Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis

Natural history of cirrhosis

Significant strides have been made in the last few years in advancing our knowledge of the natural history of cirrhosis. These include (1) a better understanding of prognosis in compensated and decompensated cirrhosis, (2) improved estimates of the natural course of variceal bleeding in patients receiving standard of care therapy, (3) recognition of renal failure and infection as important determinants of mortality in the clinic course, (4) realization of the importance of hepatic venous pressure gradient as a marker of prognosis, progression, and treatment response, and (5) evolution of noninvasive studies of liver stiffness as potential predictors of decompensation. Further studies identifying cirrhotics at highest risk of transitioning from a compensated state to a decompensated state will be important in order to alter the natural history of cirrhosis.

Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis

BACKGROUND & AIMS

Patients with cirrhosis hospitalized for an acute decompensation (AD) and organ failure are at risk for imminent death and considered to have acute-on-chronic liver failure (ACLF). However, there are no established diagnostic criteria for ACLF, so little is known about its development and progression. We aimed to identify diagnostic criteria of ACLF and describe the development of this syndrome in European patients with AD.

METHODS

We collected data from 1343 hospitalized patients with cirrhosis and AD from February to September 2011 at 29 liver units in 8 European countries. We used the organ failure and mortality data to define ACLF grades, assess mortality, and identify differences between ACLF and AD. We established diagnostic criteria for ACLF based on analyses of patients with organ failure (defined by the chronic liver failure-sequential organ failure assessment [CLIF-SOFA] score) and high 28-day mortality rate (>15%).

RESULTS

Of the patients assessed, 303 had ACLF when the study began, 112 developed ACLF, and 928 did not have ACLF. The 28-day mortality rate among patients who had ACLF when the study began was 33.9%, among those who developed ACLF was 29.7%, and among those who did not have ACLF was 1.9%. Patients with ACLF were younger and more frequently alcoholic, had more associated bacterial infections, and had higher numbers of leukocytes and higher plasma levels of C-reactive protein than patients without ACLF (P < .001). Higher CLIF-SOFA scores and leukocyte counts were independent predictors of mortality in patients with ACLF. In patients without a prior history of AD, ACLF was unexpectedly characterized by higher numbers of organ failures, leukocyte count, and mortality compared with ACLF in patients with a prior history of AD.

CONCLUSIONS

We analyzed data from patients with cirrhosis and AD to establish diagnostic criteria for ACLF and showed that it is distinct from AD, based not only on the presence of organ failure(s) and high mortality rate but also on age, precipitating events, and systemic inflammation. ACLF mortality is associated with loss of organ function and high leukocyte counts. ACLF is especially severe in patients with no prior history of AD.

Activated intestinal macrophages in patients with cirrhosis release NO and IL-6 that may disrupt intestinal barrier function

BACKGROUND & AIMS

Bacterial infections commonly occur in decompensated cirrhosis resulting from bacterial translocation from the intestine. We studied the role of intestinal macrophages and the epithelial barrier in cirrhosis.

METHODS

Forty-four patients with NASH/ASH cirrhosis (decompensated n=29, compensated n=15) and nineteen controls undergoing endoscopy were recruited. Serum was obtained and LPS and LBP levels determined. Intestinal macrophages were characterized by flow cytometry, immunohistochemistry, and nitric oxide (NO) production measured in supernatant of cultured duodenal samples. Quantitative RT-PCR was performed on duodenal biopsies assessing 84 inflammatory genes. Protein levels of cytokines/chemokines were assessed in serum and supernatant. The duodenal wall was assessed by electron microscopy, tight junction protein expression determined by RT-PCR, immunohistochemistry, and Western blot and, functional analysis performed by transepithelial resistance measurement and permeability studies.

RESULTS

Increased plasma LPS, LBP levels and higher numbers of duodenal CD33(+)/CD14(+)/Trem-1(+) macrophages, synthesizing iNOS and secreting NO were present in decompensated cirrhosis. Upregulation of IL-8, CCL2, CCL13 at the transcriptional level, and increased IL-8, and IL-6 were detected in supernatant and serum in cirrhosis. IL-6 and IL-8 co-localised with iNOS(+) and CD68(+), but not with CD11c(+) cells. Electron microscopy demonstrated an intact epithelial barrier. Increased Claudin-2 was detected by Western blot and immunohistochemistry, while decreased transepithelial resistance and increased duodenal permeability were detected in decompensated cirrhosis.

CONCLUSIONS

Our study shows the presence of activated CD14(+)Trem-1(+)iNOS(+) intestinal macrophages, releasing IL-6, NO, and increased intestinal permeability in patients with cirrhosis, suggesting that these cells may produce factors capable of enhancing permeability to bacterial products.

Single determination of C-reactive protein at the time of diagnosis predicts long-term outcome of patients with hepatocellular carcinoma

We investigated the prognostic value of C-reactive protein (CRP) in patients with hepatocellular carcinoma (HCC) not amenable to surgery. A total of 615 patients diagnosed with HCC not amenable to surgery between April 1999 and December 2009 at the Department of Gastroenterology of the Medical Universities of Vienna and Innsbruck were included. We assessed the optimal CRP cutoff by regression spline analysis and tested its impact on median overall survival (OS) by the Kaplan-Meier method, univariate analysis (log-rank test), and multivariate analysis (Cox proportional hazard regression model) in a training cohort (n = 466, Vienna) and an independent validation cohort (n = 149, Innsbruck). We found a sigmoid-shaped association of CRP and the hazard ratio of death upon regression spline analysis and defined a CRP level <1/≥1 mg/dL as optimal cutoff for further survival assessments. Elevated CRP (≥1 mg/dL) at diagnosis was associated with poor OS (CRP-elevated versus CRP-normal; 4 versus 20 months; P < 0.001) and remained a significant negative predictor for OS upon multivariate analysis (hazard ratio, 1.7; P < 0.001), which was independent of age, Child-Pugh class, tumor characteristics, and treatment allocation. Analyses with respect to Barcelona Clinic Liver Cancer (BCLC) stage and Child-Pugh class supported the relevance of CRP (BCLC-stage C and Child-Pugh A: OS for CRP-elevated versus CRP-normal, 6 versus 14; P < 0.001; BCLC-stage C and Child-Pugh B: OS for CRP-elevated versus CRP-normal, 4 versus 15 months; P < 0.001). The prognostic significance of elevated CRP was reproducible at a second CRP determination timepoint and confirmed in the independent validation cohort.

CONCLUSION

Elevated CRP is associated with a dismal prognosis in HCC patients and may become a useful marker for patient selection in HCC management. (HEPATOLOGY 2012).

Immunizations in chronic liver disease: what should be done and what is the evidence

Infections are common in patients with chronic liver disease, especially those with cirrhosis. Patients with advanced liver disease, who develop bacterial infections, are at a substantially higher risk of death. As liver disease progresses, most immunizations lose their effectiveness. Overall, it is important to address immunization needs in patients with chronic liver disease early on, when immunizations are most effective. Inactivated or killed-type vaccinations rather than live, attenuated vaccinations are always preferable in patients with cirrhosis. The influenza vaccination is less effective in patients with cirrhosis and in the early post-liver transplant setting as compared to healthy individuals. The influenza vaccination may prevent hepatic decompensation, but further data are needed to confirm this. Yearly inactivated influenza vaccinations should be provided to those with chronic liver disease. The pneumonia vaccination is less effective in patients with cirrhosis, with a further decline in protective serologies after liver transplantation. Standard guidelines for the administration of Pneumovax23 for immunocompromised hosts apply to patients with chronic liver disease. Chronic liver disease also leads to higher non-response rates to the hepatitis B vaccination. Early-stage chronic liver disease patients should receive conventional hepatitis B series. Cirrhotics benefit from a double-dose hepatitis B vaccination at standard intervals. Hepatitis A superimposed on chronic viral hepatitis or chronic liver disease increases risk of mortality. Hepatitis A vaccination effectiveness wanes in cirrhosis, and should if possible be given before the development of cirrhosis. More data are needed for routine use of herpes zoster and human papillomavirus in chronic liver disease.

A nationwide study of comorbidity and risk of reinfection after Staphylococcus aureus bacteraemia

BACKGROUND

Data on risk factors and rates of reinfection associated with Staphylococcus aureus bacteraemia (SAB) are sparse.

METHODS

We conducted a nationwide cohort study of cases of SAB diagnosed between 1995 and 2008. Reinfection was defined as an episode of SAB more than 90 days after the initial episode of SAB. Comorbidity was evaluated by the Charlson Comorbidity Index (CCI). Cox proportional hazards modelling was used to estimate hazard rates (HR).

RESULTS

Of 10,891 eligible patients, 774 (7.1%) experienced reinfection a median of 458 days (range 90-5021 days) after their primary SAB episode corresponding to a reinfection rate of 1459 (95% confidence interval (CI): 1357-1562) per 100,000 personyears. In multivariate analysis, sex, origin, a vascular or peritoneal device, endocarditis and comorbidity were associated with reinfection. The association was more than two-fold higher among patients in dialysis and for patients with severe comorbidity (CCI ≥ 2). HIV infection (Hazard ratio (HR) 6.18, 95% CI: 4.17-9.16), renal disease (HR 3.92, 95% CI: 3.22-4.78), diabetes with complications (HR 2.11, 95% CI: 1.69-2.62), diabetes without complications (HR 1.61, 95% CI: 1.34-1.93), mild (HR: 1.94, 95% CI: 1.36-2.76) and severe liver disease (HR 2.08, 95% CI: 1.08-4.03), peptic ulcer (HR 1.33, 95% CI: 1.03-1.72), and paraplegia (HR 2.15, 95% CI: 1.02-4.54) were each associated with an increased risk of reinfection.

CONCLUSIONS

Patients with previous SAB have a 60-fold higher risk of SAB compared to the general population. Patients with HIV infection, renal disease, diabetes, liver disease, peptic ulcer and paraplegia had the highest rates of reinfection.

Non-selective betablocker therapy decreases intestinal permeability and serum levels of LBP and IL-6 in patients with cirrhosis

BACKGROUND & AIMS

We evaluated the gastrointestinal permeability and bacterial translocation in cirrhotic patients with portal hypertension (PHT) prior to and after non-selective betablocker (NSBB) treatment.

METHODS

Hepatic venous pressure gradient (HVPG) was measured prior to and under NSBB treatment. Gastroduodenal and intestinal permeability was assessed by the sucrose-lactulose-mannitol (SLM) test. Anti-gliadin and anti-endomysial antibodies were measured. Levels of LPS-binding protein (LBP) and interleukin-6 (IL-6) were quantified by ELISA, and NOD2 and toll-like receptor 2 (TLR2) polymorphisms were genotyped.

RESULTS

Fifty cirrhotics were included (72% male, 18% ascites, 60% alcoholic etiology). Abnormal gastroduodenal and intestinal permeability was found in 72% and 59% of patients, respectively. Patients with severe portal hypertension (HVPG ≥20 mm Hg; n=35) had increased markers of gastroduodenal/intestinal permeability (urine sucrose levels p=0.049; sucrose/mannitol ratios p=0.007; intestinal permeability indices p=0.002), and bacterial translocation (LBP p=0.002; IL-6 p=0.025) than patients with HVPG <20 mm Hg. A substantial portion of patients showed elevated levels of anti-gliadin antibodies (IgA: 60%, IgG: 34%) whereas no anti-endomysial antibodies were detected. A significant correlation of portal pressure (i.e., HVPG) with all markers of gastroduodenal/intestinal permeability and with LBP and IL-6 levels was observed. NOD2 and TLR2 risk variants were associated with abnormal intestinal permeability and elevated markers of bacterial translocation. At follow-up HVPG measurements under NSBB, we found an amelioration of gastroduodenal/intestinal permeability and a decrease of bacterial translocation (LBP - 16% p=0.018; IL-6 - 41% p<0.0001) levels, which was not limited to hemodynamic responders. Abnormal SLM test results and higher LBP/IL-6 levels were associated with a higher risk of variceal bleeding during follow-up but not with mortality.

CONCLUSIONS

Abnormal gastroduodenal/intestinal permeability, anti-gliadin antibodies, and bacterial translocation are common findings in cirrhotic patients and are correlated with the degree of portal hypertension. NSBB treatment ameliorates gastroduodenal/intestinal permeability and reduces bacterial translocation partially independent of their hemodynamic effects on portal pressure, which may contribute to a reduced risk of variceal bleeding.

Gene- and exon-expression profiling reveals an extensive LPS-induced response in immune cells in patients with cirrhosis

BACKGROUND & AIMS

Lipopolysaccharide (LPS)-expressing bacteria cause severe inflammation in cirrhotic patients. The global gene response to LPS is unknown in cirrhotic immune cells.

METHODS

Gene-expression profiling using Affymetrix Human Exon Array analyzed the expression of 14,851 genes in LPS-stimulated peripheral blood mononuclear cells (PBMCs) from 4 patients with cirrhosis and 4 healthy subjects. We performed validation studies using RT-qPCR in LPS-stimulated PBMCs from 52 patients and 9 healthy subjects and investigated the association of gene induction with mortality in 26 patients.

RESULTS

Gene-expression profiling of LPS-stimulated cirrhotic cells showed 509 upregulated genes and 1588 downregulated genes. In LPS-stimulated "healthy" cells, 952 genes were upregulated and 838 genes downregulated. The 741 LPS-regulated genes shared by cirrhotic and "healthy" cells were involved in cytokine production/activity and induction of "immune paralysis". Comparison of functions associated with the 1356 genes, specifically regulated by LPS in cirrhotic cells, to functions of the 1049 genes, specifically regulated in "healthy" cells, allowed to define a cirrhosis-specific phenotype. Unlike in "healthy" cells, LPS failed to induce an interferon-mediated program in cirrhotic cells. In cirrhotic PBMCs, LPS specifically induced certain molecules involved in apoptosis and downregulated molecules involved in endocytic trafficking. RT-qPCR experiments showed that LPS-stimulated cirrhotic PBMCs had an enhanced induction of certain proinflammatory cytokines and chemokines. In the prognosis study, higher ex vivo LPS-induction of the inflammatory genes IL6 and CXCL5 was a significant predictor of mortality.

CONCLUSIONS

Our results show that LPS-stimulated cirrhotic PBMCs exhibit an extensive and often unexpected transcriptional response.

Inhibition of mammalian target of rapamycin aggravates the respiratory burst defect of neutrophils from decompensated patients with cirrhosis

Cirrhosis is commonly accompanied by impaired defense functions of polymorphonuclear leucocytes (PMNs), increased patient susceptibility to infections, and hepatocellular carcinoma (HCC). PMN antimicrobial activity is dependent on a massive production of reactive oxygen species (ROS) by nicotinamide adenine dinucleotide phosphate (NADPH) 2 (NADPH oxidase 2; NOX2), termed respiratory burst (RB). Rapamycin, an antagonist of mammalian target of rapamycin (mTOR), may be used in the treatment of HCC and in transplanted patients. However, the effect of mTOR inhibition on the PMN RB of patients with cirrhosis remains unexplored and was studied here using the bacterial peptide, formyl-Met-Leu-Phe (fMLP), as an RB inducer. fMLP-induced RB of PMN from patients with decompensated alcoholic cirrhosis was strongly impaired (30%-35% of control) as a result of intracellular signaling alterations. Blocking mTOR activation (phospho-S2448-mTOR) with rapamycin further aggravated the RB defect. Rapamycin also inhibited the RB of healthy PMNs, which was associated with impaired phosphorylation of the NOX2 component, p47phox (phox: phagocyte oxidase), on its mitogen-activated protein kinase (MAPK) site (S345) as well as a preferential inhibition of p38-MAPK relative to p44/42-MAPK. However, rapamycin did not alter the fMLP-induced membrane association of p47phox and p38-MAPK in patients' PMNs, but did prevent their phosphorylation at the membranes. The mTOR contribution to fMLP-induced RB, phosphorylation of p47phox and p38-MAPK was further confirmed by mTOR knockdown in HL-60 cells. Finally, rapamycin impaired PMN bactericidal activity, but not bacterial uptake.

CONCLUSION

mTOR significantly up-regulates the PMN RB of patients with cirrhosis by p38-MAPK activation. Consequently, mTOR inhibition by rapamycin dramatically aggravates their PMN RB defect, which may increase patients' susceptibility to infection. Thus, concerns should be raised about the use of rapamycin in immuno-depressed patients.

A French national survey on the use of antibiotic prophylaxis in cirrhotic patients

BACKGROUND

Guidelines recommend antibiotic prophylaxis (AP) in well-selected groups of cirrhotic patients, but the impact of these recommendations has not been assessed in France.

AIM

To evaluate AP prescription tendencies for gastrointestinal bleeding, and primary and secondary prophylaxis of spontaneous bacterial peritonitis (SBP).

METHODS

Practitioners (n = 1,159) working in general hospitals (GH) or in university hospitals (UH) received a self-administered questionnaire.

RESULTS

Three hundred and eighty-nine (33.6%; GH 35% and UH 30.4%) practitioners responded. AP was prescribed by 97.7%, 72.3% and 94.8% of practitioners, without significant differences between UH and GH, respectively, for gastrointestinal bleeding (quinolones 48.2%, third-generation cephalosporins 27.7% and amoxicillin-clavulanic acid 22.2%), primary (quinolones 97.2%) and secondary prophylaxis of SBP (quinolones 99%). For gastrointestinal bleeding, ofloxacin (47.6%) and norfloxacin (37.4%) were the main quinolones prescribed, and ceftriaxone (77%) was the main third-generation cephalosporin prescribed. The principal reasons for prescribing AP were a decrease in bacterial infection (88.9% for gastrointestinal bleeding, 91.3% for primary and 94.3% for secondary prophylaxis of SBP), a recommendation by a consensus conference (83%, 38% and 74.4% respectively) and an improvement in survival (72.8%, 41.3% and 57.7% respectively). Only 31.7% of practitioners (39.6% for UH vs. 28.6% for GH; P = 0.038) believed that AP may reduce the risk of bleeding recurrence. Reported side effects (28%) of AP mainly concerned the risk of quinolone resistance (62% of cases).

CONCLUSION

Antibiotic prophylaxis is well-recognized by French practitioners, but its routine use depends on the expertise of practitioners. Quinolones remain the main antibiotic class prescribed irrespective of the type of prophylaxis.

Long-term administration of rifaximin improves the prognosis of patients with decompensated alcoholic cirrhosis

BACKGROUND AND AIM

Cirrhotic patients are predisposed to intestinal bacterial overgrowth with translocation of bacterial products which may deteriorate liver hemodynamics. Having shown that short-term administration of rifaximin improves liver hemodynamics in decompensated cirrhosis, we conducted this study to investigate the effect of intestinal decontamination with rifaximin on the long-term prognosis of patients with alcohol-related decompensated cirrhosis (Child-Pugh > 7) and ascites.

METHODS

Patients who had received rifaximin and showed improved liver hemodynamics were enrolled in the current study and continued to receive rifaximin (1200 mg/day). Each patient was matched by age, sex, and Child-Pugh grade to two controls and followed up for up to 5 years, death or liver transplantation. Survival and risk of developing portal hypertension-related complications were compared between rifaximin group and controls.

RESULTS

Twenty three patients fulfilled the inclusion criteria and matched with 46 controls. Patients who received rifaximin had a significant lower risk of developing variceal bleeding (35% vs. 59.5%, P = 0.011), hepatic encephalopathy (31.5% vs. 47%, P = 0.034), spontaneous bacterial peritonitis (4.5% vs. 46%, P = 0.027), and hepatorenal syndrome (4.5% vs. 51%, P = 0.037) than controls. Five-year cumulative probability of survival was significantly higher in patients receiving rifaximin than in controls (61% vs. 13.5%, P = 0.012). In the multivariate analysis, rifaximin administration was independently associated with lower risk of developing variceal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, and higher survival.

CONCLUSIONS

In patients with alcohol-related decompensated cirrhosis, long-term rifaximin administration is associated with reduced risk of developing complications of portal hypertension and improved survival.

Attenuated antigen-specific T cell responses in cirrhosis are accompanied by elevated serum interleukin-10 levels and down-regulation of HLA-DR on monocytes

BACKGROUND

Advanced liver disease predisposes to bacterial translocation and endotoxaemia which can contribute to elevated circulating levels of IL-10 and down-regulation of MHC class II on antigen-presenting cells. We sought to evaluate antigen-specific T-cell responses toward common viral antigens in order to investigate defects in cellular immunity in cirrhosis.

METHODS

Peripheral blood was obtained from 22 cirrhotic patients with systemic inflammation, 13 cirrhotic patients without systemic inflammation and 14 healthy controls. C-reactive protein was used as an indicator for systemic inflammation using a cut-off of 10 mg/l. Intracellular Th1 cytokines were quantified after T cell-stimulation with the viral peptides EBNA1 and BZLF1 or the bacterial superantigen SEB by flow cytometry. Serum levels of lipopolysaccharide-binding protein (LBP) and IL-10 were quantified by ELISA.

RESULTS

Compared to healthy controls, patients with cirrhosis had higher circulating levels of LBP and IL-10, an expansion of peripheral blood CD14+ monocytes with low HLA-DR expression and an increased fraction of CD25-positive CD4+ and CD8+ T cells. These findings were most pronounced in cirrhotic patients with systemic inflammation but fell short of reaching statistical significance when comparing against cirrhotic patients without systemic inflammation. In the former group TNF-α production in CD4+ and CD8+ T cells was reduced after stimulation with SEB, whereas there was no significant difference between the total cohort of cirrhotic patients and controls. After stimulation with the overlapping peptide pools for viral antigens EBNA1 and BZLF1, the number of responding T cells and the amount of TNF-α or IFN-γ production did not differ between the three pre-defined groups. However, cirrhotic patients with null-responses to EBV peptides had significantly higher serum IL-10 levels than responders to EBV peptides. Furthermore, TNF-α production in responding T cells was attenuated in patients with a high frequency of CD14+ HLA-DR- monocytes.

CONCLUSION

Our data suggest that bacterial translocation, endotoxaemia, inflammation and T cell activation in cirrhosis are accompanied by an increase in circulating anti-inflammatory cytokines, reduced monocytic MHC class II expression and attenuated cytokine production in T cells. These changes are likely to contribute to altered adaptive immune responses during infection or after vaccination.

The conservative and interventional treatment of the complications of liver cirrhosis: Part 2 of a series on liver cirrhosis

BACKGROUND

It is estimated that 1 million persons in Germany suffer from hepatic cirrhosis, which is the final stage of chronic inflammation of the liver. Cirrhosis has multiple causes, all of which lead to structural changes of the liver and to portal hypertension. The main complications of cirrhosis arise in turn: These include bleeding from collateral veins, ascites, hepatocellular carcinoma, encephalopathy, and infection leading to organ failure.

METHODS

We present the treatment of the main complications of liver cirrhosis with reference to the relevant literature (phase II and III trials, meta-analyses, and reviews).

RESULTS

Endoscopic treatment (ligation) is used for the primary and secondary prophylaxis of variceal bleeding. Drugs to lower portal pressure (e.g., beta-blockers) are an established means of preventing initial or recurrent variceal bleeding over the long term. Vasoconstrictors such as terlipressin are mainly used to treat acute hemorrhage and type 1 hepatorenal syndrome. The main treatment of ascites is with spironolactone, in combination with a loop diuretic where indicated. A shunt (TIPS) is used to treat severe or repeat variceal hemorrhage or refractory ascites. Antibiotics play a well-established role in the treatment of acute hemorrhage, in the treatment and prevention of spontaneous bacterial peritonitis, and in the treatment of encephalopathy. The treatment of hepatocellular carcinoma depends on its extent of spread and on the degree of decompensation of cirrhosis.

CONCLUSION

For most of the main complications of liver cirrhosis, there are treatments that have been well-tested in randomized trials. Liver transplantation should also be considered in every case.

The effect of infections on the mortality of cirrhotic patients with hepatic encephalopathy

Cirrhotic patients are prone to having infections, which may aggravate hepatic encephalopathy (HE). However, the effect of infections on mortality in HE cirrhotic patients is not well described. The National Health Insurance Database, derived from the Taiwan National Health Insurance Programme, was used to identify 4150 adult HE cirrhotic patients hospitalized between 1 January 2004 and 31 December 2004. Nine hundred and eighty-five patients (23.7%) had one or more co-existing infections during their hospitalization. After Cox proportional hazard regression modelling adjusted by the patients' gender, age, and medical comorbidity disorders, the hazard ratios (HRs) in HE patients with infections for 30-day, 30- to 90-day, and 90-day to 1-year mortalities were 1.66 [95% confidence interval (CI) 1.42-1.94], 1.51 (95% CI 1.23-1.85) and 1.34 (95% CI 1.13-1.58), respectively. Compared to the non-infection group, the HRs of pneumonia, spontaneous bacterial peritonitis, urinary tract infection, sepsis without specific focus (SWSF), cellulitis, and biliary tract infection were 2.11, 1.48, 1.06, 2.21, 1.06, and 0.78, respectively, for 30-day mortality; 1.82, 1.22, 0.93, 2.24, 0.31, and 2.82, respectively, for 30- to 90-day mortality; and 2.03, 0.82, 1.24, 1.64, 1.14, and 0.60, respectively, for 90-day to 1-year mortality for HE cirrhotic patients. We conclude that infections increase the mortality of HE cirrhotic patients, especially pneumonia and SWSF.

High mortality of pneumonia in cirrhotic patients with ascites

Background

Cirrhotic patients with ascites are prone to develop various infectious diseases. This study aimed to evaluate the occurrence and effect of major infectious diseases on the mortality of cirrhotic patients with ascites.

Methods

We reviewed de-identified patient data from the National Health Insurance Database, derived from the Taiwan National Health Insurance Program, to enroll 4,576 cirrhotic patients with ascites, who were discharged from Taiwan hospitals between January 1, 2004 and June 30, 2004. We collected patients’ demographic and clinical data, and reviewed diagnostic codes to determine infectious diseases and comorbid disorders of their hospitalizations. Patients were divided into an infection group and non-infection group and hazard ratios (HR) were determined for specific infectious diseases.

Results

Of the total 4,576 cirrhotic patients with ascites, 1,294 (28.2%) were diagnosed with infectious diseases during hospitalization. The major infectious diseases were spontaneous bacterial peritonitis (SBP) (645, 49.8%), urinary tract infection (151, 11.7%), and pneumonia (100, 7.7%). After adjusting for patients’ age, gender, and other comorbid disorders, the HRs of infectious diseases for 30-day and 90-day mortality of cirrhotic patients with ascites were 1.81 (1.54-2.11) and 1.60 (1.43-1.80) respectively, compared to those in the non-infection group. The adjusted HRs of pneumonia, urinary tract infection (UTI), spontaneous bacterial peritonitis (SBP), and sepsis without specific focus (SWSF) were 2.95 (2.05-4.25), 1.32 (0.86-2.05), 1.77 (1.45-2.17), and 2.19 (1.62-2.96) for 30-day mortality, and 2.57 (1.93-3.42), 1.36 (1.01-1.82), 1.51 (1.29-1.75), and 2.13 (1.70-2.66) for 90-day mortality, compared to those in the non-infection group.

Conclusion

Infectious diseases increased 30-day and 90-day mortality of cirrhotic patients with ascites. Among all infectious diseases identified, pneumonia carried the highest risk for mortality.

Role of IL-28B and inosine triphosphatase polymorphisms in efficacy and safety of Peg-Interferon and ribavirin in chronic hepatitis C compensated cirrhosis with and without oesophageal varices

Genetic factors can influence the outcome of antiviral therapy in chronic hepatitis C (HCV). We evaluated the role of interleukin-28B single nucleotide polymorphisms (SNPs) and inosine triphosphatase (ITPA) gene variants in HCV cirrhosis treated with Peg-Interferon and ribavirin. A prospective cohort of 233 patients with compensated cirrhosis received 1-1.5 μg/kg/week of Peg-Interferon alpha-2b plus 1000-1200 mg/day of RBV for 48 weeks. A sustained virologic response (SVR) was achieved in 27% of patients. On multivariate logistic analysis, the absence of oesophageal varices (OR 3.64 CI 95% 1.27-10.44 P = 0.016), infection with genotype 2 or 3 (OR 4.06, CI 95% 1.08-15.26, P = 0.038), C/C alleles of rs12979860 SNP (OR 7.04, CI 95% 2.40-20.72, P < 0.001) and rapid virologic response (RVR) (OR 78.29, CI 95% 16.07-381.29, P < 0.001) were independently associated with SVR. Patients who experienced post-treatment relapse received lower total doses of Peg-Interferon (52.0 ± 15.8 μg/kg vs 65.7 ± 13.3 μg/kg, P < 0.001) and lower total dose of RBV (3829 ± 1210 mg vs 4709 ± 954 mg, P < 0.001) than patients who achieved an SVR. ITPA variants predictive of high ITPase activity were associated with reduction of haemoglobin ≥3 g/dL in the first 4 weeks (P < 0.001), and with reduction of haemoglobin <10 g/dL (P = 0.03) on treatment. In conclusion, combination therapy with Peg-Interferon and RBV in patients with HCV cirrhosis must be guided by virus genotype, severity of portal hypertension, favourable IL-28B polymorphisms and ITPA variants, and RVR on treatment.

Diagnosis and management of bacterial infections in decompensated cirrhosis

Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamase-producing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.

Pathological bacterial translocation in cirrhosis: pathophysiology, diagnosis and clinical implications

Bacterial translocation (BT) is defined by the passage of viable indigenous bacteria from the intestinal lumen to mesenteric lymph nodes (MLNs) and other territories, and its diagnostic criteria rely on the isolation of viable bacteria in MLNs. Small intestinal overgrowth, increased intestinal permeability and immunological alterations are the main factors involved in its pathogenesis. BT is obviously difficult to identify in patients with cirrhosis, and alternative methods have been proposed instead. Bacterial DNA detection and species identification in serum or ascitic fluid has been proposed as a reliable marker of BT. Bacterial products, such as endotoxin, or bacterial DNA can translocate to extra-intestinal sites and promote an immunological response similar to that produced by viable bacteria. Therefore, pathological BT plays an important role in the pathogenesis of the complications of cirrhosis, not only in infections, but by exerting a profound inflammatory state and exacerbating the haemodynamic derangement. This may promote in turn the development of hepatorenal syndrome, hepatic encephalopathy and other portal hypertension-related complications. Therapeutic approaches for the prevention of BT in experimental and human cirrhosis are summarized. Finally, new investigations are needed to better understand the pathogenesis and consequences of translocation by viable bacteria (able to grow in culture), or non-viable BT (detection of bacterial fragments with negative culture) and open new therapeutic avenues in patients with cirrhosis.

Acute-on chronic liver failure

Acute-on-chronic liver failure (ACLF) is an increasingly recognised entity encompassing an acute deterioration of liver function in patients with cirrhosis, which is usually associated with a precipitating event and results in the failure of one or more organs and high short term mortality. Prospective data to define this is lacking but there is a large body of circumstantial evidence suggesting that this condition is a distinct clinical entity. From the pathophysiologic perspective, altered host response to injury and infection play important roles in its development. This review focuses upon the current understanding of this syndrome from the clinical, prognostic and pathophysiologic perspectives and indicates potential biomarkers and therapeutic targets for intervention.

Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end-stage liver disease (NACSELD) experience

Bacterial infections are an important cause of mortality in cirrhosis, but there is a paucity of multicenter studies. The aim was to define factors predisposing to infection-related mortality in hospitalized patients with cirrhosis. A prospective, cohort study of patients with cirrhosis with infections was performed at eight North American tertiary-care hepatology centers. Data were collected on admission vitals, disease severity (model for endstage liver disease [MELD] and sequential organ failure [SOFA] scores), first infection site, type (community-acquired, healthcare-associated [HCA] or nosocomial), and second infection occurrence during hospitalization. The outcome was mortality within 30 days. A multivariate logistic regression model predicting mortality was created. 207 patients (55 years, 60% men, MELD 20) were included. Most first infections were HCA (71%), then nosocomial (15%) and community-acquired (14%). Urinary tract infections (52%), spontaneous bacterial peritonitis (SBP, 23%) and spontaneous bacteremia (21%) formed the majority of the first infections. Second infections were seen in 50 (24%) patients and were largely preventable: respiratory, including aspiration (28%), urinary, including catheter-related (26%), fungal (14%), and Clostridium difficile (12%) infections. Forty-nine patients (23.6%) who died within 30 days had higher admission MELD (25 versus 18, P < 0.0001), lower serum albumin (2.4 g/dL versus 2.8 g/dL, P = 0.002), and second infections (49% versus 16%, P < 0.0001) but equivalent SOFA scores (9.2 versus 9.9, P = 0.86). The case fatality rate was highest for C. difficile (40%), respiratory (37.5%), and spontaneous bacteremia (37%), and lowest for SBP (17%) and urinary infections (15%). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03) albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables.

CONCLUSION

Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort.

New therapeutic paradigm for patients with cirrhosis

Cirrhosis is a major health problem, being the 5th cause of death in the U.K. and 12th in the U.S., but 4th in the 45 to 54 age group. Until recently cirrhosis was considered a single and terminal disease stage, with an inevitably poor prognosis. However, it is now clear that 1-year mortality can range from 1% in early cirrhosis to 57% in decompensated disease. As the only treatment for advanced cirrhosis is liver transplantation, what is urgently needed is strategies to prevent transition to decompensated stages. The evidence we present in this review clearly demonstrates that management of patients with cirrhosis should change from an expectant algorithm that treats complications as they occur, to preventing the advent of all complications while in the compensated phase. This requires maintaining patients in an asymptomatic phase and not significantly affecting their quality of life with minimal impairment due to the therapies themselves. This could be achieved with lifestyle changes and combinations of already licensed and low-cost drugs, similar to the paradigm of treating risk factors for cardiovascular disease. The drugs are propranolol, simvastatin, norfloxacin, and warfarin, which in combination would cost £128/patient annually-equivalent to U.S. $196/year. This treatment strategy requires randomized controlled trials to establish improvements in outcomes. In the 21st century, cirrhosis should be regarded as a potentially treatable disease with currently available and inexpensive therapies.

High prevalence of antibiotic-resistant bacterial infections among patients with cirrhosis at a US liver center

BACKGROUND & AIMS

There are limited data on the prevalence or predictors of antibiotic-resistant bacterial infections (AR-BI) in hospitalized patients with cirrhosis in North America. Exposure to systemic antibiotics is a risk factor for AR-BI; however, little is known about the effects of the increasingly used oral nonabsorbed antibiotics.

METHODS

We analyzed data from patients with cirrhosis and bacterial infections hospitalized in a liver unit at a US hospital between July 2009 and November 2010. Multivariate logistic regression was used to determine predictors of AR-BI. Data were analyzed on the first bacterial infection of each patient (n = 115), and a sensitivity analysis was performed on all infectious episodes per patient (n = 169).

RESULTS

Thirty percent of infections were nosocomial. Urinary tract infections (32%) and spontaneous bacterial peritonitis (24%) were most common. Of the 70 culture-positive infections, 33 (47%) were found to be antibiotic resistant (12 were vancomycin-resistant Enterococci, 9 were extended-spectrum β-lactamase-producing Enterobacteriaceae, 7 were quinolone-resistant gram-negative rods, and 5 were methicillin-resistant Staphylococcus aureus). Exposure to systemic antibiotics within 30 days before infection was associated independently with AR-BI, with an odds ratio (OR) of 13.5 (95% confidence interval [CI], 2.6-71.6). Exposure to only nonabsorbed antibiotics (rifaximin) was not associated with AR-BI (OR, 0.4; 95% CI, 0.04-2.8). In a sensitivity analysis, exposure to systemic antibiotics within 30 days before infection and nosocomial infection was associated with AR-BI (OR, 5.2; 95% CI, 1.5-17.7; and OR, 4.2; 95% CI, 1.4-12.5, respectively).

CONCLUSIONS

The prevalence of AR-BI is high in a US tertiary care transplant center. Exposure to systemic antibiotics within 30 days before infection (including those used for prophylaxis of spontaneous bacterial peritonitis), but not oral nonabsorbed antibiotics, is associated with development of an AR-BI.

Proton pump inhibitors are associated with a high rate of serious infections in veterans with decompensated cirrhosis

BACKGROUND

There is increasing evidence that proton pump inhibitors (PPIs) increase the rate of infections in patients with decompensated cirrhosis.

AIMS

To estimate the extent to which proton pump inhibitors (PPIs) increase the rate of infections among patients with decompensated cirrhosis.

METHODS

We conducted a retrospective propensity-matched new user design using US Veterans Health Administration data. Only decompensated cirrhotic patients from 2001 to 2009 were included. New PPI users after decompensation (n = 1268) were 1:1 matched to those who did not initiate gastric acid suppression. Serious infections, defined as infections associated with a hospitalisation, were the outcomes. These were separated into acid suppression-related (SBP, bacteremia, Clostridium difficile and pneumonia) and non-acid suppression-related. Time-varying Cox models were used to estimate adjusted hazard ratios (HR) and 95% CIs of serious infections. Parallel analyses were conducted with H2 receptor antagonists (H2RA).

RESULTS

More than half of persons with decompensated cirrhosis were new users of gastric acid suppressants, with most using PPIs (45.6%) compared with H2RAs (5.9%). In the PPI propensity-matched analysis, 25.3% developed serious infections and 25.9% developed serious infections in the H2RA analysis. PPI users developed serious infections faster than nongastric acid suppression users (adjusted HR: 1.66; 95% CI: 1.31–2.12). For acid suppression-related serious infections, PPI users developed the outcome at a rate 1.75 times faster than non-users (95% CI: 1.32–2.34). The H2RA findings were not statistically significant (HR serious infections: 1.59; 95% CI: 0.80–3.18; HR acid suppression-related infections: 0.92; 95% CI: 0.31–2.73).

CONCLUSION

Among patients with decompensated cirrhosis, proton pump inhibitors but not H2 receptor antagonists increase the rate of serious infections.

The intestinal microbiome and the leaky gut as therapeutic targets in alcoholic liver disease

Alcoholic liver disease (ALD) encompasses hepatic steatosis, which may progress to alcoholic hepatitis, fibrosis, and cirrhosis. It remains a leading cause of morbidity and mortality in the US and worldwide. The severity of liver disease correlates with plasma levels of bacterial products in patients, and experimental ALD depends on the level of gut derived bacterial products in rodents. Since intestinal decontamination and deficiency of bacterial product receptors or their downstream signaling molecules protect from alcohol-induced liver disease, bacterial translocation (BT), qualitative, and quantitative changes of the enteric microbiome are considered as being of fundamental importance in the pathogenesis of ALD. Recent enhancements in diagnostic technologies provide a better insight into these shifts. This review highlights vital events in ALD such as BT, the importance of Toll-like receptor (TLR) signaling, intestinal bacterial overgrowth (IBO), and changes in the intestinal microbiome. Furthermore, a treatment trial section of patients reviews possible future options of therapy for ALD modifying the enteric microbiome.

Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. A randomized, controlled study

BACKGROUND & AIMS

Treatment with albumin in patients with cirrhosis and spontaneous bacterial peritonitis (SBP) prevents renal failure and improves survival. Whether albumin has similar beneficial effects in patients with infections other than SBP is unknown.

METHODS

One hundred and ten patients with cirrhosis hospitalized for infections other than SBP were randomly assigned to receive antibiotics plus albumin (1.5 g/kgbw at diagnosis and 1 g/kgbw at day 3) (albumin group; n=56) or antibiotics alone (control group; n=54). The primary end point was survival at 3 months. Secondary end points were effects on renal and circulatory function.

RESULTS

The renal function, as evaluated by differences in changes in serum creatinine and estimated glomerular filtration rate between the two groups, improved in patients treated with albumin. The circulatory function improved significantly in patients treated with albumin, but not in those from the control group. There was a trend for a lower frequency of type 1 hepatorenal syndrome in the albumin group compared to the control group (1 vs. 4 patients, respectively; p=n.s.). Probability of survival at 3 months was not significantly different among the two groups. However, when adjusted for factors with independent prognostic value, treatment with albumin was an independent predictive factor of survival.

CONCLUSIONS

As compared with standard antibiotic therapy alone, treatment with albumin together with antibiotics has beneficial effects on the renal and circulatory function and shows a potential survival benefit. Further studies with large sample sizes should be performed to confirm these findings.

The role of rifaximin in the primary prophylaxis of spontaneous bacterial peritonitis in patients with liver cirrhosis

BACKGROUND

Primary prophylaxis of spontaneous bacterial peritonitis (SBP) may provide a survival advantage in cirrhotic patients with ascites and has become an integral part of clinical practice. Rifaximin is a poorly absorbable antibiotic with a broad spectrum of antibacterial action and has low risk of introducing bacterial resistance.

AIM

To determine whether rifaximin is associated with decreasing the risk of SBP and improving transplant-free survival in cirrhotic patients with ascites.

METHODS

The medical records of all adult patients with liver cirrhosis and large ascites justifying paracentesis evaluated in our clinic (2003 to 2007) were reviewed. Patients were stratified into 2 groups by the use of rifaximin. Patients were excluded if they had received another antibiotic for SBP prophylaxis or had a history of SBP before rifaximin therapy.

RESULTS

A total of 404 patients were included, of whom 49 (12%) received rifaximin. The rifaximin and nonrifaximin groups were comparable with regards to age, sex, and race. The median follow-up time was 4.2 [1.0, 17.1] months. During this time period, 89% of patients on rifaximin remained SBP free compared with 68% of those not on rifaximin (P=0.002). After adjusting for Model of End-Stage Liver Disease score, Child-Pugh score, serum sodium, and ascitic fluid total protein, there was a 72% reduction in the rate of SBP in the rifaximin group (hazard ratio=0.28; 95% confidence interval, 0.11-0.71; P=0.007). The group treated with rifaximin also demonstrated a transplant-free survival benefit compared with those not on rifaximin (72% vs. 57%, P=0.045).

CONCLUSIONS

Intestinal decontamination with rifaximin may prevent SBP in cirrhotic patients with ascites. Prospective randomized controlled trials are needed to confirm this finding.

The new epidemiology of nosocomial bacterial infections in cirrhosis: therapeutical implications

Cirrhotic patients are at increased risk of developing infection, sepsis and death. Enterobacteriaceae and nonenterococcal streptococci are the main bacteria responsible for spontaneous and urinary infections in this population. Prompt and appropriate treatment is basic in the management of cirrhotic patients with infection. Third-generation cephalosporins continue to be the gold-standard antibiotic treatment of the majority of infections acquired in the community because responsible strains are usually susceptible to β-lactams. By contrary, nosocomial infections are nowadays frequently caused by multiresistant bacteria (extended-spectrum β-lactamase-producing Enterobacteriaceae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci among others) that are nonsusceptible to the main antibiotics. Treatment of these infections requires the use of broader spectrum antibiotics (carbapenems) or of antibiotics that are active against specific resistant bacteria (glycopeptides, linezolid, daptomycin, amikacin and colistin). Empirical antibiotic schedules must be adapted to the local epidemiological pattern of antibiotic resistance. Careful restriction of antibiotic prophylaxis to the high-risk population is also mandatory to reduce the spread of multiresistant bacteria in cirrhosis.

Bacterial infections in cirrhosis: role of proton pump inhibitors and intestinal permeability

BACKGROUND

  Cirrhotic patients are at considerable risk for bacterial infections, possibly through increased intestinal permeability and bacterial overgrowth. Proton pump inhibitors (PPIs) may increase infection risk. We aimed to explore the potential association between PPI use and bacterial infection risk in cirrhotic patients and potential underlying mechanisms in complementary patient and animal models.

MATERIALS AND METHODS

  Bacterial overgrowth was determined in jejunum of 30 rats randomly allocated to 6-week PPI treatment, gastrectomy or no treatment. In 84 consecutive cirrhotic patients, bacterial infection risk was prospectively assessed and related to PPI use. Intestinal permeability was determined by polyethylene glycol (PEG) test in nine healthy individuals and 12 cirrhotic patients.

RESULTS

  Bacterial overgrowth was much more common in jejunum of rats treated with PPI or gastrectomy compared with nontreated rats. Twenty-four patients (29%) developed a bacterial infection during a median follow-up of 28 months. Although PPI users tended to experience infection more often than patients without PPI therapy, PPI use was not an independent predictor of bacterial infection (HR 1·2, 95% CI 0·5-3·0, P = 0·72), after correction for Child-Pugh class (HR 3·6, 95% CI 1·5-8·7, P = 0·004) and age (HR 1·05, 95%CI 1·01-1·09, P = 0·02). In cirrhotic patients, 24-h urinary recovery of PEGs 1500 and 3350 was significantly higher compared with healthy controls.

CONCLUSIONS

  Although in our animal model PPIs induced intestinal overgrowth, stage of liver disease rather than PPI use was the predominant factor determining infection risk in cirrhotic patients. Increased intestinal permeability may be a factor contributing to infection risk.

Management of bacterial infections in cirrhosis

Bacterial infections are very frequent in advanced cirrhosis and become the first cause of death of these patients. Despite numerous experimental data and significant advances in the understanding of the pathogenesis of sepsis in cirrhosis, the outcome remains poor. Classical diagnostic parameters such as C-reactive protein and SIRS criteria have less diagnostic capacity in the cirrhotic population, often delaying the diagnosis and the management of bacterial infection. Prompt and appropriate empirical antibiotic treatment of infection and early resuscitation of patients with severe sepsis or septic shock are essential in determining patient's outcome. A strategy of careful restriction of prophylactic antibiotics to the high-risk populations could reduce the spread of multidrug resistant bacteria. This review is focused on the currently recommended diagnostic, therapeutic and prophylactic strategies for bacterial infections in the cirrhotic population.

Validation of three coding algorithms to identify patients with end-stage liver disease in an administrative database

PURPOSE: Use of administrative or population-based databases for post-marketing pharmacoepidemiology research in patients with end-stage liver disease (ESLD) has been limited by the difficulty of accurately identifying such patients. Algorithms to identify patients with ESLD using ICD-9-CM codes have not been developed outside of the Veterans Affairs healthcare setting. METHODS: We queried electronic medical records at two tertiary care hospitals to identify patients with ICD-9-CM codes indicative of ESLD. Coding algorithms were developed to identify patients with confirmed ESLD, and these were tested to determine their positive predictive value (PPV). RESULTS: The presence of one inpatient or outpatient ICD-9-CM code for: (i) cirrhosis; (ii) chronic liver disease, and (iii) a hepatic decompensation event yielded a PPV of 85.2% (167/196; 95% CI: 79.4%-89.9%). The PPV increased to 89.3% (150/168; 95% CI: 83.6%-93.5%) when the algorithm required two or more ICD-9-CM codes for a hepatic decompensation. However, an algorithm requiring only one ICD-9-CM code for (i) cirrhosis and (ii) a hepatic decompensation event, in the absence of a chronic liver disease code, yielded a PPV of 85.7% (30/35; 95% CI: 69.7%-95.2%). CONCLUSIONS: A coding algorithm that includes at least one ICD-9-CM code for cirrhosis plus one ICD-9-CM code for a hepatic decompensation event has a high PPV for identifying patients with ESLD. The inclusion of at least two codes indicative of a hepatic decompensation event increased the PPV. This algorithm can be used in future epidemiologic studies to examine the outcomes of a variety of long-term medical therapies in patients with ESLD. Copyright © 2012 John Wiley & Sons, Ltd.

Effect of renal impairment on mortality of patients with cirrhosis and spontaneous bacterial peritonitis

BACKGROUND & AIMS

The effects of end-stage renal disease (ESRD) on the mortality of patients with cirrhosis and spontaneous bacterial peritonitis (SBP) have not been determined.

METHODS

We collected data from Taiwan's National Health Insurance Database on 2592 patients with cirrhosis who were hospitalized with SBP from January 1 to December 31, 2004. Patients were matched with individuals from a national mortality database; 30-day and 1-year mortalities were calculated for each group and compared to calculate hazard ratios (HRs).

RESULTS

Of the patients with cirrhosis and SBP, 300 (11.5%) had renal function impairment. Of these, 145 had acute renal failure, 70 had ESRD, and 75 had chronic kidney disease. Overall, 30-day and 1-year mortality were 21.3% and 51.7%, respectively. After adjusting for age, sex, and underlying comorbidities, HRs for 30-day mortality from renal function impairment, acute renal failure, ESRD, and chronic kidney disease were 3.00, 4.68, 1.93, and 1.37, respectively. The HRs for 1-year mortality from renal function impairment, acute renal failure, ESRD, and chronic kidney disease were 2.03, 2.78, 1.70, and 1.37, respectively. The adjusted HRs for 30-day and 1-year mortality of patients with acute renal failure were 2.6 and 1.6, respectively, compared with patients with ESRD.

CONCLUSIONS

Acute renal failure is a better determinant of 30-day and 1-year mortality than renal function impairment in cirrhotic patients with SBP.

C-reactive protein predicts short-term mortality in patients with cirrhosis

BACKGROUND & AIMS

We aimed at improving prediction of short-term mortality in cirrhotic inpatients by evaluating C-reactive protein (CRP) as a surrogate marker of systemic inflammatory response syndrome (SIRS).

METHODS

One-hundred and forty-eight consecutive cirrhotic patients with Child-Pugh score ≥ B8 and without hepatocellular carcinoma were prospectively included and followed for 182 days. The primary end point was 6-month survival.

RESULTS

Main baseline characteristics were as follows: alcoholic liver disease in 88.5%; bacterial infection in 37%; hepatorenal syndrome in 7% of cases. CRP range was 1-240 mg/L (median 26 mg/L); 42 patients (28.4%) had SIRS as defined by ACCP/SCCM-criteria. CRP levels were higher in patients with SIRS (50 vs. 21 mg/L; p<0.0001), infection (46 vs. 27 mg/L; p<0.0001), and alcoholic hepatitis (44 vs. 32 mg/L, p=0.049). Forty-two patients died within the first 6 months of follow-up. Short-term mortality was associated with extrahepatic co-morbidities (p=0.002), high MELD score (p<0.001; AUROC=0.67), renal failure (p=0.008), elevated blood lactates (p<0.001), and high baseline CRP levels (p=0.003; AUROC=0.63; best cut-off value at 29 mg/L). Among patients with baseline CRP ≥ 29 mg/L, 32 still had CRP ≥ 29 mg/L at day 15 (group A). Group A was associated with 6-month mortality in the overall population (p<0.001) and also through sensitivity analyses restricted to patients without infection or alcoholic hepatitis. Multivariate analysis (Cox) adjusted for age identified three predictors of mortality: high MELD score (HR=1.08; 95% CI: 1.03-1.12; p<0.001), extrahepatic co-morbidities (HR=2.51; 95% CI: 1.31-4.84; p=0.006), and CRP level (group A) (HR=2.73; 95% CI: 1.41-5.26; p=0.003). The performance of the three variables taken together for predicting death was 0.80 (AUROC).

CONCLUSIONS

In Child-Pugh score ≥ B8 cirrhotic patients, persistent CRP levels ≥ 29 mg/L predicted short-term mortality independently of age, MELD, and co-morbidities, and better than infection or clinically-assessed SIRS.

High-sensitivity C-reactive protein levels predict survival and are related to haemodynamics in alcoholic cirrhosis

OBJECTIVES

Inflammation may be implicated in the haemodynamic deterioration and in the development of complications in patients with cirrhosis. High-sensitivity C-reactive protein (hsCRP) is a marker of low-grade inflammation, and predicts outcomes in patients at risk of ischaemic heart disease. Proinflammatory cytokines reflect immune activation and have been found to be elevated in cirrhosis. We investigated a possible association between markers of inflammation and splanchnic and systemic haemodynamics, complications and survival in patients with cirrhosis.

METHODS

In 45 stable patients with cirrhosis on the basis of alcohol consumption, we measured hsCRP, as well as monocyte chemoattractant protein-1, tumour necrosis factor-α, interleukin-6, interleukin-8 and vascular endothelial growth factor in patients and in 12 healthy controls. Systemic and splanchnic haemodynamics were investigated in patients.

RESULTS

hsCRP levels were significantly higher in patients compared with controls (P<0.05) and the highest in patients belonging to Child-Pugh class C. hsCRP levels correlated with markers of liver dysfunction and with the hepatic venous pressure gradient (r=0.48, P<0.001). hsCRP values above the median level of 5.3 mg/l were associated with a highly increased mortality (P=0.001). Model for End-Stage Liver Disease score (P=0.01) and hsCRP (P<0.05) provided independent prognostic information. Cytokines had no discernible value in predicting survival.

CONCLUSION

hsCRP is elevated in patients with cirrhosis and is associated with portal hypertension and decreased survival. hsCRP is a promising prognostic marker in cirrhosis, which may improve the selection of candidates for liver transplantation.

Bacterial infections other than spontaneous bacterial peritonitis in cirrhosis

Cirrhotic patients are immunocompromised with a high risk of infection. Proinflammatory cytokines and hemodynamic circulation derangement further facilitate the development of serious consequences of infections. Other than spontaneous bacterial peritonitis, bacteremia and bacterial infections of other organ systems are frequently observed. Gram-negative enteric bacteria are the most common causative organism. Other bacterial infections, such as enterococci, Vibrio spp., Aeromonas spp., Clostridium spp., Listeria monocytogenes, Plesiomonas shigelloides and Mycobacterium tuberculosis are more prevalent and more virulent. Generally, intravenous third generation cephalosporins are recommended as empirical antibiotic therapy. Increased incidences of gram-positive and drug-resistant organisms have been reported, particularly in hospital-acquired infections and in patients receiving quinolones prophylaxis. This review focuses upon epidemiology, microbiology, clinical features and treatment of infections in cirrhosis other than spontaneous bacterial peritonitis, including pathogen-specific and liver disease-specific issues.

The end-organ impairment in liver cirrhosis: appointments for critical care

Liver cirrhosis (LC) can lead to a clinical state of liver failure, which can exacerbate through the course of the disease. New therapies aimed to control the diverse etiologies are now more effective, although the disease may result in advanced stages of liver failure, where liver transplantation (LT) remains the most effective treatment. The extended lifespan of these patients and the extended possibilities of liver support devices make their admission to an intensive care unit (ICU) more probable. In this paper the LC is approached from the point of view of the pathophysiological alterations present in LC patients previous to ICU admission, particularly cardiovascular, but also renal, coagulopathic, and encephalopathic. Infections and available liver detoxifications devices also deserve mentioning. We intend to contribute towards ICU physician readiness to the care for this particular type of patients, possibly in dedicated ICUs.

Renal failure and hyponatremia in patients with cirrhosis and skin and soft tissue infection. A retrospective study

BACKGROUND & AIMS

Skin and soft tissue infection in cirrhosis is considered a non-severe infection, but specific information is lacking. This study aimed at assessing the characteristics, occurrence of renal failure, and outcome of cirrhotic patients with skin and soft tissue infection.

METHODS

Ninety-two patients with cirrhosis and skin and soft tissue infection admitted to hospital within a 6-year period were retrospectively analyzed. A control group matched by severity of liver disease, admitted for reasons other than infection, was also studied.

RESULTS

Resolution of the infection was achieved in 96% of patients. Twenty (21.7%) patients with skin and soft tissue infection developed renal failure, compared to only five patients (5.4%) of the control group (p=0.001). Renal failure was persistent despite infection resolution in 10 of the 20 patients vs. none of the control group. Renal failure was associated with poor prognosis. Hyponatremia developed in 40% and 25% of the infection and control group, respectively (p=0.028). Within a 3-month follow-up period, 25 patients (23%) with skin and soft tissue infection died or were transplanted compared to only four patients (4%) of the control group (p<0.001). Factors independently associated with mortality in the infection group were: site of acquisition of the infection and MELD-sodium score at diagnosis.

CONCLUSIONS

Skin and soft tissue infection is a severe complication of cirrhosis with high frequency of renal failure and hyponatremia that may persist despite resolution of the infection. MELD-sodium score is useful to assess 3-month mortality in these patients.

Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study

Epidemiology, risk factors, and clinical effect of infections by multiresistant bacteria in cirrhosis are poorly known. This work was a prospective evaluation in two series of cirrhotic patients admitted with infection or developing infection during hospitalization. The first series was studied between 2005 and 2007 (507 bacterial infections in 223 patients) and the second between 2010 and 2011 (162 bacterial infections in 110 patients). In the first series, 32% of infections were community acquired (CA), 32% healthcare associated (HCA), and 36% nosocomial. Multiresistant bacteria (92 infections; 18%) were isolated in 4%, 14%, and 35% of these infections, respectively (P < 0.001). Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E; n = 43) was the main multiresistant organism identified, followed by Pseudomonas aeruginosa (n = 17), methicillin-resistant Staphylococcus aureus (n = 14), and Enterococcus faecium (n = 14). The efficacy of currently recommended empirical antibiotic therapy was very low in nosocomial infections (40%), compared to HCA and CA episodes (73% and 83%, respectively; P < 0.0001), particularly in spontaneous bacterial peritonitis, urinary tract infection, and pneumonia (26%, 29%, and 44%, respectively). Septic shock (26% versus 10%; P < 0.0001) and mortality rate (25% versus 12%; P = 0.001) were significantly higher in infections caused by multiresistant strains. Nosocomial origin of infection (hazard ratio [HR], 4.43), long-term norfloxacin prophylaxis (HR, 2.69), recent infection by multiresistant bacteria (HR, 2.45), and recent use of β-lactams (HR, 2.39) were independently associated with the development of multiresistant infections. Results in the second series were similar to those observed in the first series.

CONCLUSIONS

Multiresistant bacteria, especially ESBL-producing Enterobacteriaceae, are frequently isolated in nosocomial and, to a lesser extent, HCA infections in cirrhosis, rendering third-generation cephalosporins clinically ineffective. New antibiotic strategies tailored according to the local epidemiological patterns are needed for the empirical treatment of nosocomial infections in cirrhosis.

Renal failure and cirrhosis: a systematic review of mortality and prognosis

BACKGROUND & AIMS

To evaluate renal failure (RF) in cirrhosis to determine and quantify its prognostic significance.

METHODS

Studies were identified by MEDLINE, EMBASE, Cochrane, ISI Web of Science (1977-2010); search terms included renal failure, mortality, and cirrhosis. Included studies (n=74) reported >10 patients and mortality data (8088 patients). Mortality at 1, 3, and 12 months was evaluated with respect to Child-Pugh score, serum creatinine, ascites, ICU status or sepsis, prospective study design, and publication year. Pooled odds ratio (POR) for death was compared for RF vs. non-RF (5668 patients).

RESULTS

Overall median mortality for RF patients was 67%: 58% at 1 month and 63% (IQR 54-79) at 12 months. POR for death RF vs. non-RF patients was 7.6 (95%CI 5.4-10.8). Overall mortality before 2005 (1264 patients) was 74% and after 2005 (2833 patients) was 63% with a marked reduction only at 30 days (71% vs. 52%).

CONCLUSIONS

This study provides a measure of the increased risk of death in cirrhosis with renal failure. RF increases mortality 7-fold, with 50% of patients dying within one month. Preventative strategies for RF are needed.

[Complications of liver cirrhosis]

The occurrence of complications increases the mortality in patients with cirrhosis of the liver. Therefore, early detection and treatment of complications of cirrhosis is of major importance. Following diagnosis of cirrhosis, a screening gastroscopy detects esophageal varices. Primary prevention of variceal bleeding can be initiated with β-receptor antagonists or variceal band ligation. With the first episode of ascites or the manifestation of other complications of cirrhosis such as hepatic encephalopathy and hepatorenal syndrome, a paracentesis excludes spontaneous bacterial peritonitis. Hepatorenal syndrome can be treated with a combination of vasopressors and albumine. Furthermore, occurrence of complications in patients with cirrhosis of the liver should prompt the evaluation of an indication for liver transplantation.

Investigation of Bacteremia due to Aeromonas Species and Comparison with That due to Enterobacteria in Patients with Liver Cirrhosis

Background. The role of Aeromonas species (sp.) in bacteremia in Japanese patients with liver cirrhosis is poorly understood. Aim. To establish the importance of Aeromonas sp. as a cause of bacteremia in patients with liver cirrhosis. Methods. Clinical and serological features and short-term prognosis were retrospectively investigated and compared in Japanese patients with bacteremia due to Aeromonas sp. (n = 11) and due to enterobacteria (E. coli, Klebsiella sp., and Enterobacter sp.) (n = 84). Results. There were no significant differences in patients' clinical background, renal dysfunction, or short-term mortality rate between the two groups. However, in the Aeromonas group, the model for end-stage liver disease (MELD) score and Child-Pugh score were significantly higher than in the enterobacteria group. Conclusion. These results indicate that the severity of liver dysfunction in Aeromonas-induced bacteremia is greater than that in enterobacteria-induced bacteremia in Japanese patients with liver cirrhosis.

Systemic inflammatory response syndrome in patients with liver cirrhosis

BACKGROUND AND STUDY AIMS

Patients with liver cirrhosis present an increased susceptibility to the systemic inflammatory response syndrome (SIRS), which is considered the cause of hospital admission in about 10% of patients and is present in about 40% of those admitted for ongoing complications. We tried to assess the prevalence of the SIRS with the possible effects on the course of the disease during hospital stay.

PATIENTS AND METHODS

Two hundred and three patients with liver cirrhosis were examined and investigated with close monitoring during hospital stay. The main clinical endpoints were death and the development of portal hypertension-related complications.

RESULTS

Eighty-one patients met the criteria of SIRS (39.9%). We found significant correlations between SIRS and jaundice (p=0.005), bacterial infection (p=0.008), white blood cell count (p<0.001), low haemoglobin concentration (p=0.004), high serum creatinine levels (p<0.001), high alanine aminotransferase levels (p<0.001), serum bilirubin levels (p<0.001), international normalised ratio (p<0.001), serum albumin levels (p=0.033), high Child-Pugh score (p<0.001). During the follow-up period, 26 patients died (12.8%), 15 developed portal hypertension-related bleeding (7.3%), 30 developed hepatic encephalopathy (14.7%), and 9 developed hepatorenal syndrome type-1 (4.4%). SIRS showed significant correlations both to death (p<0.001) and to portal hypertension-related complications (p<0.001).

CONCLUSION

The systemic inflammatory response syndrome occurs in patients with advanced cirrhosis and is associated with a bad prognosis.