551
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Lheureux O, Trepo E, Hites M, Cotton F, Wolff F, Surin R, Creteur J, Vincent JL, Gustot T, Jacobs F, Taccone FS. Serum β-lactam concentrations in critically ill patients with cirrhosis: a matched case-control study. Liver Int 2016; 36:1002-10. [PMID: 26645828 DOI: 10.1111/liv.13039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/26/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The pharmacokinetics of β-lactam antibiotics have not been well defined in critically ill patients with cirrhosis. METHODS We reviewed data from critically ill patients with cirrhosis and matched controls in whom routine therapeutic drug monitoring of two broad-spectrum β-lactam antibiotics (piperacillin/tazobactam and meropenem) had been performed. Serum drug concentrations were measured twice by high-performance liquid chromatography. Antibiotic pharmacokinetics were calculated using a one-compartment model. We considered that therapy was adequate when serum drug concentrations were between 4 and 8 times the minimal inhibitory concentration of Pseudomonas aeruginosa during optimal periods of time for each drug (≥ 50% for piperacillin/tazobactam; ≥ 40% for meropenem). RESULTS We studied 38 patients with cirrhosis (16 for piperacillin/tazobactam and 22 for meropenem) and 38 matched controls. Drug dosing was similar in the two groups. The pharmacokinetics analysis showed a lower volume of distribution of meropenem (P = 0.05) and a lower antibiotic clearance of piperacillin/tazobactam (P = 0.009) in patients with cirrhosis than in the matched controls. Patients with cirrhosis were more likely than those without cirrhosis to have excessive serum β-lactam concentrations (P = 0.015), in particular for piperacillin/tazobactam. CONCLUSIONS Standard β-lactam antibiotics regimens resulted in excessive serum concentrations in two thirds of the patients with cirrhosis. This was particularly true for piperacillin/tazobactam, probably because of reduced drug clearance.
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Affiliation(s)
- Olivier Lheureux
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Trepo
- Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Maya Hites
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Frederic Cotton
- Department of Clinical Biochemistry, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fleur Wolff
- Department of Clinical Biochemistry, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Rudy Surin
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Gustot
- Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Frederique Jacobs
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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552
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Twilla JD, Nair SP, Talwar M, Kovalic A, Satapathy SK. Severity of Systemic Inflammatory Response Syndrome Affects Outcomes in Decompensated Cirrhotics with Spontaneous Bacterial Peritonitis. Am J Gastroenterol 2016; 111:1043-5. [PMID: 27356838 DOI: 10.1038/ajg.2016.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Jennifer D Twilla
- Methodist University Hospital, Memphis, Tennessee, USA.,University of Tennessee Health Science Center, College of Pharmacy, Memphis, Tennessee, USA
| | - Satheesh P Nair
- Methodist University Hospital, Memphis, Tennessee, USA.,Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA.,University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Manish Talwar
- Methodist University Hospital, Memphis, Tennessee, USA.,Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA.,University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Alexander Kovalic
- University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Sanjaya K Satapathy
- Methodist University Hospital, Memphis, Tennessee, USA.,Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA.,University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
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553
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Irvine KM, Banh X, Gadd VL, Wojcik KK, Ariffin JK, Jose S, Lukowski S, Baillie GJ, Sweet MJ, Powell EE. CRIg-expressing peritoneal macrophages are associated with disease severity in patients with cirrhosis and ascites. JCI Insight 2016; 1:e86914. [PMID: 27699269 DOI: 10.1172/jci.insight.86914] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Infections are an important cause of morbidity and mortality in patients with decompensated cirrhosis and ascites. Hypothesizing that innate immune dysfunction contributes to susceptibility to infection, we assessed ascitic fluid macrophage phenotype and function. The expression of complement receptor of the immunoglobulin superfamily (CRIg) and CCR2 defined two phenotypically and functionally distinct peritoneal macrophage subpopulations. The proportion of CRIghi macrophages differed between patients and in the same patient over time, and a high proportion of CRIghi macrophages was associated with reduced disease severity (model for end-stage liver disease) score. As compared with CRIglo macrophages, CRIghi macrophages were highly phagocytic and displayed enhanced antimicrobial effector activity. Transcriptional profiling by RNA sequencing and comparison with human macrophage and murine peritoneal macrophage expression signatures highlighted similarities among CRIghi cells, human macrophages, and mouse F4/80hi resident peritoneal macrophages and among CRIglo macrophages, human monocytes, and mouse F4/80lo monocyte-derived peritoneal macrophages. These data suggest that CRIghi and CRIglo macrophages may represent a tissue-resident population and a monocyte-derived population, respectively. In conclusion, ascites fluid macrophage subset distribution and phagocytic capacity is highly variable among patients with chronic liver disease. Regulating the numbers and/or functions of these macrophage populations could provide therapeutic opportunities in cirrhotic patients.
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Affiliation(s)
| | | | | | | | - Juliana K Ariffin
- Institute for Molecular Bioscience (IMB), and.,IMB Centre for Inflammation and Disease Research, The University of Queensland, Brisbane, Queensland, Australia
| | | | | | | | - Matthew J Sweet
- Institute for Molecular Bioscience (IMB), and.,IMB Centre for Inflammation and Disease Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Elizabeth E Powell
- School of Medicine.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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554
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Fernández J, Tandon P, Mensa J, Garcia-Tsao G. Antibiotic prophylaxis in cirrhosis: Good and bad. Hepatology 2016; 63:2019-31. [PMID: 26528864 DOI: 10.1002/hep.28330] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 11/02/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Patients with cirrhosis, particularly those with decompensated cirrhosis, are at increased risk of bacterial infections that may further precipitate other liver decompensations including acute-on-chronic liver failure. Infections constitute the main cause of death in patients with advanced cirrhosis, and strategies to prevent them are essential. The main current strategy is the use of prophylactic antibiotics targeted at specific subpopulations at high risk of infection: prior episode of spontaneous bacterial peritonitis, upper gastrointestinal bleeding, and low-protein ascites with associated poor liver function. Antibiotic prophylaxis effectively prevents not only the development of bacterial infections in all these indications but also further decompensation (variceal bleeding, hepatorenal syndrome) and improves survival. However, antibiotic prophylaxis is also associated with a clinically relevant and increasing drawback, the development of infections due to multidrug-resistant organisms. Several strategies have been suggested to balance the risks and benefits of antibiotic prophylaxis. CONCLUSION Antibiotic stewardship principles such as the restriction of antibiotic prophylaxis to subpopulations at a very high risk for infection, the avoidance of antibiotic overuse, and early deescalation policies are key to achieve this balance; nonantibiotic prophylactic measures such as probiotics, prokinetics, bile acids, statins, and hematopoietic growth factors could also contribute to ameliorate the development and spread of multidrug-resistant bacteria in cirrhosis. (Hepatology 2016;63:2019-2031).
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Affiliation(s)
- Javier Fernández
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Barcelona, Spain
| | - Puneeta Tandon
- Cirrhosis Care Clinic, Cirrhosis Care, Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Jose Mensa
- Infectious Disease Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT.,Section of Digestive Diseases, VA-CT Healthcare System, West Haven, CT
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555
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Costabeber AM, Mattos AAD, Sukiennik TCT. PREVALENCE OF BACTERIAL RESISTANCE IN HOSPITALIZED CIRRHOTIC PATIENTS IN SOUTHERN BRAZIL: A NEW CHALLENGE. Rev Inst Med Trop Sao Paulo 2016; 58:36. [PMID: 27253738 PMCID: PMC4879993 DOI: 10.1590/s1678-9946201658036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/13/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND & AIMS An increased frequency of infections by multiresistant bacteria has been described in hospitalized patients. The aim of this study was to evaluate the bacterial resistance profile in cirrhotic patients. METHODS This is a retrospective observational study. We assessed the antimicrobial susceptibility of 5,839 bacterial isolates from patients with and without cirrhosis. Regarding the multidrug resistance, we evaluated 4,505 bacterial isolates from 2,180 patients. RESULTS Two hundred and fifty-one patients had cirrhosis (mean age 57.6 ± 11 years; 61.8% were male, 47.8% of cases associated with hepatitis C virus). Of the isolates of patients with and without cirrhosis, 174/464 (37.5%) and 1,783/4,041 (44.1%) were multiresistant, respectively (p = 0.007). E. coli was the most common multiresistant bacteria in both groups. Approximately 20% of E. coli and Klebsiella sp. isolates were ESBL-producers and 44% of S. aureus isolates were methicillin-resistant in cirrhotic patients. In cirrhotic patients admitted to the emergency department, hospital ward, and intensive care unit, 28.3%, 50% and 40% had multiresistant isolates, respectively. In patients with and without cirrhosis, 36.2% and 33.5% of isolates were resistant to third-generation cephalosporins, respectively. CONCLUSIONS The empirical treatment of infections in hospitalized patients using broad-spectrum antibiotics should consider the observed pattern of bacterial resistance.
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556
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Garbuzenko DV. [Aspects of pathogenetc pharmacotherapy for portal hypertension in liver cirrhosis]. TERAPEVT ARKH 2016; 88:101-108. [PMID: 27135108 DOI: 10.17116/terarkh2016888101-108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The review of literature considers the principles of medical treatment for portal hypertension in liver cirrhosis, which are based on the current views of its development mechanisms. It describes both current pharmacotherapy methods for portal hypertension and drugs, the efficacy of which is being investigated.
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Affiliation(s)
- D V Garbuzenko
- South Ural State Medical University, Ministry of Health of Russia, Chelyabinsk, Russia
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557
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Louvet A. Restoration of bactericidal activity of neutrophils by myeloperoxidase release: A new perspective for preventing infection in alcoholic cirrhosis. J Hepatol 2016; 64:1006-1007. [PMID: 26883848 DOI: 10.1016/j.jhep.2016.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Alexandre Louvet
- Service des maladies de l'appareil digestif, Hôpital Huriez, Lille Cedex, France; LIRIC - Lille Inflammation Research International Center, U995, Univ. Lille, Inserm, Lille, France.
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558
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Shigeto K, Kawaguchi T, Niizeki T, Kunitake Y, Takedatsu H, Tonan T, Fujimoto K, Tanaka M, Abe T, Naito H, Torimura T. Efficacy of peritoneovenous shunt for treating tolvaptan-resistant refractory ascites in a cirrhotic patient with portal vein thrombosis: A case report. Oncol Lett 2016; 11:3205-3209. [PMID: 27123091 DOI: 10.3892/ol.2016.4357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/08/2016] [Indexed: 12/16/2022] Open
Abstract
Peritoneovenous shunt is normally used for the treatment of refractory ascites. However, its efficacy in treating tolvaptan-resistant refractory ascites has not been reported thus far. In addition, the impact of peritoneovenous shunt on the prognosis of cirrhotic patients remains controversial. In the present report, a case of tolvaptan-resistant refractory ascites associated with liver cirrhosis and portal vein thrombosis is described. The male patient was diagnosed with hepatitis C virus-related liver cirrhosis at the age of 51 years. At the age of 56 years, the patient developed portal vein thrombosis, resulting in the development of refractory ascites. Since the ascites was resistant to treatment with a low-sodium diet and diuretics such as tolvaptan, a peritoneovenous shunt was implanted upon obtaining consent. The shunt immediately increased the urine volume, and the ascites was markedly decreased. The patient's body weight decreased from 62.7 to 57.1 kg in 2 days, and his ascites symptom inventory-7 score decreased from 23 to 0 points in 31 days. Although the patient succumbed to sepsis on day 486 following the shunt implant, his activities of daily living were preserved until 8 days prior to mortality. Thus, the present case supports the efficacy of peritoneovenous shunt for the treatment of tolvaptan-resistant refractory ascites associated with liver cirrhosis and portal vein thrombosis. Furthermore, the present case suggests that peritoneovenous shunt may prolong the survival of cirrhotic patents with refractory ascites.
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Affiliation(s)
- Kota Shigeto
- Department of Medicine, Division of Gastroenterology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Takumi Kawaguchi
- Department of Medicine, Division of Gastroenterology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Takashi Niizeki
- Department of Medicine, Division of Gastroenterology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Yasushi Kunitake
- Department of Medicine, Division of Gastroenterology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Hidetoshi Takedatsu
- Department of Medicine, Division of Gastroenterology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Tatsuyuki Tonan
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Kiminori Fujimoto
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | | | - Toshi Abe
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | | | - Takuji Torimura
- Department of Medicine, Division of Gastroenterology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
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559
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Boussif A, Rolas L, Weiss E, Bouriche H, Moreau R, Périanin A. Impaired intracellular signaling, myeloperoxidase release and bactericidal activity of neutrophils from patients with alcoholic cirrhosis. J Hepatol 2016; 64:1041-1048. [PMID: 26719020 DOI: 10.1016/j.jhep.2015.12.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 11/13/2015] [Accepted: 12/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Myeloperoxidase exocytosis and production of hydrogen peroxide via the neutrophil superoxide-generating nicotinamide adenine dinucleotide phosphate (NADPH) oxidase contribute to efficient elimination of bacteria. Cirrhosis impairs immune functions and increases susceptibility to bacterial infection. We recently showed that neutrophils from patients with decompensated alcoholic cirrhosis exhibit a severe impairment of formylpeptide receptor (fPR)-mediated intracellular signaling and superoxide production. Here, we performed ex vivo studies with these patients' neutrophils to further investigate myeloperoxidase release, bactericidal capacity and signaling events following fPR stimulation by the formylpeptide formyl-met-leu-phe (fMLP). METHODS Myeloperoxidase release was studied by measuring extracellular myeloperoxidase activity. Activation of signaling effectors was studied by Western blot and their respective contribution to myeloperoxidase release studied using pharmacological antagonists. RESULTS fMLP-induced myeloperoxidase release was strongly impaired in patients' neutrophils whereas the intracellular myeloperoxidase stock was unaltered. The fMLP-induced phosphorylation of major signaling effectors, AKT, ERK1/2 and p38-MAP-Kinases, was also strongly deficient despite a similar expression of signaling effectors or fPR. However, based on effector inhibition in healthy neutrophils, AKT and p38-MAPK but not ERK1/2 upregulated fMLP-induced myeloperoxidase exocytosis. Interestingly, patients' neutrophils exhibited a defective bactericidal capacity that was reversed ex vivo by the TLR7/8 agonist CL097, through potentiation of the fMLP-induced AKT/p38-MAPK signaling axis and myeloperoxidase release. CONCLUSIONS We provide first evidence that neutrophils from patients with decompensated alcoholic cirrhosis exhibit a deficient AKT/p38-MAPK signaling, myeloperoxidase release and bactericidal activity, which can be reversed via TLR7/8 activation. These defects, together with the previously described severe deficient superoxide production, may increase cirrhotic patients' susceptibility to bacterial infections.
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Affiliation(s)
- Abdelali Boussif
- INSERM UMRS-1149, Faculté de Médécine X. Bichat, 75018 Paris, France; CNRS ERL 8252, Centre de Recherche sur l'Inflammation, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Laboratoire d'excellence INFLAMEX, 75018 Paris, France; Université de Batna, Faculté des Sciences, Département de Biologie, Algeria
| | - Loïc Rolas
- INSERM UMRS-1149, Faculté de Médécine X. Bichat, 75018 Paris, France; CNRS ERL 8252, Centre de Recherche sur l'Inflammation, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Laboratoire d'excellence INFLAMEX, 75018 Paris, France
| | - Emmanuel Weiss
- INSERM UMRS-1149, Faculté de Médécine X. Bichat, 75018 Paris, France; CNRS ERL 8252, Centre de Recherche sur l'Inflammation, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Laboratoire d'excellence INFLAMEX, 75018 Paris, France; Département d'Anesthésie Réanimation, Hôpital Beaujon, APHP, 92118 Clichy, France
| | - Hamama Bouriche
- Laboratoire de Biochimie Appliquée, Département de Biochimie, Faculté des Sciences de la Nature et de Vie, Université Ferhat Abbas, Sétif 1, Algeria
| | - Richard Moreau
- INSERM UMRS-1149, Faculté de Médécine X. Bichat, 75018 Paris, France; CNRS ERL 8252, Centre de Recherche sur l'Inflammation, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Laboratoire d'excellence INFLAMEX, 75018 Paris, France; Département Hospitalo-Universitaire (DHU) Unity, Service d'Hépatologie, Hôpital Beaujon, APHP, 92118 Clichy, France
| | - Axel Périanin
- INSERM UMRS-1149, Faculté de Médécine X. Bichat, 75018 Paris, France; CNRS ERL 8252, Centre de Recherche sur l'Inflammation, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Laboratoire d'excellence INFLAMEX, 75018 Paris, France.
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560
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Vaccinating Adult Patients with Cirrhosis: Trends over a Decade in the United States. Gastroenterol Res Pract 2016; 2016:5795712. [PMID: 27239192 PMCID: PMC4867062 DOI: 10.1155/2016/5795712] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/23/2016] [Accepted: 04/17/2016] [Indexed: 02/07/2023] Open
Abstract
Introduction. The progression of chronic liver disease to cirrhosis involves both innate and adaptive immune system dysfunction resulting in increased risk of infectious complications. Vaccinations against pneumococcus, hepatitis A virus (HAV), and hepatitis B virus (HBV) are well tolerated and effective in disease prevention and reduction in morbidity and mortality. Prior studies assessing vaccination rates in patients with cirrhosis have specific limitations and to date no study has provided a comprehensive evaluation of vaccination rates in patients with cirrhosis in the United States. Aim. This study assessed vaccination rates for pneumococcus, HAV, and HBV in patients with cirrhosis. Results. Overall 59.7% of patients with cirrhosis received at least 1 vaccination during the study period. Vaccination rates within the same or following year of cirrhosis diagnosis were 19.9%, 7.7%, and 11.0% against pneumococcus, HAV, and HBV, respectively. Trend analysis revealed significant increases in vaccination rates for pneumococcus in all patients with cirrhosis and within subgroups based on age, gender, and presence of concomitant diabetes. Conclusion. The study demonstrated that vaccination rates in patients with cirrhosis remain suboptimal. Ultimately, the use of electronic medical record (EMR) reminders improved communication between healthcare professionals and public health programs to increase awareness are fundamental to reducing morbidity, mortality, and health-care related costs of vaccine preventable diseases in patients with cirrhosis.
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561
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Friedrich-Rust M, Wanger B, Heupel F, Filmann N, Brodt R, Kempf VAJ, Kessel J, Wichelhaus TA, Herrmann E, Zeuzem S, Bojunga J. Influence of antibiotic-regimens on intensive-care unit-mortality and liver-cirrhosis as risk factor. World J Gastroenterol 2016; 22:4201-4210. [PMID: 27122670 PMCID: PMC4837437 DOI: 10.3748/wjg.v22.i16.4201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/09/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the rate of infection, appropriateness of antimicrobial-therapy and mortality on intensive care unit (ICU). Special focus was drawn on patients with liver cirrhosis.
METHODS: The study was approved by the local ethical committee. All patients admitted to the Internal Medicine-ICU between April 1, 2007 and December 31, 2009 were included. Data were extracted retrospectively from all patients using patient charts and electronic documentations on infection, microbiological laboratory reports, diagnosis and therapy. Due to the large hepatology department and liver transplantation center, special interest was on the subgroup of patients with liver cirrhosis. The primary statistical-endpoint was the evaluation of the influence of appropriate versus inappropriate antimicrobial-therapy on in-hospital-mortality.
RESULTS: Charts of 1979 patients were available. The overall infection-rate was 53%. Multiresistant-bacteria were present in 23% of patients with infection and were associated with increased mortality (P < 0.000001). Patients with infection had significantly increased in-hospital-mortality (34% vs 17%, P < 0.000001). Only 9% of patients with infection received inappropriate initial antimicrobial-therapy, no influence on mortality was observed. Independent risk-factors for in-hospital-mortality were the presence of septic-shock, prior chemotherapy for malignoma and infection with Pseudomonas spp. Infection and mortality-rate among 175 patients with liver-cirrhosis was significantly higher than in patients without liver-cirrhosis. Infection increased mortality 2.24-fold in patients with cirrhosis. Patients with liver cirrhosis were at an increased risk to receive inappropriate initial antimicrobial therapy.
CONCLUSION: The results of the present study report the successful implementation of early-goal-directed therapy. Liver cirrhosis patients are at increased risk of infection, mortality and to receive inappropriate therapy. Increasing burden are multiresistant-bacteria.
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562
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Hartmann P, Seebauer CT, Schnabl B. Alcoholic liver disease: the gut microbiome and liver cross talk. Alcohol Clin Exp Res 2016; 39:763-75. [PMID: 25872593 DOI: 10.1111/acer.12704] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/18/2015] [Indexed: 01/18/2023]
Abstract
Alcoholic liver disease (ALD) is a leading cause of morbidity and mortality worldwide. Alcoholic fatty liver disease can progress to steatohepatitis, alcoholic hepatitis, fibrosis, and cirrhosis. Patients with alcohol abuse show quantitative and qualitative changes in the composition of the intestinal microbiome. Furthermore, patients with ALD have increased intestinal permeability and elevated systemic levels of gut-derived microbial products. Maintaining eubiosis, stabilizing the mucosal gut barrier, or preventing cellular responses to microbial products protect from experimental ALD. Therefore, intestinal dysbiosis and pathological bacterial translocation appear fundamental for the pathogenesis of ALD. This review highlights causes for intestinal dysbiosis and pathological bacterial translocation, their relationship, and consequences for ALD. We also discuss how the liver affects the intestinal microbiota.
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Affiliation(s)
- Phillipp Hartmann
- Department of Medicine, University of California, San Diego, La Jolla, California
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563
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Alexopoulou A, Vasilieva L, Agiasotelli D, Siranidi K, Pouriki S, Tsiriga A, Toutouza M, Dourakis SP. Extensively drug-resistant bacteria are an independent predictive factor of mortality in 130 patients with spontaneous bacterial peritonitis or spontaneous bacteremia. World J Gastroenterol 2016; 22:4049-4056. [PMID: 27099449 PMCID: PMC4823256 DOI: 10.3748/wjg.v22.i15.4049] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/18/2016] [Accepted: 02/22/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the epidemiology and outcomes of culture-positive spontaneous bacterial peritonitis (SBP) and spontaneous bacteremia (SB) in decompensated cirrhosis.
METHODS: We prospectively collected clinical, laboratory characteristics, type of administered antibiotic, susceptibility and resistance of bacteria to antibiotics in one hundred thirty cases (68.5% males) with positive ascitic fluid and/or blood cultures during the period from January 1, 2012 to May 30, 2014. All patients with SBP had polymorphonuclear cell count in ascitic fluid > 250/mm3. In patients with SB a thorough study did not reveal any other cause of bacteremia. The patients were followed-up for a 30-d period following diagnosis of the infection. The final outcome of the patients was recorded in the end of follow-up and comparison among 3 groups of patients according to the pattern of drug resistance was performed.
RESULTS: Gram-positive-cocci (GPC) were found in half of the cases. The most prevalent organisms in a descending order were Escherichia coli (33), Enterococcus spp (30), Streptococcus spp (25), Klebsiella pneumonia (16), S. aureus (8), Pseudomanas aeruginosa (5), other Gram-negative-bacteria (GNB) (11) and anaerobes (2). Overall, 20.8% of isolates were multidrug-resistant (MDR) and 10% extensively drug-resistant (XDR). Health-care-associated (HCA) and/or nosocomial infections were present in 100% of MDR/XDR and in 65.5% of non-DR cases. Meropenem was the empirically prescribed antibiotic in HCA/nosocomial infections showing a drug-resistance rate of 30.7% while third generation cephalosporins of 43.8%. Meropenem was ineffective on both XDR bacteria and Enterococcus faecium (E. faecium). All but one XDR were susceptible to colistin while all GPC (including E. faecium) and the 86% of GNB to tigecycline. Overall 30-d mortality was 37.7% (69.2% for XDR and 34.2% for the rest of the patients) (log rank, P = 0.015). In multivariate analysis, factors adversely affecting outcome included XDR infection (HR = 2.263, 95%CI: 1.005-5.095, P = 0.049), creatinine (HR = 1.125, 95%CI: 1.024-1.236, P = 0.015) and INR (HR =1.553, 95%CI: 1.106-2.180, P = 0.011).
CONCLUSION: XDR bacteria are an independent life-threatening factor in SBP/SB. Strategies aiming at restricting antibiotic overuse and rapid identification of the responsible bacteria could help improve survival.
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564
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Lizaola B, Bonder A, Tapper EB, Mendez-Bocanegra A, Cardenas A. The Changing Role of Sodium Management in Cirrhosis. ACTA ACUST UNITED AC 2016; 14:274-84. [DOI: 10.1007/s11938-016-0094-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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565
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Piano S, Fasolato S, Salinas F, Romano A, Tonon M, Morando F, Cavallin M, Gola E, Sticca A, Loregian A, Palù G, Zanus G, Senzolo M, Burra P, Cillo U, Angeli P. The empirical antibiotic treatment of nosocomial spontaneous bacterial peritonitis: Results of a randomized, controlled clinical trial. Hepatology 2016; 63:1299-309. [PMID: 26084406 DOI: 10.1002/hep.27941] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 06/16/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED Spontaneous bacterial peritonitis (SBP) is a common, life-threatening complication of liver cirrhosis. Third-generation cephalosporins have been considered the first-line treatment of SBP. In 2014, a panel of experts suggested a broader spectrum antibiotic regimen for nosocomial SBP, according to the high rate of bacteria resistant to third-generation cephalosporins found in these patients. However, a broader-spectrum antibiotic regimen has never been compared to third-generation cephalosporins in the treatment of nosocomial SBP. The aim of our study was to compare meropenem plus daptomycin versus ceftazidime in the treatment of nosocomial SBP. Patients with cirrhosis and nosocomial SBP were randomized to receive meropenem (1 g/8 hours) plus daptomycin (6 mg/kg/day) or ceftazidime (2 g/8 hours). A paracentesis was performed after 48 hours of treatment. A reduction in ascitic fluid neutrophil count <25% of pretreatment value was considered a treatment failure. The primary outcome was the efficacy of treatment defined by the resolution of SBP after 7 days of treatment. Thirty-two patients were randomized and 31 were analyzed. The combination of meropenem plus daptomycin was significantly more effective than ceftazidime in the treatment of nosocomial SBP (86.7 vs. 25%; P < 0.001). Ninety-day transplant-free survival (TFS) was not significantly different between the two groups. In the multivariate analysis, ineffective response to first-line treatment (hazard ratio [HR]: 20.6; P = 0.01), development of acute kidney injury during hospitalization (HR: 23.2; P = 0.01), and baseline mean arterial pressure (HR: 0.92; P = 0.01) were found to be independent predictors of 90-day TFS. CONCLUSION The combination of meropenem plus daptomycin is more effective than ceftazidime as empirical antibiotic treatment of nosocomial SBP. Efficacy of the empirical antibiotic treatment is a strong predictor of 90-day survival in patients with nosocomial SBP.
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Affiliation(s)
- Salvatore Piano
- Unit of Hepatic Emergencies and Liver Transplantation, University of Padova, Padova, Italy.,Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Silvano Fasolato
- Unit of Hepatic Emergencies and Liver Transplantation, University of Padova, Padova, Italy.,Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Freddy Salinas
- Division of Medicine, Private Hospital "Giovanni XXIII" of Monastier, Treviso, Italy
| | | | - Marta Tonon
- Unit of Hepatic Emergencies and Liver Transplantation, University of Padova, Padova, Italy.,Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Filippo Morando
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Marta Cavallin
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Elisabetta Gola
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | | | - Arianna Loregian
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Giorgio Palù
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Giacomo Zanus
- Unit of Hepatobiliary Surgery and Liver Transplantation, University of Padova, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Umberto Cillo
- Unit of Hepatobiliary Surgery and Liver Transplantation, University of Padova, Italy
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, University of Padova, Padova, Italy.,Department of Medicine (DIMED), University of Padova, Padova, Italy
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Vogt A, Reuken PA, Stengel S, Stallmach A, Bruns T. Dual-sugar tests of small intestinal permeability are poor predictors of bacterial infections and mortality in cirrhosis: A prospective study. World J Gastroenterol 2016; 22:3275-3284. [PMID: 27004006 PMCID: PMC4790004 DOI: 10.3748/wjg.v22.i11.3275] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/20/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To prospectively analyze the impact of increased intestinal permeability (IP) on mortality and the occurrence of infections in patients with cirrhosis.
METHODS: IP was quantified using the lactulose/mannitol (L/M) test in 46 hospitalized patients with cirrhosis (25 Child-Pugh A/B, 21 Child-Pugh C) and in 16 healthy controls. Markers of inflammation [LPS-binding protein, Interleukin-6 (IL-6)] and enterocyte death [intestinal fatty-acid binding protein (I-FABP)] were determined in serum using enzyme-linked immunosorbent assays. Patients were followed for one year and assessed for survival, liver transplantation, the necessity of hospitalization and the occurrence of bacterial infections. The primary endpoint of the study was defined as differences in survival between patients with pathological and without pathological lactulose/mannitol test.
RESULTS: Thirty-nine (85%) patients with cirrhosis had a pathologically increased IP index (L/M ratio > 0.07) compared to 4 (25%) healthy controls (P < 0.0001). The IP index correlated with the Child-Pugh score (r = 0.484, P = 0.001) and with serum IL-6 (r = 0.342, P = 0.02). Within one year, nineteen (41%) patients developed a total of 33 episodes of hospitalization with bacterial or fungal infections. Although patients who developed spontaneous bacterial peritonitis (SBP) (n = 7) had a higher IP index than patients who did not (0.27 vs 0.14, P = 0.018), the baseline IP index did not predict time to infection, infection-free survival or overall survival, neither when assessed as linear variable, as tertiles, nor dichotomized using an established cut-off. In contrast, model for end-stage liver disease score, Child-Pugh score, the presence of ascites, serum IL-6 and I-FABP were univariate predictors of infection-free survival.
CONCLUSION: Although increased IP is a frequent phenomenon in advanced cirrhosis and may predispose to SBP, it failed to predict infection-free and overall survival in this prospective cohort study.
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567
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Álvaro-Meca A, Jiménez-Sousa MA, Boyer A, Medrano J, Reulen H, Kneib T, Resino S. Impact of chronic hepatitis C on mortality in cirrhotic patients admitted to intensive-care unit. BMC Infect Dis 2016; 16:122. [PMID: 26979964 PMCID: PMC4793506 DOI: 10.1186/s12879-016-1448-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 02/29/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Cirrhosis and severe sepsis are factors associated with increased mortality in intensive care unit (ICU), but chronic hepatitis C (CHC) has been less studied in ICU. The aim of this study was to analyze the impact of CHC on the mortality of cirrhotic patients admitted to ICU according to severe sepsis and decompensated cirrhosis. METHODS We carried out a retrospective study based on CHC-cirrhotic patients (CHC-group) admitted to ICU (n = 1138) and recorded in the Spanish Minimum Basic Data Set (2005-2010). A control-group (randomly selected cirrhotic patients without HIV, HBV, or HCV infections) was also included (n = 4127). The primary outcome variable was ICU mortality. The cumulative mortality rate on days 7, 30, and 90 in patients admitted to the ICUs was calculated by dividing the number of deaths by the number of patients admitted to the ICU. The adjusted hazard ratio (aHR) for death in the ICU was estimated through a semi-parametric Bayesian model of competing risk. RESULTS The CHC-group had a higher cumulative incidence of severe sepsis than the control-group in compensated cirrhosis (37.4 vs. 31.1%; p = 0.024), but no differences between the CHC-group and the control-group in decompensated cirrhosis were found. Moreover, a higher cumulative incidence of severe sepsis was associated with decompensated cirrhosis compared to compensated cirrhosis in the control-group (40.1 vs. 31.1%; p < 0.001) whereas this was not observed in the CHC group (38.1 vs. 37.4%; p = 0.872). The CHC-group had higher cumulative mortality than the control-group by days 7 (47 vs. 41.3%; p < 0.001), 30 (78.5 vs. 73.5%; p < 0.001), and 90 (96.3 vs. 95.9%; p < 0.001). In a competitive risk model, the CHC-group had a higher risk of dying if the ICU course was complicated by severe sepsis (adjusted hazard ratio (aHR) = 1.19; p = 0.003), but no significant values in patients with absence of severe sepsis were found (aHR = 1.09; p= 0.068). When patients were stratified by cirrhosis stage and severe sepsis, CHC patients with compensated cirrhosis had the higher risk of death if they had severe sepsis (aHR = 1.35; p = 0.002). Moreover, the survival was low in patients with decompensated cirrhosis and severe sepsis but we did not find significant differences between CHC-group and control-group. CONCLUSIONS CHC was associated with an increased risk of death in cirrhotic patients admitted to ICUs, particularly in patients with compensated cirrhosis and severe sepsis.
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Affiliation(s)
- Alejandro Álvaro-Meca
- Departamento de Medicina Preventiva y Salud Pública, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - María A Jiménez-Sousa
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Alexandre Boyer
- Université de Bordeaux, INSERM U657, Pharmaco-épidémiologie et évaluation de l'impact des produits de santé sur les populations, F-33000, Bordeaux cedex, France
| | - José Medrano
- Departamento de Medicina, Universidad del País Vasco UPV/EHU, Vitoria-Gasteiz, Spain.,Servicio de Urgencias, Hospital Universitario de Araba, Vitoria-Gasteiz, Spain
| | - Holger Reulen
- Chair of Statistics, University of Goettingen, 37073, Göttingen, Germany
| | - Thomas Kneib
- Chair of Statistics, University of Goettingen, 37073, Göttingen, Germany
| | - Salvador Resino
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain. .,Centro Nacional de Microbiología, Instituto de Salud Carlos III (Campus Majadahonda), Carretera Majadahonda- Pozuelo, Km 2.2, 28220, Majadahonda, Madrid, Spain.
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568
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Bunchorntavakul C, Chamroonkul N, Chavalitdhamrong D. Bacterial infections in cirrhosis: A critical review and practical guidance. World J Hepatol 2016; 8:307-321. [PMID: 26962397 PMCID: PMC4766259 DOI: 10.4254/wjh.v8.i6.307] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/23/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection is common and accounts for major morbidity and mortality in cirrhosis. Patients with cirrhosis are immunocompromised and increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens. Once infection develops, the excessive response of pro-inflammatory cytokines on a pre-existing hemodynamic dysfunction in cirrhosis further predispose the development of serious complications such as shock, acute-on-chronic liver failure, renal failure, and death. Spontaneous bacterial peritonitis and bacteremia are common in patients with advanced cirrhosis, and are important prognostic landmarks in the natural history of cirrhosis. Notably, the incidence of infections from resistant bacteria has increased significantly in healthcare-associated settings. Serum biomarkers such as procalcitonin may help to improve the diagnosis of bacterial infection. Preventive measures (e.g., avoidance, antibiotic prophylaxis, and vaccination), early recognition, and proper management are required in order to minimize morbidity and mortality of infections in cirrhosis.
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569
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Abstract
INTRODUCTION Bacterial infections are a serious complication of cirrhosis, as they can lead to decompensation, multiple organ failure, and/or death. Preventing infections is therefore very relevant. Because gut bacterial translocation is their main pathogenic mechanism, prevention of infections is mostly based on the use of orally administered poorly absorbed antibiotics such as norfloxacin (selective intestinal decontamination). However, antibiotic prophylaxis leads to antibiotic resistance, limiting therapy and increasing morbidity and mortality. Prevention of bacterial infections in cirrhosis should therefore move away from antibiotics. AREAS COVERED This review focuses on various potentially novel methods to prevent infections in cirrhosis focusing on non-antibiotic strategies. The use of probiotics, nonselective intestinal decontamination with rifaximin, prokinetics and beta-blockers or fecal microbiota transplant as means of targeting altered gut microbiota, bile acids and FXR agonists are all potential alternatives to selective intestinal decontamination. Prokinetics and beta-blockers can improve intestinal motility, while bile acids and FXR agonists help by improving the intestinal barrier. Finally, granulocyte colony stimulating factor (G-CSF) and statins are emerging therapeutic strategies that may improve immune dysfunction in cirrhosis. EXPERT OPINION Evidence for these strategies has been restricted to animal studies and proof-of concept studies but we expect this to change in coming years.
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570
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Bartoletti M, Giannella M, Lewis RE, Viale P. Bloodstream infections in patients with liver cirrhosis. Virulence 2016; 7:309-19. [PMID: 26864729 DOI: 10.1080/21505594.2016.1141162] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Bloodstream infections are a serious complication in patients with liver cirrhosis. Dysregulated intestinal bacterial translocation is the predominant pathophysiological mechanism of infections in this setting. For this reason enteric Gram-negative bacteria are commonly encountered as the first etiological cause of infection. However, through the years, the improvement in the management of cirrhosis, the recourse to invasive procedures and the global spread of multidrug resistant pathogens have importantly changed the current epidemiology. Bloodstream infections in cirrhotic patients are characterized by high mortality rate and complications including metastatic infections, infective endocarditis, and endotipsitis (or transjugular intrahepatic portosystemic shunt-related infection). For this reason early identification of patients at risk for mortality and appropriated therapeutic management is mandatory. Liver cirrhosis can significantly change the pharmacokinetic behavior of antimicrobials. In fact hypoproteinaemia, ascitis and third space expansion and impairment of renal function can be translated in an unpredictable drug exposure.
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Affiliation(s)
- Michele Bartoletti
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna , Bologna , Italy
| | - Maddalena Giannella
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna , Bologna , Italy
| | - Russell Edward Lewis
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna , Bologna , Italy
| | - Pierluigi Viale
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna , Bologna , Italy
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571
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Kim TY, Song DS, Kim HY, Sinn DH, Yoon EL, Kim CW, Jung YK, Suk KT, Lee SS, Lee CH, Kim TH, Kim JH, Choe WH, Yim HJ, Kim SE, Baik SK, Lee BS, Jang JY, Suh JI, Kim HS, Nam SW, Kwon HC, Kim YS, Kim SG, Chae HB, Yang JM, Sohn JH, Lee HJ, Park SH, Han BH, Choi EH, Kim CH, Kim DJ. Characteristics and Discrepancies in Acute-on-Chronic Liver Failure: Need for a Unified Definition. PLoS One 2016; 11:e0146745. [PMID: 26789409 PMCID: PMC4720429 DOI: 10.1371/journal.pone.0146745] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/20/2015] [Indexed: 02/07/2023] Open
Abstract
Background & Aim To investigate the prevalence, mortalities, and patient characteristics of Acute-on-chronic liver failure (ACLF) according to the AARC (Asian Pacific Association for the Study of the Liver ACLF Research Consortium) and European Association for the Study of the Liver CLIF-C (Chronic Liver Failure Consortium) definitions. Methods We collected retrospective data for 1470 hospitalized patients with chronic liver disease (CLD) and acute deterioration between January 2013 and December 2013 from 21 university hospitals in Korea. Results Of the patients assessed, the prevalence of ACLF based on the AARC and CLIF-C definitions was 9.5% and 18.6%, respectively. The 28-day and 90-day mortality rates were higher in patients with ACLF than in those without ACLF. Patients who only met the CLIF-C definition had significantly lower 28-day and 90-day survival rates than those who only met the AARC definition (68.0% vs. 93.9%, P<0.001; 55.1% vs. 92.4%, P<0.001). Among the patients who had non-cirrhotic CLD, the 90-day mortality of the patients with ACLF was higher than of those without ACLF, although not significant (33.3% vs. 6.0%, P = 0.192). Patients with previous acute decompensation (AD) within 1- year had a lower 90-day survival rate than those with AD more than 1 year prior or without previous AD (81.0% vs. 91.9% or 89.4%, respectively, all P<0.001). Patients who had extra-hepatic organ failure without liver failure had a similar 90-day survival rate to those who had liver failure as a prerequisite (57.0% vs. 60.6%, P = 0.391). Conclusions The two ACLF definitions result in differences in mortality and patient characteristics among ACLF patients. We suggest that non-cirrhotic CLD, previous AD within 1 year, and extra-hepatic organ failure should be included in the ACLF diagnostic criteria. In addition, further studies are necessary to develop a universal definition of ACLF.
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Affiliation(s)
- Tae Yeob Kim
- Institute of Medical Science, Hanyang University, Seoul, Republic of Korea
| | - Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Eileen L. Yoon
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Chang Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Tae Hun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Jeong Han Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University, School of Medicine, Daejeon, Republic of Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jeong Ill Suh
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongju, Republic of Korea
| | - Hyoung Su Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Seong Woo Nam
- Department of Internal medicine, National Medical Center, Seoul, Republic of Korea
| | - Hyeok Choon Kwon
- Department of Internal medicine, National Medical Center, Seoul, Republic of Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Hee Bok Chae
- Department of Internal medicine, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Heon Ju Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Seung Ha Park
- Department of Internal Medicine, Inje University Haeundae Paik-Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Byung Hoon Han
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Republic of Korea
| | - Eun Hee Choi
- Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Chang H. Kim
- Department of Internal Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, United States of America
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
- * E-mail:
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572
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Fan WC, Huang CC, Yang YY, Lin A, Lee KC, Hsieh YC, Fung CP, Hsu HC, Hou MC, Lin HC. Serum pentraxin-3 and tumor necrosis factor-like weak inducer of apoptosis (TWEAK) predict severity of infections in acute decompensated cirrhotic patients. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 50:905-914. [PMID: 26872435 DOI: 10.1016/j.jmii.2015.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 12/20/2015] [Accepted: 12/29/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pentraxin-3 (PTX3) and soluble tumor necrosis factor (TNF)-like weak inducer of apoptosis (sTWEAK) are new candidate prognostic markers for comorbidities and mortality in various inflammatory diseases. Acute decompensation of cirrhosis is characterized by acute exacerbation of chronic systemic inflammation. Recently, increased circulating PTX3 levels have been reported in nonalcoholic steatohepatitis patients and positively correlated with disease severity. This study aims to explore serum PTX3/sTWEAK levels and their relationship with clinical outcomes in cirrhotic patients with acute decompensation. METHODS We analyzed serum PTX3/sTWEAK levels in relation to inhospital and 3-month new clinical events and survivals in cirrhotic patients with acute decompensation. RESULTS During admission, serum PTX3/sTWEAK levels were significantly higher in acute decompensated cirrhotic patients than controls and positively correlated with protein-energy wasting (PEW), new infections, long hospital stays, high medical costs, and high mortality. During a 3-month follow-up, acute decompensated cirrhotic patients with high serum PTX3/sTWEAK levels had more episodes of unplanned readmission and high 3-month mortality. On multivariate analysis, high PTX3/sTWEAK levels and PEW were independent risk factors for high mortality. CONCLUSION High serum PTX3/sTWEAK levels and PEW are common in cirrhotic patients with acute decompensation. As compared with low serum PTX3 and sTWEAK cases, cirrhotic patients with high serum PTX3/sTWEAK levels a have higher probability of new severe infections, severe sepsis, septic shock, type 1 hepatorenal syndrome, in-hospital, and 3-month follow-up mortalities. Therefore, high serum PTX3/sTWEAK levels on hospital admission predict disease severity and case fatality in cirrhotic patients with acute decompensation.
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Affiliation(s)
- Wen-Chien Fan
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chia-Chang Huang
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ying-Ying Yang
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
| | - Alan Lin
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Institute of Oral Biology, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Kuei-Chuan Lee
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yun-Cheng Hsieh
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chang-Phone Fung
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Hui-Chi Hsu
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Han-Chieh Lin
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
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573
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Boaretti M, Castellani F, Merli M, Lucidi C, Lleo MM. Presence of multiple bacterial markers in clinical samples might be useful for presumptive diagnosis of infection in cirrhotic patients with culture-negative reports. Eur J Clin Microbiol Infect Dis 2016; 35:433-41. [DOI: 10.1007/s10096-015-2556-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/14/2015] [Indexed: 02/07/2023]
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574
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Lutz P, Krämer B, Kaczmarek DJ, Hübner MP, Langhans B, Appenrodt B, Lammert F, Nattermann J, Hoerauf A, Strassburg CP, Spengler U, Nischalke HD. A variant in the nuclear dot protein 52kDa gene increases the risk for spontaneous bacterial peritonitis in patients with alcoholic liver cirrhosis. Dig Liver Dis 2016; 48:62-8. [PMID: 26493630 DOI: 10.1016/j.dld.2015.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/18/2015] [Accepted: 09/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis is frequently a fatal infection in patients with liver cirrhosis. We investigated if nuclear dot protein 52kDa (NDP52), a negative regulator of toll-like receptor (TLR) signalling and autophagy adaptor protein, might be involved. METHODS Two cohorts comprising 152 (derivation cohort) and 198 patients (validation cohort) with decompensated liver cirrhosis and 168 healthy controls were genotyped for the rs2303015 polymorphism in the NDP52 gene and prospectively followed-up for spontaneous bacterial peritonitis. RESULTS Overall, 57 (38%) patients in the derivation cohort and 77 (39%) in the validation cohort had spontaneous bacterial peritonitis. Cirrhosis was due to alcohol abuse in 57% of the derivation and 66% of the validation cohort. In patients with alcoholic cirrhosis, patients with spontaneous bacterial peritonitis had an increased frequency of the NDP52 rs2303015 minor variant in the derivation (p=0.04) and in the validation cohort (p=0.01). Multivariate analysis confirmed this minor variant (odds ratio 4.7, p=0.002) and the TLR2 -16934 TT variant (odds ratio 2.5, p=0.008) as risk factors for spontaneous bacterial peritonitis. In addition, presence of the NDP52 minor variant affected survival negatively. CONCLUSION Presence of the NDP52 rs2303015 minor variant increases the risk for spontaneous bacterial peritonitis in patients with alcoholic cirrhosis.
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Affiliation(s)
- Philipp Lutz
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany.
| | - Benjamin Krämer
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Dominik J Kaczmarek
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Marc P Hübner
- Institute for Medical Microbiology, Immunology and Parasitology, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Bettina Langhans
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Beate Appenrodt
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Achim Hoerauf
- Institute for Medical Microbiology, Immunology and Parasitology, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Ulrich Spengler
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Hans Dieter Nischalke
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
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575
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Abstract
BACKGROUND Diagnosis of spontaneous bacterial peritonitis in cirrhosis can be made when a patient has an ascites polymorphonuclear leukocyte count ≥250/mm3. However, symptomatic bacterascites, which is a variant of spontaneous bacterial peritonitis with signs of infection but an ascites polymorphonuclear leukocyte count <250/mm3, cannot be confirmed until the time-consuming ascites culture becomes positive. Currently, early indicators for symptomatic bacterascites remain undetermined. AIMS To develop a quick screening model for early detection of symptomatic bacterascites in cirrhosis. MATERIALS AND METHODS Data on patients with cirrhotic ascites from two hospitals (from 2010 to 2014) were collected retrospectively. Patients with symptomatic bacterascites were enrolled in the case group and compared with patients without any infection in the control group. Logistic regression analysis was used to build a model for screening symptomatic bacterascites, and a receiver operating characteristics curve was used to assess the model. RESULTS In total, 103 patients were enrolled in the case group and 204 patients were enrolled in the control group. A screening model was constructed based on body temperature, abdominal tenderness, blood neutrophil percentage, blood total bilirubin, prothrombin time, and ascites nucleated leukocyte count. The area under the receiver operating characteristic curve was 0.939; a screening score of 0.328 was the best cutoff value. CONCLUSION Patients with suspected symptomatic bacterascites can be quickly screened according to the developed model, and a screening score ≥0.328 indicates symptomatic bacterascites.
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Affiliation(s)
- Long-Chuan Zhu
- Department of Digestion, The First Affiliated Hospital of Nanchang University, Jiangxi, China,Department of Hepatology, Infectious Disease Hospital of Nanchang University, Jiangxi, China
| | - Long Xu
- Department of Hepatology, Infectious Disease Hospital of Nanchang University, Jiangxi, China
| | - Wen-Hua He
- Department of Digestion, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Wei Wu
- Department of Digestion, Children's Hospital of Jiangxi Province, Jiangxi, China
| | - Xuan Zhu
- Department of Digestion, The First Affiliated Hospital of Nanchang University, Jiangxi, China,Address for correspondence: Prof. Xuan Zhu, Department of Digestion, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China. E-mail:
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576
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Sundaram V, Jalan R. Editorial: obesity in chronic liver diseases - increased infections; authors' reply. Aliment Pharmacol Ther 2016; 43:312. [PMID: 26741983 DOI: 10.1111/apt.13483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- V Sundaram
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA. .,Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - R Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK
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577
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Bajaj JS. Review article: potential mechanisms of action of rifaximin in the management of hepatic encephalopathy and other complications of cirrhosis. Aliment Pharmacol Ther 2016; 43 Suppl 1:11-26. [PMID: 26618922 DOI: 10.1111/apt.13435] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 04/27/2015] [Accepted: 08/28/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Progressive gut milieu (microbiota) changes occur in patients with cirrhosis and are associated with complications [e.g. hepatic encephalopathy (HE)]. AIM To examine the role of rifaximin in the management of HE and other complications of cirrhosis, including potential mechanisms of action and the need for future studies. METHODS A literature search was conducted using the keywords 'rifaximin', 'hepatic encephalopathy', 'ascites', 'variceal bleeding', 'peritonitis', 'portal hypertension', 'portopulmonary hypertension' and 'hepatorenal syndrome'. RESULTS The nonsystemic agent rifaximin reduces the risk of HE recurrence and HE-related hospitalisations in cirrhosis. In patients with cirrhosis, rifaximin modulates the bacterial composition of the gut microbiota without a consistent effect on overall faecal microbiota composition. However, rifaximin can impact the function or activities of the gut microbiota. For example, rifaximin significantly increased serum levels of long-chain fatty acids and carbohydrate metabolism intermediates in patients with minimal HE. Rifaximin also favourably affects serum proinflammatory cytokine and faecal secondary bile acid levels. CONCLUSIONS The gut microenvironment and associated microbiota play an important role in the pathogenesis of HE and other cirrhosis-related complications. Rifaximin's clinical activity may be attributed to effects on metabolic function of the gut microbiota, rather than a change in the relative bacterial abundance.
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Affiliation(s)
- J S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, VA, USA
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578
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Singh S, Loomba R. Editorial: obesity in chronic liver diseases - increased infections. Aliment Pharmacol Ther 2016; 43:311-2. [PMID: 26741982 DOI: 10.1111/apt.13463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- S Singh
- NAFLD Research Center, Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - R Loomba
- NAFLD Research Center, Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
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579
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Pérez-Reyes E, Rivera-Sánchez J, Servín-Caamaño A, Pérez-Torres E, Abdo-Francis J, Higuera-de la Tijera F. Malnutrition is related to a higher frequency of serious complications in patients with cirrhosis. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2016. [DOI: 10.1016/j.hgmx.2015.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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580
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Could Adherence to Quality of Care Indicators for Hospitalized Patients With Cirrhosis-Related Ascites Improve Clinical Outcomes? Am J Gastroenterol 2016; 111:87-92. [PMID: 26729545 DOI: 10.1038/ajg.2015.402] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/02/2015] [Accepted: 11/02/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The diagnosis of cirrhotic ascites is associated with significant morbidity, mortality, and reduced health-related quality of life. Adherence by health professionals to quality indicators (QIs) of care for ascites is low. We evaluated the effect of adherence to ascites QIs on clinical outcomes for patients hospitalized with new onset cirrhotic ascites. METHODS The medical records of 302 patients admitted with new onset cirrhotic ascites were interrogated for demographic and clinical data and adherence to eight Delphi panel-derived QIs for ascites management. Associations between adherence to each QI and 30-day emergent readmission and 90-day mortality were analyzed. RESULTS The majority of patients were males (68.9%) over 50 years of age (mean 57±12.83 years) with alcohol-related cirrhosis (59%). Twenty-nine percent were readmitted within 30 days. Patients who received an abdominal paracentesis within 30 days of ascites diagnosis (QI 1, relative risk (RR) 0.41, P=0.004) or during index hospitalization (QI 2, RR 0.57, P=0.006) were significantly less likely to experience a 30-day emergent readmission. Baseline serum bilirubin >2.5 mg/dl was associated with increased 30-day cirrhosis-related readmission (RR 1.51, P=0.03). A total of 18.5% of patients died within 90 days of index admission; median interval to death was 139 days (37-562 days). Pneumonia was the most frequent cause of death. Independent predictors of 90-day mortality included older age (odds ratio (OR) 1.03, P=0.03), increased Model for End-stage Liver Disease (MELD)-Na score (OR 1.06, P=0.05), primary SBP prophylaxis (QI 7, OR 2.30, P=0.04), and readmission within 30 days (OR 30.26, P<0.001). Discharge prescription of diuretics (QI 8, OR 0.28, P=0.01) was associated with reduced 90-day mortality. CONCLUSIONS Early paracentesis in patients with new onset cirrhotic ascites lowers 30-day readmission rates, and early initiation of diuretic therapy lowers 90-day mortality.
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581
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Trifan A, Stoica O, Stanciu C, Cojocariu C, Singeap AM, Girleanu I, Miftode E. Clostridium difficile infection in patients with liver disease: a review. Eur J Clin Microbiol Infect Dis 2015; 34:2313-24. [PMID: 26440041 DOI: 10.1007/s10096-015-2501-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/28/2015] [Indexed: 02/05/2023]
Abstract
Over the past two decades, there has been a dramatic worldwide increase in both the incidence and severity of Clostridium difficile infection (CDI). Paralleling the increased incidence of CDI in the general population, there has been increased interest in CDI among patients with liver disease, particularly in those with liver cirrhosis and post liver transplantation. MEDLINE and several other electronic databases from January 1995 to December 2014 were searched in order to identify potentially relevant literature. Patients with cirrhosis and liver transplant recipients are at high risk for the development CDI because of antibiotics and proton pump inhibitors use, frequent and prolonged hospitalization, immunosuppressant therapy, and multiple comorbidities. Enzyme immunoassay to detect C. difficile toxins A and B in stool remains the most widely used test for CDI diagnosis, although, more recently, polymerase chain reaction (PCR)-based assays have become the preferred diagnostic test in many laboratories. Metronidazole and vancomycin, given orally, have proved to be effective in the treatment of CDI. Both cirrhotic patients and liver transplant recipients with CDI have longer length of hospital stay, increased mortality, and higher healthcare costs than those without CDI. A rapid diagnosis and adequate therapy of CDI are of paramount importance to improve liver disease patients' outcome. The aim of this review is to provide up-to-date information on the epidemiology, risk factors, pathogenesis, treatment, and outcomes in liver disease patients with CDI.
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Affiliation(s)
- A Trifan
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - O Stoica
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
| | - C Stanciu
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania.
| | - C Cojocariu
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - A-M Singeap
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - I Girleanu
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
| | - E Miftode
- Hospital of Infectious Diseases, "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
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582
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Stutchfield BM, Antoine DJ, Mackinnon AC, Gow DJ, Bain CC, Hawley CA, Hughes MJ, Francis B, Wojtacha D, Man TY, Dear JW, Devey LR, Mowat AM, Pollard JW, Park BK, Jenkins SJ, Simpson KJ, Hume DA, Wigmore SJ, Forbes SJ. CSF1 Restores Innate Immunity After Liver Injury in Mice and Serum Levels Indicate Outcomes of Patients With Acute Liver Failure. Gastroenterology 2015; 149:1896-1909.e14. [PMID: 26344055 PMCID: PMC4672154 DOI: 10.1053/j.gastro.2015.08.053] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 08/01/2015] [Accepted: 08/27/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Liver regeneration requires functional liver macrophages, which provide an immune barrier that is compromised after liver injury. The numbers of liver macrophages are controlled by macrophage colony-stimulating factor (CSF1). We examined the prognostic significance of the serum level of CSF1 in patients with acute liver injury and studied its effects in mice. METHODS We measured levels of CSF1 in serum samples collected from 55 patients who underwent partial hepatectomy at the Royal Infirmary Edinburgh between December 2012 and October 2013, as well as from 78 patients with acetaminophen-induced acute liver failure admitted to the Royal Infirmary Edinburgh or the University of Kansas Medical Centre. We studied the effects of increased levels of CSF1 in uninjured mice that express wild-type CSF1 receptor or a constitutive or inducible CSF1-receptor reporter, as well as in chemokine receptor 2 (Ccr2)-/- mice; we performed fate-tracing experiments using bone marrow chimeras. We administered CSF1-Fc (fragment, crystallizable) to mice after partial hepatectomy and acetaminophen intoxication, and measured regenerative parameters and innate immunity by clearance of fluorescent microbeads and bacterial particles. RESULTS Serum levels of CSF1 increased in patients undergoing liver surgery in proportion to the extent of liver resected. In patients with acetaminophen-induced acute liver failure, a low serum level of CSF1 was associated with increased mortality. In mice, administration of CSF1-Fc promoted hepatic macrophage accumulation via proliferation of resident macrophages and recruitment of monocytes. CSF1-Fc also promoted transdifferentiation of infiltrating monocytes into cells with a hepatic macrophage phenotype. CSF1-Fc increased innate immunity in mice after partial hepatectomy or acetaminophen-induced injury, with resident hepatic macrophage as the main effector cells. CONCLUSIONS Serum CSF1 appears to be a prognostic marker for patients with acute liver injury. CSF1 might be developed as a therapeutic agent to restore innate immune function after liver injury.
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Affiliation(s)
- Benjamin M. Stutchfield
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom,Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Daniel J. Antoine
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Edinburgh, Edinburgh, United Kingdom
| | - Alison C. Mackinnon
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Deborah J. Gow
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, United Kingdom
| | - Calum C. Bain
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Catherine A. Hawley
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael J. Hughes
- Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Benjamin Francis
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Davina Wojtacha
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Tak Y. Man
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - James W. Dear
- National Poisons Information Service Edinburgh, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, United Kingdom
| | - Luke R. Devey
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Alan M. Mowat
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Jeffrey W. Pollard
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - B. Kevin Park
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephen J. Jenkins
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Kenneth J. Simpson
- Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - David A. Hume
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephen J. Wigmore
- Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Stuart J. Forbes
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom,Reprint requests Address requests for reprints to: S. J. Forbes, MD, Scottish Centre for Regenerative Medicine, 5 Little France Drive, Edinburgh BioQuarter, Edinburgh EH16 4UU, United Kingdom. fax: (44) (0)131-651-9501.
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583
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Sundaram V, Kaung A, Rajaram A, Lu SC, Tran TT, Nissen NN, Klein AS, Jalan R, Charlton MR, Jeon CY. Obesity is independently associated with infection in hospitalised patients with end-stage liver disease. Aliment Pharmacol Ther 2015; 42:1271-80. [PMID: 26510540 DOI: 10.1111/apt.13426] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 09/03/2015] [Accepted: 09/20/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infection is the most common cause of mortality in end-stage liver disease (ESLD). The impact of obesity on infection risk in ESLD is not established. AIM To characterise the impact of obesity on infection risk in ESLD. METHODS We evaluated the association between infection and obesity in patients with ESLD. Patients grouped as non-obese, obesity class I-II and obesity class III were studied using the Nationwide Inpatient Sample. Validated diagnostic code based algorithms were utilised to determine weight category and infections, including bacteraemia, skin/soft tissue infection, urinary tract infection (UTI), pneumonia/respiratory infection, Clostridium difficile infection (CDI) and spontaneous bacterial peritonitis (SBP). Risk factors for infection and mortality were assessed using multivariable logistic regression analysis. RESULTS Of 115 465 patients identified, 100 957 (87.5%) were non-obese and 14 508 (12.5%) were obese, with 9489 (8.2%) as obesity class I-II and 5019 (4.3%) as obesity class III. 37 117 patients (32.1%) had an infection diagnosis. Infection was most prevalent among obesity class III (44.0%), followed by obesity class I-II (38.9%) and then non-obese (31.9%). In multivariable modelling, class III obesity (OR = 1.41; 95% CI 1.32-1.51; P < 0.001), and class I-II obesity (OR = 1.08; 95% CI 1.01-1.15; P = 0.026) were associated with infection. Compared to non-obese patients, obese individuals had greater prevalence of bacteraemia, UTI, and skin/soft tissue infection as compared to non-obese patients. CONCLUSIONS Obesity is newly identified to be independently associated with infection in end-stage liver disease. The distribution of infection sites varies based on weight category.
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Affiliation(s)
- V Sundaram
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - A Kaung
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - A Rajaram
- Department of Medicine, Touro College of Osteopathic Medicine, Henderson, NV, USA
| | - S C Lu
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - T T Tran
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - N N Nissen
- Department of Surgery and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - A S Klein
- Department of Surgery and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - R Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - M R Charlton
- Department of Medicine, Intermountain Medical Center, Murray, UT, USA
| | - C Y Jeon
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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584
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Conti F, Dall'Agata M, Gramenzi A, Biselli M. Biomarkers for the early diagnosis of bacterial infection and the surveillance of hepatocellular carcinoma in cirrhosis. Biomark Med 2015; 9:1343-51. [PMID: 26580585 DOI: 10.2217/bmm.15.100] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The early detection of bacterial infections and hepatocellular carcinoma (HCC) could ameliorate the prognosis of cirrhosis. C-reactive protein and procalcitonin are under investigation in the setting of cirrhosis as markers of sepsis. In the attempt to discriminate bacterial infection from systemic inflammation, the role of novel biomarkers such as lypopolysaccharide binding-protein, mid-regional fragment of pro-adrenomedullin and delta neutrophil index are currently in development. Concerning HCC, many studies attempted to evaluate biomarkers in the hope of ameliorating the accuracy of the surveillance based on ultrasound. The use of α-fetoprotein (AFP) has been extensively investigated, as well as other biomarkers expressed in the serum of HCC patients like lens culinaris agglutinin-reactive fraction of AFP, des-γ-carboxy prothrombin, glypican-3, α-l-fucosidase and their combined use.
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Affiliation(s)
- Fabio Conti
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Marco Dall'Agata
- Dipartimento di Scienze Mediche, Sezione di Medicina Interna e Cardiorespiratoria, Università di Ferrara, Ferrara, Italy
| | - Annagiulia Gramenzi
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Maurizio Biselli
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
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585
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Blasco-Algora S, Masegosa-Ataz J, Gutiérrez-García ML, Alonso-López S, Fernández-Rodríguez CM. Acute-on-chronic liver failure: Pathogenesis, prognostic factors and management. World J Gastroenterol 2015; 21:12125-40. [PMID: 26576097 PMCID: PMC4641130 DOI: 10.3748/wjg.v21.i42.12125] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/17/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is increasingly recognized as a complex syndrome that is reversible in many cases. It is characterized by an acute deterioration of liver function in the background of a pre-existing chronic liver disease often associated with a high short-term mortality rate. Organ failure (OF) is always associated, and plays a key role in determining the course, and the outcome of the disease. The definition of ACLF remains controversial due to its overall ambiguity, with several disparate criteria among various associations dedicated to the study of liver diseases. Although the precise pathogenesis needs to be clarified, it appears that an altered host response to injury might be a contributing factor caused by immune dysfunction, ultimately leading to a pro-inflammatory status, and eventually to OF. The PIRO concept (Predisposition, Insult, Response and Organ Failure) has been proposed to better approach the underlying mechanisms. It is accepted that ACLF is a different and specific form of liver failure, where a precipitating event is always involved, even though it cannot always be ascertained. According to several studies, infections and active alcoholism often trigger ACLF. Viral hepatitis, gastrointestinal haemorrhage, or drug induced liver injury, which can also provoke the syndrome. This review mainly focuses on the physiopathology and prognostic aspects. We believe these features are essential to further understanding and providing the rationale for improveddisease management strategies.
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586
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Theocharidou E, Agarwal B, Jeffrey G, Jalan R, Harrison D, Burroughs AK, Kibbler CC. Early invasive fungal infections and colonization in patients with cirrhosis admitted to the intensive care unit. Clin Microbiol Infect 2015; 22:189.e1-189.e7. [PMID: 26551838 DOI: 10.1016/j.cmi.2015.10.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/15/2015] [Accepted: 10/21/2015] [Indexed: 12/15/2022]
Abstract
Bacterial infections in cirrhosis are common and associated with increased mortality, but little is known about fungal infections. The aim of this study, a sub-analysis of the Fungal Infection Risk Evaluation study, was to assess the incidence and implications of early invasive fungal disease (IFD) in patients with cirrhosis admitted to intensive care units (ICU). Clinical and laboratory parameters collected in the first 3 days of ICU stay for 782 patients with cirrhosis and/or portal hypertension were analysed and compared with those of 273 patients with very severe cardiovascular disease (CVD). The CVD patients had more co-morbidities and higher APACHE II scores. The overall incidence of IFD was similar in the two groups, but the incidence of IFD in ICU was higher in liver patients (1% versus 0.4%; p 0.025) as was fungal colonization (23.8% versus 13.9%; p 0.001). The ICU and in-hospital mortality, and length of stay were similar in the two groups. A higher proportion of liver patients received antifungal therapy (19.2% versus 7%; p <0.0005). There was no difference in mortality between colonized patients who received antifungal therapy and colonized patients who did not. The incidence of IFD in patients with cirrhosis in ICU is higher compared with another high-risk group, although it is still very low. This risk might be higher in patients with advanced liver disease admitted with acute-on-chronic liver failure, and this should be investigated further. Our data do not support prophylactic use of antifungal therapy in cirrhosis.
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Affiliation(s)
- E Theocharidou
- Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - B Agarwal
- Intensive Care Unit, Royal Free Hospital, London, UK
| | - G Jeffrey
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - R Jalan
- Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - D Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - A K Burroughs
- Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, UK.
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587
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Zapater P, González-Navajas JM, Such J, Francés R. Immunomodulating effects of antibiotics used in the prophylaxis of bacterial infections in advanced cirrhosis. World J Gastroenterol 2015; 21:11493-11501. [PMID: 26556982 PMCID: PMC4631956 DOI: 10.3748/wjg.v21.i41.11493] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
The use of norfloxacin either as primary or secondary prophylaxis of bacterial infections in advanced cirrhosis has improved patient’s survival. This may be explained not only due to a significant decrease in the number of infections, but also because of a direct immunomodulatory effect. Selective intestinal decontamination with norfloxacin reduces translocation of either viable bacteria or bacteria-driven products from the intestinal lumen. In addition, norfloxacin directly modulates the systemic inflammatory response. The pro-inflammatory cytokine profile secreted by neutrophils from these patients shows a close, significant, and inverse correlation with serum norfloxacin levels. Similar effects have been described with other quinolones in different clinical conditions. Although the underlying mechanisms are not well defined for most of the antibiotics, the pathways triggered for norfloxacin to induce such immunomodulatory effects involve the down-regulation of pro-inflammatory inducible nitric oxide synthase, cyclooxygenase-2, and NF-κB and the up-regulation of heme-oxygenase 1 and IL-10 expression. The knowledge of these immunomodulatory effects, additional to their bactericidal role, improves our comprehension of the interaction between antibiotics and the cellular host response and offer new possibilities for the development of new therapeutic strategies to manage and prevent bacterial infections in cirrhosis.
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588
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Gut Microbiota and Host Reaction in Liver Diseases. Microorganisms 2015; 3:759-91. [PMID: 27682116 PMCID: PMC5023261 DOI: 10.3390/microorganisms3040759] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/08/2015] [Accepted: 10/21/2015] [Indexed: 02/07/2023] Open
Abstract
Although alcohol feeding produces evident intestinal microbial changes in animals, only some alcoholics show evident intestinal dysbiosis, a decrease in Bacteroidetes and an increase in Proteobacteria. Gut dysbiosis is related to intestinal hyperpermeability and endotoxemia in alcoholic patients. Alcoholics further exhibit reduced numbers of the beneficial Lactobacillus and Bifidobacterium. Large amounts of endotoxins translocated from the gut strongly activate Toll-like receptor 4 in the liver and play an important role in the progression of alcoholic liver disease (ALD), especially in severe alcoholic liver injury. Gut microbiota and bacterial endotoxins are further involved in some of the mechanisms of nonalcoholic fatty liver disease (NAFLD) and its progression to nonalcoholic steatohepatitis (NASH). There is experimental evidence that a high-fat diet causes characteristic dysbiosis of NAFLD, with a decrease in Bacteroidetes and increases in Firmicutes and Proteobacteria, and gut dysbiosis itself can induce hepatic steatosis and metabolic syndrome. Clinical data support the above dysbiosis, but the details are variable. Intestinal dysbiosis and endotoxemia greatly affect the cirrhotics in relation to major complications and prognosis. Metagenomic approaches to dysbiosis may be promising for the analysis of deranged host metabolism in NASH and cirrhosis. Management of dysbiosis may become a cornerstone for the future treatment of liver diseases.
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589
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Honar N, Geramizadeh B, Dehghani SM, Kalvandi G, Shahramian I, Rahmani A, Javaherizadeh H. EVALUATION OF LEUKOCYTE ESTERASE REAGENT STRIPS TEST IN THE DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS IN CHILDREN WITH CIRRHOSIS. ARQUIVOS DE GASTROENTEROLOGIA 2015; 52:195-9. [PMID: 26486286 DOI: 10.1590/s0004-28032015000300008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 04/27/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis is defined as an ascetic fluid infection without an evident intra-abdominal surgically treatable source. Spontaneous bacterial peritonitis is one of the severe complications in patients with cirrhosis and ascites. Without early antibiotic treatment, this complication is associated with high mortality rate; therefore, early diagnosis and treatment of spontaneous bacterial peritonitis is necessary for survival. Leukocyte esterase reagent can rapidly diagnose the spontaneous bacterial peritonitis. OBJECTIVE This study aimed to find out the diagnostic accuracy of leukocyte esterase dipstick test for the diagnosis of spontaneous bacterial peritonitis. METHODS A single centered hospital-based cross-sectional study was conducted during July 2013 to August 2014 on children with cirrhotic liver disease and ascites who were admitted in the Department of Pediatric Gastroenterology in Nemazee Hospital affiliated to Shiraz University of Medical Sciences (Iran). All patients underwent abdominal paracentesis, and the ascitic fluid was processed for cell count, leukocyte esterase reagent strip test (Combiscreen SL10) and culture. Spontaneous bacterial peritonitis was defined as having a polymorphonuclear count (PMN ≥250/m3) in ascitic fluid. Sensitivity, specificity, positive predictive value and negative predictive value of leukocyte esterase test were calculated according to the formula. RESULTS Totally, 150 ascitic fluid sample of cirrhotic male patients (53.2%) and their mean age (4.33±1.88 years) were analyzed. Biliary atresia (n=44, 29.4%) and idiopathic neonatal hepatitis (n=29, 19.3%) were the most frequent etiology of cirrhosis. Also, abdominal pain (68.6%) and distension (64%) were the most common presenting complaint. Of all cases, 41 patients (27.35%) were diagnosed to have spontaneous bacterial peritonitis (PMN ≥250/mm3). Sensitivity and specificity of leukocyte esterase reagent test according to PMNs ≥250 mm3 were 87.80% and 91.74%, also on ascitic fluid culture results were 88.23% and 77.44%. Positive predictive value and negative predictive value of this test in PMNs ≥250 mm3 were 80% and 95.23% and in cases with positive culture 33.33% and 98.09% were obtained, respectively. Efficiency of leukocyte esterase reagent test in diagnosing spontaneous bacterial peritonitis, according to PMNs ≥250 mm3 and culture results were 90.66% and 78.66%. CONCLUSION The leukocyte esterase strip test may be used as rapid test for diagnosis of spontaneous bacterial peritonitis due to its high diagnostic validity.
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Affiliation(s)
- Naser Honar
- Gastroenterohepatology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Fars, IR
| | - Bita Geramizadeh
- Gastroenterohepatology Research Center
- Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Fars, IR
| | - Seyed-Mohsen Dehghani
- Gastroenterohepatology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Fars, IR
| | - Gholamreza Kalvandi
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, IR
| | - Iraj Shahramian
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, IR
| | - Asghar Rahmani
- Student Research committee, School of medicine, Ilam University of Medical Sciences, Ilam, Ilam, IR
| | - Hazhir Javaherizadeh
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, IR
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590
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Abstract
Acute-on-chronic liver failure combines an acute deterioration in liver function in an individual with pre-existing chronic liver disease and hepatic and extrahepatic organ failures, and is associated with substantial short-term mortality. Common precipitants include bacterial and viral infections, alcoholic hepatitis, and surgery, but in more than 40% of patients, no precipitating event is identified. Systemic inflammation and susceptibility to infection are characteristic pathophysiological features. A new diagnostic score, the Chronic Liver Failure Consortium (CLIF-C) organ failure score, has been developed for classification and prognostic assessment of patients with acute-on-chronic liver failure. Disease can be reversed in many patients, and thus clinical management focuses upon the identification and treatment of the precipitant while providing multiorgan-supportive care that addresses the complex pattern of physiological disturbance in critically ill patients with liver disease. Liver transplantation is a highly effective intervention in some specific cases, but recipient identification, organ availability, timing of transplantation, and high resource use are barriers to more widespread application. Recognition of acute-on-chronic liver failure as a clinically and pathophysiologically distinct syndrome with defined diagnostic and prognostic criteria will help to encourage the development of new management pathways and interventions to address the unacceptably high mortality.
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, King's College Hospital, London, UK.
| | - Rajiv Jalan
- Liver Failure Group, Division of Medicine, University College London, London, UK; Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Alberto Quaglia
- Histopathology Section, Institute of Liver Studies, King's College Hospital, London, UK
| | - Kenneth Simpson
- Department of Hepatology, University of Edinburgh, Edinburgh, UK
| | - Julia Wendon
- Liver Intensive Therapy Unit, King's College Hospital, London, UK
| | - Andrew Burroughs
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
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591
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Ferenci P, Kozbial K, Mandorfer M, Hofer H. HCV targeting of patients with cirrhosis. J Hepatol 2015; 63:1015-22. [PMID: 26100497 DOI: 10.1016/j.jhep.2015.06.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 06/09/2015] [Accepted: 06/10/2015] [Indexed: 12/15/2022]
Abstract
Interferon (IFN)-free treatments are now the treatment of choice for patients with chronic hepatitis C. Previously difficult to treat patients by IFN-containing treatments can now be treated safely by IFN-free therapies. More than 90% of hepatitis C genotype 1 and 4 patients with compensated cirrhosis or after orthotopic liver transplantation (OLT) can be cured by sofosbuvir combined with simeprevir, daclatasvir or ledipasvir, or by the paritaprevir/ritona-vir/ombitasvir/±dasabuvir (3D) combination. Addition of ribavirin confers to a minimal, if any, benefit to increase SVR. The need for ribavirin is controversial and remains to be studied. The optimal length of treatment is still unknown, and an individual approach may be needed. Most patients require only 12weeks of therapy. The safety of these drugs is not fully explored in patients with decompensated cirrhosis (Child-Pugh C), who should not be treated with protease inhibitors. In cirrhosis hepatitis C virus eradication does not necessarily mean a cure of the disease and patients regularly require follow-up. Drug-drug interactions with immunosuppressant in patients after OLT are easier to manage but still require attention. Better drugs are needed for genotype 3 patients.
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Affiliation(s)
- Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Karin Kozbial
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Harald Hofer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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592
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Liver Cirrhosis: Evaluation, Nutritional Status, and Prognosis. Mediators Inflamm 2015; 2015:872152. [PMID: 26494949 PMCID: PMC4606163 DOI: 10.1155/2015/872152] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/08/2015] [Accepted: 07/13/2015] [Indexed: 02/07/2023] Open
Abstract
The liver is the major organ for the metabolism of three major nutrients: protein, fat, and carbohydrate. Chronic hepatitis C virus infection is the major cause of chronic liver disease. Liver cirrhosis (LC) results from different mechanisms of liver injury that lead to necroinflammation and fibrosis. LC has been seen to be not a single disease entity but one that can be graded into distinct clinical stages related to clinical outcome. Several noninvasive methods have been developed for assessing liver fibrosis and these methods have been used for predicting prognosis in patients with LC. On the other hand, subjects with LC often have protein-energy malnutrition (PEM) and poor physical activity. These conditions often result in sarcopenia, which is the loss of skeletal muscle volume and increased muscle weakness. Recent studies have demonstrated that PEM and sarcopenia are predictive factors for poorer survival in patients with LC. Based on these backgrounds, several methods for evaluating nutritional status in patients with chronic liver disease have been developed and they have been preferably used in the clinical field practice. In this review, we will summarize the current knowledge in the field of LC from the viewpoints of diagnostic method, nutritional status, and clinical outcomes.
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593
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Spinella R, Sawhney R, Jalan R. Albumin in chronic liver disease: structure, functions and therapeutic implications. Hepatol Int 2015; 10:124-32. [PMID: 26420218 DOI: 10.1007/s12072-015-9665-6] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/19/2015] [Indexed: 02/08/2023]
Abstract
Human serum albumin is a critical plasma protein produced by the liver with a number of accepted clinical indications in chronic liver disease including management of circulatory and renal dysfunction in patients with ascites. Advanced cirrhosis is characterised by reduced albumin concentration as well as impaired albumin function as a result of specific structural changes and oxidative damage. Traditionally, the biologic and therapeutic role of albumin in liver disease was attributed to its oncotic effects but it is now understood that albumin has a wide range of other important physiologic functions such as immunomodulation, endothelial stabilisation, antioxidant effects and binding multiple drugs, toxins and other molecules. This review discusses the multifunctional properties of albumin and, in particular, the biologic and clinical implications of structural and functional changes of albumin that are associated with cirrhosis. Based on these insights, we explore the current and potential future therapeutic uses of albumin in liver disease.
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Affiliation(s)
- Rosaria Spinella
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, NW3 2PF, UK.
| | - Rohit Sawhney
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, NW3 2PF, UK
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, NW3 2PF, UK.
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594
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Li YT, Yu CB, Huang JR, Qin ZJ, Li LJ. Pathogen profile and drug resistance analysis of spontaneous peritonitis in cirrhotic patients. World J Gastroenterol 2015; 21:10409-10417. [PMID: 26420967 PMCID: PMC4579887 DOI: 10.3748/wjg.v21.i36.10409] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 07/01/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the microbiological characteristics and drug resistance in liver cirrhosis patients with spontaneous peritonitis.
METHODS: We analyzed the data of patients with liver cirrhosis and abdominal infection at the First Affiliated Hospital of Zhejiang University between January 2011 and December 2013. Pathogens present in the ascites were identified, and their sensitivity to various antibiotics was determined.
RESULTS: We isolated 306 pathogenic bacteria from 288 cases: In 178 cases, the infection was caused by gram-negative strains (58.2%); in 85 cases, gram-positive strains (27.8%); in 9 cases, fungi (2.9%); and in 16 cases, more than one pathogen. The main pathogens were Escherichia coli (E. coli) (24.2%), Klebsiella pneumoniae (18.9%), Enterococcus spp. (11.1%), and Staphylococcus aureus (7.5%). Of the 306 isolated pathogens, 99 caused nosocomial infections and 207 caused community-acquired and other infections. The E. coli and K. pneumoniae strains produced more extended-spectrum β-lactamases in cases of nosocomial infections than non-nosocomial infections (62.5% vs 38%, P < 0.013; 36.8% vs 12.8%, P < 0.034, respectively). The sensitivity to individual antibiotics differed between nosocomial and non-nosocomial infections: Piperacillin/tazobactam was significantly more effective against non-nosocomial E. coli infections (4% vs 20.8%, P < 0.021). Nitrofurantoin had stronger antibacterial activity against Enterococcus species causing non-nosocomial infections (36.4% vs 86.3%, P < 0.009).
CONCLUSION: The majority of pathogens that cause abdominal infection in patients with liver cirrhosis are gram-negative, and drug resistance is significantly higher in nosocomial infections than in non-nosocomial infections.
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595
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Koutsounas I, Kaltsa G, Siakavellas SI, Bamias G. Markers of bacterial translocation in end-stage liver disease. World J Hepatol 2015; 7:2264-2273. [PMID: 26380651 PMCID: PMC4568487 DOI: 10.4254/wjh.v7.i20.2264] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/13/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
Bacterial translocation (BT) refers to the passage of viable bacteria or bacterial products from the intestinal lumen, through the intestinal epithelium, into the systemic circulation and extraintestinal locations. The three principal mechanisms that are thought to be involved in BT include bacterial overgrowth, disruption of the gut mucosal barrier and an impaired host defence. BT is commonly observed in liver cirrhosis and has been shown to play an important role in the pathogenesis of the complications of end stage liver disease, including infections as well as hepatic encephalopathy and hepatorenal syndrome. Due to the importance of BT in the natural history of cirrhosis, there is intense interest for the discovery of biomarkers of BT. To date, several such candidates have been proposed, which include bacterial DNA, soluble CD14, lipopolysaccharides endotoxin, lipopolysaccharide-binding protein, calprotectin and procalcitonin. Studies on the association of these markers with BT have demonstrated not only promising data but, oftentimes, contradictory results. As a consequence, currently, there is no optimal marker that may be used in clinical practice as a surrogate for the presence of BT.
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596
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Kamimura K, Kumaki D, Arita M, Kobayashi Y, Mizuno KI, Kusama F, Kobayashi M, Abe H, Takahashi Y, Ogawa K, Shinagawa Y, Takeuchi M, Sato Y, Kawai H, Yamagiwa S, Terai S. First case of bacteremia caused by Helicobacter cinaedi in a patient with liver cirrhosis: a case report and literature review. Clin J Gastroenterol 2015; 8:306-17. [DOI: 10.1007/s12328-015-0600-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/13/2015] [Indexed: 12/17/2022]
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597
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Fan YC, Wang N, Sun YY, Xiao XY, Wang K. TIPE2 mRNA Level in PBMCs Serves as a Novel Biomarker for Predicting Short-Term Mortality of Acute-on-Chronic Hepatitis B Liver Failure: A Prospective Single-Center Study. Medicine (Baltimore) 2015; 94:e1638. [PMID: 26426653 PMCID: PMC4616875 DOI: 10.1097/md.0000000000001638] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
It remains difficult to accurately predicate short-term mortality of acute-on-chronic hepatitis B liver failure (ACHBLF). Tumor necrosis factor-α-induced protein 8-like 2 (TIPE2) is a novel identified negative regulator of immune response and we have previously demonstrated TIPE2 play an essential role in the pathogenesis of ACHBLF. We therefore aimed to evaluate the diagnosis value of TIPE2 mRNA in peripheral blood mononuclear cells (PBMCs) for predicting 3-month mortality of ACHBLF patients. This prospective study consisted of 108 ACHBLF patients from March 2009 to May 2013 as training cohort and 63 ACHBLF patients from June 2013 to December 2014 as validation cohort. Forty-two patients with chronic hepatitis B (CHB) and 22 healthy volunteers were also included as controls. The mRNA level of TIPE2 in PBMCs was determined using quantitative real-time polymerase chain reaction. Univariate analysis and Cox proportional hazard regression analysis were performed to identify independent risk factors to 3-month mortality. Area under the receptor operating characteristic curve (AUROC) was performed to assess diagnostic value of TIPE2 mRNA in training and validation cohort. The level of TIPE2 mRNA was significantly higher in ACHBLF patients (median (interquartile): 6.5 [3.7, 9.6]) compared with CHB (2.3 [1.6, 3.7]) and healthy controls (0.4 [0.3, 0.6]; both P < 0.05). Cox proportional hazards regression analyses showed 5 independent risk factors associated with 3-month mortality of ACHBLF: white blood cells (HR = 1.058, 95% CI: 1.023-1.095), spontaneous bacterial peritonitis (HR = 2.541, 95% CI: 1.378-4.686), hepatic encephalopathy (HR = 1.848, 95% CI: 1.028-3.321), model for end-stage liver diseases (MELD) score (HR = 1.062, 95% CI: 1.009-1.118), and TIPE2 mRNA (HR = 1.081, 95% CI: 1.009-1.159). An optimal cut-off point 6.54 of TIPE2 mRNA showed sensitivity of 74.63%, specificity of 90.24%, positive predictive value of 92.5%, and negative predictive value of 67.3% for predicting 3-month mortality in training cohort. Furthermore, TIPE2 mRNA plus MELD performed better than MELD alone for predicting 3-month mortality in training (AUROC, 0.853 vs 0.722, P < 0.05) and validation cohort (AUROC, 0.909 vs 0.717, P < 0.001). TIPE2 mRNA level might be a novel biomarker in predicting 3-month mortality of ACHBLF. Combination of TIPE2 mRNA and MELD would improve the diagnostic value of MELD alone in predicting 3-month mortality of patients with ACHBLF.
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Affiliation(s)
- Yu-Chen Fan
- From the Department of Hepatology, Qilu Hospital of Shandong University, Jinan, China (Y-CF, NW, Y-YS, KW); Institute of Hepatology, Shandong University, Jinan, China (Y-CF, KW); and Department of Nephrology, Qilu Hospital of Shandong University, Jinan, China (X-YX)
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598
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Merli M, Lucidi C, Lattanzi B, Riggio O. Albumin infusion in cirrhotic patients with infections other than spontaneous bacterial peritonitis: End of the story? J Hepatol 2015; 63:767-8. [PMID: 25988298 DOI: 10.1016/j.jhep.2015.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 04/09/2015] [Accepted: 04/11/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Manuela Merli
- Gastroenterology, Department of Clinical Medicine, "Sapienza" University of Rome, Italy.
| | - Cristina Lucidi
- Gastroenterology, Department of Clinical Medicine, "Sapienza" University of Rome, Italy
| | - Barbara Lattanzi
- Gastroenterology, Department of Clinical Medicine, "Sapienza" University of Rome, Italy
| | - Oliviero Riggio
- Gastroenterology, Department of Clinical Medicine, "Sapienza" University of Rome, Italy
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599
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Schwabl P, Bucsics T, Soucek K, Mandorfer M, Bota S, Blacky A, Hirschl AM, Ferlitsch A, Trauner M, Peck-Radosavljevic M, Reiberger T. Risk factors for development of spontaneous bacterial peritonitis and subsequent mortality in cirrhotic patients with ascites. Liver Int 2015; 35:2121-8. [PMID: 25644943 DOI: 10.1111/liv.12795] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 01/27/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with ascites are at risk for developing spontaneous bacterial peritonitis (SBP) - a severe complication associated with high mortality. We aimed to identify risk factors for SBP development and mortality to optimize stratification for primary prophylaxis and therapeutic strategies to improve survival. METHODS 575 patients with cirrhosis and ascites undergoing paracentesis at a tertiary care hospital were included in this retrospective cohort study. Demographical, clinical and laboratory parameters were recorded at first paracentesis and during follow-up. Multivariate logistic regression analysis was used to identify independent predictors of SBP development and mortality. RESULTS Child-Pugh stage C (OR: 3.323; P = 0.009), ascitic fluid polymorph-nuclear cell (PMN) count (OR: 1.544; P = 0.028) and low serum sodium (OR: 0.917; P = 0.029) emerged as independent risk factors for SBP development. SBP-naïve patients undergoing paracentesis and presenting with PMN-counts ≥100 cells/μl, or hyponatraemia <125 mM were at highest risk for developing SBP. Increases in MELD and CRP levels indicated SBP development, while no changes where observed in a matched control group with sterile ascites at multiple paracenteses. MELD score (OR: 1.565; P = 0.001) and CRP (OR: 1.067; P = 0.037) were identified as independent risk factors for 30-day mortality after SBP diagnosis. In particular SBP patients with MELD≥22, CRP ≥3.5 mg/dl and development of grade III/IV hepatic encephalopathy showed highest mortality. CONCLUSIONS Low serum sodium levels, Child-Pugh stage C and elevated ascites PMN counts (≥100 cells/μl) indicate a significant risk for SBP development. SBP-related mortality is highest in patients with MELD≥22 and elevated CRP levels.
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Affiliation(s)
- Philipp Schwabl
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Kathrin Soucek
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Simona Bota
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Alexander Blacky
- Division of Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Alexander M Hirschl
- Division of Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Arnulf Ferlitsch
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
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Abstract
Chronic liver disease results from a wide range of conditions, for which individual management is beyond the scope of this article. General education, counseling, and harm reduction practices are important to the primary care of these patients, as are monitoring for cirrhosis and management of its complications. For patients with advanced liver disease, comprehensive care includes considering referral for liver transplantation, educating and empowering patients to prioritize goals of care, and optimizing symptom relief.
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Affiliation(s)
- Jocelyn James
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Box 359892, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Iris W Liou
- Division of Gastroenterology, Department of Medicine, University of Washington, Box 356175, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
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