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

The Effect of Adrenal Replacement Therapy on Rates of Fungal Colonization and Mortality in Critically Ill Patients Awaiting Liver Transplantation

BACKGROUND

The effect of adrenal replacement therapy (ART) with hydrocortisone on critical endpoints such as infection and mortality in critically ill patients with cirrhosis remains unclear. We evaluated our indications for ART in patients with cirrhosis with clinical symptoms of adrenal insufficiency (AI), and examined the rate of peri-transplant fungal colonization and mortality associated with ART.

METHODS

Seventy-eight patients with cirrhosis admitted to our institution's surgical intensive care unit (ICU) over a 4-year period met criteria for AI by vasopressor requirement and baseline cortisol levels. Outcomes included disposition at 90-days, fungal colonization, and fungal infection in the presence or absence of ART.

RESULTS

In total, 56 patients received hydrocortisone (HC+) while 22 did not (HC-). The HC+ and HC- groups had comparable median Model for End-stage Liver Disease (MELD) scores (26.5 vs. 25, respectively; p=0.93), median ICU lengths of stay (23 vs. 20 days, respectively; p=0.54) and median cortisol levels (18 μg/dL for both, p=0.87). Fungal cultures (FC) from blood, urine or bronchoalveolar lavage/sputum were positive for 44% of HC+, and 40.9% of HC- (p=0.77) had mortality rates between HC+ and HC- groups that were not significantly different (60.7% vs. 50%, respectively; p=0.39; α=0.05). The 90-day outcomes for HC+ vs. HC- (39.3% vs. 50% discharged, respectively; p=0.39; α=0.05) and those surviving to transplant (17.9% vs. 36.4%, respectively; p=0.08; α=0.05) were not significantly different between the two groups.

CONCLUSION

In this small single-center series, we found that steroid administration for AI does not affect the rate of fungal colonization/infection or mortality. Further prospective studies are required to determine the utility of ART and factors affecting the rate of FC and mortality in these patients.

Non-selective beta-blockers are not associated with serious infections in veterans with cirrhosis

BACKGROUND

Studies evaluating outcomes associated with non-selective beta-blockers (NSBB) in cirrhosis have yielded mixed results. A major cause of death in decompensated cirrhosis is infection.

AIM

To determine the effect of NSBB use on serious infections (requiring hospitalisation) in compensated and decompensated cirrhosis.

METHODS

Using data from the US Veterans Health Administration from 2001-2009, we identified two cohorts: compensated cirrhotics (n = 12,656) and decompensated cirrhotics (n = 4834). From each cohort, we identified new NSBB users and propensity-matched them 1:1 to non-users (n = 1836 each in compensated users/non-users and n = 1462 each in decompensated users/non-users). They were followed up for serious infections (median time: 3.1 years), death and transplant. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) from Cox regression models.

RESULTS

Death or transplantation occurred in 0.7% compensated and 2.7% of decompensated patients. Among decompensated cirrhotics, death (P = 0.0061) and transplantation (P = 0.0086) occurred earlier in NSBB users compared with non-users. Serious infections were observed in 4.8% of compensated cirrhotics and in 13.7% of decompensated cirrhotics. There was no difference in the rate of serious infection development in new NSBB users compared with non-users in the compensated (adjusted HR: 0.90, CI: 0.59-1.36) or in the decompensated group (adjusted HR: 1.10, CI: 0.96-1.25).

CONCLUSION

The use of non-selective beta-blockers in U.S. veterans is not associated with an increased rate of serious infections in compensated or decompensated cirrhosis.

Different changes in mitochondrial apoptotic pathway in lymphocytes and granulocytes in cirrhotic patients with sepsis

BACKGROUND & AIMS

Apoptosis regulates leucocyte response during bacterial infections. This study explored leucocyte apoptotic pathway in cirrhotic patients with or without infections or sepsis.

METHODS

In cirrhotic patients with bacterial infection or sepsis, the expression of Caspase 9, Bcl-2 family proteins, which comprises pro-apoptotic molecules, such as Bax, and anti-apoptotic molecules, such as Bcl-2 and Bcl-xL, were measured in peripheral lymphocytes and granulocytes. Regulatory microRNAs MIR-15 and MIR-16 were also measured.

RESULTS

This study enrolled 80 patients with cirrhosis, of whom 28 had no evidence of infections, 32 had bacterial infections and 20 had sepsis; reference values were obtained from 10 age-matched healthy subjects. An over-expression of Caspase-9 and pro-apoptotic protein Bax was found in lymphocytes of cirrhotic patients with infection or sepsis as compared with non-infected cases (P = 0.05 and 0.0001, respectively), while anti-apoptotic proteins Bcl-2 and Bcl-xL were downregulated. In granulocytes, lowest expression of pro-apoptotic protein Bax occurred in septic patients, while in cirrhotics with infections anti-apoptotic Bcl-2 and Bcl-xL were upregulated. Eight patients died; the survivors had less derangements in Bax, Bcl-2 and BcL-xL expression than non-survivors. The pro-apoptotic miRNA, MIR-15 and MIR-16, were upregulated in cirrhotics with bacterial infections.

CONCLUSIONS

Overall, the data show in lymphocytes, and not in granulocytes, an activation of the pro-apoptotic pathway in cirrhotic patients with bacterial infections, which correlates with the severity of the infection and the outcome.

Targeting the gut-liver axis in cirrhosis: antibiotics and non-selective β-blockers

The gut-liver axis in cirrhosis and portal hypertension is gaining increasing attention as a key pathophysiological mechanism responsible for progression of liver failure and development of complications such as spontaneous infections and hepatocellular carcinoma. Antibiotics and non-selective β-blockers (NSBB) intercept this axis and each drug has proven efficacy in clinical trials. A synergistic effect is a hitherto unproven possibility. There is an increasing body of evidence supporting improved outcome with expanded use of NSBB and antibiotic therapy beyond current indications. This review addresses the issue of pharmacological treatment of cirrhosis and portal hypertension with antibiotics and NSBB. We discuss their mechanism of action and suggest that combining the two treatment modalities could potentially reduce the risk of complications.

Antibiotics for the treatment of hepatic encephalopathy

The treatment of hepatic encephalopathy (HE) is complex and therapeutic regimens vary according to the acuity of presentation and the goals of therapy. Most treatments for HE rely on manipulating the intestinal milieu and therefore antibiotics that act on the gut form a key treatment strategy. Prominent antibiotics studied in HE are neomycin, metronidazole, vancomycin and rifaximin. For the management of the acute episode, all antibiotics have been tested. However the limited numbers studied, adverse effects (neomycin oto- and nephrotoxicity, metronidazole neurotoxicity) and potential for resistance emergence (vancomycin-resistant enterococcus) has limited the use of most antibiotics, apart from rifaximin which has the greatest evidence base. Rifaximin has also demonstrated, in conjunction with lactulose, to prevent overt HE recurrence in a multi-center, randomized trial. Despite its cost in the US, rifaximin may prove cost-saving by preventing hospitalizations for overt HE. In minimal/covert HE, rifaximin is the only systematically studied antibiotic. Rifaximin showed improvement in cognition, inflammation, quality-of-life and driving simulator performance but cost-analysis does not favor its use at the current time. Antibiotics, especially rifaximin, have a definite role in the management across the spectrum of HE.

Risk of waitlist mortality in patients with primary sclerosing cholangitis and bacterial cholangitis

Patients with primary sclerosing cholangitis (PSC) are at increased risk for bacterial cholangitis because of biliary strictures and bile stasis. A subset of PSC patients suffer from repeated episodes of bacterial cholangitis, which can lead to frequent hospitalizations and impaired quality of life. Although waitlist candidates with PSC and bacterial cholangitis frequently receive exception points and/or are referred for living donor transplantation, the impact of bacterial cholangitis on waitlist mortality is unknown. We performed a retrospective cohort study of all adult waitlist candidates with PSC who were listed for initial transplantation between February 27, 2002 and June 1, 2012 at the University of Pennsylvania and the University of Colorado-Denver. During this period, 171 PSC patients were waitlisted for initial transplantation. Before waitlisting, 38.6% (66/171) of the patients had a history of bacterial cholangitis, whereas 28.0% (44/157) of the patients with at least 1 Model for End-Stage Liver Disease update experienced cholangitis on the waitlist. During follow-up, 30 patients (17.5%) were removed from the waitlist for death or clinical deterioration, with 46.7% (14/30) developing cholangiocarcinoma. Overall, 12 of the 82 waitlist candidates (14.6%) who ever had an episode of cholangitis were removed for death or clinical deterioration, whereas 18 of the 89 candidates (20.2%) without cholangitis were removed (P = 0.34 for a comparison of the 2 groups). No patients were removed because of bacterial cholangitis. In multivariate competing-risk models, a history of bacterial cholangitis was not associated with an increased risk of waitlist removal for death or clinical deterioration (subhazard ratio = 0.67, 95% confidence interval = 0.65-0.70, P < 0.001). In summary, waitlist transplant candidates with PSC and bacterial cholangitis do not have an increased risk of waitlist mortality. The data call into question the systematic granting of exception points or referral for living donor transplantation due to a perceived risk of increased waitlist mortality.

Mortality after urinary tract infections in patients with advanced cirrhosis - Relevance of acute kidney injury and comorbidities

BACKGROUND

Bacterial infections increase mortality four-fold in patients with decompensated cirrhosis. However, specific mortality associated with urinary tract infections (UTI) in cirrhosis is not known.

METHODS

Retrospective single-centre analysis of all hospitalized patients with cirrhosis and ascites who underwent first paracentesis between 2006 and 2011 to determine 90-day mortality associated with UTI defined as pyuria with significant bacteriuria using Cox proportional hazard models.

RESULTS

A total of 108 patients with at least one episode of UTI and 291 with exclusion of UTI were identified. Bacterial infections other than UTI were diagnosed in 136 (34%) of patients at the time of urine analysis. Female gender, Child-Pugh stage C, higher grade of ascites and systemic inflammatory response syndrome were associated with UTI. After adjustment for liver function and co-morbidity, the hazard ratios (HR) of death within 90 days after urine analysis were 2.08 (95% CI 1.28-3.38) in patients with UTI, 2.93 (1.90-4.52) in patients with other bacterial infections and 3.39 (2.03-5.65) in patients with UTI and concomitant infection. Independent predictors of death after UTI were renal dysfunction at presentation (HR 2.52; 95% CI 2.52), subsequent acute kidney injury within 48 h after diagnosis (4.57; 2.54-8.24), concomitant bacterial infection (1.77; 1.04-3.00) and malignant comorbidity (1.85; 1.03-3.30). The combination of these factors was more accurate in predicting 90-day mortality than the MELD score or C-reactive protein.

CONCLUSIONS

The presence of UTI indicates an increased risk of 90-day mortality in patients with advanced cirrhosis. Renal dysfunction and comorbidities are predictors of death in these patients.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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