Cause of death in alcoholic hepatitis

Clinical and microbiological features of infection in alcoholic hepatitis: an international cohort study

BACKGROUND

Previous studies have described the clinical impact of infection in alcoholic hepatitis (AH) but none have comprehensively explored the aetiopathogenesis of infection in this setting. We examined the causes, consequences and treatment of infection in a cohort of patients with AH.

METHODS

We undertook a retrospective cohort study of patients with AH admitted between 2009 and 2014 to seven centres in Europe and the USA. Clinical and microbiological data were extracted from medical records. Survival was analysed with Kaplan-Meier analysis and Cox proportional hazards analysis to control the data for competing factors. Propensity score matching was used to examine the efficacy of prophylactic antibiotics administered in the absence of infection.

RESULTS

We identified 404 patients with AH. Of these, 199 (49%) showed clinical or culture evidence of infection. Gut commensal bacteria, particularly Escherichia coli and Enterobacter species, were most commonly isolated in culture. Fungal infection was rarely seen. Cultured organisms and antibiotic resistance differed markedly between centres. Infection was an independent risk factor for death (hazard ratio for death at 90 days 2.33, 95% confidence interval 1.63-3.35, p < 0.001). Initiation of antibiotic therapy on admission in the absence of infection did not reduce mortality or alter the incidence of subsequent infections. Corticosteroid use increased the incidence of infection but this did not impact on survival.

CONCLUSIONS

In this large real-world cohort of patients with AH, infection was common and was associated with reduced short-term survival. Gram-negative, gut commensal bacteria were the predominant infective organisms, consistent with increased translocation of gut bacteria in AH; however, the characteristics of infection differ between centres. Infection should be actively sought and treated, but we saw no benefits of prophylactic antibiotics.

Methods to determine intestinal permeability and bacterial translocation during liver disease

Liver disease is often times associated with increased intestinal permeability. A disruption of the gut barrier allows microbial products and viable bacteria to translocate from the intestinal lumen to extraintestinal organs. The majority of the venous blood from the intestinal tract is drained into the portal circulation, which is part of the dual hepatic blood supply. The liver is therefore the first organ in the body to encounter not only absorbed nutrients, but also gut-derived bacteria and pathogen associated molecular patterns (PAMPs). Chronic exposure to increased levels of PAMPs has been linked to disease progression during early stages and to infectious complications during late stages of liver disease (cirrhosis). It is therefore important to assess and monitor gut barrier dysfunction during hepatic disease. We review methods to assess intestinal barrier disruption and discuss advantages and disadvantages. We will in particular focus on methods that we have used to measure increased intestinal permeability and bacterial translocation in experimental liver disease models.

Short-term and long-term causes of death in patients with alcoholic hepatitis in Denmark

BACKGROUND & AIMS

The incidence of acute alcoholic hepatitis is increasing, and mortality is high. However, causes of death among patients with alcoholic hepatitis have not been systematically recorded. We investigated causes of death in a population-based cohort of patients with alcoholic hepatitis who were followed for as long as 10 years.

METHODS

We used the Danish National Registry of Patients to identify all patients with a first-time episode of alcoholic hepatitis from 1999 through 2008. We collected and analyzed data on 1951 patients, identifying causes of death, diagnoses of cirrhosis, and alcohol abuse.

RESULTS

Of the 1951 patients, 401 died within the first 84 days after admission, and 600 died later (through December 31, 2008). Most deaths within the first 84 days after admission resulted from liver failure (40%), infections (20%), or hepatorenal syndrome (11%). Beyond 84 days, causes of deaths differed between patients with and without cirrhosis; most patients without cirrhosis (n = 326) died of causes related to alcohol abuse, whereas most patients with cirrhosis (n = 675) died of liver failure (34%), infections (16%), or variceal bleeding (11%). Cirrhosis was present in 51% of patients diagnosed with alcoholic hepatitis. Among patients without cirrhosis, 24% developed cirrhosis within 10 years; continued alcohol abuse was a strong risk factor for cirrhosis (hazard ratio, 2.14; 95% confidence interval, 1.50-3.05). The 10-year risk of a second episode of alcoholic hepatitis was 12%.

CONCLUSIONS

On the basis of a study of the Danish population, the most common causes of death among patients with alcoholic hepatitis, within 84 days and within 10 years, are liver-related events and infections. Strategies are to identify and treat these complications and to reduce alcoholism.

Systematic review: pentoxifylline for the treatment of severe alcoholic hepatitis

BACKGROUND

Acute alcoholic hepatitis (AH) is a severe manifestation of alcoholic liver disease with a grave prognosis. Pentoxifylline, an oral antitumour necrosis factor agent, has been reported to reduce mortality and incidence of hepatorenal syndrome (HRS) in severe alcoholic hepatitis (SAH).

AIM

To summarise evidence for the use of pentoxifylline in SAH.

METHODS

A literature search was undertaken using MeSH terms 'hepatitis, alcoholic' and 'pentoxifylline' using the set operator AND. We included randomised controlled trials examining pentoxifylline in SAH, published as abstracts or full manuscripts. Risk ratios (RRs) were calculated for pooled data using random effects modelling. Risk of bias was assessed using Cochrane group criteria and quality of trials assessed using 'Consolidated Standards of Reporting Trials' CONSORT guidelines.

RESULTS

Ten trials including 884 participants were included, from six papers and four abstracts. There was significant heterogeneity between trials regarding control groups and trial end-points. Treatment was given for 28 days in all trials except one. Pooling of data showed a reduced incidence of fatal HRS with pentoxifylline compared with placebo (RR: 0.47, 0.26-0.86, P = 0.01), but no survival benefit at 1 month (RR: 0.58, 0.31-1.07, P = 0.06). There were no significant differences between treatment groups in trials of pentoxifylline vs. corticosteroid, or vs. combination therapy.

CONCLUSIONS

Pentoxifylline appears superior to placebo in prevention of fatal HRS and thus may be effective treatment of SAH when corticosteroids are contraindicated. However, multiple trials have failed to show conclusive superiority of either pentoxifylline or corticosteroids.