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Ferrarese A, Senzolo M, Sasset L, Bassi D, Cillo U, Burra P. Multidrug-resistant bacterial infections in the liver transplant setting. Updates Surg 2024:10.1007/s13304-024-01903-6. [PMID: 38918314 DOI: 10.1007/s13304-024-01903-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/21/2024] [Indexed: 06/27/2024]
Abstract
Bacterial infections pose a life-threatening complication in patients with decompensated liver cirrhosis and acute-on-chronic liver failure. An increasing prevalence of infections caused by multidrug-resistant organisms (MDROs) has been observed in these patients, significantly impacting prognosis. A growing body of evidence has identified the most common risk factors for such infections, enabling the development of preventive strategies and therapeutic interventions. MDRO infections may also occur after liver transplantation (most commonly in the early post-operative phase), affecting both graft and patient survival. This review provides an overview of MDRO infections before and after liver transplantation, discussing epidemiological aspects, risk factors, prevention strategies, and novel therapeutic approaches. Furthermore, it examines the implications of MDRO infections in the context of prioritizing liver transplantation for the most severe patients, such as those with acute-on-chronic liver failure.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy.
| | - Marco Senzolo
- Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Lolita Sasset
- Infectious Disease Unit, Padua University Hospital, Padua, Italy
| | - Domenico Bassi
- Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Umberto Cillo
- Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
- Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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2
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You JY, Sato R, Chawla S, Kapoor A, Wang X, Collier P, Auzinger G, Duggal A, Dugar S. Hemodynamic profile of cirrhotic patients with sepsis and septic shock: A propensity score matched case-control study. J Crit Care 2024; 81:154532. [PMID: 38330737 DOI: 10.1016/j.jcrc.2024.154532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/15/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Our understanding of hemodynamics in cirrhotic patients with sepsis remains limited. Our study aims to investigate differences in hemodynamic profiles using echocardiography between septic patients with and without cirrhosis. MATERIALS AND METHODS This is a single-center, retrospective study of septic patients with echocardiogram within 3 days of ICU admission. We compared baseline characteristics, echocardiographic markers of LV systolic function arterial load between patients with and without cirrhosis. A propensity score-matched case-control model was developed to describe the differences in those echocardiography derived parameters between the groups. RESULTS 3151 patients with sepsis were included of which 422 (13%) had cirrhosis. In the propensity score matched group with 828 patients, cirrhotic patients had significantly higher left ventricular ejection fraction (64 vs.56%, p < 0.001) and stroke volume (72 vs.48 ml, p < 0.001) along with lower arterial elastance (Ea) (1.35 1vs.20.3, p < 0.001) and systemic vascular resistance (SVR) (851 vs.1209 dynes/s/m-5, p = 0.001). The left ventricular elastance (Ees) (2.83 vs 2.45, p = 0.002) was higher and ventricular-arterial coupling (Ea/Ees) (0.48 vs. 0.86, p < 0.001) lower in cirrhotic compared to non-cirrhotic. CONCLUSIONS Septic patients with cirrhosis had higher LVEF with lower Ea and SVR with higher Ees and significantly lower Ea/Ees suggesting vasodilation as the principal driver of the hyperdynamic profile in cirrhosis.
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Affiliation(s)
- Jee Young You
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI, USA.
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Aanchal Kapoor
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
| | - Patrick Collier
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Georg Auzinger
- Department of Critical Care, Cleveland Clinic London, London, UK; Reader in Critical Care King's College London, London, UK; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
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3
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Lin HR, Liao QX, Lin XX, Zhou Y, Lin JD, Xiao XJ. Development of a nomogram for predicting in-hospital mortality in patients with liver cirrhosis and sepsis. Sci Rep 2024; 14:9759. [PMID: 38684696 PMCID: PMC11059344 DOI: 10.1038/s41598-024-60305-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
In this study, we aimed to investigate the risk factors associated with in-hospital mortality in patients with cirrhosis and sepsis, establish and validate the nomogram. This retrospective study included patients diagnosed with liver cirrhosis and sepsis in the Medical Information Mart for Intensive Care IV (MIMIC-IV). Models were compared by the area under the curve (AUC), integrated discriminant improvement (IDI), net reclassification index (NRI) and decision curve analysis (DCA). A total of 1,696 patients with cirrhosis and sepsis were included in the final cohort. Our final model included the following 9 variables: age, heartrate, total bilirubin (TBIL), glucose, sodium, anion gap (AG), fungal infections, mechanical ventilation, and vasopressin. The nomogram were constructed based on these variables. The AUC values of the nomograms were 0.805 (95% CI 0.776-0.833), which provided significantly higher discrimination compared to that of SOFA score [0.684 (95% CI 0.647-0.720)], MELD-Na [0.672 (95% CI 0.636-0.709)] and ABIC [0.674(95% CI 0.638-0.710)]. We established the first nomogram for predicting in-hospital mortality in patients with liver cirrhosis and sepsis based on these factors. This nomogram can performs well and facilitates clinicians to identify people at high risk of in-hospital mortality.
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Affiliation(s)
- Hai-Rong Lin
- Department of Intensive Care Unit, First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, China
- Department of Intensive Care Unit, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Qiu-Xia Liao
- Department of Intensive Care Unit, First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, China
- Department of Intensive Care Unit, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Xin-Xin Lin
- Department of Intensive Care Unit, First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, China
- Department of Intensive Care Unit, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Ye Zhou
- Department of Intensive Care Unit, First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, China
- Department of Intensive Care Unit, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Jian-Dong Lin
- Department of Intensive Care Unit, First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, China
- Department of Intensive Care Unit, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Xiong-Jian Xiao
- Department of Intensive Care Unit, First Affiliated Hospital of Fujian Medical University, Fuzhou, 350004, China.
- Department of Intensive Care Unit, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
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Piccolo Serafim L, Simonetto DA, Choi DH, Weister TJ, Hanson AC, Kamath PS, Gajic O, Gallo de Moraes A. DERIVATION OF A MORTALITY PREDICTION MODEL IN CRITICAL CARE PATIENTS WITH CIRRHOSIS AND SEPSIS. Shock 2024; 61:382-386. [PMID: 38517233 DOI: 10.1097/shk.0000000000002323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
ABSTRACT Objective : The aim of the study is to develop a predictive model for in-hospital mortality in critically ill patients with cirrhosis and sepsis, using clinical and laboratory data. Design : This is a retrospective cohort study. Setting: Medical and mixed intensive care units (ICUs) of a tertiary medical center. Patients : Cirrhotic adults were admitted with sepsis to the ICUs from January of 2007 to May of 2017. Interventions : None. Measurements and Main Results : Of 2,595 ICU admissions of patients with cirrhosis, 277 with first ICU admission for sepsis were included in the analysis, and 37% died in the hospital. Patients who stayed in the ICU for at least 6 h (n = 275) were considered for the multivariate model. Ten-fold cross-validation was used to estimate best parameter values and model performance, and the final model was chosen as the model maximizing area under the receiver-operating characteristic curve. Variables in order of impact were Acute Physiology and Chronic Health Evaluation (APACHE) III score, initial serum lactate, conjugated bilirubin, serum creatinine, model for end-stage liver disease score, age, body mass index, and serum hemoglobin. The final best model from cross-validation presented an area under the receiver operator characteristic curve (AUC) of 0.75, using a cut-point of 50% estimated probability, sensitivity and specificity were 0.46 and 0.90, respectively, with positive predictive value of 0.72 and negative predictive value of 0.74. These results were similar to the APACHE III only model (AUC = 0.74, sensitivity = 0.43, specificity = 0.89, positive predictive value = 0.69, negative predictive value = 0.73). Conclusion : The combination of initial serum lactate level, conjugated bilirubin, initial serum creatinine, model for end-stage liver disease score, age, body mass index, and serum hemoglobin did not yield meaningful improvement in the AUC and did not provide advantage over the APACHE III score for the prediction of in-hospital mortality in critically ill patients with cirrhosis and sepsis.
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Affiliation(s)
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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5
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Smith TN, Choi C, Rattan P, Piccolo Serafim L, Kassmeyer BA, Lennon RJ, Gajic O, Olson JC, Kamath PS, Gallo De Moraes A, Simonetto DA. Serum lactate and mean arterial pressure thresholds in patients with cirrhosis and septic shock. Hepatol Commun 2024; 8:e0353. [PMID: 38180993 PMCID: PMC10781124 DOI: 10.1097/hc9.0000000000000353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/06/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND The Sepsis-3 guidelines have incorporated serum lactate levels of >2 mmol/L in septic shock definition to account for higher observed mortality. Further evidence is needed to support this threshold in cirrhosis, as well as target mean arterial pressure (MAP) during resuscitation. METHODS This observational cohort study investigated the association between initial serum lactate and resuscitation MAP levels on in-hospital mortality in patients with and without cirrhosis. Patients admitted to the intensive care unit for the treatment of septic shock between 2006 and 2021 in a quaternary academic center were included. Patients with cirrhosis documented on imaging and International Classification of Disease codes (n=595) were compared to patients without cirrhosis (n=575). The association of intensive care unit admission lactate levels and median 2-hour MAP with in-hospital mortality and the need for continuous renal replacement therapy was assessed. The association between median 24-hour MAP and in-hospital mortality was analyzed post hoc. RESULTS Within the cirrhosis group, admission lactate levels of 2-4 and >4 mmol/L were associated with increased in-hospital mortality compared to lactate <2 mmol/L [adjusted odds ratio (aOR): 1.69, CI: 1.03-2.81, aOR: 4.02, CI: 2.53-6.52]. Median 24-hour MAP 60-65 and <60 mm Hg were also associated with increased in-hospital mortality compared with MAP >65 mm Hg (aOR: 2.84, CI: 1.64-4.92 and aOR: 7.34, CI: 3.17-18.76). In the noncirrhosis group, associations with in-hospital mortality were weaker for lactate 2-4 and >4 mmol/L (aOR: 1.32, CI: 0.77-2.27 and aOR: 2.25, CI: 1.40-3.67) and median 24-hour MAP 60-65 and <60 mm Hg (aOR: 1.70, CI: 0.65-4.14 and aOR: 4.41, CI: 0.79-29.38). CONCLUSIONS These findings support utilizing lactate >2 mmol/L in the definition of septic shock, as well as a target MAP of >65 mm Hg during resuscitation in patients with cirrhosis.
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Affiliation(s)
- Thomas N. Smith
- Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Chansong Choi
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Puru Rattan
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Laura Piccolo Serafim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Blake A. Kassmeyer
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ryan J. Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jody C. Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Alice Gallo De Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Douglas A. Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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6
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Kou Y, Yang Y, Du S, Liu X, He K, Yuan W, Nie B. Risk factors for the development of sepsis in patients with cirrhosis in intensive care units. Clin Transl Sci 2023; 16:1748-1757. [PMID: 37226657 PMCID: PMC10582674 DOI: 10.1111/cts.13549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 05/26/2023] Open
Abstract
Sepsis is a serious complication of liver cirrhosis. This study aimed to develop a risk prediction model for sepsis among patients with liver cirrhosis. A total of 3130 patients with liver cirrhosis were enrolled from the Medical Information Mart for Intensive Care IV database, and randomly assigned into training and validation cohorts in a 7:3 ratio. The least absolute shrinkage and selection operator (LASSO) regression was used to filter variables and select predictor variables. Multivariate logistic regression was used to establish the prediction model. Based on LASSO and multivariate logistic regression, gender, base excess, bicarbonate, white blood cells, potassium, fibrinogen, systolic blood pressure, mechanical ventilation, and vasopressor use were identified as independent risk variables, and then a nomogram was constructed and validated. The consistency index (C-index), receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA) were used to measure the predictive performance of the nomogram. As a result of the nomogram, good discrimination was achieved, with C-indexes of 0.814 and 0.828 for the training and validation cohorts, respectively, and an area under the curve of 0.849 in the training cohort and 0.821 in the validation cohort. The calibration curves demonstrated good agreement between the predictions and observations. The DCA curves showed the nomogram had significant clinical value. We developed and validated a risk-prediction model for sepsis in patients with liver cirrhosis. This model can assist clinicians in the early detection and prevention of sepsis in patients with liver cirrhosis.
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Affiliation(s)
- Yan‐qi Kou
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Yu‐ping Yang
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical UniversityGuangdong Medical UniversityZhanjiangChina
| | - Shen‐shen Du
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Xiongxiu Liu
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Kun He
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Wei‐nan Yuan
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Biao Nie
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
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7
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Bai Z, Méndez-Sánchez N, Romeiro FG, Mancuso A, Philips CA, Tacke F, Basaranoglu M, Primignani M, Ibrahim M, Wong YJ, Nery FG, Teschke R, Ferreira CN, Muñoz AE, Pinyopornpanish K, Thevenot T, Singh SP, Mohanty A, Satapathy SK, Ridola L, Maruyama H, Cholongitas E, Levi Sandri GB, Yang L, Shalimar, Yang Y, Villa E, Krag A, Wong F, Jalan R, O’Brien A, Bernardi M, Qi X. Use of albumin infusion for cirrhosis-related complications: An international position statement. JHEP Rep 2023; 5:100785. [PMID: 37456673 PMCID: PMC10339261 DOI: 10.1016/j.jhepr.2023.100785] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 07/18/2023] Open
Abstract
Background & Aims Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. Methods Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. Results Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. Conclusions Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. Impact and implications Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion.
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Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico
| | | | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Metin Basaranoglu
- Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Massimo Primignani
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Filipe Gaio Nery
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Alberto E. Muñoz
- Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina
| | - Kanokwan Pinyopornpanish
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thierry Thevenot
- Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d’Hépatologie et de Soins Intensifs Digestifs, Besançon, France
| | | | - Arpan Mohanty
- Section of Gastroenterology, Boston Medical Center, Boston, MA, USA
| | - Sanjaya K. Satapathy
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Li Yang
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Yongping Yang
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Erica Villa
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Aleksander Krag
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK
| | | | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - the Liver Cirrhosis-related Complications (LCC)-International Special Interest Group
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico
- Internal Medicine Department, Botucatu Medical School, São Paulo, Brazil
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
- Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d’Hépatologie et de Soins Intensifs Digestifs, Besançon, France
- Kalinga Gastroenterology Foundation, Odisha, India
- Section of Gastroenterology, Boston Medical Center, Boston, MA, USA
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
- Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK
- Division of Medicine, Royal Free Campus, London, UK
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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8
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Hu W, Chen H, Ma C, Sun Q, Yang M, Wang H, Peng Q, Wang J, Zhang C, Huang W, Xie J, Huang Y. Identification of indications for albumin administration in septic patients with liver cirrhosis. Crit Care 2023; 27:300. [PMID: 37507790 PMCID: PMC10385943 DOI: 10.1186/s13054-023-04587-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Albumin infusion is the primary therapeutic strategy for septic patients with liver cirrhosis. Although recent studies have investigated the efficacy of albumin in the resuscitation stage of septic patients with liver cirrhosis, it remains unclear whether daily albumin administration can improve outcomes. Furthermore, the indications for initiating albumin therapy are not well defined. METHODS Septic patients with liver cirrhosis were obtained from the Medical Information Mart for Intensive Care (MIMIC-IV 2.0) database. Marginal structural Cox models were employed to investigate the association between daily albumin infusion and 28-day mortality. We also aimed to explore under what circumstances enrolled patients could benefit most from albumin administration, based on the clinical parameters collected on the day of albumin infusion, including serum albumin concentration, serum lactate concentration, mean arterial pressure (MAP), and vasopressor dosage. RESULTS A total of 2265 patients were included in the final analysis, of whom 1093 (48.3%) had received albumin treatment at least once. The overall 28-day mortality was 29.6%. After marginal structural modeling, daily albumin infusion was associated with a reduced risk of 28-day death (hazard ratio, 0.76; 95% CI 0.61-0.94). We found that patients benefit most from albumin infusion when initiated on the day of serum albumin concentration between 2.5 and 3.0 g/dL, serum lactate concentration greater than or equal to 2 mmol/L, MAP less than 60 mmHg, or vasopressor dosage between 0.2 and 0.3 mcg/kg/min (norepinephrine equivalent, NEE). CONCLUSIONS Albumin infusion is associated with a reduction in mortality in septic patients with liver cirrhosis under specific circumstances. Serum albumin concentration, serum lactate, MAP, and vasopressor dosage were found to be modifiers of treatment effectiveness and should be considered when deciding to initial albumin infusion.
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Affiliation(s)
- Wenhan Hu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, No. 899 Pinghai Road, Suzhou, 215000, People's Republic of China
| | - Chencheng Ma
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Meicheng Yang
- The State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, People's Republic of China
| | - Haofei Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Qingyun Peng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Jinlong Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Chen Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Wei Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Yingzi Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China.
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Ndomba N, Soldera J. Management of sepsis in a cirrhotic patient admitted to the intensive care unit: A systematic literature review. World J Hepatol 2023; 15:850-866. [PMID: 37397933 PMCID: PMC10308287 DOI: 10.4254/wjh.v15.i6.850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/22/2023] [Accepted: 05/31/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Sepsis is a severe medical condition that occurs when the body's immune system overreacts to an infection, leading to life-threatening organ dysfunction. The "Third international consensus definitions for sepsis and septic shock (Sepsis-3)" defines sepsis as an increase in sequential organ failure assessment score of 2 points or more, with a mortality rate above 10%. Sepsis is a leading cause of intensive care unit (ICU) admissions, and patients with underlying conditions such as cirrhosis have a higher risk of poor outcomes. Therefore, it is critical to recognize and manage sepsis promptly by administering fluids, vasopressors, steroids, and antibiotics, and identifying and treating the source of infection.
AIM To conduct a systematic review and meta-analysis of existing literature on the management of sepsis in cirrhotic patients admitted to the ICU and compare the management of sepsis between cirrhotic and non-cirrhotic patients in the ICU.
METHODS This study is a systematic literature review that followed the PRISMA statement's standardized search method. The search for relevant studies was conducted across multiple databases, including PubMed, Embase, Base, and Cochrane, using predefined search terms. One reviewer conducted the initial search, and the eligibility criteria were applied to the titles and abstracts of the retrieved articles. The selected articles were then evaluated based on the research objectives to ensure relevance to the study's aims.
RESULTS The study findings indicate that cirrhotic patients are more susceptible to infections, resulting in higher mortality rates ranging from 18% to 60%. Early identification of the infection source followed by timely administration of antibiotics, vasopressors, and corticosteroids has been shown to improve patient outcomes. Procalcitonin is a useful biomarker for diagnosing infections in cirrhotic patients. Moreover, presepsin and resistin have been found to be reliable markers of bacterial infection in patients with decompensated liver cirrhosis, with similar diagnostic performance compared to procalcitonin.
CONCLUSION This review highlights the importance of early detection and management of infections in cirrhosis patients to reduce mortality. Therefore, early detection of infection using procalcitonin test and other biomarker as presepsin and resistin, associated with early management with antibiotics, fluids, vasopressors and low dose corticosteroids might reduce the mortality associated with sepsis in cirrhotic patients.
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Affiliation(s)
- Nkola Ndomba
- Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
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10
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Jagdish RK, Roy A, Kumar K, Premkumar M, Sharma M, Rao PN, Reddy DN, Kulkarni AV. Pathophysiology and management of liver cirrhosis: from portal hypertension to acute-on-chronic liver failure. Front Med (Lausanne) 2023; 10:1060073. [PMID: 37396918 PMCID: PMC10311004 DOI: 10.3389/fmed.2023.1060073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic encephalopathy. Additionally, the severity of portal hypertension is the central driver for further advanced complications of hyperdynamic circulation, hepatorenal syndrome, and cirrhotic cardiomyopathy. The management of these individual complications has specific nuances which have undergone significant developments. In contrast to the classical natural history of cirrhosis and its complications which follows an insidious trajectory, acute-on-chronic failure (ACLF) leads to a rapidly downhill course with high short-term mortality unless intervened at the early stages. The management of ACLF involves specific interventions, which have quickly evolved in recent years. In this review, we focus on complications of portal hypertension and delve into an approach toward ACLF.
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Affiliation(s)
- Rakesh Kumar Jagdish
- Department of Hepatology, Gastroenterology and Liver Transplant Medicine, Metro Hospital, Noida, India
| | - Akash Roy
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Hospitals, Kolkata, India
| | - Karan Kumar
- Department of Hepatology, Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Padaki Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
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11
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Banc-Husu AM, Shiau H, Dike P, Shneider BL. Beyond Varices: Complications of Cirrhotic Portal Hypertension in Pediatrics. Semin Liver Dis 2023; 43:100-116. [PMID: 36572031 DOI: 10.1055/s-0042-1759613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Complications of cirrhotic portal hypertension (PHTN) in children are broad and include clinical manifestations ranging from variceal hemorrhage, hepatic encephalopathy (HE), ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS) to less common conditions such as hepatopulmonary syndrome, portopulmonary hypertension, and cirrhotic cardiomyopathy. The approaches to the diagnosis and management of these complications have become standard of practice in adults with cirrhosis with many guidance statements available. However, there is limited literature on the diagnosis and management of these complications of PHTN in children with much of the current guidance available focused on variceal hemorrhage. The aim of this review is to summarize the current literature in adults who experience these complications of cirrhotic PHTN beyond variceal hemorrhage and present the available literature in children, with a focus on diagnosis, management, and liver transplant decision making in children with cirrhosis who develop ascites, SBP, HRS, HE, and cardiopulmonary complications.
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Affiliation(s)
- Anna M Banc-Husu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Henry Shiau
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Peace Dike
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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12
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Abstract
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.
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Affiliation(s)
- Mahathi Avadhanam
- Department of Emergency Medicine, Queen Elizabeth hospital, London, UK
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Gachibowli, Hyderabad, India-500032.
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13
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Abstract
Patients with cirrhosis frequently require admission to the intensive care unit as complications arise in the course of their disease. These admissions are associated with high short- and long-term morbidity and mortality. Thus, understanding and characterizing complications and unique needs of patients with cirrhosis and acute-on-chronic liver failure helps providers identify appropriate level of care and evidence-based treatments. While there is no widely accepted critical care admission criteria for patients with cirrhosis, the presence of organ failure and primary or nosocomial infections are associated with particularly high in-hospital mortality. Optimal management of patients with cirrhosis in the critical care setting requires a system-based approach that acknowledges deviations from canonical pathophysiology. In this review, we discuss appropriate considerations and evidence-based practices for the general care of patients with cirrhosis and critical illness.
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Affiliation(s)
- Thomas N Smith
- Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota
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14
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Maiwall R, Kumar A, Pasupuleti SSR, Hidam AK, Tevethia H, Kumar G, Sahney A, Mitra LG, Sarin SK. A randomized-controlled trial comparing 20% albumin to plasmalyte in patients with cirrhosis and sepsis-induced hypotension [ALPS trial]. J Hepatol 2022; 77:670-682. [PMID: 35460725 DOI: 10.1016/j.jhep.2022.03.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The choice of resuscitation fluid in patients with cirrhosis and sepsis-induced hypotension is unclear. 5% albumin was superior to normal saline in the FRISC study. We compared the efficacy and safety of 20% albumin, which has greater oncotic properties, to plasmalyte in reversing sepsis-induced hypotension. METHODS Critically ill patients with cirrhosis underwent open-label randomization to receive either 20% albumin (0.5-1.0 g/kg over 3 hours; n = 50) or plasmalyte (30 ml/kg over 3 hours, n = 50). The primary endpoint of the study was the attainment of mean arterial pressure (MAP) above 65 mmHg at 3 hours. RESULTS Baseline characteristics were comparable in albumin and plasmalyte groups; arterial lactate (6.16±3.18 mmol/L vs. 6.38±4.77 mmol/L; p = 0.78), MAP (51.4±6.52 mmHg vs. 49.9±4.45 mmHg; p = 0.17) and SOFA score (10.8±2.96 vs. 11.1±4.2; p = 0.68), respectively. Most patients were alcoholics (39%) and had pneumonia (40%). In the intention-to-treat analysis, albumin was superior to plasmalyte in achieving the primary endpoint (62% vs. 22%; p <0.001). A faster decline in arterial lactate (p = 0.03), a reduced need for dialysis (48% vs. 62%; p = 0.16), and a longer time to initiation of dialysis (in hours) (68.13±47.79 vs. 99.7± 63.4; p = 0.06) were seen with albumin. However, the 28-day mortality rate was not different (58% vs. 62%, p = 0.57) and treatment had to be discontinued in 11 (22%) patients in the albumin group due to adverse effects compared to no discontinuations in the plasmalyte group. CONCLUSION In patients with cirrhosis and sepsis-induced hypotension, 20% albumin leads to a faster improvement in hemodynamics and lactate clearance than plasmalyte, while 28-day survival was similar. However, patients on 20% albumin need to be closely monitored as it was more often associated with pulmonary complications. CLINICAL TRIAL REGISTRATION NCT02721238. LAY SUMMARY The current randomized-controlled trial performed in critically ill patients with cirrhosis and sepsis-induced hypotension highlights that 20% albumin restores arterial pressure more quickly but causes more pulmonary complications than plasmalyte. The impact on renal functions was also modest. These effects did not result in improvement in survival at 28 days. Plasmalyte is safer and well-tolerated and can be considered for volume resuscitation in patients with cirrhosis and sepsis-induced hypotension.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India
| | - Abhinav Kumar
- Department of Hepatology, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India
| | - Samba Siva Rao Pasupuleti
- Department of Statistics, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India
| | - Ashini Kumar Hidam
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Harshvardhan Tevethia
- Department of Hepatology, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India
| | - Guresh Kumar
- Department of Biostatistics, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India
| | - Amrish Sahney
- Department of Hepatology, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India
| | - Lalita Gouri Mitra
- Department of Critical Care and Anaesthesia, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India.
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15
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Kulkarni AV, Premkumar M, Arab JP, Kumar K, Sharma M, Reddy ND, Padaki NR, Reddy RK. Early Diagnosis and Prevention of Infections in Cirrhosis. Semin Liver Dis 2022; 42:293-312. [PMID: 35672014 DOI: 10.1055/a-1869-7607] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Juan P Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Karan Kumar
- Department of Hepatology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nageshwar D Reddy
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nagaraja R Padaki
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rajender K Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
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16
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Sudo M, Shamekhi J, Sedaghat A, Aksoy A, Zietzer A, Tanaka T, Wilde N, Weber M, Sinning JM, Grube E, Veulemans V, Adam M, Kelm M, Baldus S, Nickenig G, Zimmer S, Tiyerili V, Al-Kassou B. Predictive value of the Fibrosis-4 index in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. Clin Res Cardiol 2022; 111:1367-1376. [DOI: 10.1007/s00392-022-02055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022]
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17
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Sehgal R, Maiwall R, Rajan V, Islam M, Baweja S, Kaur N, Kumar G, Ramakrishna G, Sarin SK, Trehanpati N. Granulocyte-Macrophage Colony-Stimulating Factor Modulates Myeloid-Derived Suppressor Cells and Treg Activity in Decompensated Cirrhotic Patients With Sepsis. Front Immunol 2022; 13:828949. [PMID: 35720398 PMCID: PMC9205181 DOI: 10.3389/fimmu.2022.828949] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/03/2022] [Indexed: 11/28/2022] Open
Abstract
Background Decompensated cirrhosis patients are more prone to bacterial infections. Myeloid-derived suppressor cells (MDSCs) expand in sepsis patients and disrupt immune cell functions. Granulocyte-macrophage colony-stimulating factor (GM-CSF) therapy helps in restoring immune cell functions and resolving infections. Its role in MDSC modulation in cirrhosis with sepsis is not well understood. Methods A total of 164 decompensated cirrhotic—62 without (w/o), 72 with sepsis, and 30 with sepsis treated with GM-CSF—and 15 healthy were studied. High-dimensional flow cytometry was performed to analyze MDSCs, monocytes, neutrophils, CD4 T cells, and Tregs at admission and on days 3 and day 7. Ex vivo co-cultured MDSCs with T cells were assessed for proliferation and apoptosis of T cells and differentiation to Tregs. Plasma factors and mRNA levels were analyzed by cytokine-bead assay and qRT-PCR. Results Frequencies of MDSCs and Tregs were significantly increased (p = 0.011 and p = 0.02) with decreased CD4 T cells (p = 0.01) in sepsis than w/o sepsis and healthy controls (HCs) (p = 0.000, p = 0.07, and p = 0.01) at day 0 and day 7. In sepsis patients, MDSCs had increased IL-10, Arg1, and iNOS mRNA levels (p = 0.016, p = 0.043, and p = 0.045). Ex vivo co-cultured MDSCs with T cells drove T-cell apoptosis (p = 0.03, p = 0.03) with decreased T-cell proliferation and enhanced FOXP3+ expression (p = 0.044 and p = 0.043) in sepsis compared to w/o sepsis at day 0. Moreover, blocking the MDSCs with inhibitors suppressed FOXP3 expression. GM-CSF treatment in sepsis patients significantly decreased MDSCs and FOXP3+ Tregs but increased CD4 T-cell functionality and improved survival. Conclusion MDSCs have an immunosuppressive function by expanding FOXP3+ Tregs and inhibiting CD4+ T-cell proliferation in sepsis. GM-CSF treatment suppressed MDSCs, improved T-cell functionality, and reduced Tregs in circulation.
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Affiliation(s)
- Rashi Sehgal
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
- Amity Institute of Biotechnology, Amity University, Noida, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vijayaraghavan Rajan
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Mojahidul Islam
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Baweja
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Navkiran Kaur
- Amity Institute of Biotechnology, Amity University, Noida, India
| | - Guresh Kumar
- Department of Clinical Research and Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Gayatri Ramakrishna
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K. Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
- *Correspondence: Nirupma Trehanpati, ; ; Shiv K. Sarin, ;
| | - Nirupma Trehanpati
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
- *Correspondence: Nirupma Trehanpati, ; ; Shiv K. Sarin, ;
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18
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Choi C, Choi DH, Spears GM, Peeraphatdit TB, Serafim LP, Gajic O, Kamath PS, Shah VH, Gallo de Moraes A, Simonetto DA. Relationship Between Etiology of Cirrhosis and Survival Among Patients Hospitalized in Intensive Care Units. Mayo Clin Proc 2022; 97:274-284. [PMID: 35090753 PMCID: PMC8883528 DOI: 10.1016/j.mayocp.2021.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 05/25/2021] [Accepted: 08/06/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine short-term outcomes of patients with alcohol-associated cirrhosis (ALC) admitted to the intensive care unit (ICU) compared with other etiologies of liver disease. In addition, we investigate whether quick sequential organ failure assessment accurately predicts presence of sepsis and in-hospital mortality in critically ill patients with various etiologies of cirrhosis. METHODS A retrospective cohort of 1174 consecutive patients with cirrhosis admitted to the ICU between January of 2006 and December of 2015 was analyzed. Outcomes of interest included survival rates within the ICU, post-ICU in-hospital, or at 30 days post-ICU discharge. RESULTS Five hundred seventy-eight patients were found to have ALC with 596 in the non-ALC group. There was no significant difference in ICU mortality rates in ALC versus non-ALC cohorts (10.2% vs 11.7%, P=.40). However, patients with ALC had significantly higher post-ICU in-hospital death (10.0% vs 6.5%, P=.04) as well as higher mortality at 30-day post-ICU discharge (18.7% vs 11.2%, P<.001). Sustained alcohol abstinence did not offer survival advantage over nonabstinence. The predictive power for quick sequential organ failure assessment for sepsis and in-hospital mortality for patients with cirrhosis was limited. CONCLUSION Critically ill patients with ALC have decreased survival after ICU discharge compared with patients with other etiologies of cirrhosis, independent of alcohol abstinence.
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Affiliation(s)
- Chansong Choi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Dae Hee Choi
- Department of Internal Medicine, School of Medicine, Kangwon National University, Republic of Korea
| | - Grant M Spears
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Thoetchai Bee Peeraphatdit
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Laura Piccolo Serafim
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Alice Gallo de Moraes
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
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19
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Abstract
In patients with cirrhosis and chronic liver disease, acute-on-chronic liver failure is emerging as a major cause of mortality. These guidelines indicate the preferred approach to the management of patients with acute-on-chronic liver failure and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation process. In instances where the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, but there was consensus of significant clinical merit, key concept statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not only, approach to clinical scenarios.
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20
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Mehrdad R, Zahra K, Mansouritorghabeh H. Hemostatic System (Fibrinogen Level, D-Dimer, and FDP) in Severe and Non-Severe Patients With COVID-19: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2021; 27:10760296211010973. [PMID: 34933579 PMCID: PMC8728788 DOI: 10.1177/10760296211010973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
SARS-CoV-2 in COVID-19 triggers abnormalities in coagulation parameters that can
contribute to thrombosis. The goals of this research were to determine the
levels of fibrinogen, D-dimer and FDP in COVID-19 patients. Following a
systematic study, among 1198 articles, 35 studies were included in the
meta-analysis of fibrinogen levels in both severe and non-severe groups. The
funnel plot, Egger’s regression asymmetry test, and Begg’s test used to measure
the bias of publications. All meta-analysis performed by comprehensive
meta-analysis version 2 (CMA2). The pooled findings of fibrinogen levels
revealed a significant rise in fibrinogen levels in severe COVID-19 than
non-severe patients with COVID-19. The D-dimer and FDP levels were significantly
higher in severe patients than non-severe patients with COVID-19 were. The
levels of fibrinogen, D-dimer, and FDP have increased significantly in ICU
patients compared to non-ICU patients. Although, levels of clotting parameters
do not always correlate with the severity of disease, these findings showed the
diagnostic importance for fibrinogen, D-dimer, and FDP in COVID-19. The presence
of a continuous rise in serial measurements of fibrinogen, D-dimer, and FDP may
predict that patients with COVID-19 may become critically ill.
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Affiliation(s)
- Rostami Mehrdad
- Laboratory Hematology and Blood Banking, Mashhad University of
Medical Sciences, Mashhad, Iran
| | - Khoshnegah Zahra
- Laboratory Hematology and Blood Banking, Mashhad University of
Medical Sciences, Mashhad, Iran
| | - Hassan Mansouritorghabeh
- Central Diagnostic Laboratories, Ghaem Hospital, Mashhad University
of Medical Sciences, Mashhad, Iran
- Hassan Mansouritorghabeh, PhD, Central
Diagnostic Laboratories, Ghaem Hospital, Mashhad University of Medical Sciences,
Mashhad, Iran.
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21
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Trends and outcomes of infective endocarditis in cirrhosis: a propensity-matched national study. Eur J Gastroenterol Hepatol 2021; 33:e580-e586. [PMID: 35048650 DOI: 10.1097/meg.0000000000002177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Cirrhosis is the most common cause of liver-related death and bacterial infection is a common comorbidity in cirrhosis. We aimed to study the trends and outcomes of infective endocarditis in cirrhosis. METHODS A propensity-matched analysis of the National Inpatient Sample database was performed to assess outcomes of infective endocarditis in adult patients (>18 years) from 2004-2013 with and without cirrhosis. Various outcomes were assessed for outcomes of infective endocarditis in cirrhosis. Multivariate regression analysis was performed for predictors of mortality in infective endocarditis. RESULTS There has been no significant change in incidence (3.3-3.6%, P = 0.27) and overall mortality (6.3-8.6%, P = 0.42) of infective endocarditis in cirrhosis. After propensity matching, patients with cirrhosis had significantly higher in-hospital mortality (15 vs. 10.6%, P < 0.001) and acute kidney injury (AKI) (31.8 vs. 28.5%, P < 0.001) as compared to no cirrhosis. Microbiological analysis revealed significantly higher rates of streptococci (35.3 vs. 31.9%, P < 0.001) and fungal infective endocarditis (0.03 vs. 0%, P < 0.001) and lower incidence of Gram-negative infective endocarditis (3.9 vs. 6.3%, P < 0.001) in cirrhosis. Cirrhosis patients had significantly less surgical intervention (10.2 vs. 30.3%, P < 0.001) along with overall total cost and length of stay as compared to no cirrhosis. On multivariate analysis, advanced age, AKI, shock and mechanical ventilation were positive predictors of mortality in infective endocarditis patients with cirrhosis patients. CONCLUSIONS Cirrhosis is an independent predictor of mortality in infective endocarditis with worse outcomes and less surgical intervention. Gram-negative infective endocarditis is lower in cirrhosis, whereas streptococci and fungal infective endocarditis are higher than noncirrhotic patients.
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22
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Peng M, Deng F, Qi D, Hu Z, Zhang L. The Hyperbilirubinemia and Potential Predictors Influence on Long-Term Outcomes in Sepsis: A Population-Based Propensity Score-Matched Study. Front Med (Lausanne) 2021; 8:713917. [PMID: 34604255 PMCID: PMC8484885 DOI: 10.3389/fmed.2021.713917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/16/2021] [Indexed: 01/20/2023] Open
Abstract
Objective: Although hyperbilirubinemia has been associated with mortality in patients who are critically ill, yet no clinical studies dissect the effect of dynamic change of hyperbilirubinemia on long-term septic prognosis. The study aims to investigate the specific stages of hyperbilirubinemia and potential risk factors on long-term outcomes in patients with sepsis. Methods: In this retrospective observational cohort study, patients with sepsis, without previous chronic liver diseases, were identified from the Medical Information Mart for the Intensive Care III MIMIC-III database. We used propensity scores (PS) to adjust the baseline differences in septic patients with hyperbilirubinemia or not. The multivariate Cox was employed to investigate the predictors that influence a clinical outcome in sepsis. Results: Of 2,784 patients with sepsis, hyperbilirubinemia occurred in 544 patients (19.5%). After PS matching, a survival curve demonstrated that patients with sepsis with the new onset of total bilirubin (TBIL) levels more than or equal to 5 mg/dl survived at significantly lower rates than those with TBIL levels <5 mg/dl. Multivariate Cox hazard analysis showed that patients with TBIL at more than or equal to 5 mg/dl during sepsis exhibit 1.608 times (95% CI: 1.228-2.106) higher risk of 1-year mortality than those with TBIL levels <5 mg/dl. Also, age above 65 years old, preexisting malignancy, a respiratory rate above 30 beats/min at admission, serum parameters levels within 24-h admission, containing international normalized ratio (INR) above 1.5, platelet <50*10∧9/L, lactate above 4 mmol/L, and bicarbonate <22 or above 29 mmol/L are the independent risk factors for long-term mortality of patients with sepsis. Conclusions: After PS matching, serum TBIL levels at more than or equal to 5 mg/dl during hospitality are associated with increased long-term mortality for patients with sepsis. This study may provide clinicians with some cutoff values for early intervention, which may improve the prognosis of patients with sepsis.
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Affiliation(s)
- Milin Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Fuxing Deng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Desheng Qi
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Department of Emergency, Xiangya Hospital, Central South University, Changsha, China
| | - Zhonghua Hu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Molecular Precision Medicine, Xiangya Hospital, Institute of Molecular Precision Medicine, Central South University, Changsha, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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23
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Choudhury A, Vijayaraghavan R, Maiwall R, Kumar M, Duan Z, Yu C, Hamid SS, Jafri W, Butt AS, Devarbhavi H, Ning Q, Ma K, Tan SS, Shukla A, Dhiman R, Duseja A, Taneja S, Eapen CE, Goel A, Treeprasertsuk S, Al-Mahtab M, Ghazinyan H, Kim DJ, Sahu MK, Lee GH, Lesmana LA, Lesmana RC, Shah S, Abbas Z, Sollano JD, Rao PN, Kulkarni A, Shiha G, Shrestha A, Dokmeci AK, Yuen MF, Payawal DA, Kalista KF, Prasad VGM, Lau GK, Karim F, Jain P, Kumar G, Arora V, Pamecha V, Sinha P, Sarin SK. 'First week' is the crucial period for deciding living donor liver transplantation in patients with acute-on-chronic liver failure. Hepatol Int 2021; 15:1376-1388. [PMID: 34608586 DOI: 10.1007/s12072-021-10206-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Acute-on-chronic liver failure (ACLF) is a rapidly progressive illness with high short-term mortality. Timely liver transplant (LT) may improve survival. We evaluated various indices for assessment of the severity of liver failure and their application for eligibility and timing of living donor LT (LDLT). METHODS Altogether 1021 patients were analyzed for the severity and organ failure at admission to determine transplant eligibility and 28 day survival with or without transplant. RESULTS The ACLF cohort [mean age 44 ± 12.2 years, males 81%) was of sick patients; 55% willing for LT at admission, though 63% of them were ineligible due to sepsis or organ failure. On day 4, recovery in sepsis and/or organ failure led to an improvement in transplant eligibility from 37% at baseline to 63.7%. Delay in LT up to 7 days led to a higher incidence of multiorgan failure (p < 0.01) contributing to 23% of the first week and 55% of all-cause 28-day mortality. In a matched cohort analysis, the actuarial survival with LT (n = 41) and conditional survival in the absence of transplant (n = 191) were comparable, when the condition, i.e., transplant was adjusted. The comparison curve showed differentiation in survival beyond 7 days (p < 0.01). CONCLUSIONS ACLF is a rapidly progressive disease and risk stratification within the first week of hospitalization is needed. 'Emergent LT' should be defined in the first week in the ACLF patients; the transplant window for improving survival in a live donor setting.
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Affiliation(s)
- Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajan Vijayaraghavan
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Zhongping Duan
- Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
| | - Chen Yu
- Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
| | - Saeed Sadiq Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Amna Subhan Butt
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St John Medical College, Bangalore, India
| | - Qin Ning
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Ma
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Soek-Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Akash Shukla
- Department of Hepatology, KEM Hospital and Seth GSMC, Mumbai, India
| | - Radhakrishna Dhiman
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - C E Eapen
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Ashish Goel
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | | | - Mamun Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Hasmik Ghazinyan
- Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia
| | - Dong Joon Kim
- Centre for Liver and Digestive Diseases, Gangwon-Do, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
| | - Manoj K Sahu
- Department of Gastroenterology and Biliary Sciences, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Guan Huei Lee
- Department of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
| | | | | | - Samir Shah
- Department of Hepatology, Global Hospital, Mumbai, India
| | - Zaigham Abbas
- Department of Hepatogastroenterology, Ziauddin University, Karachi, Pakistan
| | - Jose D Sollano
- Department of Hepatology, Cardinal Santos Medical Centre, Manila, Philippines
| | - P N Rao
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Gamal Shiha
- Department of Internal Medicine, Egyptian Liver Research Institute and Hospital, Cairo, Egypt
| | | | - AKadir Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Man Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | | | - Kemal Fariz Kalista
- Division of Hepatobiliary Cipto Mangunkusuamo Hospital, University of Indonesia, Jakarta, Indonesia
| | | | - George K Lau
- Department of Gastroenterology, Humanity and Health Medical Centre, Hong Kong, China
| | - Fazal Karim
- Department of Hepatology, Sir Salimullah Medical College, Dhaka, Bangladesh
| | - Priyanka Jain
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepatobiliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India.,Department of Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Piyush Sinha
- Department of Hepatobiliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India.,Department of Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India. .,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
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24
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Villanueva C, Albillos A, Genescà J, Garcia-Pagan JC, Brujats A, Calleja JL, Aracil C, Bañares R, Morillas RM, Poca M, Peñas B, Augustin S, Abraldes JG, Alvarado E, Torres F, Bosch J. Bacterial infections adversely influence the risk of decompensation and survival in compensated cirrhosis. J Hepatol 2021; 75:589-599. [PMID: 33905794 DOI: 10.1016/j.jhep.2021.04.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/25/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The prognosis of compensated cirrhosis is good until decompensation. In decompensated cirrhosis, bacterial infections (BIs) are common and increase the risk of death. The incidence and prognostic implications of BIs in compensated cirrhosis are less-well characterized. This study aimed to assess whether BIs influence the risk of decompensation and survival in patients with compensated cirrhosis. METHODS This is a cohort study nested to the PREDESCI study, a double-blind, multicenter, randomized controlled trial designed to assess whether β-blockers could prevent decompensation of cirrhosis. Patients with compensated cirrhosis and hepatic venous pressure gradient ≥10 mmHg were included. Development of BIs during follow-up was prospectively registered. Using a competing-risk time-dependent regression analysis, we investigated whether BIs affect the risk of decompensation and survival. Decompensation was defined as development of ascites, bleeding or overt encephalopathy. RESULTS A total of 201 patients were randomized and followed for a median of 36 months (IQR 24-47 months); 34 patients (17%) developed BIs, which occurred before decompensation in 33 cases, and 29 (14%) developed ascites. Respiratory and urinary tract infections were the most frequent BIs. Decompensation occurred in 26% patients with BIs vs. 16% without BIs. Patients with BIs were at higher risk of decompensation (subdistribution hazard ratio [SHR] 2.93; 95% CI 1.02-8.42; p = 0.047) and of developing ascites (SHR 3.55; 95% CI 1.21-10.47; p = 0.022) than those without BIs. Risk of death was also higher in patients with BIs (subdistribution HR 6.93; 95% CI 2.64-18.18; p <0.001), although decompensation occurred before death in 71% of such cases. CONCLUSIONS BIs have a marked impact on the natural history of compensated cirrhosis, significantly increasing the risk of decompensation, mainly that of ascites, and increasing the risk of death, which usually occurs after decompensation. Our results suggest that BIs may constitute a target to prevent decompensation. LAY SUMMARY It is widely known that bacterial infections are common and increase the mortality risk in patients with decompensated cirrhosis. However, the relevance of bacterial infections in compensated cirrhosis has not been well studied. This study shows that in patients with compensated cirrhosis and clinically significant portal hypertension, bacterial infections occur as frequently as the development of ascites, which is the most frequent decompensating event. Bacterial infections increase the risk of progression to decompensation, mainly by increasing the risk of ascites, and also increase the risk of death, which usually occurs after decompensation. CLINICALTRIALS. GOV IDENTIFIER NCT01059396.
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Affiliation(s)
- Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, 08025, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Joan Genescà
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Liver Unit, Department of Internal Medicine, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Spain
| | - Joan C Garcia-Pagan
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain(‡)
| | - Anna Brujats
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, 08025, Barcelona, Spain
| | - José L Calleja
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Hospital Universitario Puerta de Hierro, IDIPHIM, Universidad Autónoma de Madird, Madrid, Spain
| | - Carles Aracil
- Hospital Universitari Arnau de Vilanova, Lleida, Institut de Recerca Biomèdica (IRBLleida), Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Hospital General Universitario Gregorio Marañón, IISGM, Universidad Complutense, Madrid, Spain
| | - Rosa M Morillas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Liver Section, Hospital Universitari Germans Trias i Pujol, IGTP, Universitat Autònoma de Barcelona, Badalona, Spain
| | - María Poca
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, 08025, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Beatriz Peñas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Salvador Augustin
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Liver Unit, Department of Internal Medicine, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Spain
| | - Juan G Abraldes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain(‡); Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| | - Edilmar Alvarado
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, 08025, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Ferran Torres
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain; Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Bosch
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain(‡); University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University, Switzerland
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25
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Chen Z, Jiang H, Wang Y, Liang R, Xu L, Lai J, Shen J, Li J, Li D, Li S, Lei K, Zhou Q, Peng B, Peng H, Peng S, Kuang M. Three-day postoperative antibiotics reduces post-hepatectomy infection rate in hepatitis B virus-related hepatocellular carcinoma. J Gastroenterol Hepatol 2021; 36:2531-2539. [PMID: 33948991 DOI: 10.1111/jgh.15528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/06/2021] [Accepted: 02/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM The evidences for use of postoperative antibiotics (POA) in hepatocellular carcinoma (HCC) patients who underwent hepatectomy are controversial. We aimed to explore the relationship between POA and hepatectomy-related infection in a hepatitis B virus (HBV)-related HCC population. METHODS We retrospectively collected 934 HCC patients who underwent hepatectomy for curative intent from three tertiary hospitals in China. The incidences of postoperative infection including surgical site infection and remote site infection were recorded and calculated. Univariable and multivariable logistic regression analyses were performed to explore related factors of postoperative infection and POA. And the relationship between infection rates with different durations of POA was investigated. RESULTS The overall infection rate was 8.2% (77/934), including 6.5% (61/934) of surgical site infection and 2.0% (19/934) of remote site infection. Multivariable analysis revealed that the administration of POA was negatively related with the incidence of postoperative infection significantly (odds ratio = 0.50, 95% confidence interval = 0.30 to 0.83; P = 0.008). Albumin-bilirubin score, Barcelona Clinic Liver Cancer (BCLC) stage and extent of hepatectomy were independently related to the POA. And 3-day regimen seemed to be the shortest duration of POA to gain the lowest incidence of postoperative infection. CONCLUSIONS Postoperative antibiotic is necessary for HBV-related HCC patients to prevent postoperative infection, especially for those with higher albumin-bilirubin score, at BCLC stage B-C, or who underwent major hepatectomy. For HBV-related HCC patients, postoperative second-generation cephalosporins, or ceftriaxone for 3 days after surgery might be proper.
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Affiliation(s)
- Zebin Chen
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Jiang
- Department of Pediatric Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuanqi Wang
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruiming Liang
- Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lixia Xu
- Department of Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiaming Lai
- Department of Pancreato-biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingxian Shen
- Department of Medical Imaging, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jiali Li
- Department of Hepatobiliary Surgery, Dongguan People's Hospital, Dongguan, China
| | - Dongming Li
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoqiang Li
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Kai Lei
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Zhou
- Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Baogang Peng
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Peng
- Department of Pancreato-biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Sui Peng
- Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Kuang
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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26
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Yu C, Zhu X, Zheng C, Luo Y, Wang F, Gao Y, Wu H, Sun X, Kong X. Methyl Diet Enhanced Sepsis-Induced Mortality Through Altering Gut Microbiota. J Inflamm Res 2021; 14:3107-3121. [PMID: 34276224 PMCID: PMC8277458 DOI: 10.2147/jir.s305202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/29/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction Mortality of sepsis is caused by an inappropriately amplified systemic inflammatory response and bacteremia. Methyl diet has been shown to associate with greater inflammation response in different diseases. This study aimed to determine whether dietary supplementation with methyl donors affects the inflammation response and mortality in sepsis and to investigate the underlying mechanisms. Methods Four-week-old male C57BL/6 mice were fed with a high-methyl diet (HMD) or a regulator diet (RD) till the experiment time. Mice septic model was induced by Cecal ligation and puncture (CLP), lipopolysaccharide (LPS), or E.coli. Inflammatory cytokine was analyzed by ELISA and qRT-PCR. Immune cell infiltration was evaluated by H&E and IHC. The composition of gut microbiota was determined by 16S rRNA sequencing. The effect of gut microbiota on sepsis was further verified by fecal microbiome transplantation. Results Our results showed that the diet riches in methyl donors exacerbated mortality, organ injury, and circulating levels of inflammatory mediators in CLP-induced septic mice model, compared to the control diet group. However, no significant differences have been observed in the inflammatory responses in the LPS-induced septic model and macrophages activation between the two groups of mice. There was a higher bacterial burden in CLP-induced HMD mice suggested that methyl diet might modulate gut microbiota. Bacterial 16S rRNA sequencing results showed that the composition of gut microbiota was altered. The high methyl donor diet reduced the abundance of Akkermansia and Lachnospiraceae, which were associated with protective effects in sepsis, in the gut. Moreover, fecal microbiome transplantation experiment showed that the transfer of feces, which obtained from high methyl diet mice, aggravated the mortality and inflammation responses in recipient mice. Discussion Methyl diet enhanced CLP-induced septic mortality and inflammatory responses through altering the composition of gut microbiota. This result indicated that diet-based gut microbiota may be a new therapeutic strategy for sepsis patients.
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Affiliation(s)
- Chang Yu
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, People's Republic of China
| | - Xiaojun Zhu
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, People's Republic of China
| | - Chao Zheng
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, People's Republic of China
| | - Yichun Luo
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, People's Republic of China
| | - Fang Wang
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, People's Republic of China
| | - Yueqiu Gao
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, People's Republic of China
| | - Hailong Wu
- Shanghai Key Laboratory of Molecular Imaging, Shanghai University of Medicine and Health Sciences, Shanghai, People's Republic of China
| | - Xuehua Sun
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, People's Republic of China
| | - Xiaoni Kong
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, People's Republic of China
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Van der Merwe S, Chokshi S, Bernsmeier C, Albillos A. The multifactorial mechanisms of bacterial infection in decompensated cirrhosis. J Hepatol 2021; 75 Suppl 1:S82-S100. [PMID: 34039494 DOI: 10.1016/j.jhep.2020.11.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 02/08/2023]
Abstract
Infections, due to a dysfunctional immune response, pose a great risk to patients with decompensated cirrhosis and herald the beginning of the terminal phase of this disease. Infections typically result from breaches in innate immune barriers and inadequate clearance by immune cells. This leads to bacterial and bacterial product translocation to the systemic circulation, which is already primed by ongoing hepatic inflammation in patients with cirrhosis, who are particularly prone to developing organ failure in the presence of an infection. Early identification of bacterial infection, along with the prompt use of appropriate antibiotics, have reduced the mortality associated with certain infections in patients with decompensated cirrhosis. Judicious use of antibiotic therapy remains imperative given the emergence of multidrug-resistant infections in the cirrhotic population. Important research over the last few years has identified molecular targets on immune cells that may enhance their function, and theoretically prevent infections. Clinical trials are ongoing to delineate the beneficial effects of targeted molecules from their off-target effects. Herein, we review the mechanisms that predispose patients with cirrhosis to bacterial infections, the clinical implications of infections and potential targets for the prevention or treatment of infections in this vulnerable population.
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Affiliation(s)
- Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, University hospital, Leuven, Belgium; Laboratory of Hepatology, University of Leuven, Belgium.
| | - Shilpa Chokshi
- Institute of Hepatology, Foundation for Liver Research, London, UK; Division of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College, London, United Kingdom
| | - Christine Bernsmeier
- Department of Biomedicine, University of Basel, Switzerland; University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Agustin Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
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28
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Affiliation(s)
- Jasmohan S Bajaj
- From Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond (J.S.B.); Mayo Clinic College of Medicine and Science, Rochester, MN (P.S.K.); and the University of Pennsylvania, Philadelphia (K.R.R.)
| | - Patrick S Kamath
- From Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond (J.S.B.); Mayo Clinic College of Medicine and Science, Rochester, MN (P.S.K.); and the University of Pennsylvania, Philadelphia (K.R.R.)
| | - K Rajender Reddy
- From Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond (J.S.B.); Mayo Clinic College of Medicine and Science, Rochester, MN (P.S.K.); and the University of Pennsylvania, Philadelphia (K.R.R.)
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29
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Yang YY, Hsu YC. Effectiveness of sepsis bundle application and outcomes predictors to cirrhotic patients with septic shock. BMC Infect Dis 2021; 21:483. [PMID: 34039297 PMCID: PMC8157624 DOI: 10.1186/s12879-021-06194-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 05/17/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Cirrhotic patients with septic shock have a poorer prognosis compared with the general population. Our study aimed to investigate the survival benefit of the implementation of hour-1 bundle proposed by Surviving Sepsis Campaign, and to analyze the predictors associated with short-term mortality of these patients. Methods A single-center, retrospective case-control study was conducted among adult patients who visited the emergency department between January 1, 2018 and December 31, 2019. All patients with a diagnosis of liver cirrhosis and septic shock were enrolled. Their baseline characteristics, laboratory results, source of sepsis, and sepsis bundle management were recorded. We further divided the patients into survivor and non-survivor groups to identify independent prognostic factors. Results A total of 88 patients were eligible for this study. The overall 30-day mortality rate was 53.4% (47/88). The proportion of hour-1 bundle achievement was 30.7% (27/88). There were no significant mortality differences between the hour-1 bundle achievement and non-achievement groups (44.4% vs. 57.4%, p = 0.35). Compared with the patients in the survivor group, patients in the non-survivor group had significantly more advanced stage of cirrhosis and a lower proportion of receiving source control (4.3% vs. 22.0%, p = 0.02). The chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score (adjusted hazard ratio [AHR] =1.52, p < 0.01), serum lactate (AHR =1.03, p < 0.01), and source control (AHR =0.54, p = 0.02) were identified as independent prognostic factors in the multivariate regression model. Furthermore, the CLIF-SOFA score (area under curve [AUC]: 0.81) and lactate levels (AUC: 0.77) revealed good mortality discrimination ability in cirrhotic patients with septic shock. Conclusions The application of the hour-1 bundle did not reveal a significant survival benefit to cirrhotic patients with septic shock. Clinicians could utilize CLIF-SOFA scores and lactate levels for mortality risk stratification and put more emphasis on the feasibility of source control to improve their prognosis.
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Affiliation(s)
- Yong-Ye Yang
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, No.1, Yida Road, Jiao-su Village, Yan-chao District, Kaohsiung City, 82445, Taiwan
| | - Yin-Chou Hsu
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, No.1, Yida Road, Jiao-su Village, Yan-chao District, Kaohsiung City, 82445, Taiwan. .,School of Medicine for International Student, I-Shou University, Kaohsiung, Taiwan.
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30
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Durst MM, Eitzen EA, Benken ST. Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis. Ann Pharmacother 2020; 55:970-979. [PMID: 33327736 DOI: 10.1177/1060028020980727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Patients with cirrhosis have immune dysfunction, altered inflammatory response, and hemodynamic changes which increase risk of septic shock and potentially prolong management with fluids, vasopressors, and other therapies. Due to limited available guidance, this study aimed to characterize vasopressor use in patients with cirrhosis in relation to patients without cirrhosis in septic shock. METHODS This was a retrospective matched cohort analysis of 122 patients admitted to the intensive care unit (ICU) at an academic medical center from January 2015 to November 2017. Patients were grouped based on the presence or absence of cirrhosis and matched based on severity of illness scoring. The primary outcome was vasopressor duration. Secondary comparisons included total vasopressor requirement, length of hospital and ICU stay, in-hospital mortality, change in organ function, and discharge disposition. RESULTS The group with cirrhosis had significantly longer median (interquartile range [IQR]) durations of vasopressor therapy compared with the group without cirrhosis (86.0 [42.0-164.5] vs 39.0 [14.5-82.0] hours; P = 0.003) leading to increased median (IQR) vasopressor exposure (71.7 [15.5-239.5] vs 24.7 [5.3-77.9] mg norepinephrine [NE] equivalents; P = 0.003). No difference was found in in-hospital mortality between groups. However, regression analysis showed vasopressor exposure was associated with in-hospital mortality. CONCLUSION AND RELEVANCE Patients with cirrhosis in septic shock have increased vasopressor durations and overall requirements compared with patients without cirrhosis. Increased durations and requirements is associated with poorer outcomes independent of presence of cirrhosis. Future studies are needed to improve vasopressor treatment strategies and end points utilized in cirrhosis.
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Abstract
The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3- to 4-year recurring cycle of topics. These topics will be presented at the 2020 International Conference. Below is the adult critical care medicine core including complications of chemotherapy, acute-on-chronic liver failure, alcohol withdrawal syndrome, mechanical circulatory support, direct oral anticoagulants, upper gastrointestinal hemorrhage, and vasopressor selection.
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32
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Update on diagnosis and management of sepsis in cirrhosis: Current advances. World J Hepatol 2020; 12:451-474. [PMID: 32952873 PMCID: PMC7475781 DOI: 10.4254/wjh.v12.i8.451] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/27/2020] [Indexed: 02/06/2023] Open
Abstract
Sepsis and septic shock are catastrophic disease entities that portend high mortality in patients with cirrhosis. In cirrhosis, hemodynamic perturbations, immune dysregulation, and persistent systemic inflammation with altered gut microbiota in the background of portal hypertension enhance the risk of infections and resistance to antimicrobials. Patients with cirrhosis develop recurrent life-threatening infections that progress to multiple organ failure. The definition, pathophysiology, and treatment options for sepsis have been ever evolving. In this exhaustive review, we discuss novel advances in the understanding of sepsis, describe current and future biomarkers and scoring systems for sepsis, and delineate newer modalities and adjuvant therapies for the treatment of sepsis from existing literature to extrapolate the same concerning the management of sepsis in cirrhosis. We also provide insights into the role of gut microbiota in initiation and progression of sepsis and finally, propose a treatment algorithm for management of sepsis in patients with cirrhosis.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Thachil J. The protective rather than prothrombotic fibrinogen in COVID-19 and other inflammatory states. J Thromb Haemost 2020; 18:1849-1852. [PMID: 32588535 PMCID: PMC7300603 DOI: 10.1111/jth.14942] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/11/2020] [Accepted: 05/31/2020] [Indexed: 01/09/2023]
Abstract
Hypercoagulability has been recognized as a common complication of COVID-19. Exact mechanisms for this extreme coagulation activation have not yet been elucidated. However, one of the consistent laboratory finding is the increase in fibrinogen, in some cases, marked elevation. High circulating levels of fibrinogen have been linked to thrombosis for years and for this reason, hyperfibrinogenemia is considered one of the mechanisms for COVID-19 coagulopathy. In this forum article, instead of the prothrombotic role, a protective function for fibrinogen is discussed. Fibrinogen, like the other well-known acute phase reactants, is increased in COVID-19 possibly to protect the host.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
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34
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Gupta T, Lochan D, Verma N, Rathi S, Agrawal S, Duseja A, Taneja S, Chawla YK, Dhiman RK. Prediction of 28-day mortality in acute decompensation of cirrhosis through the presence of multidrug-resistant infections at admission. J Gastroenterol Hepatol 2020; 35:461-466. [PMID: 31334860 DOI: 10.1111/jgh.14788] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/10/2019] [Accepted: 07/17/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM The aim of this study is to evaluate the epidemiology and impact of bacterial infections at admission in patients with acute decompensation (AD) of cirrhosis. METHODS A cohort with AD of cirrhosis (European Association for the Study of the Liver criteria) admitted at a tertiary center was evaluated between 2013 and 2014 for the presence of bacterial infections at admission. Clinical, demographic, and microbiological data were collected prospectively till death, transplant, or 90 days. RESULTS Of 179 patients with AD, 102 (56.9%) had bacterial infections at admission. The commonest infections were spontaneous bacterial peritonitis (SBP) (n = 65; 63.7%), spontaneous bacteremia (n = 10; 9.8%), pneumonia (n = 9; 8.8%), urinary tract infection (n = 8; 7.8%), spontaneous bacterial empyema (n = 4; 3.9%), and cellulitis (n = 2; 1.9%). The commonest source was community acquired (n = 85; 83.3%). Serum albumin and sodium levels were lower in infected as compared with non-infected cohort (P = 0.015; for both). Escherichia coli was the commonest organism isolated from SBP (n = 14; 21.5%), urinary tract infection (n = 5; 45.5%), and bacteremia (n = 3; 20%). There was a trend toward higher 28-day mortality in infected cohort as compared with non-infected cohort (48 [52.7%] vs 28 [32%]; P = 0.152). Multidrug-resistant organisms (MDROs) were isolated in 63% of all culture-positive infections. The presence of MDRO was an independent predictor of 28-day mortality. CONCLUSIONS Infections are the leading reason for the occurrence of AD; SBP is the most common infection, and E. coli is the commonest microorganism based on this single-center study of Indian patients with AD of cirrhosis. There is a high prevalence of MDROs among culture-positive infections that independently predict 28-day mortality in AD of cirrhosis.
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Affiliation(s)
- Tarana Gupta
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Dibya Lochan
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Swastik Agrawal
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Yogesh K Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Radha K Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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