory bowel disease (IBD) may differ from sporadic pediatric-onset IBD in its genetic and environmental background and may have distinct clinical and therapeutic implications. Objective: To evaluate the influence of a positive family history of IBD on the use of medical therapies and surgical interventions in adult patients with pediatric-onset IBD. Methods: Retrospective case-control study using the Spanish ENEIDA registry, including adults diagnosed with pediatric-onset IBD since 2006. Familial forms (FFs) (defined by a first-degree relative with IBD) and sporadic forms (SF) (with no relatives of any grade with IBD) were matched 1:4 by type of IBD, sex, age at IBD diagnosis, disease location, disease pattern, development of perianal disease and smoking status at diagnosis. The study outcomes were the use of immunomodulators, biological therapies, intestinal surgery, and perianal surgery during follow-up. Results: Six-hundred and fifty-five Crohn's disease (CD) (131 FF) and 440 ulcerative colitis (UC) (88 FF) patients were included. Immunomodulators, biological therapy, and intestinal surgery were used evenly among FF and SF patients for both UC and CD. However, a higher requirement for perianal surgery among FF-CD patients (18.3% vs. 10.5%, p = 0.014), together with a shorter time to perianal surgery (11 vs. 20 months, log-rank p = 0.004), was observed. Conclusions: Patients with FF of pediatric-onset IBD do not exhibit an increased use of immunomodulators, biological agents, or intestinal surgery, but do exhibit a higher need for perianal surgery, as compared to patients with SF pediatric-onset IBD.

Xyloglucan protects the intestinal barrier and reduces bacterial translocation in experimental cirrhosis - A promising non-antibiotic strategy

BACKGROUND

Cirrhosis alters the intestinal barrier, increasing permeability and promoting bacterial translocation (BT). Norfloxacin is currently the only effective strategy to reduce BT, but the rise of multidrug-resistant bacteria highlights the need for new approaches.

AIMS

To evaluate the effect of xyloglucan, alone or with norfloxacin, on the intestinal barrier in cirrhotic rats with ascites.

METHODS

Decompensated cirrhosis with ascites was induced in 32 rats using CCl4. They were then administered xyloglucan (XG), norfloxacin (NF), xyloglucan+norfloxacin (XG+NF), or water (control) for one week. Parameters measured included BT incidence, endotoxemia, IFN-, IL-23, PV1/CD34 ratio, occludin and liver histology.

RESULTS

BT incidence was lower in all treatment groups (XG, NF, XG+NF) compared to controls, and significantly so in NF and XG+NF. Endotoxemia was reduced significantly in all treatment groups compared to controls, with values correlating significantly with BT incidence, occludin expression, IFN- levels, IL-23 levels, and PV1/CD34 ratio. There were no differences in IL-23 levels, but all treatment groups exhibited a decrease in IFN-, which was significant in the NF and XG+NF groups. All treatment groups showed significant increases in occludin levels and decreases in PV1/CD34 ratio compared to controls. All groups showed similar histological signs of cirrhosis.

CONCLUSIONS

Xyloglucan reduces intestinal mucosal inflammation, improves mucosal integrity and vascular permeability, and reduces endotoxemia and BT incidence. Xyloglucan alone showed similar results to norfloxacin; however, combining xyloglucan with norfloxacin does not provide additional benefits. These findings support evaluating xyloglucan as a new therapeutic strategy to prevent infections in cirrhosis.

The impact of COVID-19 pandemic on hospitalization rate, clinical impairment and mortality of cirrhotic patients

The COVID-19 pandemic caused widespread disruption to global healthcare systems, necessitating the reallocation of resources to address the immediate demands. This reorganization had significant repercussions on the management of chronic diseases, including cirrhosis. We sought to provide a comprehensive picture of the COVID-19 impact on monthly hospitalization rates of cirrhotic patients at Local Health Board 1 hospitals in the Abruzzo Region, Italy. Using the International Classification of Diseases, Ninth Revision, we identified cases of alcohol-related, nonalcohol-related, biliary, and decompensated cirrhosis. We analyzed 957 Hospital Discharge Records from January 1 to December 31, 2019 (pre-pandemic), and from January 1 to December 31, 2022 (post-pandemic). We evaluated patients' clinical impairment, length of stay, and mortality before and after the pandemic. We identified 494 hospitalizations for nonalcohol-related cirrhosis and 310 for alcohol-related cirrhosis. As key findings, hospitalizations for nonalcohol-related cirrhosis decreased (69% vs. 48%; p < .0001), while hospitalizations for alcohol-related cirrhosis increased (31% vs. 52%; p < .0001), in the post-pandemic period. Additionally, there was a significant rise in decompensated patients with alcohol-related cirrhosis post-COVID (77% vs. 65%; p = .0216). Mortality risk increased for both nonalcohol- (11% vs. 18.5%; p = .0176) and alcohol-related cirrhosis (7.7% vs. 18%; p = .0059) in the post-pandemic era. The increase in hospitalizations for alcohol-related cirrhosis is alarming and likely to have a prolonged impact on the natural history of liver diseases. There is an urgent need to reduce alcohol consumption at the population level. Continued awareness and personalized follow-up are essential for guaranteeing the standard of care during health emergencies.

Clinical trajectories in liver cirrhosis: An evidence-based reappraisal for the internist

Over the last few years, the approach to clinical recognition and risk stratification of advanced liver disease has changed substantially, and liver cirrhosis has been increasingly conceptualized as a clinical rather than a histopathologic condition. In this Clinical Insight, we summarize the latest developments on recognition and management of 'clinically' advanced chronic liver disease.

Serum Interleukin-6 Levels may be a Key Determinant of 6-week Further Decompensation Risk in Patients With Cirrhosis and Acute Variceal Bleed: A Proof of Concept Study

Background and aims

Limited data exist on the role of systemic inflammation and gut barrier dysfunction in acute variceal bleed (AVB). We studied inflammatory markers and changes in the intestinal barrier in patients with AVB and assessed if these can be used to identify a higher risk subgroup with regard to outcomes.

Methods

In this prospective observational study, patients with cirrhosis and AVB presenting at a tertiary care center were stratified by whether or not they developed acute decompensation (AD) over 6 weeks follow-up. Utility of systemic inflammatory markers (interleukin-6 [IL-6], C-reactive protein), endotoxinemia (serum IgM/IgG anti-endotoxin antibodies), and duodenal epithelial tight junction proteins (TJPs) by immunohistochemistry (IHC) for tight-junction proteins (claudin-2,-4, zonula occludens-1(ZO-1), junctional adhesion molecule (JAM)) was assessed to predict the outcomes. These parameters were compared with a pre-existing cohort of patients with cirrhosis and no recent variceal bleed and with those without cirrhosis (dyspepsia with no endoscopic pathology). A nomogram was developed from multivariate model to predict 6-wk AD in patients with AVB.

Results

Patients with AVB(n = 66) (age:46.4 ± 11.7 years; etiology: alcohol/NASH/HBV/HCV [48.5%/12.1%/12.1%/7.6%]) were included. Twenty-four (36.3%) patients developed 6-wk AD. Patients with 6-wk AD had higher serum IL-6 (median: 156.14 pg/ml [IQR: 136.12-170.52] vs 58.28 pg/ml [31.70-110.67]; P < 0.001) and Child score (median: 9 [6.75-10.25] vs 7 [6-9]; P = 0.042) at baseline. Serum endotoxinemia and duodenal epithelial TJP were similar. A nomogram combining CTP and IL-6 was generated that predicted 6-wk AD with optimism-corrected c-statistic of 0.87. Comparison with non-bleeder cirrhosis (n = 52) (7.57 [5.48-9.87]) and dyspepsia controls (n = 53) (5.72 [4.40-6.45]; P < 0.001) also identified significant elevation of serum IL-6, not entirely explainable by derangements in TJP and bacterial translocation markers.

Conclusion

6-wk AD rates in patients with cirrhosis and AVB can be predicted using combination of Child score and serum IL-6.

Sterile systemic inflammation reaction associated with 90-day mortality in patients with HBV-related acute-on-chronic liver failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) represents the terminal and most lethal phase of acute decompensated cirrhosis. Systemic inflammation plays a critical role in the pathogenesis of ACLF. Systemic inflammation reaction syndrome (SIRS) is a marker of ongoing inflammation. Therefore, we aim to evaluate the relationship of sterile SIRS with hepatitis B virus (HBV)-related ACLF (HBV-ACLF).

METHODS

HBV-ACLF patients with sterile SIRS who were hospitalized between December 2016 and December 2018 were retrospectively analyzed. All patients were followed up until 90 days. Risk factors associated with 90-day mortality and sterile SIRS development were assessed.

RESULTS

Among 151 HBV-ACLF patients without infection, 37 patients (24.5%) presented with or developed sterile SIRS. During the 90-day follow-up, 23 of the 37 patients with sterile SIRS died (62.2%), compared to 40 patients without sterile SIRS (35.1%, P  = 0.004). Univariate analysis showed that age, total bilirubin (TBIL), international normalized ratio, ammonia, presence of sterile SIRS, model for end-stage liver disease score, presence of complications, and organ failures were associated with 90-day mortality. In multivariate analyses, the presence of sterile SIRS was an independent risk factor for 90-day mortality. Among SIRS components, heart rate (HR) was the most frequently met criterion (56 patients, 37.09%). Patients who met the HR or temperature criterion had lower 90-day survival rate than those who did not (46.4 vs 65.3%, P  = 0.020; 16.7 vs 60.0%, P  = 0.020).

CONCLUSION

The presence of sterile SIRS in HBV-ACLF patients was closely associated with prognosis.

Temporal Trends of Fungal Infections in Cirrhotic Patients: A Retrospective Cohort Study 2016-2020

Background

Patients with cirrhosis are susceptible to infections due to abnormalities in humoral and cell-mediated immunity. Fungal infections are associated with delayed diagnosis and high mortality rates, emphasizing the importance of performing fungal cultures and maintaining elevated levels of suspicion in this patient population.

Methods

This retrospective cohort study analyzes cirrhotic patients readmitted with bacterial and fungal infections and investigates outcomes, including in-hospital mortality and hospital resource utilization. Data was acquired from the Nationwide Readmission Database (NRD) from 2016 to 2020. Total hospital costs were calculated using HCUP Cost-to-Charge Ratio files and adjusted for inflation based on the Consumer Price Index (CPI) for medical care services in the U.S., with 2020 as the reference year. The NRD dataset lacks details like ascitic fluid cell counts, antifungal/antibacterial drugs used, and treatment responses, limiting the clinical insights that can be derived.

Results

The study analyzed 393,195 index hospitalizations. Among these, 102,505 account for 30-day and 157,079 account for 90-day readmissions. The 30-day and 90-day readmissions for spontaneous bacterial peritonitis (SBP) are 8478 and 15,690 respectively. The 30-day and 90-day readmissions for spontaneous fungal peritonitis (SFP) are 3106 and 5798 respectively. The mean age of patients was 57.9 years (standard deviation between 57.7 and 58.1). The mean length of stay (LOS) for SBP at 30 days is 9.4 days, while SFP has ranged from 14.9 to 32.3 days for various fungal infections. Aspergilloses have the longest LOS among SFP. There is an increased rate of mortality as well as hospital charges with SFP compared to SBP (P < 0.001). The 30-day index admission total charges for SBP are $42,258 and SFP are $51,739. The 30-day readmission total charges for SBP are 64, 266 and for SFP 89,913.

Conclusions

There is increased mortality, LOS, and hospital costs for SFP compared to SBP. It is important to consider SFP in the diagnostic workup for patients who do not respond to antibiotics. Early recognition and administration of antifungals can be associated with improved outcomes.

Higher Rate of Spontaneous Bacterial Peritonitis Recurrence With Secondary Spontaneous Bacterial Peritonitis Prophylaxis Compared With No Prophylaxis in 2 National Cirrhosis Cohorts

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) bacteriology has changed over time. Reappraisal of primary SBP prophylaxis showed an increased rate of resistance in patients on primary prophylaxis with resultant discontinuation of this prophylaxis throughout the Veterans Affairs (VA). We aimed to re-evaluate the risk-benefit ratio of secondary SBP prophylaxis (SecSBPPr).

METHODS

Using validated International Classification of Diseases-9/10 codes, we used the VA Corporate Data Warehouse and the Non-VA National TriNetX database to identify patients in 2 different large US systems who survived their first SBP diagnosis (with chart review from 2 VA centers) between 2009 and 2019. We evaluated the prevalence of SecSBPPr and compared outcomes between those who started on SecSBPPr vs not.

RESULTS

We identified 4,673 veterans who survived their index SBP episode; 54.3% of whom were prescribed SecSBPPr. Multivariable analysis showed higher SBP recurrence risk in those on vs off SecSBPPr (hazards ratio 1.63 [1.40-1.91], P < 0.001). This was accompanied by higher fluoroquinolone resistance odds in SecSBPPr patients (odds ratio = 4.32 [1.36-15.83], P = 0.03). In TriNetX, we identified 6,708 patients who survived their index SBP episode; 48.6% were on SecSBPPr. Multivariable analysis similarly showed SecSBPPr increased SBP recurrence risk (hazards ratio 1.68 [1.33-1.80], P < 0.001). Both data sets showed higher SBP recurrence trends over time in SecSBPPr patients. Results remained consistent at 6-month and 2-year timepoints.

DISCUSSION

In 2 national data sets of >11,000 patients with SBP, we found that SecSBPPr was prescribed in roughly half of patients. When initiated, SecSBPPr, compared with no prophylaxis after SBP, increased the risk of SBP recurrence in multivariable analysis by 63%-68%, and this trend worsened over time. SecSBPPr should be reconsidered in cirrhosis.

HLA DQA1*05 and Risk of Antitumor Necrosis Factor Treatment Failure and Anti-Drug Antibody Development in Children With Crohn's Disease

INTRODUCTION

Human leukocyte antigen (HLA) DQA1*05 has been associated with the development of anti-drug antibodies (ADA) to tumor necrosis factor antagonists (anti-TNFα) and treatment failure among adults with Crohn's disease (CD). However, findings from other studies have been inconsistent with limited pediatric data.

METHODS

We analyzed banked serum from patients with CD aged <21 years enrolled in clinical outcomes of Methotrexate Binary Therapy in practice, a multicenter, prospective randomized trial of anti-TNFα monotherapy vs combination with methotrexate. The primary outcome was a composite of factors indicative of treatment failure. The secondary outcome was ADA development.

RESULTS

A trend toward increased treatment failure among HLA DQA1*05-positive participants was not significant (hazard ratio 1.58, 95% confidence interval [CI] 0.95-2.62; P = 0.08). After stratification by HLA DQA1*05 and by methotrexate vs placebo, patients who were HLA DQA1*05 negative and assigned to methotrexate experienced less treatment failures than HLA DQA1*05-positive patients on placebo (hazard ratio 0.31, 95% CI 0.13-0.70; P = 0.005). A trend toward increased ADA development among HLA DQA1*05-positive participants was not significant (odds ratio 1.96, 95% CI 0.90-4.31, P = 0.09). After further stratification, HLA DQA1*05-negative participants assigned to methotrexate were less likely to develop ADA relative to HLA DQA1*05-positive patients on placebo (odds ratio 0.12, 95% CI 0.03-0.55; P = 0.008).

DISCUSSION

In a randomized trial of children with CD initiating anti-TNFα, 40% were HLA DQ-A1*05 positive, which was associated with a trend toward increased risk of both treatment failure and ADA. These risks were mitigated, but not eliminated, by adding oral methotrexate. HLA DQ-A1*05 is an important biomarker for prognosis and risk stratification.

Extracorporeal liver support systems in patients with acute-on-chronic liver failure: An updated systematic review and meta-analysis

BACKGROUND

The utilization of extracorporeal liver support systems is increasingly prevalent for the management of acute-on-chronic liver failure in clinical settings. Yet, the efficacy of these interventions in terms of tangible clinical benefits for patients remains a matter of debate, underscoring the need for meta-analysis.

METHODS

An updated meta-analysis was performed to elucidate the relationship between the application of extracorporeal liver support versus standard pharmacological treatment and the prognostic endpoints of patient survival, specifically assessing 1-month and 3-month mortality rates, as well as the incidence of complications such as hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. Literature were searched via PubMed, EMBASE, and Web of Science.

RESULTS

The meta-analysis revealed the following: the odds ratio for 1-month mortality was 0.63 (95% confidence interval [CIs]: 0.51-0.76), for 3-month mortality was 0.70 (95% CI: 0.61-0.81), for hepatic encephalopathy was 0.81 (95% CI: 0.67-0.97), for spontaneous bacterial peritonitis was 0.66 (95% CI: 0.44-0.99), and for hepatorenal syndrome was 0.68 (95% CI: 0.51-0.92). These results suggest that patients with acute-on-chronic liver failure undergoing extracorporeal liver support system therapy have significantly better survival rates and lower complication incidences compared to those receiving conventional drug therapy. Further subgroup analysis indicated that patients with lower model for end-stage liver disease (MELD) scores and reduced total bilirubin (Tbil) levels demonstrated greater benefits from extracorporeal hepatic support.

CONCLUSION

This study establishes that in the management of acute-on-chronic liver failure, extracorporeal liver support systems confer a survival advantage and reduce complications relative to standard pharmacotherapy.

Comparison of Bacterial Infections in Patients With Cirrhosis Between Hospitals With and Without Liver Transplant in Catalonia

BACKGROUND AND AIMS

Infections by multidrug resistant (MDR) bacteria are increasing and vary across regions and hospitals. We aimed to assess the epidemiology, prevalence, and outcomes of bacterial infections in patients with decompensated cirrhosis, comparing liver transplant (LT) and non-LT centers in Catalonia.

METHODS

This is a multicenter retrospective study including all patients with decompensated cirrhosis and bacterial infections hospitalised between January 2021 and 2022 from 5 university hospitals in the Barcelona metropolitan area. Two of them were LT centres. Clinical, laboratory, microbiological data, and in-hospital mortality were collected.

RESULTS

A total of 576 infections were reported in 352 patients. LT centers had more health-related infections, recurrent infections, and septic shock than non-LT centers, while there were no differences in cirrhosis severity, acute-on-chronic liver failure (ACLF) or comorbidities. Although the most commonly isolated microorganisms and types of infection were similar in both centers, LT centers had higher rates of extended-spectrum beta-lactamase (12% vs. 6%), carbapenem (3% vs. 0%) and piperacillin-tazobactam resistant bacteria (14% vs. 7%). MDR rate was also higher in LT centers (38% vs. 25%, p = 0.02) and varied across hospitals (18%-42%, p < 0.05). Furthermore, in-hospital mortality was higher in LT centers (20% vs. 10%; p = 0.01). Independent predictors of in-hospital mortality were septic shock, ACLF, Child-Pugh, age, and leukocyte count.

CONCLUSIONS

Our study showed differences in epidemiology, prevalence of MDR infections, and outcomes across university hospitals, particularly between centers with and without LT. Further studies are warranted to unveil the nuances of bacterial infections across different healthcare institutions in Europe and elsewhere.

Gram-positive infections in special populations. Expert view on the role of dalbavancin

INTRODUCTION

This review considers special populations as those patients for whom Gram-positive infections are particularly challenging to treat. We examine the potential benefits of dalbavancin in these patients.

AREAS COVERED

We focus on patients with renal impairment, hepatic failure or obesity, and, also, pediatric patients, elderly patients and socially vulnerable individuals. Five independent experts conducted exhaustive literature searches on PubMed. Papers were selected for inclusion according to their relevance to the topic. For each special population, we outline the most significant characteristics for infection management, describing the challenges of the most frequent Gram-positive infections, and reviewing the potential role of dalbavancin.

EXPERT OPINION

Dalbavancin may be a valid alternative to overcome the difficulties of infection management in these populations. We hope our insights will prove useful for patient-centered care. A long half-life, evidence-based efficacy and good safety profile make dalbavancin an adequate option, particularly for patients for whom oral treatment or continued IV access may be challenging, or those for whom hospital stay is more impactful. [Figure: see text].

The Liver Intensive Care Unit

Major advances in managing critically ill patients with liver disease have improved their prognosis and access to intensive care facilities. Acute-on-chronic liver failure (ACLF) is now a well-defined disease and these patients can be fast-tracked for liver transplantation (LT) with good outcomes if there are no contraindications. In acute liver failure, plasma exchange has improved prognosis for patients not eligible for immediate transplant. Further advances in novel therapies and refinement of the criteria for early LT in ACLF and also clinical implementation of artificial intelligence tools will probably constitute the next major breakthroughs in critically ill patients with liver disease.

Role of liposomal amphotericin B in intensive care unit: an expert opinion paper

INTRODUCTION

Invasive fungal infections (IFI) are frequent in patients admitted to the intensive care unit (ICU). The use of first-line antifungals like triazoles or echinocandins may be limited by the global spread of multi-drug resistance species, drug-drug interactions, low organ penetration, and some safety concerns in case of multi-organ failure. Liposomal amphotericin B (L-AmB) is a polyene drug with a broad activity against mold and yeast and an acceptable safety profile. To outline the role of L-AmB in the treatment of IFI in critically ill patients, a panel of experts was invited to draw up an expert opinion paper on the appropriate place in therapy of L-AmB in different clinical scenarios of patients admitted to ICU.

METHODS

A multidisciplinary group of 16 specialists in infectious disease, microbiology, pharmacology, and intensive care elaborated an expert opinion document through a multi-step approach: (1) the scientific panel defined the items and wrote the statements on the management of IFI in ICU, (2) a survey was submitted to an external panel to express agreement or disagreement on the statements, and (3) the panel reviewed the survey and implemented the final document.

RESULTS

The final document included 35 statements that focused on epidemiology and microbiological rationale of the use of systemic L-AmB in critically ill patients and its potential role in specific clinical scenarios in the ICU.

CONCLUSION

Systemic L-AmB may represent an appropriate therapeutic choice for IFI in ICU patients with different underlying conditions, especially when the use of first-line agents is undermined. This expert opinion paper may provide a useful guide for clinicians.

Systemic treatment in patients with hepatocellular carcinoma and advanced liver dysfunction

Systemic therapy represents the standard of care treatment for patients with advanced hepatocellular carcinoma (HCC). Given the increased risk of death from cirrhosis-related complications in patients with advanced liver dysfunction, pivotal phase III trials traditionally limited inclusion to patients with Child-Pugh class A, where death is more likely to be attributed to HCC progression. Therefore, Western guidelines recommend the use of systemic therapies primarily in patients with preserved liver function. However, patients with HCC and Child-Pugh class B are commonly encountered in clinical practice, but due to limited prospective evidence, there is no clear guidance on their optimal management.In this recent advances article, we discuss how the clinical course of cirrhosis can affect eligibility to treatment in the modern era of systemic therapy for HCC, elaborate on strategies to improve liver function in HCC patients by targeting cirrhosis-related and tumour-related factors and summarise the current literature on systemic therapy in HCC patients with Child-Pugh class B. Based on this information, we finally propose a clinical algorithm on how to systematically approach patients with HCC and advanced liver dysfunction in clinical practice.

The prognostic value of sarcopenia in acute-on-chronic liver failure: a systematic review and meta-analysis

BACKGROUND

Sarcopenia is prevalent in patients with chronic liver diseases, especially in cirrhosis patients. While sarcopenia is identified as a predictor of mortality in cirrhosis, its influence on acute-on-chronic liver failure (ACLF) remains unclear. This systematic review with meta-analysis aimed to explore the prognostic value of sarcopenia in ACLF patients.

METHODS

A comprehensive online literature search was performed in Medline (via PubMed), Web of Science, Embase, and Cochrane Library, and eligible studies were screened according to the predetermined criteria. The quality of the included studies was assessed by using the revised Cochrane Collaboration Risk of Bias Tool for randomized-control studies and the Newcastle-Ottawa Quality Assessment Scale for observational studies. Available outcomes measured by odds ratio (OR), hazard ratio (HR), and risk ratio (RR) with a 95% confidence interval (CI) were extracted and further included in the meta-analysis. Stata (version 18.0) was used for all statistical analyses.

RESULTS

Nine studies were included in further analysis. The pooled prevalence of sarcopenia was 53.3% (95% CI: 53.26 - 71.23%). The presence of sarcopenia was positively associated with 28-day mortality (HR = 2.11, 95% CI: 1.50-2.95, p < 0.001, I2 = 0.0%; OR = 2.73, 95% CI: 1.37-5.42, p = 0.004, I2 = 0.0%), 90-day mortality (HR = 1.66, 95% CI: 1.13-2.46, p = 0.01, I2 = 72.3%), and overall mortality (HR = 1.81, 95% CI: 1.30-2.51, p < 0.01, I2 = 0.0%). When using continuous variables to describe sarcopenia, a 1-unit increase in these indicators was almost significantly related to reduced 90-day mortality (HR = 0.98, 95% CI: 0.95-1.00, p = 0.052, I2 = 0.0%) and significantly associated with lower 1-year post-transplantation mortality (HR = 0.91, 95% CI: 0.85-0.98, p = 0.012, I2 = 32.7%).

CONCLUSION

Current evidence illustrates that sarcopenia is an unfavorable factor for both short- and long-term prognosis. More studies are needed to validate these findings in the future.

The diagnostic efficacy of metagenomic next-generation sequencing in spontaneous bacterial peritonitis: System review and meta-analysis

OBJECTIVE

The objective of this research is to assess the accuracy and reliability of metagenomic next-generation sequencing (mNGS) in identifying pathogens in spontaneous bacterial peritonitis (SBP) patients and its impact on antibiotic treatment decisions.

METHODS

Electronic databases were searched up to July 31, 2023. Studies reporting mNGS diagnostic sensitivity and specificity in SBP were included. Random or fixed-effects models were used. Heterogeneity was assessed using Chi-squared test and I2 statistics.

RESULTS

Out of 75 identified studies, four studies with a total of 420 SBP patients were included. The pooled sensitivity for mNGS in ascites was 94% (95% CI: 86-97%), and specificity was 81% (95% CI: 71-89%). The AUC was calculated to be 0.95 (95% CI: 0.92-0.96), indicating high diagnostic accuracy. The most common pathogens identified by mNGS were Gram-positive bacteria (36%), followed by Gram-negative bacteria (29%), viruses (22%), and fungi (11%).

CONCLUSION

mNGS shows high diagnostic accuracy in detecting pathogens in SBP patients, offering significant value in optimizing antimicrobial therapy. Its ability to identify a broad spectrum of pathogens makes it a promising tool in clinical management of SBP.

Predictive Factors of Post-ERCP Hepatic Decompensation in Patients with Cirrhosis: A Retrospective Case-Control Study

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is a crucial diagnostic and therapeutic procedure in patients with cirrhosis; however, it carries the risk of post-procedural hepatic decompensation. This study aims to identify predictive factors associated with post-ERCP hepatic decompensation in patients with cirrhosis to better inform clinical decision-making and minimize adverse outcomes.

METHODS

A retrospective analysis was conducted on patients with cirrhosis undergoing ERCP. Clinical, biochemical, and procedural variables were evaluated to determine their association with hepatic decompensation. Multivariate analysis was performed to identify independent predictors.

RESULTS

A total of 277 patients with cirrhosis who underwent an ERCP were included. The cohort had a mean age of 63.4 years, with a male predominance (65.3%) and various etiologies of cirrhosis, including alcohol-related (39.3%) and hepatitis C (11.4%). Post-ERCP complications occurred in 26.7% of patients. The most common complications were hepatic decompensation events (18.4%), sepsis (10.8%), and cholangitis (6.1%). Patients with complications had significantly higher baseline MELD scores, INR, chronic kidney disease (CKD) and history of ascites, hepatic encephalopathy, and hepatorenal syndrome (HRS). A Multivariate analysis revealed that factors such as higher MELD score, ascites, hepatic encephalopathy, and stent placement were associated with post-ERCP complications. Subgroup analyses indicated that patients who developed hepatic decompensation events (ascites, SBP, or HRS) had a more severe liver dysfunction at baseline, as reflected by a higher MELD score and INR, and prior episodes of ascites and hepatic encephalopathy.

CONCLUSION

Pre-procedural liver function parameters and procedural factors are crucial predictors of post-ERCP hepatic decompensation in patients with cirrhosis. Key risk factors include higher MELD score, CKD, history of ascites, and hepatic encephalopathy. Careful pre-procedural evaluation and management are essential to reduce these risks.

NT-proBNP predicts the development of acute-on-chronic liver failure and mortality in patients with cirrhosis listed for liver transplantation

Acute-on-chronic liver failure (ACLF) is a major clinical event in cirrhosis that is characterized by high mortality rates and a short window for liver transplantation. N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been suggested as a prognostic biomarker in cirrhosis. However, its accuracy in predicting the development of ACLF or mortality in candidates for liver transplantation remains unknown. This observational, retrospective, single-center study included 277 consecutive patients with cirrhosis who were listed for liver transplantation between 2014 and 2020 in Hospital Italiano, Buenos Aires, Argentina. Clinical data, including sarcopenia, serum cystatin C (CysC), and NT-proBNP levels, were collected at listing. The median MELD-Na and NT-proBNP levels at the time of listing were 16 points (13-22) and 123 (58-257) pg/mL, respectively. High NT-proBNP levels (≥125 pg/mL) were associated with the development of ACLF (subhazard ratio: 4.00, 95% CI: 1.76-9.10; p <0.001) and mortality (subhazard ratio: 3.89, 95% CI: 1.28-11.79, p =0.02) after adjusting for MELD-Na and CysC. Patients with NT-proBNP ≥125 pg/mL showed a significantly higher incidence of ACLF at 3 months (28.5% vs. 3.6%; p <0.001) and 12 months (49.2% vs. 6.1%; p <0.001). Mortality in the waiting list at 1 year was also significantly higher in patients with NT-proBNP ≥125 pg/mL (22.3% vs. 4%; p <0.001). Serum NT-proBNP emerges as a promising prognostic biomarker for ACLF development and mortality in patients with cirrhosis on the waiting list. Its integration into clinical practice could facilitate preventive interventions and improve prioritization on the waiting list.

Decompensated cirrhosis: an update of the BSG/BASL admission care bundle

Acute decompensated cirrhosis (DC) and acute-on-chronic liver failure are common reasons for hospital admission that have a high in-hospital mortality rate (10%–20%). Patients require a detailed assessment for precipitating factors and management of complications such as infections, ascites, acute kidney injury and hepatic encephalopathy. Multiple reports have demonstrated unwarranted variability in the care of patients with DC. In 2014, the British Society of Gastroenterology (BSG)/British Association for the Study of the Liver (BASL) DC care bundle (DCCB) was introduced to provide a structured approach for the management of patients with DC in the first 24 hours. Usage of the DCCB has been shown to improve care of patients with DC. However, despite evidence indicating the beneficial impact of the DCCB, overall usage across the UK was only 11.4% in a national audit. Our aim was to update the DCCB to incorporate recent advances in care and improve its usability and develop a strategy to improve its usage nationally. The updated bundle was developed by a multidisciplinary group of specialists from BSG, BASL and the Society for Acute Medicine with the quality of evidence supporting the bundle recommendations assessed using the Grading of Recommendation Assessment Development and Evaluation tool. Proposed minimum standards for audit were also developed. Finally, a strategy to promote usage of the bundle including education/training at a national and local level, improving accessibility for the bundle, and promotion of frameworks for use at an institutional level to improve and monitor utilisation of DCCB.

Multiplex PCR for Microbiological Testing in Patients with Peritoneal Dialysis- and Liver Cirrhosis-Related Peritonitis: Faster, but Less Sensitive

Background: We analyzed the performance of a multiplex PCR application (Unyvero IAI) in comparison to culture in a cohort of peritonitis patients undergoing peritoneal dialysis or with liver cirrhosis. Methods: We performed a single-center study of 47 patients with clinically suspected peritonitis and compared pathogen detection rates of culture and PCR. The main outcome of interest was a comparison of accuracy and time to final positive result. Results: In the total cohort, the pathogen detection rate in culture was 58.14% versus 34.88% in PCR (p = 0.03). Detection rates of bacteria in peritoneal dialysis patients were even higher by culture (70.83%) but comparably low by PCR (37.50%; p = 0.04). The majority of discordant results were in the Gram-positive spectrum (81.82%). Differential time to final positive result was 37.39 ± 16.75 h. Conclusion: Time gains by using PCR diagnostic have to be weighed against lower detection rates, mainly in Gram-positive infections.

Machine learning integration of multimodal data identifies key features of circulating NT-proBNP in people without cardiovascular diseases

N-Terminal Pro-Brain Natriuretic Peptide (NT-proBNP) is important for diagnosing and predicting heart failure or many other diseases. However, few studies have comprehensively assessed the factors correlated with NT-proBNP levels in people with cardiovascular health. We used data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). Machine learning was employed to assess 66 factors that associated with NT-proBNP levels, including demographic, anthropometric, lifestyle, biochemical, blood, metabolic, and disease characteristics. The predictive power of the model was assessed using five-fold cross-validation. The optimal features predicting NT-proBNP levels were identified using univariate and step-forward multivariate models. Weighted least squares regression (WLS) was applied for supplementary analysis. Finally, the relationship between the corresponding features and NT-proBNP was validated using weighted and adjusted generalized additive models (GAM). We included 12, 526 participants without cardiovascular diseases. In the univariate model, age exhibited the highest association with NT-proBNP levels (the coefficient of determination (R2) = 36.91%). The multivariate models revealed that age, gender, red blood cell count, race/ethnicity, systolic blood pressure, and total protein level were the top six predictors of NT-proBNP. GAM demonstrated a noteworthy non-linear association between NT-proBNP and age, red blood cell count, systolic blood pressure, and total protein. Our study contributes to explaining the biological mechanisms of NT-proBNP and will facilitate the design of relevant cohort studies. We underscore the significance of assessing various population subgroups when employing NT-proBNP as a biomarker, and the need for developing innovative clinical algorithms to establish personalized levels.

Hepatorenal Syndrome: direct treatment costs and characteristics of patients admitted to intensive care

BACKGROUND

Hepatorenal Syndrome is a potentially reversible syndrome of endstage cirrhosis. It is a severe complication of cirrhosis that involves a high mortality rate and a significant economic impact on the healthcare system. This study shows the costs of the resources used for disease management and complications to be Int$14,189. Quantifying this figure contributes to an understanding of the economic impact of Hepatorenal Syndrome on patient survival.

OBJECTIVE

The purpose of this study was to describe the direct medical costs incurred in Brazil for the treatment of Hepatorenal Syndrome in intensive care and intermediate therapy care units, and to investigate the impact of this syndrome on patient survival.

METHODS

This longitudinal observational retrospective study included patients with Hepatorenal Syndrome admitted to the intensive and intermediate therapy care units of a public tertiary hospital. The cost generated by each patient was the sum of the direct costs and overheads.

RESULTS

Forty-four patients with 49 episodes of suspected Hepatorenal Syndrome were analyzed, 73% male, with a mean age of 55 years (SD= 11). Diagnosis was presumed in 21 episodes (43%), because not all of the Ascites International Club's criteria were met. Alcoholic cirrhosis was the main etiology (43%); 59% of the patients were Child-Pugh Class C at admission, with a mean (SD) model for end-stage liver disease score of 24.6 (8). Seventy-seven percent of the patients died, 32% from multiple organ failure, 29% of septic shock and 27% of hypovolemic shock. The median (IQR) of the total treatment cost for each patient was Int$14,819 (8,732-23,854). The median (IQR) length of intensive care unit stay in intensive care was 11 days (7-19). Patients with a presumed diagnosis did not have a higher hospitalization cost (p=0.249) than those with true Hepatorenal Syndrome.

CONCLUSION

The treatment of Hepatorenal Syndrome represents a significant cost, and new resource allocation in strategic areas, such as the treatment and monitoring of patients with cirrhosis, is necessary to improve their outcomes.

BACKGROUND

■ The treatment of Hepatorenal Syndrome places a huge economic burden on healthcare systems.

BACKGROUND

■ Cost analysis studies of Hepatorenal Syndrome management can help to rationally allocate resources in healthcare.

BACKGROUND

■ Timely diagnosis and management of Hepatorenal Syndrome may reduce mortality, resource utilization and costs.

Fluoroquinolones for the Prophylaxis of Spontaneous Bacterial Peritonitis in Patients with Liver Cirrhosis: Are They Losing Ground?

Spontaneous bacterial peritonitis (SBP) is the most common bacterial infection in cirrhotic patients. Historically, the bacterial spectrum was dominated by Gram-negative bacteria. However, recent studies showed that fluoroquinolone (FQ)-based prophylaxis promotes the intestinal overgrowth of Gram-positive bacteria and contributes to the selection of quinolone-resistant Gram-negative bacteria, increasing multidrug-resistant (MDR) organism infections. FQ resistance rates reach up to nearly one-third in community-acquired cases and 50% in hospital-acquired cases, raising concerns about FQ efficacy. Moreover, rare but serious side effects further limit FQ use. Predictive factors of FQ treatment failure have been identified, guiding management strategies. Rifaximin has emerged as a promising alternative for SBP prophylaxis, with encouraging results. This review aims to explore the shifting role of FQ-based SBP prophylaxis, focusing on the emerging concerns, side effects, and alternative strategies. While norfloxacin remains a first-line prophylactic in cirrhotic patients with low ascitic protein levels, its efficacy appears to be reduced in those with advanced liver failure or additional risk factors for MDR organisms. In these subgroups, alternative prophylactics, such as trimethoprim-sulfamethoxazole or rifaximin, may be preferable. We propose a risk-stratification approach to guide treatment selection, with further studies needed to refine these criteria.

Bacterial resistance profile and its association with poor outcome among cirrhosis patients attending a tertiary care referral center in northern India

BACKGROUND AND OBJECTIVE

The epidemiological connections, predisposing factors and clinical outcomes of infections by drug-resistant bacteria in cirrhosis are poorly documented. Thus, this study was conducted to assess the risk factors, complications and patterns of bacterial resistance among these patients.

METHODS

This retrospective observational study was conducted from March 1, 2021, to July 31, 2023, at a tertiary care centre in Uttar Pradesh. Patients of cirrhosis aged ≥ 18 years with microbial infection were included in the study. Samples, as indicated, were sent to the microbiology lab for culture and sensitivity. The patient's clinical history, details regarding bacterial culture and antibiotic sensitivity results were extracted from the hospital information system (HIS) and entered into an excel sheet. Univariate analysis of the variables was done and the statistical significance of these variables was determined using the p-value. A p-value of < 0.05 was considered significant.

RESULTS

During the study period, 765 patients were diagnosed with cirrhosis, of which 248 (32%) had a positive bacterial culture report. Among them, 206 (83.1%) patients recovered and were discharged in stable condition. Among the cirrhotic patients, the most common infection was spontaneous bacterial peritonitis (49.5%), followed by bacteremia (39.1%), lower respiratory tract infections (6.4%), urinary tract infections (2.9%) and skin and soft tissue infections (2%). Escherichia coli (28%) was the most common gram-negative bacteria. Multidrug-resistant organism infections were seen in 134 (54%) patients. Multidrug-resistant (MDR) infection (31.4%) and extensively drug-resistant (XDR) infection (22.6%) were significantly associated with poor outcomes among these patients. Carbapenem-resistant organisms (22.6%) were the predominant resistant patterns seen among the gram-negative isolates in cirrhosis patients. The mortality rate among these cirrhotic patients with bacterial infection was 16.9%.

CONCLUSIONS

MDR and XDR bacterial infections in cirrhotic patients are an emerging threat that has a detrimental effect on prognosis. Thus, it is critical to assess strategies to prevent the development of antibiotic resistance in cirrhosis.

Preventing the progression of cirrhosis to decompensation and death

Two main stages are differentiated in patients with advanced chronic liver disease (ACLD), one compensated (cACLD) with an excellent prognosis, and the other decompensated (dACLD), defined by the appearance of complications (ascites, variceal bleeding and hepatic encephalopathy) and associated with high mortality. Preventing the progression to dACLD might dramatically improve prognosis and reduce the burden of care associated with ACLD. Portal hypertension is a major driver of the transition from cACLD to dACLD, and a portal pressure of ≥10 mmHg defines clinically significant portal hypertension (CSPH) as the threshold from which decompensating events may occur. In recent years, innovative studies have provided evidence supporting new strategies to prevent decompensation in cACLD. These studies have yielded major advances, including the development of noninvasive tests (NITs) to identify patients with CSPH with reasonable confidence, the demonstration that aetiological therapies can prevent disease progression and even achieve regression of cirrhosis, and the finding that non-selective β-blockers can effectively prevent decompensation in patients with cACLD and CSPH, mainly by reducing the risk of ascites, the most frequent decompensating event. Here, we review the evidence supporting new strategies to manage cACLD to prevent decompensation and the caveats for their implementation, from patient selection using NITs to ancillary therapies.

Oral-gut microbiome interactions in advanced cirrhosis: characterisation of pathogenic enterotypes and salivatypes, virulence factors and antimicrobial resistance

BACKGROUND & AIMS

Cirrhosis complications are often triggered by bacterial infections with multidrug-resistant organisms. Alterations in the gut and oral microbiome in decompensated cirrhosis (DC) influence clinical outcomes. We interrogated: (i) gut and oral microbiome community structures, (ii) virulence factors (VFs) and antimicrobial resistance genes (ARGs) and (iii) oral-gut microbial overlap in patients with differing cirrhosis severity.

METHODS

Fifteen healthy controls (HCs), as well as 26 patients with stable cirrhosis (SC), 46 with DC, 14 with acute-on-chronic liver failure (ACLF) and 14 with severe infection without cirrhosis participated. Metagenomic sequencing was undertaken on paired saliva and faecal samples. 'Salivatypes' and 'enterotypes' based on genera clustering were assessed against cirrhosis severity and clinical parameters. VFs and ARGs were evaluated in oral and gut niches, and distinct resistotypes identified.

RESULTS

Salivatypes and enterotypes revealed a greater proportion of pathobionts with concomitant reduction in autochthonous genera with increasing cirrhosis severity and hyperammonaemia. Increasing overlap between oral and gut microbiome communities was observed in DC and ACLF vs. SC and HCs, independent of antimicrobial, beta-blocker and gastric acid-suppressing therapies. Two distinct gut microbiome clusters harboured genes encoding for the PTS (phosphoenolpyruvate:sugar phosphotransferase system) and other VFs in DC and ACLF. Substantial ARGs (oral: 1,218 and gut: 672) were detected (575 common to both sites). The cirrhosis resistome was distinct, with three oral and four gut resistotypes identified, respectively.

CONCLUSIONS

The degree of oral-gut microbial community overlap, frequency of VFs and ARGs all increase significantly with cirrhosis severity, with progressive dominance of pathobionts and loss of commensals. Despite similar antimicrobial exposure, patients with DC and ACLF have reduced microbial richness compared to patients with severe infection without cirrhosis, supporting the additive pathobiological effect of cirrhosis.

IMPACT AND IMPLICATIONS

This research underscores the crucial role of microbiome alterations in the progression of cirrhosis in an era of escalating multidrug resistant infections, highlighting the association and potential impact of increased oral-gut microbial overlap, virulence factors, and antimicrobial resistance genes on clinical outcomes. These findings are particularly significant for patients with decompensated cirrhosis and acute-on-chronic liver failure, as they reveal the intricate relationship between microbiome alterations and cirrhosis complications. This is relevant in the context of multidrug-resistant organisms and reduced oral-gut microbial diversity that exacerbate cirrhosis severity, drive hepatic decompensation and complicate treatment. For practical applications, these insights could guide the development of targeted microbiome-based therapeutics and personalised antimicrobial regimens for patients with cirrhosis to mitigate infectious complications and improve clinical outcomes.

Assessment of intestinal inflammation via fecal calprotectin for early prediction of adverse outcomes in advanced chronic liver disease

BACKGROUND AND AIMS

Intestinal inflammation assessed by fecal calprotectin (F-CAL) in advanced chronic liver disease (ACLD) may represent an early sign of intestinal barrier dysfunction. We aimed to explore the usefulness of F-CAL testing in ACLD in the prediction of adverse outcomes (AO, death, or LT) and refinement of prognostic stratification.

PATIENTS AND METHODS

We explored the RH7 cirrhosis registry comprising consecutive hospitalized patients and a control group with data on disease phenotype, demographics, anthropometrics, prognostic indices, and medication. The F-CAL was evaluated on admission and reported in multiples of the upper limit of normal or terciles. Predictive power was tested in the Cox model for AO over 180 days. Additional risk refinement by F-CAL was tested for both groups.

RESULTS

We enrolled 263 cases in the study group with a median age of 57.2 years, M/F ratio 167/96, with alcohol, metabolic dysfunction-associated steatotic liver disease, MetALD, and viral etiologies in 72.2%, 9.1, 8.0, 3.4%. The median F-CAL was 3.92 × ULN. The control group comprised 108 cases. The adjusted Cox model confirmed F-CAL (hazard ratio [HR] = 1.05, p < 0.001) and F-CAL terciles (HR = 1.413, p = 0.009) as independent predictors of AO. F-CAL terciles had higher predictive accuracy in CLIF-C-AD<50 (HR = 2.49, p = 0.013) and Child stages A and B (HR = 1.706, p = 0.025), in whom high F-CAL (cut-off >11 × ULN) could identify patients having 2-3 times higher risk of AO. This approach has been validated in the control group.

CONCLUSION

Among hospitalized patients with ACLD, F-CAL values were independently proportional to the risk of AO, particularly in early disease stages when high F-CAL values could refine prognostic stratification.

Recompensation of Liver Cirrhosis by TIPS Reduces Epithelial Cell Death Markers, Translating Into Improved Clinical Outcome

BACKGROUND AND AIMS

Portal hypertension is the main pathophysiological driver of decompensation in patients with liver cirrhosis. Epithelial cell death markers, m30 and m65, correlate with hepatic injury and predict outcomes across various stages of liver disease. We aim (i) to evaluate whether portal hypertension itself contributes to liver outcome-relevant epithelial injury, and (ii) to analyse the capacity of m30/m65 to predict outcome in patients receiving a transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites.

METHODS

Sixty-six patients undergoing TIPS placement for refractory ascites and 20 patients with compensated cirrhosis as controls were prospectively enrolled in this monocentric cohort study. Epithelial cell death markers were analysed pre-TIPS, as well as 1-3 and 6-9 months post-TIPS. The capacity of baseline levels of m30/m65 in predicting six-month transplant-free survival rates was analysed by multivariable Cox proportional hazards regression.

RESULTS

Levels of m30 and m65 were higher in patients with decompensated cirrhosis (pre-TIPS) compared with compensated cirrhosis (controls). Following correction of portal hypertension by TIPS and recompensation, both markers decreased over time, reaching levels comparable to patients with compensated cirrhosis. On multivariable analysis, pre-TIPS baseline levels of m30 and m65 were not predictive for six-month survival.

CONCLUSION

Correction of portal hypertension via TIPS reduces levels of epithelial cell death markers, indicating that portal hypertension is a driver of outcome-relevant, hepatic cell death in patients with decompensated cirrhosis. Baseline m30/m65 values do not affect six-month survival rates, which suggests that TIPS placement overcomes the unfavourable spontaneous prognosis otherwise indicated by elevated baseline m30/65 levels.

Hyperbilirubinemia at hospitalization predicts nosocomial infection in decompensated cirrhosis: Data from ATTIRE trial

BACKGROUND

To identify clinical characteristics and serological biomarkers that predicted subsequent nosocomial infection in ATTIRE trial patients.

METHODS

We identified 360 patients at hospitalization without infection and not prescribed antibiotics and compared clinical characteristics between those who subsequently developed a nosocomial infection and not. In a 68-patient subcohort, we compared plasma biomarkers of bacterial translocation, infection, and inflammation at hospitalization between those who developed a nosocomial infection and not. In a 56-patient subcohort, we investigated plasma lipidomic profiles in those who did and did not develop nosocomial infection using Lipotype Shotgun platform analysis and multivariate statistical techniques. To further investigate lipid pathways, we compared outcomes in patients taking statins or not at hospitalization.

RESULTS

Serum bilirubin >188 µmol/L at hospitalization predicted subsequent nosocomial infection in univariate and multivariate analyses, with 80% specificity. The most common nosocomial infections were respiratory tract (29%) and those developing infection had significantly greater 28 and 90-day mortality than those not (p=9.34E-05 and 0.014). Serological biomarkers of bacterial translocation, infection, and inflammation did not predict subsequent infection. Partial least squares discriminatory analyses identified cholesterol esters (CEs) (CE.18.1.2, CE.18.1.0, and CE.16.0.0) as important predictors of infection but provided only a small improvement in predictive ability over bilirubin alone. RNA-sequencing analyses suggest this is mediated by a downregulation of the cellular cholesterol esterification enzyme sterol O-acyltransferase 1. Statin use was not associated with nosocomial infection prevention.

CONCLUSIONS

In ATTIRE, elevated serum bilirubin at hospitalization was the only clinical characteristic that predicted subsequent development of nosocomial infection. Considering the rising incidence of antimicrobial resistance, these data could be used to limit antibiotic prophylaxis or aid trial design for investigating use in high-risk patients.