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Fernández J, Prado V, Trebicka J, Amoros A, Gustot T, Wiest R, Deulofeu C, Garcia E, Acevedo J, Fuhrmann V, Durand F, Sánchez C, Papp M, Caraceni P, Vargas V, Bañares R, Piano S, Janicko M, Albillos A, Alessandria C, Soriano G, Welzel TM, Laleman W, Gerbes A, De Gottardi A, Merli M, Coenraad M, Saliba F, Pavesi M, Jalan R, Ginès P, Angeli P, Arroyo V. Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe. J Hepatol 2019; 70:398-411. [PMID: 30391380 DOI: 10.1016/j.jhep.2018.10.027] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 10/23/2018] [Accepted: 10/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Antibiotic resistance has been increasingly reported in patients with decompensated cirrhosis in single-center studies. Prospective investigations reporting broad epidemiological data are scarce. We aimed to analyze epidemiological changes in bacterial infections in patients with decompensated cirrhosis. METHODS This was a prospective evaluation of 2 series of patients hospitalized with decompensated cirrhosis. The Canonic series included 1,146 patients from Northern, Southern and Western Europe in 2011. Data on epidemiology, clinical characteristics of bacterial infections, microbiology and empirical antibiotic schedules were assessed. A second series of 883 patients from Eastern, Southern and Western Europe was investigated between 2017-2018. RESULTS A total of 455 patients developed 520 infections (39.7%) in the first series, with spontaneous bacterial peritonitis, urinary tract infections and pneumonia the most frequent infections. Nosocomial episodes predominated in this series. Nearly half of the infections were culture-positive, of which 29.2% were caused by multidrug-resistant organisms (MDROs). MDR strains were more frequently isolated in Northern and Western Europe. Extended-spectrum beta-lactamase-producing Enterobacteriaceae were the most frequent MDROs isolated in this series, although prevalence and type differed markedly among countries and centers. Antibiotic resistance was associated with poor prognosis and failure of antibiotic strategies, based on third-generation cephalosporins or quinolones. Nosocomial infection (odds ratio [OR] 2.74; p < 0.001), intensive care unit admission (OR 2.09; p = 0.02), and recent hospitalization (OR 1.93; p = 0.04) were identified as independent predictors of MDR infection. The prevalence of MDROs in the second series (392 infections/284 patients) was 23%; 38% in culture-positive infections. A mild increase in the rate of carbapenem-resistant Enterobacteriaceae was observed in this series. CONCLUSIONS MDR bacterial infections constitute a prevalent, growing and complex healthcare problem in patients with decompensated cirrhosis and acute-on-chronic liver failure across Europe, negatively impacting on prognosis. Strategies aimed at preventing the spread of antibiotic resistance in cirrhosis should be urgently evaluated. LAY SUMMARY Infections caused by bacteria resistant to the main antibiotic families are prevalent in patients with cirrhosis. This study demonstrates that this healthcare problem is increasing and extends through all European regions. Infections caused by these difficult to treat bacteria resolve less frequently and often cause the death of the patient. The type of resistant bacteria varies markedly among different hospitals.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain.
| | - Verónica Prado
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jonel Trebicka
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; University of Bonn, Germany
| | - Alex Amoros
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Thierry Gustot
- Liver Transplant Unit, Erasme Hospital, Brussels, Belgium
| | - Reiner Wiest
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Carme Deulofeu
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Elisabet Garcia
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | | | | | | | - Cristina Sánchez
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Maria Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Hungary
| | | | - Victor Vargas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Vall d'Hebron, Barcelona, Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Gregorio Marañon, Madrid, Spain
| | | | | | | | | | - German Soriano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital of Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Andrea De Gottardi
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Faouzi Saliba
- Centre Hepato-Biliare, Hòpital Paul Brousse, Paris, France
| | - Marco Pavesi
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Rajiv Jalan
- ILDH, Division of Medicine, University College London Medical School, London, United Kingdom
| | - Pere Ginès
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain
| | | | - Vicente Arroyo
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
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152
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Zhao H, Zhao R, Hu J, Zhang X, Ma J, Shi Y, Ma W, Sheng J, Li L. Upper gastrointestinal hemorrhage in acute-on-chronic liver failure: prevalence, characteristics, and impact on prognosis. Expert Rev Gastroenterol Hepatol 2019; 13:263-269. [PMID: 30791764 DOI: 10.1080/17474124.2019.1567329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Upper gastrointestinal hemorrhage (UGH) is a life-threatening complication in patients with cirrhosis; however, data regarding the role of UGH in acute-on-chronic liver failure (ACLF) are limited. METHODS A prospective, observational cohort study was performed from February 2014 to Mach 2015. RESULTS UGH was identified in 170 of 492 cirrhotic patients with acute decompensation (AD) at the time of admission. Logistic regression analysis showed that fecal occult blood test positivity was an independent risk factor for UGH in patients with or without ACLF [OR(95%CI): 8.31(4.89-14.10), p < 0.001; and 6.29 (1.48-26.76), p = 0.031]. Other independent risk factors were a history of gastrointestinal bleeding [OR(95% CI): 13.43 (7.17-25.15), p < 0.001], older age [OR(95% CI): 0.98(0.96-0.99), p = 0.003], greater INR level [OR(95% CI): 0.48(0.28-0.81), p = 0.007] in patients without ACLF. Multivariate Cox proportional hazard model analysis indicated that UGH did not increase mortality at different times in cirrhotic patients with acute decompensation. CONCLUSIONS UGH is a frequent complication in cirrhotic patients with AD, even those with ACLF. Positive fecal occult blood tests and previous GI bleeding were shown to be associated with the risk of UGH. UGH did not significantly increase the risk of mortality in cirrhotic patients with AD or ACLF.
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Affiliation(s)
- Hong Zhao
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Ruihong Zhao
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jianhua Hu
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Xuan Zhang
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jianke Ma
- b Department of Infectious Diseases , Cixi People's Hospital , Cixi , China
| | - Yemin Shi
- c Department of Infectious Diseases , Yuyao People's Hospital , Ningbo , China
| | - Weihang Ma
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jifang Sheng
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Lanjuan Li
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
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Abstract
Alcoholic hepatitis is a unique type of alcohol-associated liver disease characterized by acute liver inflammation caused by prolonged heavy alcohol use. Treatment is mostly supportive. The short-term prognosis of acute alcoholic hepatitis depends on liver recovery, and ranges widely from rapid improvement to grim multiorgan failure despite treatment. Refinement of scoring systems have enhanced prognostication to guide clinical decision making in alcoholic hepatitis. Recent advances in the treatment of alcoholic hepatitis have solidified corticosteroids as the cornerstone of treatment to enhance short-term survival, but not intermediate or long-term survival.
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Affiliation(s)
- Gene Y Im
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, Recanati-Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029, USA.
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154
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Mani I, Alexopoulou A, Vasilieva L, Hadziyannis E, Agiasotelli D, Bei M, Alexopoulos T, Dourakis SP. Human beta-defensin-1 is a highly predictive marker of mortality in patients with acute-on-chronic liver failure. Liver Int 2019; 39:299-306. [PMID: 30261128 DOI: 10.1111/liv.13977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/16/2018] [Accepted: 09/19/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIM Human beta-defensin-1 (hBD-1) is a natural antimicrobial peptide expressed in the epithelia of multiple tissues including the digestive tract. In the current study, hBD-1 levels were determined in different subsets of patients with decompensated cirrhosis including acute-on-chronic liver failure (ACLF). In addition, the association with mortality of hBD-1, C-reactive protein (CRP) and procalcitonin (PCT) was assessed. METHODS A total of 125 patients were divided into three groups: 39 with ACLF (derivation cohort), 46 with acute decompensation without ACLF (AD) and 40 with decompensated cirrhosis without an acute event (DC). The data from 24 different ACLF patients were used for validation and 15 healthy individuals as control group. RESULTS Serum hBD-1, CRP and PCT levels were higher in ACLF compared to both AD and DC groups (P < 0.001). Healthy controls demonstrated similar hBD-1 and PCT values compared to DC group. In ROC curve, the performance of hBD-1 to predict 60-day mortality in ACLF group was similar in derivation and validation cohorts (c-statistic 0.834 and 0.879, respectively). CRP was a poor predictor of mortality. In ACLF group, patients with high hBD-1 (>36.625 ng/mL) had a poor prognosis at 60 days compared to those with lower values (log-rank P = 0.001). In Cox multivariate regression analysis, only hBD-1 (HR 1.020, 95%CI 1.006-1.035, P = 0.006) emerged as an independent predictor of death in ACLF group. In AD group, neither hBD-1 nor PCT or CRP variables were associated with mortality. CONCLUSIONS High hBD-1 was detected at presentation in patients with ACLF who died during follow-up period. hBD-1 is an accurate predictor of short-term mortality in patients with ACLF.
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Affiliation(s)
- Iliana Mani
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandra Alexopoulou
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Larisa Vasilieva
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Emilia Hadziyannis
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Danai Agiasotelli
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Myrianthi Bei
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Alexopoulos
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyros P Dourakis
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
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155
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Saleem S, Katragadda R, Weissman S, Bleibel W. Morbidity and mortality of infections in the cirrhotic patients: a US population-based study. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2019; 12:233-238. [PMID: 31528307 PMCID: PMC6668770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
AIM This study aims to investigate the morbidity, mortality, and health care utilization of infection in patients with cirrhosis, with the hope of making clinical recommendations. BACKGROUND The pathophysiology of liver cirrhosis makes patients susceptible to a variety of complications including infection. It contributes to a staggering rate of death and places a tremendous financial burden on the health care system. METHODS The pathophysiology of liver cirrhosis makes patients susceptible to a variety of complications including infection. It contributes to a staggering rate of death and places a tremendous financial burden on the health care system. RESULTS In this cross-sectional study, we queried the National Inpatient Sample (NIS) database for patients discharged from United States (US) hospitals with International classification of diseases (ICD) diagnostic codes consistent with liver cirrhosis, between January 2011 and December 2014. The patients were classified based upon the presence or absence of an infection, as well as their demographics and comorbidities. The data was then analyzed using the IBM SPSS version 25 statistical software. CONCLUSION From 2011 to 2014, 660,727 cirrhotic patients were identified. Of these, 20.6% were found to have an infection. The mortality rate during hospitalization was 4.7% of all cirrhotic patients. The hospital length of stay was significantly longer for the study group than the control group (8.22 days versus 5.11 days) (P <0.0001). Similarly, the mean hospital cost was higher in the study group compared to the control group ($74,729.53 ± $125,963.75 vs. $46,413.32 ± $71,936.50 P< 0.0001).
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Affiliation(s)
- Saad Saleem
- Division of Gastroenterology and Hepatology, Department of Medicine, Mercy St. Vincent Medical Centre, Toledo, Ohio, USA
| | - Rathnavali Katragadda
- Division of Gastroenterology and Hepatology, Department of Medicine, Mercy St. Vincent Medical Centre, Toledo, Ohio, USA
| | | | - Wissam Bleibel
- Division of Gastroenterology and Hepatology, Department of Medicine, Mercy St. Vincent Medical Centre, Toledo, Ohio, USA
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156
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Abstract
OBJECTIVES In a population-based study, we examined time trends in chronic liver disease (CLD)-related hospitalizations in a large and diverse metroplex. METHODS We examined all CLD-related inpatient encounters (2000-2015) in Dallas-Fort Worth (DFW) using data from the DFW council collaborative that captures claims data from 97% of all hospitalizations in DFW (10.7 million regional patients). RESULTS There were 83,539 CLD-related hospitalizations in 48,580 unique patients across 84 hospitals. The age and gender standardized annual rate of CLD-related hospitalization increased from 48.9 per 100,000 in 2000 to 125.7 per 100,000 in 2014. Mean age at hospitalization increased from 54.0 (14.1) to 58.5 (13.5) years; the proportion of CLD patients above 65 years increased from 24.2% to 33.1%. HCV-related hospitalizations plateaued, whereas an increase was seen in hospitalizations related to alcohol (9.1 to 22.7 per 100,000) or fatty liver (1.4 per 100,000 to 19.5 per 100,000). The prevalence of medical comorbidities increased for CLD patients: coronary artery disease (4.8% to 14.3%), obesity (2.8% to 14.6%), chronic kidney disease (2.8% to 18.2%), and diabetes (18.0% to 33.2%). Overall hospitalizations with traditional complications of portal hypertension (ascites, varices, and peritonitis) remained stable over time. However, hospitalization with complications related to infection increased from 54.7% to 66.4%, and renal failure increased by sevenfold (2.7% to 19.5%). CONCLUSIONS CLD-related hospitalizations have increased twofold over the last decade. Hospitalized CLD patients are older and sicker with multiple chronic conditions. Traditional complications of portal hypertension have been superseded by infection and renal failure, warranting a need to redefine what it means to have decompensated CLD.
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157
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Acharya C, Bajaj JS. Altered Microbiome in Patients With Cirrhosis and Complications. Clin Gastroenterol Hepatol 2019; 17:307-321. [PMID: 30099098 PMCID: PMC6314917 DOI: 10.1016/j.cgh.2018.08.008] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/06/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
In patients with cirrhosis, the gut microbiome are affected by multiple gut and systemic alterations. These changes lead to dysbiosis in the microbiota of different parts of the body, resulting in inflammation. The constant immune stimulation resulting in part from dysbiosis is associated with morbidity in patients with cirrhosis. Dysbiosis as a dynamic event worsens with decompensation such as with hepatic encephalopathy, infections or acute-on-chronic liver failure (ACLF). These microbial patterns could be applied as diagnostic and prognostic measures in cirrhosis in the outpatient and inpatient setting. Current therapies for cirrhosis have differing impacts on gut microbial composition and functionality. Dietary modifications and the oral cavity have emerged as newer targetable factors to modulate the microbiome, which could affect inflammation and, potentially improve outcomes. Additionally, fecal microbial transplant is being increasingly studied to provide compositional and functional modulation of the microbiome. Ultimately, a combination of targeted therapies may be needed to provide an optimal gut milieu to improve outcomes in cirrhosis.
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158
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Place of death and factors associated with hospital death in patients who have died from liver disease in England: a national population-based study. Lancet Gastroenterol Hepatol 2019; 4:52-62. [DOI: 10.1016/s2468-1253(18)30379-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 12/13/2022]
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159
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Dirchwolf M, Marciano S, Martínez J, Ruf AE. Unresolved issues in the prophylaxis of bacterial infections in patients with cirrhosis. World J Hepatol 2018; 10:892-897. [PMID: 30631393 PMCID: PMC6323518 DOI: 10.4254/wjh.v10.i12.892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/05/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
Bacterial infections are highly prevalent and a frequent cause of hospitalization and short-term mortality in patients with cirrhosis. Due to their negative impact on survival, antibiotic prophylaxis for bacterial infections in high-risk subgroups of patients with cirrhosis has been the standard of care for decades. Patients with prophylaxis indications include those at risk for a first episode of spontaneous bacterial peritonitis (SBP) due to a low ascitic fluid protein count and impaired liver and kidney function, patients with a prior episode of SBP and those with an episode of gastrointestinal bleeding. Only prophylaxis due to gastrointestinal bleeding has a known and short-time duration. All other indications imply long-lasting exposure to antibiotics - once the threshold requirement for initiating prophylaxis is met - without standardized criteria for re-assessing antibiotic interruption. Despite the fact that the benefit of antibiotic prophylaxis in reducing bacterial infections episodes and mortality has been thoroughly reported, the extended use of antibiotics in patients with cirrhosis has also had negative consequences, including the emergence of multi-drug resistant bacteria. Currently, it is not clear whether restricting the use of broad and fixed antibiotic regimens, tailoring the choice of antibiotics to local bacterial epidemiology or selecting non-antibiotic strategies will be the preferred antibiotic prophylaxis strategy for patients with cirrhosis in the future.
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Affiliation(s)
- Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario 2000, Argentina
| | - Sebastián Marciano
- Unidad de Hígado, and Departamento de Investigación del Hospital Italiano de Buenos Aires, Buenos Aires 1424, Argentina
| | - José Martínez
- Unidad de Hígado, Hospital Privado de Rosario, Rosario 2000, Argentina
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160
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Shao L, Ling Z, Chen D, Liu Y, Yang F, Li L. Disorganized Gut Microbiome Contributed to Liver Cirrhosis Progression: A Meta-Omics-Based Study. Front Microbiol 2018; 9:3166. [PMID: 30631318 PMCID: PMC6315199 DOI: 10.3389/fmicb.2018.03166] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/07/2018] [Indexed: 12/14/2022] Open
Abstract
Early detection and effective interventions for liver cirrhosis (LC) remain an urgent unmet clinical need. Inspired from intestinal disorders in LC patients, we investigated the associations between gut microbiome and disease progression based on a raw metagenomic dataset of 47 healthy controls, 49 compensated, and 46 decompensated LC patients from our previous study, and a metabolomic dataset of urine samples from the same controls/patients using ultra-performance liquid chromatography/mass spectrophotometry system. It was found that the combination and relative abundance of gut microbiome, the inter-microbiome regulatory networks, and the microbiome-host correlation patterns varied during disease progression. The significant reduction of bacteria involved in fermentation of plant cell wall polysaccharides and resistant starch (such as Alistipes sp. HG5, Clostridium thermocellum) contributed to the reduced supply of energy sources, the disorganized self-feeding and cross-feeding networks and the thriving of some opportunistic pathogens in genus Veillonella. The marked decrease of butyrate-producing bacteria and increase of Ruminococcus gnavus implicated in degradation of elements from the mucus layer provided an explanation for the impaired intestinal barrier function and systematic inflammation in LC patients. Our results pave the way for further developments in early detection and intervention of LC targeting on gut microbiome.
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Affiliation(s)
- Li Shao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zongxin Ling
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Deying Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yufeng Liu
- Pharmaceutical Informatics Institute, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Fengling Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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161
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Abstract
Alcohol-associated liver disease (AALD) is the third most common preventable cause for disease burden and mortality in the US. AALD, including alcoholic hepatitis (AH), contributes to half of admissions from decompensated liver disease and 20% of all liver transplants in the US. Peripheral blood cells contribute to systemic inflammation, oxidative stress, mitochondrial dysfunction, and fibrosis in AALD and AH. Alcohol dysregulates function of lymphocytes, neutrophils, monocytes, and tissue macrophages of the innate immune system. These alterations in turn can modulate adaptive immune responses. In this review, we describe these disruptive effects of alcohol on cells of the innate and adaptive immune system and focus on cellular-based emerging biomarkers on diagnosis and prognosis of patients with AALD and AH.
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Affiliation(s)
- Ashwani K. Singal
- *Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shannon M. Bailey
- †Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
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162
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Xu L, Ying S, Hu J, Wang Y, Yang M, Ge T, Huang C, Xu Q, Zhu H, Chen Z, Ma W. Pneumonia in patients with cirrhosis: risk factors associated with mortality and predictive value of prognostic models. Respir Res 2018; 19:242. [PMID: 30514312 PMCID: PMC6280505 DOI: 10.1186/s12931-018-0934-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/12/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cirrhosis always goes with profound immunity compromise, and makes those patients easily be the target of pneumonia. Cirrhotic patients with pneumonia have a dramatically increased mortality. To recognize the risk factors of mortality and to optimize stratification are critical for improving survival rate. METHODS Two hundred and three cirrhotic patients with pneumonia at a tertiary care hospital were included in this retrospective study. Demographical, clinical and laboratory parameters, severity models and prognosis were recorded. Multivariate Cox regression analysis was used to identify independent predictors of 30-day and 90-day mortality. Area under receiver operating characteristics curves (AUROC) was used to compare the predictive value of different prognostic scoring systems. RESULTS Patients with nosocomial acquired or community acquired pneumonia indicated similar prognosis after 30- and 90-day follow-up. However, patients triggered acute-on-chronic liver failure (ACLF) highly increased mortality (46.4% vs 4.5% for 30-day, 69.6% vs 11.2% for 90-day). Age, inappropriate empirical antibiotic therapy (HR: 2.326 p = 0.018 for 30-day and HR: 3.126 p < 0.001 for 90-day), bacteremia (HR: 3.037 p = 0.002 for 30-day and HR: 2.651 p = 0.001 for 90-day), white blood cell count (WBC) (HR: 1.452 p < 0.001 for 30-day and HR: 1.551 p < 0.001 for 90-day) and total bilirubin (HR: 1.059 p = 0.002 for 90-day) were independent factors for mortality in current study. Chronic liver failure-sequential organ failure assessment (CLIF-SOFA) displayed highest AUROC (0.89 and 0.90, 95% CI: 0.83-0.95 and 0.85-0.95 for 30-day and 90-day respectively) in current study. CONCLUSIONS This study found age, bacteremia, WBC, total bilirubin and inappropriate empirical antibiotic therapy were independently associated with increased mortality. Pneumonia triggered ACLF remarkably increased mortality. CLIF-SOFA was more accurate in predicting mortality than other five prognostic models (model for end-stage liver disease (MELD), MELD-Na, quick sequential organ failure assessment (qSOFA), pneumonia severity index (PSI), Child-Turcotte-Pugh (CTP) score).
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Affiliation(s)
- Lichen Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Shuangwei Ying
- Department of Hematology, Taizhou Hospital of Zhejiang Province, Linhai, Taizhou, China
| | - Jianhua Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Yunyun Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Meifang Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Tiantian Ge
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Chunhong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Qiaomai Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Haihong Zhu
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Zhi Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China.
| | - Weihang Ma
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China.
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Xiong J, Pu L, Xiong H, Xiang P, Zhang M, Liu J, Li A. Evaluation of the criteria of hepatorenal syndrome type of acute kidney injury in patients with cirrhosis admitted to ICU. Scand J Gastroenterol 2018; 53:1590-1596. [PMID: 30621473 DOI: 10.1080/00365521.2018.1545423] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a common and devastating complication in patients with cirrhosis. In 2015, the International Club of Ascites (ICA) proposed the definition of hepatorenal syndrome (HRS) type of AKI (HRS-AKI) in patients with cirrhosis. This study aims to evaluate the criteria of HRS-AKI in patients with cirrhosis admitted to ICU with regard to the prognosis. METHODS A total of 349 cirrhotic patients consecutively admitted to intensive care unit (ICU) from 2010 to 2017 were retrospectively analyzed. Demographic parameters and clinical variables were collected with case report forms. The occurrence of AKI was determined according to ICA-AKI criteria. The phenotypes of AKI comprised pre-renal azotemia (PRA), acute tubular necrosis (ATN) and HRS. In our study, patients with PRA or ATN were classified to the non-HRS-AKI group. RESULTS The incidence of AKI was 73.0%, comprising PRA (18.6%), ATN (16.3%) and HRS (38.1%). The overall hospital mortality was 64.5%. Patients with AKI had a significantly higher in-hospital (76.1%) and 180-d (86.7%) mortality. AKI type was an independent risk factor for in-hospital mortality by a multivariate logistic regression. The in-hospital and 180-d mortality rates were of no significant difference among patients with HRS-AKI stages 1-3. CONCLUSIONS AKI is common in patients with cirrhosis admitted to ICU, associated with significant in-hospital mortality. HRS-AKI was the most common and severe type of AKI in patients with cirrhosis admitted to ICU. The current staging system may not be applicable for HRS-AKI in patients with cirrhosis admitted to ICU.
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Affiliation(s)
- Jian Xiong
- a Department of Critical Care Medicine , Beijing Ditan Hospital, Capital Medical University , Beijing , PR China
| | - Lin Pu
- a Department of Critical Care Medicine , Beijing Ditan Hospital, Capital Medical University , Beijing , PR China
| | - Haofeng Xiong
- a Department of Critical Care Medicine , Beijing Ditan Hospital, Capital Medical University , Beijing , PR China
| | - Pan Xiang
- a Department of Critical Care Medicine , Beijing Ditan Hospital, Capital Medical University , Beijing , PR China
| | - Ming Zhang
- a Department of Critical Care Medicine , Beijing Ditan Hospital, Capital Medical University , Beijing , PR China
| | - Jingyuan Liu
- a Department of Critical Care Medicine , Beijing Ditan Hospital, Capital Medical University , Beijing , PR China
| | - Ang Li
- a Department of Critical Care Medicine , Beijing Ditan Hospital, Capital Medical University , Beijing , PR China
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Ferstl PG, Müller M, Filmann N, Hogardt M, Kempf VA, Wichelhaus TA, Lange CM, Vermehren J, Zeuzem S, Reinheimer C, Waidmann O. Noninvasive screening identifies patients at risk for spontaneous bacterial peritonitis caused by multidrug-resistant organisms. Infect Drug Resist 2018; 11:2047-2061. [PMID: 30464547 PMCID: PMC6223386 DOI: 10.2147/idr.s172587] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and aims Spontaneous bacterial peritonitis (SBP) is a severe complication of decompensated cirrhosis. The prevalence of multidrug-resistant organisms (MDROs) in patients with cirrhosis is increasing. Identification of patients at risk for SBP due to MDROs (ie, SBP with the evidence of MDROs or Stenotrophomonas maltophilia in ascitic culture, MDRO-SBP) is crucial to the early adaptation of antibiotic treatment in such patients. We therefore investigated whether MDROs found in ascitic cultures can also be found in specimens determined by noninvasive screening procedures. Patients and methods This retrospective study was conducted at the liver center of the University Hospital Frankfurt, Germany. Between 2011 and 2016, patients with cirrhosis were included upon diagnosis of SBP and sample collection of aerobic/anaerobic ascitic cultures. Furthermore, the performance of at least one complete MDRO screening was mandatory for study inclusion. Results Of 133 patients diagnosed with SBP, 75 (56.4%) had culture-positive SBP and 22 (16.5%) had MDRO-SBP. Multidrug-resistant Escherichia coli (10/22; 45.5%) and vancomycin-resistant enterococci (7/22; 36.4%) resembled the major causatives of MDRO-SBP. Rectal swabs identified MDROs in 17 of 22 patients (77.3%) who developed MDRO-SBP with a time-dependent sensitivity of 77% and 87% after 30 and 90 days upon testing, while negative predictive value was 83% and 76%, respectively. The majority of patients were included from intensive care unit or intermediate care unit. Conclusion MDRO screening may serve as a noninvasive diagnostic tool to identify patients at risk for MDRO-SBP. Patients with decompensated cirrhosis should be screened for MDROs from the first day of inpatient treatment onward.
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Affiliation(s)
- Philip G Ferstl
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Mona Müller
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Hogardt
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany, .,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center of Competence for Infection Control at the Universities Frankfurt, Giessen, and Marburg, Frankfurt am Main, State of Hesse, Germany
| | - Volkhard Aj Kempf
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany, .,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center of Competence for Infection Control at the Universities Frankfurt, Giessen, and Marburg, Frankfurt am Main, State of Hesse, Germany
| | - Thomas A Wichelhaus
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany, .,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center of Competence for Infection Control at the Universities Frankfurt, Giessen, and Marburg, Frankfurt am Main, State of Hesse, Germany
| | - Christian M Lange
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Johannes Vermehren
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Stefan Zeuzem
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
| | - Claudia Reinheimer
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany, .,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center of Competence for Infection Control at the Universities Frankfurt, Giessen, and Marburg, Frankfurt am Main, State of Hesse, Germany
| | - Oliver Waidmann
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany, .,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany,
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165
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Rice J, Dodge JL, Bambha KM, Bajaj JS, Reddy KR, Gralla J, Ganapathy D, Mitrani R, Reuter B, Palecki J, Acharya C, Shaw J, Burton JR, Biggins SW. Neutrophil-to-Lymphocyte Ratio Associates Independently With Mortality in Hospitalized Patients With Cirrhosis. Clin Gastroenterol Hepatol 2018; 16:1786-1791.e1. [PMID: 29705264 DOI: 10.1016/j.cgh.2018.04.045] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/15/2018] [Accepted: 04/17/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The neutrophil to lymphocyte ratio (NLR) is a biomarker of immune dysregulation in patients with cirrhosis and is inexpensive to measure. We investigated the association between NLR and mortality in hospitalized patients with cirrhosis at 4 liver transplant centers, controlling for severity of acute-on-chronic liver failure (ACLF). METHODS We performed a retrospective study using data from the North American Consortium for the Study of End-stage Liver Disease on patients with index hospitalizations for cirrhosis from December 2011 through December 2016. We collected data on patient demographics, NLR, model for end-stage liver disease (MELD) scores, serum levels of Na, cirrhosis stages, infections, hepatocellular carcinomas, and ACLF severity (based on number of organ failures). Competing risk regression analysis evaluated mortality within 1 year after hospital discharge, accounting for competing events (liver transplant). RESULTS At admission, the patients' mean age was 57 years, mean MELD score was 21, and mean serum level of Na was 134 mmol/L. Sixty-eight patients had no organ failure, 21 patients had 1 organ failures, 7 patients had 2 organ failures, 4 patients had 3 organ failures, and 1 patient had 4 organ failures; 36% of the patients had confirmed or suspected infections. In univariate models, risk of death associated with increasing NLR, up to a value of 8 (hazard ratio [HR]= 1.14; 95% CI, 1.07-1.20; P < .001), and NLR quartile (for NLR range of 3-5, HR = 2.17; for NLR range of >5-9, HR=2.46; for NLR quartile >9, HR=2.84 vs the lowest quartile [NLR<3]) (P ≤ .001). The NLR remained statistically significant in multivariable models, adjusting for age, MELD score, hepatocellular carcinoma, and ACLF severity. Additionally, NLR was a statistically significant independent predictor of length of index hospital stay and mortality within 90 days after discharge. CONCLUSION In a retrospective analysis of patients with cirrhosis, we found NLR to associate with death within 1 year after non-elective hospitalization. In these patients, the risk of death associated with acute immune dysregulation persists long after their initial hospitalization.
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Affiliation(s)
- Jonathan Rice
- Division of Gastroenterology, University of Colorado, Aurora, Colorado
| | - Jennifer L Dodge
- Center for Liver Investigation Fostering Discovery (C-LIFE), University of Washington, Seattle, Washington; Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Kiran M Bambha
- Center for Liver Investigation Fostering Discovery (C-LIFE), University of Washington, Seattle, Washington; Division of Gastroenterology, University of Washington, Seattle, Washington
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia; Division of Gastroenterology, McGuire VA Medical Center, Richmond, Virginia
| | - K Rajender Reddy
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane Gralla
- Division of Gastroenterology, University of Colorado, Aurora, Colorado
| | - Dinesh Ganapathy
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia; Division of Gastroenterology, McGuire VA Medical Center, Richmond, Virginia
| | - Robert Mitrani
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bradley Reuter
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia; Division of Gastroenterology, McGuire VA Medical Center, Richmond, Virginia
| | - Julia Palecki
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chathur Acharya
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia; Division of Gastroenterology, McGuire VA Medical Center, Richmond, Virginia
| | - Jawaid Shaw
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia; Division of Gastroenterology, McGuire VA Medical Center, Richmond, Virginia
| | - James R Burton
- Division of Gastroenterology, University of Colorado, Aurora, Colorado
| | - Scott W Biggins
- Center for Liver Investigation Fostering Discovery (C-LIFE), University of Washington, Seattle, Washington; Division of Gastroenterology, University of Washington, Seattle, Washington.
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Rout G, Jadaun SS, Ranjan G, Kedia S, Gunjan D, Nayak B, Acharya SK, Kumar A, Kapil A. Prevalence, predictors and impact of bacterial infection in acute on chronic liver failure patients. Dig Liver Dis 2018; 50:1225-1231. [PMID: 29910108 DOI: 10.1016/j.dld.2018.05.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/18/2018] [Accepted: 05/20/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute on chronic liver failure (ACLF) is associated with high short term mortality. We aimed to evaluate the prevalence, predictors and impact of bacterial infection in ACLF. METHODS Consecutive hospitalized patients with cirrhosis and acute decompensation (AD), from January 2011-March 2017, were included. Predictors of survival and infection were assessed. RESULTS 572 patients with cirrhosis and AD were classified into 3 groups - no infection (group 1, n = 190, 33.2%), infection at admission/within 48 h (group 2, n = 298, 52.1%) and infection after 48 h (group 3, n = 84, 14.7%). Higher frequency of organ failures - kidney, brain, circulation and respiratory failure - were seen in groups 2 and 3 as compared with group 1 (P < 0.001 for all). Most common site of infection was lungs, followed by spontaneous bacterial peritonitis and urinary tract infection. The frequency of infection increased with higher ACLF grades. Among ACLF patients, on Cox-proportional multivariate analysis, presence of infection was associated with significantly higher mortality [group 2 (HR 2.93; 95%CI, 1.97-4.38, P < 0.001) and group 3 (HR 1.84; 95%CI, 1.16-2.91, P = 0.009)], as compared with group 1. On multivariate logistic regression analysis, advanced hepatic encephalopathy and elevated total leucocyte count were independently associated with development of infection. CONCLUSIONS Infections are common in ACLF, and associated with poor outcome.
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Affiliation(s)
- Gyanranjan Rout
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Shekhar S Jadaun
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Gyan Ranjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Baibaswata Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Subrat Kumar Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Ajay Kumar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research, New Delhi, India, India.
| | - Arti Kapil
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India, India.
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Habib S, Patel N, Yarlagadda S, Hsu CH, Patel S, Schader L, Walker C, Twesigye I. Safety and efficacy of antibiotics among acutely decompensated cirrhosis patients. J Gastroenterol Hepatol 2018; 33:1882-1888. [PMID: 29697158 DOI: 10.1111/jgh.14267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/02/2018] [Accepted: 04/10/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Infection is a leading precipitant of acute-on-chronic liver failure. This study aims to determine the safety and efficacy of antibiotics within acute-on-chronic liver failure. METHODS Retrospective study of 457 acute-on-chronic liver failure patients admitted to the University of Arizona Health Network between January 1 and December 31, 2014. Eligibility criteria were as follows: at least 18 years of age and 6 months follow-up, data available to calculate systemic inflammatory response syndrome (SIRS), and acute-on-chronic liver failure. This study collected patient's clinical features and historical data. Key data points were infection, antibiotic use, and SIRS. This study used Cox proportional hazards to model the effects of clinical factors on risk of death. RESULTS A total of 521 of 1243 met the inclusion criteria, and 64 had missing data, leaving 457 patients. Infection resulted in higher hazard (hazard ratio [HR] = 1.6, confidence interval [CI]: 1.1-1.3, P = 0.01). Patients with infections and antibiotics, compared with non-infected patients without antibiotics, had higher hazard (HR = 1.633, CI: 1.022-2.609, P = .04). Of those infected patients with antibiotics, SIRS patients experienced higher hazard (HR = 1.9, CI: 1.1-3.0, P = .007). Multivariable Cox proportional hazards associated the following with higher hazard: SIRS (HR = 1.866, CI: 1.242-2.804, P = 0.003), vancomycin (HR = 1.640, CI: 1.119-2.405, P = 0.011), Model for End-Stage Liver Disease (HR = 1.051, CI: 1.030-1.073, P < 0.001), gastrointestinal bleeding (HR = 1.727, CI: 1.180-2.527, P = 0.005), and hepatic encephalopathy (HR = 1.807, CI: 1.247-2.618, P = 0.002). CONCLUSION Overall, treatment of infection with antibiotics did not improve survival; however, patients not meeting SIRS criteria had better outcomes, and vancomycin was associated with poorer survival among acute-on-chronic liver failure patients.
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Affiliation(s)
| | - Nehali Patel
- Department of Medicine, College of Medicine Tucson, The University of Arizona, Tucson, Arizona, USA
| | | | - Chiu-Hsieh Hsu
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Arizona, USA
| | - Sarah Patel
- Department of Medicine, College of Medicine Tucson, The University of Arizona, Tucson, Arizona, USA
| | | | - Courtney Walker
- Department of Medicine, College of Medicine Tucson, The University of Arizona, Tucson, Arizona, USA
| | - Innocent Twesigye
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Arizona, USA
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China L, Skene SS, Bennett K, Shabir Z, Hamilton R, Bevan S, Chandler T, Maini AA, Becares N, Gilroy D, Forrest EH, O’Brien A. ATTIRE: Albumin To prevenT Infection in chronic liveR failurE: study protocol for an interventional randomised controlled trial. BMJ Open 2018; 8:e023754. [PMID: 30344180 PMCID: PMC6196858 DOI: 10.1136/bmjopen-2018-023754] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Circulating prostaglandin E2 levels are elevated in acutely decompensated cirrhosis and have been shown to contribute to immune suppression. Albumin binds to and inactivates this immune-suppressive lipid mediator. Human albumin solution (HAS) could thus be repurposed as an immune-restorative drug in these patients.This is a phase III randomised controlled trial (RCT) to verify whether targeting a serum albumin level of ≥35 g/L in hospitalised patients with decompensated cirrhosis using repeated intravenous infusions of 20% HAS will reduce incidence of infection, renal dysfunction and mortality for the treatment period (maximum 14 days or discharge if <14 days) compared with standard medical care. METHODS AND ANALYSIS Albumin To prevenT Infection in chronic liveR failurE stage 2 is a multicentre, open-label, interventional RCT. Patients with decompensated cirrhosis admitted to the hospital with a serum albumin of <30 g/L are eligible, subject to exclusion criteria. Patients randomised to intravenous HAS will have this administered, according to serum albumin levels, for up to 14 days or discharge. The infusion protocol aims to increase serum albumin to near-normal levels.The composite primary endpoint is: new infection, renal dysfunction or mortality within the trial treatment period. Secondary endpoints include mortality at up to 6 months, incidence of other organ failures, cost-effectiveness and quality of life outcomes and time to liver transplant. The trial will recruit 866 patients at more than 30 sites across the UK. ETHICSANDDISSEMINATION Research ethics approval was given by the London-Brent research ethics committee (ref: 15/LO/0104). The clinical trials authorisation was issued by the medicines and healthcare products regulatory agency (ref: 20363/0350/001-0001). The trial is registered with the European Medicines Agency (EudraCT 2014-002300-24) and has been adopted by the National Institute for Health Research (ISRCTN 14174793). This manuscript refers to version 6.0 of the protocol. Results will be disseminated through peer-reviewed journals and international conferences. Recruitment of the first participant occurred on 25 January 2016.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, London, UK
| | - Simon S Skene
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Kate Bennett
- Comprehensive Clinical Trials Unit, UCL, London, UK
| | | | | | - Scott Bevan
- Comprehensive Clinical Trials Unit, UCL, London, UK
| | | | | | | | - Derek Gilroy
- Division of Medicine, University College London, London, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
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Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24:4311-4329. [PMID: 30344417 PMCID: PMC6189843 DOI: 10.3748/wjg.v24.i38.4311] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/11/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.
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Affiliation(s)
- Elda Righi
- Department of Infectious Diseases, Santa Maria della Misericordia University Hospital, Udine 33100, Italy
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Bajaj JS, Moreau R, Kamath PS, Vargas HE, Arroyo V, Reddy KR, Szabo G, Tandon P, Olson J, Karvellas C, Gustot T, Lai JC, Wong F. Acute-on-Chronic Liver Failure: Getting Ready for Prime Time? Hepatology 2018; 68:1621-1632. [PMID: 29689120 DOI: 10.1002/hep.30056] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/19/2018] [Indexed: 02/06/2023]
Abstract
UNLABELLED Acute on chronic liver failure (ACLF) is the culmination of chronic liver disease and extrahepatic organ failures, which is associated with a high short-term mortality and immense health care expenditure. There are varying definitions for organ failures and ACLF in Europe, North America, and Asia. These differing definitions need to be reconciled to enhance progress in the field. The pathogenesis of ACLF is multifactorial and related to interactions between the immunoinflammatory system, microbiota, and the various precipitating factors. Individual organ failures related to the kidney, brain, lungs, and circulation have cumulative adverse effects on mortality and are often complicated or precipitated by infections. Strategies to prevent and rapidly treat these organ failures are paramount in improving survival. With the aging population and paucity of organs for liver transplant, the prognosis of ACLF patients is poor, highlighting the need for novel therapeutic strategies. The role of liver transplant in ACLF is evolving and needs further investigation across large consortia. A role for early palliative care and management of frailty as approaches to alleviate disease burden and improve patient-reported outcomes is being increasingly recognized. CONCLUSION ACLF is a clinically relevant syndrome that is epidemic worldwide and requires a dedicated multinational approach focused on prognostication and management; investigations are underway worldwide to prepare ACLF for prime time. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Richard Moreau
- INSERM, Université Paris Diderot-Paris 7, Centre de Recherche sur l'Inflammation, Paris, France; Département Hospitalo-Universitaire UNITY, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
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Li Y, Chaiteerakij R, Kwon JH, Jang JW, Lee HL, Cha S, Ding XW, Thongprayoon C, Ha FS, Nie CY, Zhang Q, Yang Z, Giama NH, Roberts LR, Han T. A model predicting short-term mortality in patients with advanced liver cirrhosis and concomitant infection. Medicine (Baltimore) 2018; 97:e12758. [PMID: 30313084 PMCID: PMC6203558 DOI: 10.1097/md.0000000000012758] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Infection is a common cause of death in patients with advanced cirrhosis. We aimed to develop a predictive model in Child-Turcotte-Pugh (CTP) class C cirrhotics hospitalized with infection for optimizing treatment and improving outcomes.Clinical information was retrospectively abstracted from 244 patients at Tianjin Third Central Hospital, China (cohort 1). Factors associated with mortality were determined using logistic regression. The model for predicting 90-day mortality was then constructed by decision tree analysis. The model was further validated in 91 patients at Mayo Clinic, Rochester, MN (cohort 2) and 82 patients at Seoul St. Mary's Hospital, Korea (cohort 3). The predictive performance of the model was compared with that of the CTP, model for end-stage liver disease (MELD), MELD-Na, Chronic Liver Failure-Sequential Organ Failure Assessment, and the North American consortium for the Study of End-stage Liver Disease (NACSELD) models.The 3-month mortality was 58%, 58%, and 54% in cohort 1, 2, and 3, respectively. In cohort 1, respiratory failure, renal failure, international normalized ratio, total bilirubin, and neutrophil percentage were determinants of 3-month mortality, with odds ratios of 16.6, 3.3, 2.0, 1.1, and 1.03, respectively (P < .05). These parameters were incorporated into the decision tree model, yielding area under receiver operating characteristic (AUROC) of 0.804. The model had excellent reproducibility in the U.S. (AUROC 0.808) and Korea cohort (AUROC 0.809). The proposed model has the highest AUROC and best Youden index of 0.488 and greatest overall correctness of 75%, compared with other models evaluated.The proposed model reliably predicts survival of advanced cirrhotics with infection in both Asian and U.S.
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Affiliation(s)
- Ying Li
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Roongruedee Chaiteerakij
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jung Hyun Kwon
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon
| | - Jeong Won Jang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hae Lim Lee
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Stephen Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN
| | - Xi Wei Ding
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Charat Thongprayoon
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Fu Shuang Ha
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
| | - Cai Yun Nie
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
| | - Qian Zhang
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
| | - Zhen Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Nasra H. Giama
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Lewis R. Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Tao Han
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
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Sundaram V, Jalan R, Ahn JC, Charlton MR, Goldberg DS, Karvellas CJ, Noureddin M, Wong RJ. Class III obesity is a risk factor for the development of acute-on-chronic liver failure in patients with decompensated cirrhosis. J Hepatol 2018; 69:617-625. [PMID: 29709681 DOI: 10.1016/j.jhep.2018.04.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 03/10/2018] [Accepted: 04/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is a syndrome of systemic inflammation and organ failures. Obesity, also characterized by chronic inflammation, is a risk factor among patients with cirrhosis for decompensation, infection, and mortality. Our aim was to test the hypothesis that obesity predisposes patients with decompensated cirrhosis to the development of ACLF. METHODS We examined the United Network for Organ Sharing (UNOS) database, from 2005-2016, characterizing patients at wait-listing as non-obese (body mass index [BMI] <30), obese class I-II (BMI 30-39.9) and obese class III (BMI ≥40). ACLF was determined based on the CANONIC study definition. We used Cox proportional hazards regression to assess the association between obesity and ACLF development at liver transplantation (LT). We confirmed our findings using the Nationwide Inpatient Sample (NIS), years 2009-2013, using validated diagnostic coding algorithms to identify obesity, hepatic decompensation and ACLF. Logistic regression evaluated the association between obesity and ACLF occurrence. RESULTS Among 387,884 patient records of decompensated cirrhosis, 116,704 (30.1%) were identified as having ACLF in both databases. Multivariable modeling from the UNOS database revealed class III obesity to be an independent risk factor for ACLF at LT (hazard ratio 1.24; 95% CI 1.09-1.41; p <0.001). This finding was confirmed using the NIS (odds ratio 1.30; 95% CI 1.25-1.35; p <0.001). Regarding specific organ failures, analysis of both registries demonstrated patients with class I-II and class III obesity had a greater prevalence of renal failure. CONCLUSION Class III obesity is a newly identified risk factor for ACLF development in patients with decompensated cirrhosis. Obese patients have a particularly high prevalence of renal failure as a component of ACLF. These findings have important implications regarding stratifying risk and preventing the occurrence of ACLF. LAY SUMMARY In this study, we identify that among patients with decompensated cirrhosis, class III obesity (severe/morbid obesity) is a modifiable risk factor for the development of acute-on-chronic liver failure (ACLF). We further demonstrate that regarding the specific organ failures associated with ACLF, renal failure is significantly more prevalent in obese patients, particularly those with class III obesity. These findings underscore the importance of weight management in cirrhosis, to reduce the risk of ACLF. Patients with class III obesity should be monitored closely for the development of renal failure.
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Affiliation(s)
- Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Joseph C Ahn
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | | | - David S Goldberg
- Department of Medicine and Department of Epidemiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Constantine J Karvellas
- Division of Gastroenterology and Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Mazen Noureddin
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA, United States
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173
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Trebicka J, Reiberger T, Laleman W. Gut-Liver Axis Links Portal Hypertension to Acute-on-Chronic Liver Failure. Visc Med 2018; 34:270-275. [PMID: 30345284 PMCID: PMC6189544 DOI: 10.1159/000490262] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Acute-on-chronic liver failure (ACLF) is considered a distinct syndrome in patients with liver disease, with systemic inflammation playing a central role. Portal hypertension (PHT) is also aggravated by inflammation and may subsequently impact the course of ACLF. PHT is more than just an increase in portal pressure in the portal venous system; it aggravates the course of liver disease and, thus, also facilitates the development of acute decompensation and ACLF. A critical mechanistic link between PHT and ACLF might be the gut-liver axis, which is discussed in this review.
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Affiliation(s)
- Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Institute for Bioengineering of Catalonia, Barcelona, Spain
| | - 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
| | - Wim Laleman
- Liver and Biliopancreatic Section, Department of Gastroenterology & Hepatology, Hospital Gasthuisberg, K.U. Leuven, Leuven, Belgium
- Laboratory of Hepatology, Department Chronic Diseases, Metabolism & Ageing (CHROMETA), KU Leuven, Leuven, Belgium
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174
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Engelmann C, Berg T. Management of Infectious Complications Associated with Acute-on-Chronic Liver Failure. Visc Med 2018; 34:261-268. [PMID: 30345283 DOI: 10.1159/000491107] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction Acute-on-chronic liver failure (ACLF) is associated with a high susceptibility to infections leading to complications and poor prognosis. The sensitized immune system overwhelmingly responds to invading bacteria leading to organ damage. After resolution of infection or prolonged disease duration, the phagocytic system becomes irresponsive with a reduced bacterial clearance capacity promoting secondary infection. Methods This review focuses on the best management strategies for patients with ACLF and infections. Using the following terms, an extensive literature research on the Medline database was performed: 'acute-on-chronic liver failure', 'infection', 'ACLF', 'bacteria', 'multi-resistance'. Results Analysis of the literature confirmed that delayed diagnosis and treatment of infections in patients with ACLF results in a poor prognosis. Patients with ACLF should be considered as having a potential infection and should undergo a complete screening for sepsis. Once biochemical analysis indicates a potential infection, such as abnormal levels of C-reactive protein and procalcitonin, antibiotic treatment should be initiated immediately without microbiological culture results. For community-acquired infections third-generation cephalosporins are still the first choice, whereas in the nosocomial setting antibiotics with broader spectrum, such as piperacillin/combactam or carbapenems ± glycopeptides, are preferred. The patient should be re-assessed 48 h after treatment initiation in order to tailor the treatment. Non-response is suspicious, likely due to bacterial resistance or fungal infection, which should be considered when choosing further treatment strategies. Albumin substitution to prevent hepatorenal syndrome and to improve patients' outcome is mandatory in patients with spontaneous bacterial peritonitis. Prophylactic antibiotic therapy is suitable to prevent infections in high-risk patients. Conclusion The screening for infections and its treatment is an essential part of managing patients with ACLF. In order to improve patients' prognosis, antibiotic treatment should be initiated once an infection is suspected. However, preventive strategies are already established and should be applied according to the guidelines.
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Affiliation(s)
- Cornelius Engelmann
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Thomas Berg
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
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175
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诸 聪, 卢 观, 祁 婷, 何 钦, 陈 永, 文 维, 周 福, 陈 金. [Long-term prognosis and quality of life of survivors with hepatitis B virus-related acute-on-chronic liver failure]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:736-741. [PMID: 29997098 PMCID: PMC6765706 DOI: 10.3969/j.issn.1673-4254.2018.06.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To explore the long-term prognosis and health-related quality of life of patients surviving hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). METHODS The clinical data were collected from patients with HBV-ACLF, who were hospitalized in our department between November, 2011 and October, 2016 and survived for more than 90 days. The patients were followed for occurrence of newly diagnosed cirrhosis, decompensation events, hepatocellular carcinoma and death. The quality of life of the patients was evaluated using SF-36 score, and the patients with chronic hepatitis B (CHB) and cirrhosis treated during the same period served as controls. RESULTS A total of 223 ACLF survivors were included in this study. According to the presence of cirrhosis on admission, the enrolled patients were divided into chronic hepatitis B-related ACLF (CHB-ACLF) group (n=130) and liver cirrhosis ACLF (CIR-ACLF) group (n=93). The 12-, 24- and 50-month survival rates in CHB-ACLF group were 97%, 95.7% and 93.9%, respectively, significantly higher than the rates in CIR-ACLF group (91%, 86% and 74%, respectively; P=0.007). In patients with CHB-ACLF, the 12-, 24- and 36-month progression rates of cirrhosis were 37.9%, 58.4% and 68.7% respectively. Multivariate Cox regression identified the peak value of serum creatinine (HR=1.015, P=0.026) and INR (HR=2.032, P=0.006) within 28 days as independent risk factors and serum sodium at baseline (HR=0.84, P=0.035) as an independent protective factor of occurrence of cirrhosis. The score of mental health on SF-36 in ACLF group was significantly lower than the national norms, and the scores for general health and body pain of ACLF patients were significantly higher than those in patients with CHB or cirrhosis. CONCLUSION The long-term prognosis of ACLF survivors with and without cirrhosis can be different. Acute attacks are associated with an increased rate of cirrhosis progression in CHB patients who recovered from ACLF, possibly in relation with the severity of extra-hepatic organ injuries. The physical and social functions of long-term survivors of ACLF do not significantly decline, but their psychological status can be affected.
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Affiliation(s)
- 聪妍 诸
- />南方医科大学南方医院肝病中心, 广东 广州 510515Center of Hepatology, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 观婷 卢
- />南方医科大学南方医院肝病中心, 广东 广州 510515Center of Hepatology, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 婷婷 祁
- />南方医科大学南方医院肝病中心, 广东 广州 510515Center of Hepatology, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 钦俊 何
- />南方医科大学南方医院肝病中心, 广东 广州 510515Center of Hepatology, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 永鹏 陈
- />南方医科大学南方医院肝病中心, 广东 广州 510515Center of Hepatology, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 维群 文
- />南方医科大学南方医院肝病中心, 广东 广州 510515Center of Hepatology, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 福元 周
- />南方医科大学南方医院肝病中心, 广东 广州 510515Center of Hepatology, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 金军 陈
- />南方医科大学南方医院肝病中心, 广东 广州 510515Center of Hepatology, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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176
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Krohn S, Zeller K, Böhm S, Chatzinotas A, Harms H, Hartmann J, Heidtmann A, Herber A, Kaiser T, Treuheit M, Hoffmeister A, Berg T, Engelmann C. Molecular quantification and differentiation of Candida species in biological specimens of patients with liver cirrhosis. PLoS One 2018; 13:e0197319. [PMID: 29897895 PMCID: PMC5999271 DOI: 10.1371/journal.pone.0197319] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/29/2018] [Indexed: 12/26/2022] Open
Abstract
Patients with liver cirrhosis are susceptible to fungal infections. Due to low sensitivity of culture-based methods, we applied a real-time PCR assay targeting the 18S rRNA gene in combination with direct sequencing and terminal-restriction fragment length polymorphism (T-RFLP) in order to establish a novel tool to detect fungal DNA and to quantify and differentiate Candida DNA, also in polyfungal specimens. In total, 281 samples (blood n = 135, ascites n = 92, duodenal fluid n = 54) from 135 patients with liver cirrhosis and 52 samples (blood n = 26, duodenal fluid n = 26) from 26 control patients were collected prospectively. Candida DNA was quantified in all samples. Standard microbiological culture was performed for comparison. Blood and ascites samples, irrespective of the patient cohort, showed a method-independent low fungal detection rate of approximately 1%, and the Candida DNA content level did not exceed 3.0x101 copies ml-1 in any sample. In contrast, in duodenal fluid of patients with liver cirrhosis high fungal detection rates were discovered by using both PCR- and culture-based techniques (81.5% vs. 66.7%; p = 0.123) and the median level of Candida DNA was 3.8x105 copies ml-1 (2.3x102-6.3x109). In cirrhosis and controls, fungal positive culture results were confirmed by PCR in 96% and an additional amount of 44% of culture negative duodenal samples were PCR positive. Using T-RFLP analysis in duodenal samples, overall 85% of results from microbial culture were confirmed and in 75% of culture-negative but PCR-positive samples additional Candida species could be identified. In conclusion, PCR-based methods and subsequent differentiation of Candida DNA might offer a quick approach to identifying Candida species without prior cultivation.
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Affiliation(s)
- Sandra Krohn
- University Hospital Leipzig, Section of Hepatology, Clinic of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
- Helmholtz Centre for Environmental Research—UFZ, Department of Environmental Microbiology, Leipzig, Germany
- * E-mail:
| | - Katharina Zeller
- University Hospital Leipzig, Section of Hepatology, Clinic of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Stephan Böhm
- Ludwig Maximilians-University, Max von Pettenkofer-Institute for Hygiene and Clinical Microbiology, Munich, Germany
| | - Antonis Chatzinotas
- Helmholtz Centre for Environmental Research—UFZ, Department of Environmental Microbiology, Leipzig, Germany
| | - Hauke Harms
- Helmholtz Centre for Environmental Research—UFZ, Department of Environmental Microbiology, Leipzig, Germany
| | - Jan Hartmann
- Department of Gastroenterology and Hepatology, Hospital and Outpatient Clinic for Internal Medicine A, Ernst Moritz Arndt University of Greifswald, Greifswald, Germany
| | - Anett Heidtmann
- Helmholtz Centre for Environmental Research—UFZ, Department of Environmental Microbiology, Leipzig, Germany
| | - Adam Herber
- University Hospital Leipzig, Section of Hepatology, Clinic of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Thorsten Kaiser
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig, Germany
| | - Maud Treuheit
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Interdisciplinary Endoscopy Unit, Clinic of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Thomas Berg
- University Hospital Leipzig, Section of Hepatology, Clinic of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Cornelius Engelmann
- University Hospital Leipzig, Section of Hepatology, Clinic of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
- University College London, Institute for Liver and Digestive Health, Royal Free Campus, London, United Kingdom
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177
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Bernsmeier C, Triantafyllou E, Brenig R, Lebosse FJ, Singanayagam A, Patel VC, Pop OT, Khamri W, Nathwani R, Tidswell R, Weston CJ, Adams DH, Thursz MR, Wendon JA, Antoniades CG. CD14 + CD15 - HLA-DR - myeloid-derived suppressor cells impair antimicrobial responses in patients with acute-on-chronic liver failure. Gut 2018; 67:1155-1167. [PMID: 28592438 PMCID: PMC5969362 DOI: 10.1136/gutjnl-2017-314184] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Immune paresis in patients with acute-on-chronic liver failure (ACLF) accounts for infection susceptibility and increased mortality. Immunosuppressive mononuclear CD14+HLA-DR- myeloid-derived suppressor cells (M-MDSCs) have recently been identified to quell antimicrobial responses in immune-mediated diseases. We sought to delineate the function and derivation of M-MDSC in patients with ACLF, and explore potential targets to augment antimicrobial responses. DESIGN Patients with ACLF (n=41) were compared with healthy subjects (n=25) and patients with cirrhosis (n=22) or acute liver failure (n=30). CD14+CD15-CD11b+HLA-DR- cells were identified as per definition of M-MDSC and detailed immunophenotypic analyses were performed. Suppression of T cell activation was assessed by mixed lymphocyte reaction. Assessment of innate immune function included cytokine expression in response to Toll-like receptor (TLR-2, TLR-4 and TLR-9) stimulation and phagocytosis assays using flow cytometry and live cell imaging-based techniques. RESULTS Circulating CD14+CD15-CD11b+HLA-DR- M-MDSCs were markedly expanded in patients with ACLF (55% of CD14+ cells). M-MDSC displayed immunosuppressive properties, significantly decreasing T cell proliferation (p=0.01), producing less tumour necrosis factor-alpha/interleukin-6 in response to TLR stimulation (all p<0.01), and reduced bacterial uptake of Escherichia coli (p<0.001). Persistently low expression of HLA-DR during disease evolution was linked to secondary infection and 28-day mortality. Recurrent TLR-2 and TLR-4 stimulation expanded M-MDSC in vitro. By contrast, TLR-3 agonism reconstituted HLA-DR expression and innate immune function ex vivo. CONCLUSION Immunosuppressive CD14+HLA-DR- M-MDSCs are expanded in patients with ACLF. They were depicted by suppressing T cell function, attenuated antimicrobial innate immune responses, linked to secondary infection, disease severity and prognosis. TLR-3 agonism reversed M-MDSC expansion and innate immune function and merits further evaluation as potential immunotherapeutic agent.
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Affiliation(s)
- Christine Bernsmeier
- Institute of Liver Studies, King’s College Hospital, King’s College London, London, UK,Liver Biology Laboratory, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Evangelos Triantafyllou
- Institute of Liver Studies, King’s College Hospital, King’s College London, London, UK,Division of Digestive Diseases, St. Mary’s Campus, Imperial College London, London, UK,Institute of Immunology and Immunotherapy, NIHR Biomedical Research Unit, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Robert Brenig
- Liver Biology Laboratory, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Fanny J Lebosse
- Division of Digestive Diseases, St. Mary’s Campus, Imperial College London, London, UK
| | - Arjuna Singanayagam
- Institute of Liver Studies, King’s College Hospital, King’s College London, London, UK,Division of Digestive Diseases, St. Mary’s Campus, Imperial College London, London, UK,Institute of Immunology and Immunotherapy, NIHR Biomedical Research Unit, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Vishal C Patel
- Institute of Liver Studies, King’s College Hospital, King’s College London, London, UK
| | - Oltin T Pop
- Institute of Liver Studies, King’s College Hospital, King’s College London, London, UK
| | - Wafa Khamri
- Division of Digestive Diseases, St. Mary’s Campus, Imperial College London, London, UK
| | - Rooshi Nathwani
- Division of Digestive Diseases, St. Mary’s Campus, Imperial College London, London, UK
| | - Robert Tidswell
- Institute of Liver Studies, King’s College Hospital, King’s College London, London, UK
| | - Christopher J Weston
- Institute of Immunology and Immunotherapy, NIHR Biomedical Research Unit, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - David H Adams
- Institute of Immunology and Immunotherapy, NIHR Biomedical Research Unit, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Mark R Thursz
- Division of Digestive Diseases, St. Mary’s Campus, Imperial College London, London, UK
| | - Julia A Wendon
- Institute of Liver Studies, King’s College Hospital, King’s College London, London, UK
| | - Charalambos Gustav Antoniades
- Institute of Liver Studies, King’s College Hospital, King’s College London, London, UK,Division of Digestive Diseases, St. Mary’s Campus, Imperial College London, London, UK,Institute of Immunology and Immunotherapy, NIHR Biomedical Research Unit, Centre for Liver Research, University of Birmingham, Birmingham, UK
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178
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O'Leary JG, Reddy KR, Garcia-Tsao G, Biggins SW, Wong F, Fallon MB, Subramanian RM, Kamath PS, Thuluvath P, Vargas HE, Maliakkal B, Tandon P, Lai J, Thacker LR, Bajaj JS. NACSELD acute-on-chronic liver failure (NACSELD-ACLF) score predicts 30-day survival in hospitalized patients with cirrhosis. Hepatology 2018; 67:2367-2374. [PMID: 29315693 DOI: 10.1002/hep.29773] [Citation(s) in RCA: 188] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 12/02/2017] [Accepted: 12/13/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED The North American Consortium for the Study of End-Stage Liver Disease's definition of acute-on-chronic liver failure (NACSELD-ACLF) as two or more extrahepatic organ failures has been proposed as a simple bedside tool to assess the risk of mortality in hospitalized patients with cirrhosis. We validated the NACSELD-ACLF's ability to predict 30-day survival (defined as in-hospital death or hospice discharge) in a separate multicenter prospectively enrolled cohort of both infected and uninfected hospitalized patients with cirrhosis. We used the NACSELD database of 14 tertiary care hepatology centers that prospectively enrolled nonelective hospitalized patients with cirrhosis (n = 2,675). The cohort was randomly split 60%/40% into training (n = 1,605) and testing (n = 1,070) groups. Organ failures assessed were (1) shock, (2) hepatic encephalopathy (grade III/IV), (3) renal (need for dialysis), and (4) respiratory (mechanical ventilation). Patients were most commonly Caucasian (79%) men (62%) with a mean age of 57 years and a diagnosis of alcohol-induced cirrhosis (45%), and 1,079 patients had an infection during hospitalization. The mean Model for End-Stage Liver Disease score was 19, and the median Child score was 10. No demographic differences were present between the two split groups. Multivariable modeling revealed that the NACSELD-ACLF score, as determined by number of organ failures, was the strongest predictor of decreased survival after controlling for admission age, white blood cell count, serum albumin, Model for End-Stage Liver Disease score, and presence of infection. The c-statistics were 0.8073 for the training set and 0.8532 for the validation set. CONCLUSION Although infection status remains an important predictor of death, NACSELD-ACLF was independently validated in a separate large multinational prospective cohort as a simple, reliable bedside tool to predict 30-day survival in both infected and uninfected patients hospitalized with a diagnosis of cirrhosis. (Hepatology 2018;67:2367-2374).
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Affiliation(s)
- Jacqueline G O'Leary
- Dallas VA Medical Center, Dallas, TX.,Baylor University Medical Center, Dallas, TX
| | | | | | | | | | | | | | | | | | | | | | | | - Jennifer Lai
- University of California, San Francisco, San Francisco, CA
| | - Leroy R Thacker
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
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179
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Bajaj JS, Liu EJ, Kheradman R, Fagan A, Heuman DM, White M, Gavis EA, Hylemon P, Sikaroodi M, Gillevet PM. Fungal dysbiosis in cirrhosis. Gut 2018; 67:1146-1154. [PMID: 28578302 DOI: 10.1136/gutjnl-2016-313170] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Cirrhotics have a high rate of infections, which are increasingly fungal or culture-negative in nature. While infected cirrhotics have bacterial dysbiosis, the role of fungi is unclear. We aimed to evaluate gut bacterial and fungal dysbiosis in cross-sectional and longitudinal analyses of outpatient and inpatient cirrhotics and prediction of hospitalisations. METHODS Cross-sectional: Age-matched controls, outpatients (with/without antibiotics) and hospitalised uninfected, culture-negative and culture-positive cirrhotics were included and followed for 90 days. Longitudinal: Three studies were conducted: (1) cirrhotics followed over 6 months, (2) outpatient cirrhotics administered antibiotics per standard of care for 5 days and (3) cirrhotics and controls administered omeprazole over 14 days. In all studies, stool bacterial/fungal profiles were analysed. RESULTS Cross-sectional: In 143 cirrhotics and 26 controls, bacterial and fungal diversities were significantly linked. Outpatients on antibiotics and patients with culture-positive infections had the lowest diversities. Bacterial and fungal correlations were complex in uninfected, outpatient and control groups but were markedly skewed in infected patients. 21% were admitted on 90-day follow-up. A lower Bacteroidetes/Ascomycota ratio was associated with lower hospitalisations. Longitudinal: Fungal and bacterial profiles were stable on follow-up (5 days and 6 months). After antibiotics, a significantly reduced bacterial and fungal diversity, higher Candida and lower autochthonous bacterial relative abundance were seen. After omeprazole, changes in bacterial diversity and composition were seen but fungal metrics remained stable. CONCLUSION There is a significant fungal dysbiosis in cirrhosis, which changes differentially with antibiotics and proton pump inhibitor use, but is otherwise stable over time. A combined bacterial-fungal dysbiosis metric, Bacteroidetes/Ascomycota ratio, can independently predict 90-day hospitalisations in patients with cirrhosis. CLINICAL TRIAL NUMBER NCT01458990.
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
| | - Eric J Liu
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | - Raffi Kheradman
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | - Andrew Fagan
- Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
| | - Douglas M Heuman
- Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
| | - Melanie White
- Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
| | - Edith A Gavis
- Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
| | - Phillip Hylemon
- Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
| | - Masoumeh Sikaroodi
- Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
| | - Patrick M Gillevet
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
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180
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China L, Skene SS, Shabir Z, Maini A, Sylvestre Y, Bennett K, Bevan S, O'Beirne J, Forrest E, Portal J, Ryder S, Wright G, Gilroy DW, O'Brien A. Administration of Albumin Solution Increases Serum Levels of Albumin in Patients With Chronic Liver Failure in a Single-Arm Feasibility Trial. Clin Gastroenterol Hepatol 2018; 16:748-755.e6. [PMID: 28911947 PMCID: PMC6168936 DOI: 10.1016/j.cgh.2017.09.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/21/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infections are life-threatening to patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF). Patients with AD/ACLF have prostaglandin E2-mediated immune suppression, which can be reversed by administration of albumin; infusion of 20% human albumin solution (HAS) might improve outcomes of infections. We performed a feasibility study to determine optimal trial design, assess safety, and validate laboratory assessments of immune function to inform design of a phase 3 trial. METHODS We performed a prospective multicenter, single-arm, open-label trial of 79 patients with AD/ACLF and levels of albumin lower than 30 g/L, seen at 10 hospitals in the United Kingdom from May through December 2015. Patients were given daily infusions of 20% HAS, based on serum levels, for 14 days or until discharge from the hospital. Rates of infection, organ dysfunction, and in-hospital mortality were recorded. The primary end point was daily serum albumin level during the treatment period. Success would be demonstrated if 60% achieved and maintained serum albumin levels at or above 30 g/L on at least one third of days with recorded levels. RESULTS The patients' mean model for end-stage disease score was 20.9 ± 6.6. The primary end point (albumin ≥30 g/L on at least one third of days recorded) was achieved by 68 of the 79 patients; 75% of administrations were in accordance with suggested dosing regimen. Mean treatment duration was 10.3 days (104 ± 678 mL administered). There were 8 deaths and 13 serious adverse events, considered by the independent data-monitoring committee to be consistent with those expected. Twelve of 13 patients that developed either respiratory or cardiovascular dysfunction (based on ward-based clinical definitions) as their only organ dysfunction were alive at 30 days compared with 1 of 3 that developed renal dysfunction. Only 1 case of brain dysfunction was recorded. CONCLUSIONS In a feasibility trial, we found that administration of HAS increased serum levels of albumin in patients with AD/ACLF. The dosing regimen was acceptable at multiple sites and deemed safe by an independent data-monitoring committee. We also developed a robust system to record infections. The poor prognosis for patients with renal dysfunction was confirmed. However, patients with cardiovascular or respiratory dysfunction had good outcomes, which is counterintuitive. Severe encephalopathy appeared substantially under-reported, indicating that ward-based assessment of these parameters cannot be recorded with sufficient accuracy for use as a primary outcome in phase 3 trials. Trial registration no: EudraCT 2014-002300-24 and ISRCTN14174793.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, United Kingdom.
| | - Simon S Skene
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Zainib Shabir
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Alexander Maini
- Division of Medicine, University College London, United Kingdom
| | - Yvonne Sylvestre
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Kate Bennett
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Scott Bevan
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - James O'Beirne
- Royal Free National Health Service Trust, London, United Kingdom
| | - Ewan Forrest
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Jim Portal
- Bristol Royal Infirmary, Bristol, United Kingdom
| | - Steve Ryder
- Nottingham University Hospital, Nottingham, United Kingdom
| | - Gavin Wright
- Basildon University Hospital, Essex, United Kingdom
| | - Derek W Gilroy
- Division of Medicine, University College London, United Kingdom
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181
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China L, Maini A, Skene SS, Shabir Z, Sylvestre Y, Colas RA, Ly L, Becares Salles N, Belloti V, Dalli J, Gilroy DW, O’Brien A. Albumin Counteracts Immune-Suppressive Effects of Lipid Mediators in Patients With Advanced Liver Disease. Clin Gastroenterol Hepatol 2018; 16:738-747.e7. [PMID: 28859868 PMCID: PMC6168974 DOI: 10.1016/j.cgh.2017.08.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/28/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF) have immune dysfunction, which increases their risk for infections; however, there are no effective treatments to restore their immune function. We investigated whether the potentially immune-restorative effects of albumin are mediated by its effects on prostaglandin E2 (PGE2) and other lipids. METHODS We analyzed bloods samples from 45 of 79 patients with AD/ACLF and serum levels of albumin less than 30 g/L for whom infusion of 20% human albumin solution (HAS) increased serum levels of albumin 30 g/L or more in a feasibility study of effects of 20% HAS. Immune function was determined by comparison of macrophage function following addition of plasma samples. We also used samples from 12 healthy individuals. We measured binding of plasma proteins to PGE2 and serum levels of endotoxin (lipopolysaccharide) and cytokines; using 10 patients' samples, we investigated the effects of PGE2 inhibitors. We performed a comprehensive lipid metabolomic analysis using samples from 10 different patients, before and after HAS administration. RESULTS At baseline, AD/ACLF patient plasma induced significantly lower production of tumor necrosis factor by healthy macrophages than plasma from healthy individuals (P < .0001). Plasma from patients after HAS infusion induced significantly higher levels of tumor necrosis factor production by macrophages (19.5 ± 4.8 ng/mL) compared with plasma collected before treatment (17.7 ± 4.5 ng/mL; P = .0013). There was a significantly lower proportion of plasma protein (albumin) binding to PGE2 from patients with AD/ACLF plasma (mean, 61.9%) compared with plasma from control subjects (77.1%; P = .0012). AD/ACLF plasma protein binding to PGE2 increased following HAS treatment compared with baseline (mean increase, 8.7%; P < .0001). Circulating levels of PGE2, lipopolysaccharide, and inflammatory or anti-inflammatory cytokines were higher in patients with AD/ACLF than healthy volunteers. Unexpectedly, HAS infusion had no effect on mediator levels. Principal component analysis of baseline levels of lipids that induce or resolve inflammation identified 2 distinct groups of patients that differed according to baseline plasma level of lipopolysaccharide. Sample analyses after HAS treatment indicated that albumin regulates circulating levels of lipid mediators, but this effect was distinct in each group. CONCLUSIONS Analysis of blood samples from patients with AD/ACLF participating in a feasibility study of 20% HAS infusions has shown that infusions to raise serum albumin above 30 g/L reversed plasma-mediated immune dysfunction by binding and inactivating PGE2. We also describe a method to classify the inflammatory response in AD/ACLF, based on lipid profile, which could improve identification of patients most likely to respond to HAS treatment. A randomized controlled trial is needed to determine whether these effects of HAS reduce infections in AD/ACLF. Trial registered with European Medicines Agency (EudraCT 2014-002300-24) and adopted by NIHR (ISRCTN14174793).
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, London, United Kingdom.
| | - Alexander Maini
- Division of Medicine, University College London, London, United Kingdom
| | - Simon S. Skene
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Zainib Shabir
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Yvonne Sylvestre
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Romain A. Colas
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Lucy Ly
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | | | - Vittorio Belloti
- Division of Medicine, University College London, London, United Kingdom
| | - Jesmond Dalli
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Derek W. Gilroy
- Division of Medicine, University College London, London, United Kingdom
| | - Alastair O’Brien
- Division of Medicine, University College London, London, United Kingdom
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182
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Bajaj JS, Reddy RK, Tandon P, Wong F, Kamath PS, Biggins SW, Garcia-Tsao G, Fallon M, Maliakkal B, Lai J, Vargas HE, Subramanian RM, Thuluvath P, Thacker LR, OʼLeary JG. Prediction of Fungal Infection Development and Their Impact on Survival Using the NACSELD Cohort. Am J Gastroenterol 2018; 113:556-563. [PMID: 29257141 DOI: 10.1038/ajg.2017.471] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Bacterial infections are associated with negative outcomes in cirrhosis but fungal infections are being increasingly recognized. The objective of this study is to define risk factors for fungal infection development and impact on 30-day survival. METHODS In a large, multi-center cirrhotic inpatient cohort, demographics, cirrhosis details, intensive care unit (ICU), organ failures/acute-on-chronic liver failure (ACLF), and 30-day survival were compared between patients without infections and with bacterial infections alone, with those with fungal infections. Variables associated with fungal infection development were determined using multi-variable regression. Ordinal variables (0=no infection, 1=community-acquired bacterial infection, 2=nosocomial bacterial, and 3=fungal infection) were input into a 30-day survival model. RESULTS A total of 2,743 patients (1,691 no infection, 918 bacterial, and 134 fungal infections) were included. Patients with fungal infection, all of which were nosocomial, were more likely to be admitted with bacterial infections, on spontaneous bacterial peritonitis prophylaxis, and have diabetes and advanced cirrhosis. Bacterial infection types did not predict risk for fungal infections. Multi-variable analysis showed male gender to be protective, whereas diabetes, longer stay, ICU admission, acute kidney injury (AKI), and admission bacterial infection were associated with fungal infection development (area under the curve (AUC)=0.82). Fungal infections were associated with significantly higher ACLF, inpatient stay, ICU admission, and worse 30-day survival. The case fatality rate was 30% with most fungal infections but >50% for fungemia and fungal peritonitis. On a multi-variable analysis, age, AKI, model for end-stage liver disease, ICU admission, and ordinal infection variables impaired survival (P<0.0001, AUC=0.83). CONCLUSIONS Fungal infections are associated with a poor 30-day survival in hospitalized cirrhotic patients compared with uninfected patients, and those with bacterial infections. Patients with diabetes, AKI, and those with an admission bacterial infection form a high-risk subgroup.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | | | | | | | | | - Scott W Biggins
- University of Colorado, Denver, Colorado, USA.,University of Washington, Seattle, Washington, USA
| | | | - Michael Fallon
- University of Texas, Houston, Texas, USA.,University of Arizona, Phoenix, Arizona, USA
| | - Benedict Maliakkal
- University of Rochester, Rochester, New York, USA.,University of Tennessee, Memphis, Tennessee, USA
| | - Jennifer Lai
- University of California, San Francisco, California, USA
| | | | | | | | - Leroy R Thacker
- Department of Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Jacqueline G OʼLeary
- Baylor University Medical Center, Dallas, Texas, USA.,Dallas VA Medical Center, Dallas, Texas, USA
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183
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Mücke MM, Rumyantseva T, Mücke VT, Schwarzkopf K, Joshi S, Kempf VAJ, Welsch C, Zeuzem S, Lange CM. Bacterial infection-triggered acute-on-chronic liver failure is associated with increased mortality. Liver Int 2018; 38:645-653. [PMID: 28853199 DOI: 10.1111/liv.13568] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/23/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is characterized by an acute deterioration of liver function in patients with cirrhosis in combination with recently defined organ failures. Our aim was to independently validate the prognostic value of the recently established EASL-CLIF-Consortium definition of ACLF and to identify new predictors of short-term mortality. METHODS Patients with cirrhosis and the International Classification of Diseases, Tenth Revision diagnosis of (sub)acute liver failure were retrospectively categorized according to the EASL-CLIF-Consortium definition. Logistic regression analyses were performed to identify clinical and epidemiological predictors of 30- and 90-day mortality. RESULTS From 2008 to 2015, 257 patients were included. Overall, 173 (67%) patients met the EASL criteria for ACLF (grade 1: n = 43 [25%], grade 2: n = 52 [30%], grade 3: n = 79 [45%]). Mortality within 30 days in patients without ACLF was 3.6%, and 18.6%, 37.3% and 62.0% in patients with ACLF grades 1, 2 and 3 respectively. Outcome of patients with bacterial infection-triggered ACLF was distinct from non-infection-triggered ACLF (71.6% vs 33.8% 30-day survival, P < .001), and infection-triggered ACLF was independently associated with increased mortality (odds ratio [OR] = 4.28, P < .001). Pneumonia was a particularly frequent infection and burdened with high mortality. In addition, infections with multidrug-resistant organisms were frequent and independently associated with mortality (P = .030, OR = 4.41), as was glycopeptide antibiotic therapy as initial empirical antibiotic therapy (P = .005). CONCLUSIONS This study confirmed the EASL-CLIF-Consortium definition of ACLF as strong predictor of mortality in patients with acute decompensation of cirrhosis. However, we have observed a remarkably higher mortality in infection-triggered ACLF compared to other precipitating events.
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Affiliation(s)
- Marcus M Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tatiana Rumyantseva
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Victoria T Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Katharina Schwarzkopf
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sabrina Joshi
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Volkhard A J Kempf
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany.,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christoph Welsch
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian M Lange
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
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184
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The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36:689-698. [DOI: 10.1016/j.ajem.2017.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
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185
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Abstract
Hepatic encephalopathy (HE) is a common complication of liver dysfunction, including acute liver failure and liver cirrhosis. HE presents as a spectrum of neuropsychiatric symptoms ranging from subtle fluctuating cognitive impairment to coma. It is a significant contributor of morbidity in patients with liver disease. HE is observed in acute liver failure, liver bypass procedures, for example, shunt surgry and transjugular intrahepatic portosystemic shunt, and cirrhosis. These are classified as Type A, B and C HE, respectively. HE can also be classified according to whether its presence is overt or covert. The pathogenesis is linked with ammonia and glutamine production, and treatment is based on mechanisms to reduce the formation and/or removal of these compounds. There is no specific diagnostic test for HE, and diagnosis is based on clinical suspicion, excluding other causes and use of clinical tests that may support its diagnosis. Many tests are used in trials and experimentally, but have not yet gained universal acceptance. This review focuses on the definitions, pathogenesis and treatment of HE. Consideration will be given to existing treatment, including avoidance of precipitating factors and novel therapies such as prebiotics, probiotics, antibiotics, laxatives, branched-chain amino acids, shunt embolization and the importance of considering liver transplant in appropriate cases.
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Affiliation(s)
| | - Mark Alexander Ellul
- Faculty of Health and Life Sciences, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Timothy JS Cross
- Department of Gastroenterology, Royal Liverpool University Hospital
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186
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Bajaj JS, Thacker LR, Fagan A, White MB, Gavis EA, Hylemon PB, Brown R, Acharya C, Heuman DM, Fuchs M, Dalmet S, Sikaroodi M, Gillevet PM. Gut microbial RNA and DNA analysis predicts hospitalizations in cirrhosis. JCI Insight 2018. [PMID: 29515036 DOI: 10.1172/jci.insight.98019] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cirrhosis is associated with gut microbial changes, but current 16S rDNA techniques sequence both dead and live bacteria. We aimed to determine the rRNA content compared with DNA from the same stool sample to evaluate cirrhosis progression and predict hospitalizations. METHODS Cirrhotics and controls provided stool for RNA and DNA analysis. Comparisons were made between cirrhotics/controls and within cirrhosis (compensated/decompensated, infected/uninfected, renal dysfunction/not, rifaximin use/not) with respect to DNA and RNA bacterial content using linear discriminant analysis. A separate group was treated with omeprazole for 14 days with longitudinal microbiota evaluation. Patients were followed for 90 days for hospitalizations. Multivariable models for hospitalizations with clinical data with and without DNA and RNA microbial data were created. RESULTS Twenty-six controls and 154 cirrhotics (54 infected, 62 decompensated, 20 renal dysfunction, 18 rifaximin) were included. RNA and DNA analysis showed differing potentially pathogenic taxa but similar autochthonous taxa composition. Thirty subjects underwent the omeprazole study, which demonstrated differences between RNA and DNA changes. Thirty-six patients were hospitalized within 90 days. In the RNA model, MELD score and Enterococcus were independently predictive of hospitalizations, while in the DNA model MELD was predictive and Roseburia protective. In both models, adding microbiota significantly added to the MELD score in predicting hospitalizations. CONCLUSION DNA and RNA analysis of the same stool sample demonstrated differing microbiota composition, which independently predicts the hospitalization risk in cirrhosis. RNA and DNA content of gut microbiota in cirrhosis are modulated differentially with disease severity, infections, and omeprazole use. TRIAL REGISTRATION NCT01458990. FUNDING VA Merit I0CX001076.
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Affiliation(s)
| | | | - Andrew Fagan
- Division of Gastroenterology, Hepatology and Nutrition
| | | | - Edith A Gavis
- Division of Gastroenterology, Hepatology and Nutrition
| | - Phillip B Hylemon
- Department of Microbiology and Immunology, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Robert Brown
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | | | | | - Michael Fuchs
- Division of Gastroenterology, Hepatology and Nutrition
| | - Swati Dalmet
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | - Masoumeh Sikaroodi
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | - Patrick M Gillevet
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
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187
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Wu J, Li YY, Hu JH, Jia L, Shi M, Meng FP, Li J, Zhao J, Wang FS, Meng QH. Differential characteristics and prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure defined by European Association for the Study of the Liver - Chronic Liver Failure criteria. Hepatol Res 2018; 48:153-164. [PMID: 28456135 DOI: 10.1111/hepr.12909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 04/18/2017] [Accepted: 04/28/2017] [Indexed: 12/18/2022]
Abstract
AIM To determine the differential characteristics and prognosis of patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) detected using Asian Pacific Association for the Study of the Liver (APASL) criteria and then classified using European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) criteria. METHODS We retrospectively reviewed 316 HBV-related APASL ACLF patients treated at Beijing 302 Hospital or Beijing You'An Hospital (both Beijing, China) between February 2015 and February 2016. Clinical characteristics and mortality rates were compared among patients with different EASL-CLIF ACLF severity grades (no ACLF, and ACLF grades 1-3). RESULTS According to the EASL-CLIF criteria, 138 patients had no ACLF, 123 had ACLF at enrollment, and 55 developed ACLF during hospitalization. Both 28-day and 90-day transplant-free mortality were dramatically lower in patients without EASL-CLIF ACLF (0.7% and 5.1%, respectively) than in patients with EASL-CLIF ACLF (40.7% and 63.2%, respectively; both P < 0.001). Liver failure rates were similar in patients with and without EASL-CLIF ACLF, but extrahepatic organ failure was rare in patients without EASL-CLIF ACLF. Baseline serum creatinine, new bacterial infection and new acute kidney injury during hospitalization, maximum rising rates of CLIF-C ACLF score, and Model for End-stage Liver Disease score were independent predictors of EASL-CLIF ACLF after enrollment. CONCLUSIONS The EASL-CLIF ACLF classification can accurately prognosticate the short-term mortality of patients with HBV-related APASL ACLF. It can also distinguish distinct clinical characteristics and prognoses in patients with and without EASL-CLIF ACLF.
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Affiliation(s)
- Juan Wu
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Yuan-Yuan Li
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Jin-Hua Hu
- Medical Center for Liver Failure, Beijing 302 Hospital, Beijing, China
| | - Lin Jia
- Department of Critical Care Medicine of Liver Disease, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Ming Shi
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Fan-Ping Meng
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Juan Li
- Department of Critical Care Medicine of Liver Disease, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Juan Zhao
- Department of Critical Care Medicine of Liver Disease, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Fu-Sheng Wang
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Qing-Hua Meng
- Department of Critical Care Medicine of Liver Disease, Beijing You'An Hospital, Capital Medical University, Beijing, China
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188
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Zhao H, Shi Y, Dong H, Hu J, Zhang X, Yang M, Fan J, Ma W, Sheng J, Li L. Community- or Healthcare-Associated Bacterial Infections Increase Long-Term Mortality in Patients With Acute Decompensation of Cirrhosis. Am J Med Sci 2018; 355:132-139. [DOI: 10.1016/j.amjms.2017.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/22/2017] [Accepted: 08/01/2017] [Indexed: 12/15/2022]
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189
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Garcia Garcia de Paredes A, Tellez L, Rodriguez-Gandia MA, Martinez J, Rodriguez de Santiago E, Aguilera Castro L, Gea F, Albillos A. Incidence, predictive factors and impacts of acute kidney injury in cirrhotic patients hospitalized for cellulitis. Liver Int 2018; 38:285-294. [PMID: 28688141 DOI: 10.1111/liv.13515] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 06/30/2017] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Cellulitis is a common infection in patients with cirrhosis but its impact on progression of liver disease has been hardly addressed. This study examines the incidence of acute kidney injury (AKI), predictive factors and its impacts on mortality in cirrhotic patients hospitalized for cellulitis. METHODS Retrospective data from cirrhotic patients hospitalized for cellulitis over the period January 2006 to September 2015 were analysed. AKI was defined according to revised criteria of the International Club of Ascites. RESULTS A total of 101 episodes of cellulitis were examined (70.3% men; mean age 60.6 ± 13.6 years). Of patients, 27% met criteria for acute on chronic liver failure (ACLF) (grade 1: 63%; grade 2: 22%; grade 3: 15%). AKI was recorded in 50.5% (type 1: 67%; type 2: 19%; type 3: 14%). AKI was present on admission in 21 of the 51 patients (41%) who developed it. In the remaining 30 patients (59%), AKI appeared during hospitalization and its development was associated with a MELD score >14 (70% vs 30%, P=.024). In-hospital mortality was 10% and all patients who died had AKI. A high MELD score on admission, AKI and ACLF were associated with in-hospital mortality (P<.05). One-month transplant-free survival was 84% (70% vs 98% in patients with and without AKI, P=.001). CONCLUSIONS In cirrhotic patients, cellulitis is a serious infection that often leads to AKI and ACLF. AKI is a strong predictor of mortality in this setting.
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Affiliation(s)
- Ana Garcia Garcia de Paredes
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Luis Tellez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Miguel Angel Rodriguez-Gandia
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Javier Martinez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Lara Aguilera Castro
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Francisco Gea
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
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190
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Piano S, Brocca A, Mareso S, Angeli P. Infections complicating cirrhosis. Liver Int 2018; 38 Suppl 1:126-133. [PMID: 29427501 DOI: 10.1111/liv.13645] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 11/23/2017] [Indexed: 12/15/2022]
Abstract
Patients with cirrhosis have a high risk of bacterial infections. Bacterial infections induce systemic inflammation that may lead to organ failure and acute-on-chronic liver failure (ACLF) resulting in a high risk of short term mortality. The early diagnosis and treatment of bacterial infections is essential to improve the patient's prognosis. However, in recent years, the spread of multidrug resistant (MDR) bacterial infections has reduced the efficacy of commonly used antibiotics such as third generation cephalosporins. In patients at high risk of MDR bacteria, such as those with nosocomial infections, the early administration of broad spectrum antibiotics has been shown to improve the prognosis. However, early de-escalation of antibiotics is recommended to reduce a further increase in antibiotic resistance. Strategies to prevent acute kidney injury and other organ failures should be implemented. Although prophylaxis of bacterial infections with antibiotics improves the prognosis in selected patients, their use should be limited to patients at high risk of developing infections. In this article, we review the pathogenesis and management of bacterial infections in patients with cirrhosis.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Alessandra Brocca
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Sara Mareso
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
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191
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Sonika U, Jadaun S, Ranjan G, Rout G, Gunjan D, Kedia S, Nayak B, Shalimar. Alcohol-related acute-on-chronic liver failure-Comparison of various prognostic scores in predicting outcome. Indian J Gastroenterol 2018; 37:50-57. [PMID: 29476404 DOI: 10.1007/s12664-018-0827-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 01/10/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Various prognostic scores are available for predicting outcome in acute-on-chronic liver failure (ACLF). We compared the available prognostic models as predictors of outcome in alcohol-related ACLF patients. METHODS All consecutive patients with alcohol-related ACLF were included. At admission, prognostic indices-acute physiology and chronic health evaluation score (APACHE II), model for end-stage liver disease (MELD), MELD-Na, Maddrey's discriminant function (DF), age-bilirubin-INR-creatinine (ABIC), and Chronic Liver Failure Consortium (CLIF-C) ACLF score (CLIF-C ACLF) score were calculated. Receiver operator characteristic (ROC) curves were plotted for all prognostic scores with in-hospital, 90-day, and 1-year mortality as outcome. RESULTS Of the 171 patients, 170 were males, and grade 1 ACLF in 20 (11.7%), grade 2 in 52 (30.4%), and grade 3 in 99 (57.9%) patients. One hundred and nineteen (69.6%) died in-hospital. The median (IQR) Maddrey's score, MELD, MELD-Na, ABIC, APACHE II, and CLIF-C ACLF were 87.8 (66.5-123.0), 33.1 (27.6-40.0), 34.4 (29.5-40.0), 8.5 (7.3-9.6), 15 (12-21), and 51.1 (44.1-56.4), respectively. On multivariate Cox regression analysis, independent predictors of in-hospital outcome were presence of hepatic encephalopathy (early HR, 2.078; 95%CI, 1.173-3.682, p = 0.012 and advanced, HR, 2.330; 95% CI, 1.270-4.276, p = 0.006), elevated serum creatinine (HR, 1.140; 95% CI, 1.023-1.270, p = 0.018), and infection at admission (HR, 1.874; 95% CI, 1.160-23.029, p = 0.010). On comparison of ROC curves, APACHE II and CLIF-C ACLF AUROC were significantly higher than MELD, MELD-Na, DF, and ABIC (p < 0.05) for predicting in-hospital, 90-day, and 1-year mortality. The AUROC was highest for APACHE II followed by CLIF-C ACLF (Hanley and McNeil, p = 0.660). CONCLUSIONS Alcohol-related ACLF has high in-hospital mortality. Among the available prognostic scores, CLIF-C ACLF and APACHE II perform best.
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Affiliation(s)
- Ujjwal Sonika
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shekhar Jadaun
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Gyan Ranjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Gyanranjan Rout
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
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192
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Bhutta AQ, Garcia-Tsao G, Reddy KR, Tandon P, Wong F, O'Leary JG, Acharya C, Banerjee D, Abraldes JG, Jones TM, Shaw J, Deng Y, Ciarleglio M, Bajaj JS. Beta-blockers in hospitalised patients with cirrhosis and ascites: mortality and factors determining discontinuation and reinitiation. Aliment Pharmacol Ther 2018; 47:78-85. [PMID: 28994122 PMCID: PMC6016372 DOI: 10.1111/apt.14366] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/14/2017] [Accepted: 09/18/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND It has been suggested that beta-blockers may increase mortality in patients with cirrhosis and refractory ascites but the effect of beta-blockers discontinuation or reinitiation has not been examined. AIMS To compare, in hospitalised patients with cirrhosis and ascites, the effect of BB on survival and to examine the effect/predictors of beta-blockers discontinuation and reinitiation. METHODS Sub-analysis of NACSELD (North American consortium for the study of end-stage liver disease, database containing prospective data on hospitalised patients with cirrhosis) data from 7 centres enrolling >100 patients with ascites. Data on BB discontinuation and reinitiation were collected by chart review. RESULTS Seven hundred and sixteen patients, 307 (43%) on beta-blockers at admission and 366 (51%) with refractory ascites, were followed to death or hospital discharge. Beta-blocker use was associated with a lower white blood cell count at admission. Beta-blocker use in hospitalised patients with ascites was not associated with a higher mortality, even in those with refractory ascites. No significant changes in mean arterial pressure (MAP) were observed between groups. Discontinuation of beta-blockers (49%) was driven by low MAP, infection and acute kidney injury at time of discontinuation but was not associated with a higher mortality. Beta-blocker reinitiation occurred in 40% prior to discharge and was mainly driven by an increase in MAP. CONCLUSIONS Beta-blocker use is safe in patients with cirrhosis and ascites (including those with refractory ascites) provided beta-blockers are discontinued in the presence of a low MAP and reinitiated once MAP reincreases. A potentially beneficial anti-inflammatory effect of beta-blockers is suggested.
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Affiliation(s)
- Abdul Q. Bhutta
- Yale-New Haven Hospitalist Service, Yale-New Haven Hospital, New Haven, CT
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University, New Haven, CT,Section of Digestive Diseases, VA-CT Healthcare System, West Haven, CT
| | | | | | | | | | | | | | | | | | | | - Yanhong Deng
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Maria Ciarleglio
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Jasmohan S. Bajaj
- Virginia Commonwealth University, Richmond, VA,McGuire VA Medical Center, Richmond, VA
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193
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Khalid MA, Achakzai IK, Ahmed Khan S, Majid Z, Hanif FM, Iqbal J, Laeeq SM, Luck NH. The use of Karnofsky Performance Status (KPS) as a predictor of 3 month post discharge mortality in cirrhotic patients. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2018; 11:301-305. [PMID: 30425808 PMCID: PMC6204247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM Is Karnofsky Performance Status (KPS) a predictor of 3 month post discharge mortality in cirrhotic patients? BACKGROUND Cirrhotic patients often experience an abrupt decline in their health, which often leads to frequent hospitalization and can cause morbidity and mortality. Various models are currently used to predict mortality in cirrhotics however these have their limitations. The Karnofsky Performance Status (KPS) being one of the oldest performance status scales, is a health care provider-administered assessment that has been validated to predict mortality across the elderly and in the chronic disease populations. METHODS We used the KPS performance status scale to envisage short-term mortality in cirrhotic and HCC patients who survive to be discharged from hospital. RESULTS Our study showed that KPS one week post-discharge, child pugh score, hospital stay, international normalized ratio, serum albumin, total bilirubin and serum creatinine showed statistical significance on univariate analysis. On multivariate analysis, KPS was found to be statistical significant predictor of 3-month mortality. CONCLUSION Hence KPS can be utilized to identify cirrhotic patients at risk of 3-month post discharge mortality.
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194
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Alexopoulou A, Vasilieva L, Mani I, Agiasotelli D, Pantelidaki H, Dourakis SP. Single center validation of mortality scores in patients with acute decompensation of cirrhosis with and without acute-on-chronic liver failure. Scand J Gastroenterol 2017; 52:1385-1390. [PMID: 28851246 DOI: 10.1080/00365521.2017.1369560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Acute decompensation (AD) of cirrhosis is characterized by high mortality. We aimed to validate the performance in predicting mortality of both the chronic-liver-failure-consortium (CLIF-C) acute-on-chronic liver failure (ACLF) and CLIF-C AD scores in a cohort of patients admitted for AD. METHODS In this prospective cohort study, patients were followed-up during their hospital stay and for 365 days thereafter. RESULTS About 182 patients with AD were enrolled including 78 (42.8%) who met the criteria for ACLF (ACLF-group) while the remaining had AD without ACLF (AD-group). 56.4% and 56.7% of the ACLF- and AD-groups, respectively, had alcoholic cirrhosis and 85.9% of the ACLF-group hepatic encephalopathy. Only few patients were hospitalized in the intensive care unit (ICU) or transplanted. The probabilities of death estimated for both scores were similar to the overall mortality rates observed at all time points. The model had a good fit in the AD-group at 90 days (p = .974) but a worse, yet adequate, in the ACLF-group at 28 days (p = .08). The CLIF-C ACLF or AD scores had an adequate, predictive discrimination ability for mortality at all time points, with Harrel's concordance index-C ranging between 0.64 and 0.65 or 0.64 and 0.68, respectively. Both scores showed a similar predictive accuracy for mortality compared to those of MELD, MELD-Na and Child-Pugh. CONCLUSIONS In this population without access to appropriate ICU treatment, the CLIF-C ACLF and AD performed worse than in studies with patients having ICU access. In addition, the CLIF scores were not superior to classical ones in this setting.
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Affiliation(s)
- Alexandra Alexopoulou
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Larisa Vasilieva
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Iliana Mani
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Danai Agiasotelli
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Helen Pantelidaki
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Spyros P Dourakis
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
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195
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Bajaj JS, Kassam Z, Fagan A, Gavis EA, Liu E, Cox IJ, Kheradman R, Heuman D, Wang J, Gurry T, Williams R, Sikaroodi M, Fuchs M, Alm E, John B, Thacker LR, Riva A, Smith M, Taylor-Robinson SD, Gillevet PM. Fecal microbiota transplant from a rational stool donor improves hepatic encephalopathy: A randomized clinical trial. Hepatology 2017; 66:1727-1738. [PMID: 28586116 PMCID: PMC6102730 DOI: 10.1002/hep.29306] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/12/2017] [Accepted: 06/05/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED Recurrent hepatic encephalopathy (HE) is a leading cause of readmission despite standard of care (SOC) associated with microbial dysbiosis. Fecal microbiota transplantation (FMT) may improve dysbiosis; however, it has not been studied in HE. We aimed to define whether FMT using a rationally derived stool donor is safe in recurrent HE compared to SOC alone. An open-label, randomized clinical trial with a 5-month follow-up in outpatient men with cirrhosis with recurrent HE on SOC was conducted with 1:1 randomization. FMT-randomized patients received 5 days of broad-spectrum antibiotic pretreatment, then a single FMT enema from the same donor with the optimal microbiota deficient in HE. Follow-up occurred on days 5, 6, 12, 35, and 150 postrandomization. The primary outcome was safety of FMT compared to SOC using FMT-related serious adverse events (SAEs). Secondary outcomes were adverse events, cognition, microbiota, and metabolomic changes. Participants in both arms were similar on all baseline criteria and were followed until study end. FMT with antibiotic pretreatment was well tolerated. Eight (80%) SOC participants had a total of 11 SAEs compared to 2 (20%) FMT participants with SAEs (both FMT unrelated; P = 0.02). Five SOC and no FMT participants developed further HE (P = 0.03). Cognition improved in the FMT, but not the SOC, group. Model for End-Stage Liver Disease (MELD) score transiently worsened postantibiotics, but reverted to baseline post-FMT. Postantibiotics, beneficial taxa, and microbial diversity reduction occurred with Proteobacteria expansion. However, FMT increased diversity and beneficial taxa. SOC microbiota and MELD score remained similar throughout. CONCLUSION FMT from a rationally selected donor reduced hospitalizations, improved cognition, and dysbiosis in cirrhosis with recurrent HE. (Hepatology 2017;66:1727-1738).
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Affiliation(s)
- Jasmohan S. Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Zain Kassam
- OpenBiome, Somerville, Massachusetts, USA,Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Andrew Fagan
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Edith A. Gavis
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Eric Liu
- George Mason University, Manassas, Virginia, USA
| | - I. Jane Cox
- Institute of Hepatology London, Foundation for Liver Research, United Kingdom
| | | | - Douglas Heuman
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Jessica Wang
- George Mason University, Manassas, Virginia, USA
| | - Thomas Gurry
- Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Roger Williams
- Institute of Hepatology London, Foundation for Liver Research, United Kingdom
| | | | - Michael Fuchs
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Eric Alm
- Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Binu John
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Leroy R Thacker
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Antonio Riva
- Institute of Hepatology London, Foundation for Liver Research, United Kingdom
| | - Mark Smith
- OpenBiome, Somerville, Massachusetts, USA
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196
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Ferstl PG, Filmann N, Brandt C, Zeuzem S, Hogardt M, Kempf VAJ, Müller M, Waidmann O, Reinheimer C. The impact of carbapenem resistance on clinical deterioration and mortality in patients with liver disease. Liver Int 2017; 37:1488-1496. [PMID: 28374901 DOI: 10.1111/liv.13438] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 03/28/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Infections with multidrug-resistant gram-negative bacteria are significantly impairing the prognosis of patients with liver disease. In particular, carbapenem resistance further narrows therapeutic options. This study investigates the impact of carbapenem-resistant gram-negative bacteria on the outcome of patients with liver disease and cirrhosis. METHODS Between January 2011 and July 2015, 132 patients treated at the tertiary liver transplant centre at University Hospital Frankfurt, Germany, were tested positive for carbapenem-resistant gram-negative bacteria and retrospectively analysed in this study. Risk factors for fatal outcome were evaluated using multivariate regression analysis. Competing-risk analysis was performed on patients tested positive for Enterobacteriaceae or non-fermenting species, for example, Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia. Subgroup analysis of cirrhotic patients was performed on a matched cohort of cirrhotic patients, comparable model for end-stage liver disease and tested negative for carbapenem-resistant gram-negative bacteria. RESULTS 97 (73.5%) and 35 (26.5%) patients were infected or colonised with carbapenem-resistant gram-negative bacteria respectively. Within the observation period, 61/132 (46.2%) patients died, with sepsis being the leading cause (38/61, 62.3%). Decompensated liver disease, sepsis and admission to intensive care unit were independent risk factors for fatal outcome. Lethal sepsis in patients positive for non-fermenting bacteria was significantly more frequent than in those positive for Enterobacteriaceae, independently from liver function. Subgroup analysis of cirrhotic patients showed that sepsis (54.9% vs 13%) and lethal sepsis were significantly more frequent after detection of carbapenem-resistant gram-negative bacteria, independently from localisation of pathogen detection. CONCLUSIONS Patients with advanced liver disease are prone to fatal infections caused by carbapenem-resistant gram-negative bacteria.
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Affiliation(s)
- Philip G Ferstl
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Brandt
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany.,Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Hogardt
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany.,Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Volkhard A J Kempf
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany.,Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Mona Müller
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Oliver Waidmann
- Department for Internal Medicine I/Gastroenterology and Hepatology, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Claudia Reinheimer
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Frankfurt am Main, Germany.,Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany
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197
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Abstract
Acute on chronic liver failure (ACLF) was first described in 1995 as a clinical syndrome distinct to classic acute decompensation. Characterized by complications of decompensation, ACLF occurs on a background of chronic liver dysfunction and is associated with high rates of organ failure and significant short-term mortality estimated between 45% and 90%. Despite the clinical relevance of the condition, it still remains largely undefined with continued disagreement regarding its precise etiological factors, clinical course, prognostic criteria and management pathways. It is concerning that, despite our relative lack of understanding of the condition, the burden of ACLF among cirrhotic patients remains significant with an estimated prevalence of 30.9%. This paper highlights our current understanding of ACLF, including its etiology, diagnostic and prognostic criteria and pathophysiology. It is evident that further refinement of the ACLF classification system is required in order to detect high-risk patients and improve short-term mortality rates. The field of metabolomics certainly warrants investigation to enhance diagnostic and prognostic parameters, while the use of granulocyte-colony stimulating factor is a promising future therapeutic intervention for patients with ACLF.
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Affiliation(s)
- Azeem Alam
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW7 2AZ, UK
| | - Ka Chun Suen
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW7 2AZ, UK
| | - Daqing Ma
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW7 2AZ, UK
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198
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Lin S, Chen J, Wang M, Han L, Zhang H, Dong J, Zeng D, Jiang J, Zhu Y. Prognostic nomogram for acute-on-chronic hepatitis B liver failure. Oncotarget 2017; 8:109772-109782. [PMID: 29312647 PMCID: PMC5752560 DOI: 10.18632/oncotarget.21012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 08/28/2017] [Indexed: 12/12/2022] Open
Abstract
Background & Aims To establish an effective prognostic nomogram for acute-on-chronic hepatitis B liver failure (ACHBLF). Materials and Methods The nomogram was based on clinical data of 203 ACHBLF patients who admitted to the First Affiliated Hospital of Fujian Medical University from 2009 to 2014. The area under the receiver-operating characteristic curve (AUC) and calibration curve were carried out to verify the predictive accuracy ability of the nomogram. The result was validated in internal and external validation cohorts. Kaplan-Meier survival curve was used in survival analysis. Results We developed a new prognostic nomogram to predict 3-month mortality based on risk factors selected by multivariate analysis. This nomogram consisted three independent factors: age, liver to abdominal area ratio (LAAR) and model for end-stage liver disease (MELD) score. The AUC of this nomogram for survival prediction was 0.877 (95% CI 0.831–0.923), which was higher than that of MELD score, MELD-Na and Child-Turcotte-Pugh (CTP). Good agreement of calibration plot for the probability of survival at 3-month was shown between the prediction by nomogram and actual observation. These results were supported by internal and external validation studies. Conclusions The ACHBLF nomogram could predict the short-term survival for ACHBLF patients.
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Affiliation(s)
- Su Lin
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Juan Chen
- Digestive System Department, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Mingfang Wang
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Lifen Han
- Department of Infectious Disease, Meng Chao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Haoyang Zhang
- Division of Biostatistics, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin, Hongkong, China
| | - Jing Dong
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Dawu Zeng
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Jiaji Jiang
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yueyong Zhu
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
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199
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Cai J, Zhang M, Han T, Jiang HQ. Characteristics of infection and its impact on short-term outcome in patients with acute-on-chronic liver failure. Medicine (Baltimore) 2017; 96:e8057. [PMID: 28906399 PMCID: PMC5604668 DOI: 10.1097/md.0000000000008057] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bacterial infections are an important cause of mortality in liver failure. However, the type of infection, predictors of infection, and their impact on outcomes in patients with acute-on-chronic liver failure (ACLF) are limited.A total of 389 patients with ACLF were admitted in this retrospective, corhort study. Once admitted, clinical data including first infection site, type (community-acquired, healthcare-associated, or nosocomial), and second infection occurrence during hospitalization were collected. The outcome was mortality within 90 days. Multivariable logistic regression models were preformed to predict second infection development and 90-day mortality. Survival probability curves were calculated by the Kaplan-Meier method.Among 389 patients, 316 (81.2%) patients had infection. The 90-day mortality of patients with and without infection was 52.2% and 16.4%, respectively (P <.001). The most common first infection was healthcare associated (51.3%), followed by nosocomial (30.1%) and community-acquired infections (18.7%). Respiratory tract infection, spontaneous bacterial peritonitis, and urinary tract infection were most prevalent. Gram-positive organism was more frequently seen than gram-negative organisms. Of note, fungi accounted for 15.9% of the total infection cases. During hospitalization, 26.6% patients developed second infections. The 90-day mortality of patients developed or did not develop a second infection were 67.9% and 46.6%, respectively (P <.001). Independent predictors of 90-day mortality in infected patients with ACLF were age, white blood cell (WBC) count, model for end-stage liver disease (MELD) score, hepatic encephalopathy (HE), and second infection.Infections (regardless of first or second infection) can increase the 90-day mortality significantly in patients with ACLF. And age, WBC count, MELD score, HE, and the presence of second infection are independent risk factors affecting 90-day mortality in patients with ACLF showing infection.
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Affiliation(s)
- Junjun Cai
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Shijiazhuang
| | - Mengchen Zhang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Shijiazhuang
| | - Tao Han
- Department of Hepatology, Tianjin Third Central Hospital, Tianjin Institute of Hepatobiliary Disease, Tianjin Key laboratory of Artificial Cell, Tianjin, China
| | - Hui-qing Jiang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Shijiazhuang
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200
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Understanding hepatic encephalopathy. Intensive Care Med 2017; 44:231-234. [PMID: 28547522 DOI: 10.1007/s00134-017-4845-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/13/2017] [Indexed: 02/08/2023]
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