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Trad N, Mohamed G, Bizid S, Abdallah HB, Bouali R, Abdelli MN. Clinical impact of multidrug-resistant bacterial infections in patients with cirrhosis. Future Sci OA 2024; 10:FSO945. [PMID: 38813115 PMCID: PMC11131343 DOI: 10.2144/fsoa-2023-0160] [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: 08/11/2023] [Accepted: 11/17/2023] [Indexed: 05/31/2024] Open
Abstract
Aim: Recently, the emergency of multidrug-resistant organisms (MDRO) has complicated the management of bacterial infections (BI) in cirrhosis. We aimed to assess their clinical impact on patients with decompensated cirrhosis. Methods: A retrospective study included consecutive cirrhotic patients hospitalized for acute decompensation (AD) between January 2010 and December 2019. Results: A total of 518 AD admissions in 219 patients were included, with 260 BI episodes (50.2%). MDRO prevalence was 38.2% of the total isolates. Recent antibiotic use (OR = 4.91), nosocomial infection (OR = 2.95), and healthcare-associated infection (OR = 3.45) were their main risk factors. MDROs were associated with empiric treatment failure (OR = 23.42), a higher prevalence of sepsis (OR = 4.93), ACLF (OR = 3.42) and mortality. Conclusion: The clinical impact of MDROs was pejorative, with an increased risk of empiric treatment failure, organ failure and death.
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Affiliation(s)
- Nouha Trad
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Ghanem Mohamed
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Sondes Bizid
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Hatem Ben Abdallah
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Riadh Bouali
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Mohamed Nabil Abdelli
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
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Bengtsson B, Maucourant C, Sandberg JK, Björkström NK, Hagström H. Evaluation of mucosal-associated invariant T-cells as a potential biomarker to predict infection risk in liver cirrhosis. PLoS One 2024; 19:e0294695. [PMID: 38691552 PMCID: PMC11062522 DOI: 10.1371/journal.pone.0294695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/07/2023] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND AIMS Infection is a serious complication in patients with cirrhosis. Mucosal-associated invariant T (MAIT) cells are involved in the immune defense against infections and known to be impaired in several chronic conditions, including cirrhosis. Here, we evaluated if MAIT cell levels in peripheral blood are associated with risk of bacterial infections in patients with cirrhosis. METHODS Patients with cirrhosis seen at the Karolinska University Hospital, Stockholm, Sweden, between 2016 and 2019 were included. Levels of MAIT cells in peripheral blood were determined using flow cytometry. Baseline and follow-up data after at least two years of follow-up were collected by chart review for the primary outcome (bacterial infection) and secondary outcomes (decompensation and death). Competing risk and Cox regression were performed. RESULTS We included 106 patients with cirrhosis. The median MAIT cells fraction in the circulation was 0.8% in cirrhosis compared to 6.1% in healthy controls. In contrast to our hypothesis, we found an association in the adjusted analysis between relatively preserved MAIT cell levels, and a slightly higher risk to develop bacterial infections (adjusted subdistribution hazard ratio (aSHR) 1.15 (95%CI = 1.01-1.31). However, MAIT cell levels were not associated with the risk of hepatic decompensation (aSHR 1.19 (95%CI = 0.91-1.56)) nor with death (adjusted hazard ratio 1.10 (95%CI = 0.97-1.22)). CONCLUSIONS Relatively preserved MAIT cell levels in blood of patients with cirrhosis were associated with a somewhat higher risk of bacterial infections. The clinical relevance of this might not be strong. MAIT cells might however be an interesting biomarker to explore in future studies.
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Affiliation(s)
- Bonnie Bengtsson
- Department of Internal Medicine, Section of Gastroenterology, Södersjukhuset, Stockholm, Sweden
- Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Christopher Maucourant
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Johan K. Sandberg
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Niklas K. Björkström
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Department of Internal Medicine, Section of Gastroenterology, Södersjukhuset, Stockholm, Sweden
- Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
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Zaman T, Ahmed Attari MB, Ahmad A, Butt MA, Fayyaz K, Zubair SA. Comparison of Rifaximin Alone and With Quinolones in the Primary Prevention of Spontaneous Bacterial Peritonitis in Patients With Decompensated Chronic Liver Disease. Cureus 2024; 16:e55251. [PMID: 38558603 PMCID: PMC10981471 DOI: 10.7759/cureus.55251] [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] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Background In cirrhotic patients with ascites, primary prevention of spontaneous bacterial peritonitis (SBP) is a key strategy to lower morbidity and death. Rifaximin and fluoroquinolone used alternately as main prophylaxis are as effective as reported. This study aimed to compare the frequency of occurrence of SBP in patients with decompensated chronic liver disease treated with rifaximin alone and in combination with fluoroquinolone. Methodology A total of 76 patients with hepatitis C virus-related decompensated chronic liver disease and ascites were divided into two groups based on matching age, sex, and Child-Pugh class. Group A (38 patients) received rifaximin 1,100 mg/day in two divided doses with daily fluoroquinolone 400 mg/day, whereas group B (38 patients) received rifaximin 1,100 mg/day alone as a two dosage. The patients were monitored for up to three months. The study's endpoints were SBP, hepatocellular carcinoma, compliance failure, death, or liver transplantation. Results In this comparative study involving 76 patients, the demographic and clinical characteristics were assessed across two treatment groups: rifaximin alone (n = 38) and rifaximin with fluoroquinolone (n = 38). The combination therapy demonstrated a statistically significant reduction in SBP compared to rifaximin alone. Additionally, the overall survival rate was higher in the combination group. These findings suggest potential benefits of the combined approach in managing hepatic encephalopathy-related complications. Conclusions When compared to rifaximin alone for primary SBP prophylaxis, the combination of rifaximin with fluoroquinolone exhibited greater effectiveness with the same safety profile.
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Affiliation(s)
- Tahir Zaman
- Department of Medicine, Lahore General Hospital, Lahore, PAK
| | | | - Adeel Ahmad
- Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, Chelsea, GBR
| | | | - Khurram Fayyaz
- Department of Medicine, Azra Naheed Medical College, Lahore, PAK
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Lan NTN, Lieu DQ, Anh TN, Thuong LH, Tuong TTK, Bang MH. Characteristics and Related Factors of Bacterial Infection Among Patients With Cirrhosis. Mater Sociomed 2024; 36:90-96. [PMID: 38590588 PMCID: PMC10999149 DOI: 10.5455/msm.2024.36.90-96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/25/2024] [Indexed: 04/10/2024] Open
Abstract
Background Infection causes cirrhosis to decompensate, affecting liver function and resulting in several complications, including esophageal variceal hemorrhage, hepatic encephalopathy, and hepatorenal syndrome. Objective: This study aimed to identify the prevalence, essential features, and related factors of bacterial infection among patients with cirrhosis in Vietnam. Methods This retrospective study included 317 patients diagnosed with cirrhosis, who were divided into two groups: group 1 including 125 patients with bacterial infection and group 2 including 192 patients without bacterial infection. Infection was diagnosed on the basis of its localization. Results Spontaneous bacterial peritonitis (SBP; 31.2%) and pneumonia (28.8%) were the most common infections identified. The procalcitonin (PCT) level had a strong diagnostic value with an area under the curve value of 0.868. The most common type of gram-negative bacteria was Escherichia coli, while the gram-positive bacteria seen were Staphylococcus, Enterococcus, and Streptococcus among the patients with infection. In the logistic regression analysis, Child-Pugh class B and C (p<0.001, OR=4.14, CI=1.90-9.03; OR=4.76, CI=2.03-11.16, respectively) and the presence of acute kidney injury (p=0.009, OR=2.57, CI=1.27-5.22) and gastrointestinal hemorrhage (p=0.035, OR=0.39, CI=0.16-0.94) significantly differed between the groups. Conclusion The most prevalent type of bacterial infection in patients with cirrhosis is SBP, with gram-negative bacteria being the most common cause. The PCT level is useful in identifying infection in patients with cirrhosis. Decompensated cirrhosis is linked to a higher risk of infection.
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Affiliation(s)
| | - Dau Quang Lieu
- Department of Internal Medicine, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Tran Ngoc Anh
- Department of Internal Medicine, Hanoi Medical University Hospital, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Le Hoai Thuong
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Tran-Thi Khanh Tuong
- Department of Internal Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Mai Hong Bang
- Department of Gastroenterology, 108 Military Central Hospital, Hanoi, Vietnam
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Vazquez C, Gutierrez-Acevedo MN, Barbero S, Notari LDC, Agozino M, Fernandez JL, Anders MM, Grigera NL, Antinucci F, Orozco-Ganem ONF, Murga MD, Perez MD, Palazzo AG, Rejtman LM, Duarte IG, Vorobioff JD, Trevizan V, Bulaty S, Bessone F, Valverde M, Elizondo M, Borzi SM, Stieben TE, Masola AC, Ferretti SE, Arufe D, Demirdjian E, Raffa MP, Peralta M, Fainboim HA, Vazquez CE, Ruiz PM, Martínez JE, Heffner LA, Odzak A, Dirchwolf M, Smud A, Mendizabal M, Calzetta PA, Martinez A, Tomatis J, Bruno A, Ramos A, Pages J, Tevez S, Gadano AC, Giunta DH, Marciano S. Clinical and microbiological characteristics of bacterial infections in patients with cirrhosis. A prospective cohort study from Argentina and Uruguay. Ann Hepatol 2023; 28:101097. [PMID: 37030570 DOI: 10.1016/j.aohep.2023.101097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/01/2023] [Accepted: 03/03/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION AND OBJECTIVES there is insufficient data regarding bacterial infections in patients with cirrhosis to support recommendations for empiric antibiotic treatments, particularly in Latin America. This study aimed to evaluate bacterial infection's clinical impact and microbiological characteristics, intending to serve as a platform to revise current practices. MATERIALS AND METHODS a multicenter prospective cohort study of patients with cirrhosis and bacterial infections from Argentina and Uruguay. Patients and infection-related information were collected, focusing on microbiology, antibiotic susceptibility patterns, and outcomes. RESULTS 472 patients were included. Spontaneous bacterial infections and urinary tract infections (UTI) were registered in 187 (39.6%) and 116 (24.6%) patients, respectively, representing the most common infections. Of the 256 culture-positive infections, 103 (40.2%) were caused by multidrug-resistant organisms (reaching 50% for UTI), and 181 (70.7%) received adequate initial antibiotic treatment. The coverage of cefepime and ceftriaxone was over 70% for the empirical treatment of community-acquired spontaneous infections, but ceftazidime´s coverage was only 40%. For all cases of UTI and for healthcare-associated or nosocomial spontaneous bacterial infections, the lower-spectrum antibiotics that covered at least 70% of the isolations were imipenem and meropenem. During hospitalization, a second bacterial infection was diagnosed in 9.8% of patients, 23.9% required at least one organ support, and 19.4% died. CONCLUSIONS short-term mortality of bacterial infections in patients with cirrhosis is very high, and a high percentage were caused by multidrug-resistant organisms, particularly in UTIs. The information provided might serve to adapt recommendations, particularly related to empirical antibiotic treatment in Argentina and Uruguay. The study was registered in Clinical Trials (NCT03919032).
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Affiliation(s)
- Carolina Vazquez
- Hospital Italiano de Buenos Aires, Internal Medicine Department, Buenos Aires, Argentina.
| | | | - Sabrina Barbero
- Hospital Churruca Visca, Liver Unit, Buenos Aires, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sofía Bulaty
- Hospital provincial del Centenario, Liver Unit, Rosario, Argentina
| | - Fernando Bessone
- Hospital provincial del Centenario, Liver Unit, Rosario, Argentina
| | - Marcelo Valverde
- Unidad Bi-Institucional de Trasplante Hepático, Hospital de Clínicas - Hospital Militar, Liver Unit, Montevideo, Uruguay
| | - Martín Elizondo
- Unidad Bi-Institucional de Trasplante Hepático, Hospital de Clínicas - Hospital Militar, Liver Unit, Montevideo, Uruguay
| | | | | | | | | | - Diego Arufe
- Sanatorio Sagrado Corazón, Liver Unit, Buenos Aires, Argentina
| | | | - María Pia Raffa
- Sanatorio Sagrado Corazón, Liver Unit, Buenos Aires, Argentina
| | | | | | | | | | | | | | - Andrea Odzak
- Hospital Argerich, Liver Unit, Buenos Aires, Argentina
| | | | - Astrid Smud
- Hospital Italiano de Buenos Aires, Infectious Diseases Section, Buenos Aires, Argentina
| | | | | | - Ana Martinez
- Hospital Fernández, Liver Unit, Buenos Aires, Argentina
| | - Jesica Tomatis
- Hospital Privado de Rosario, Liver Unit, Rosario, Argentina
| | - Andres Bruno
- Hospital Argerich, Liver Unit, Buenos Aires, Argentina
| | - Agñel Ramos
- Sanatorio Parque, Liver Unit, Rosario, Argentina
| | - Josefina Pages
- Hospital Universitario Austral, Liver Unit, Pilar, Argentina
| | - Silvina Tevez
- Sanatorio Güemes, Liver Unit, Buenos Aires, Argentina
| | - Adrian Carlos Gadano
- Hospital Italiano de Buenos Aires, Liver Unit, Buenos Aires, Argentina; Hospital Italiano de Buenos Aires, Department of Research, Buenos Aires, Argentina
| | - Diego H Giunta
- Hospital Italiano de Buenos Aires, Department of Research, Buenos Aires, Argentina; Center for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Sebastián Marciano
- Hospital Italiano de Buenos Aires, Liver Unit, Buenos Aires, Argentina; Hospital Italiano de Buenos Aires, Department of Research, Buenos Aires, Argentina
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Dirchwolf M, Gomez Perdiguero G, Grech IM, Marciano S. Challenges and recommendations when selecting empirical antibiotics in patients with cirrhosis. World J Hepatol 2023; 15:377-385. [PMID: 37034233 PMCID: PMC10075007 DOI: 10.4254/wjh.v15.i3.377] [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: 11/12/2022] [Revised: 12/28/2022] [Accepted: 03/10/2023] [Indexed: 04/11/2023] Open
Abstract
There is abundant evidence that bacterial infections are severe complications in patients with cirrhosis, being the most frequent trigger of acute-on-chronic liver failure and causing death in one of every four patients during hospitalization. For these reasons, early diagnosis and effective treatment of infections are mandatory to improve patient outcomes. However, treating physicians are challenged in daily practice since diagnosing bacterial infections is not always straightforward. This situation might lead to delayed antibiotic initiation or prescription of ineffective regimens, which are associated with poor outcomes. On the other hand, prescribing broad-spectrum antibiotics to all patients suspected of bacterial infections might favor bacterial resistance development. This is a significant concern given the alarming number of infections caused by multidrug-resistant microorganisms worldwide. Therefore, it is paramount to know the local epidemiology to propose tailored guidelines for empirical antibiotic selection in patients with cirrhosis in whom bacterial infections are suspected or confirmed. In this article, we will revise current knowledge in this area and highlight the importance of surveillance programs.
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Affiliation(s)
- Melisa Dirchwolf
- Liver Unit, Hospital Privado de Rosario, Rosario 2000, Santa Fe, Argentina
| | | | - Ingrid Mc Grech
- Liver Unit, Hospital Privado de Rosario, Rosario 2000, Santa Fe, Argentina
| | - Sebastian Marciano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires 1181, Argentina
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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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Kasztelan-Szczerbinska B, Zygo B, Rycyk-Bojarzynska A, Surdacka A, Rolinski J, Cichoz-Lach H. Blood concentrations of mediators released from activated neutrophils are related to the severity of alcohol-induced liver damage. PLoS One 2023; 18:e0280068. [PMID: 36607987 PMCID: PMC9821433 DOI: 10.1371/journal.pone.0280068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Immune dysregulation and neutrophil infiltration are hallmarks of alcohol-related liver disease (ALD). Our objective was to evaluate the blood profile of neutrophil-derived mediators [neutrophil elastase (NE), myeloperoxidase (MPO), alpha1-antitrypsin (A1AT)], and their potential relevance in ALD. METHODS 62 patients with ALD /47 males, and 15 females, aged 49,2 ± 9,9/ were prospectively recruited and distributed according to their 1/ gender, 2/ severity of liver dysfunction (by Child-Turcotte-Pugh, MELD scores, and mDF) 3/ presence of complications of ALD complications, and followed for 90 days. 24 age- and sex-matched healthy volunteers served as the control group. Neutrophil-derived biomarkers were quantified using enzyme-linked immunosorbent assays (ELISAs). RESULTS Blood concentrations of MPO and NE were significantly higher in ALD patients in comparison with controls. A1AT levels were not different. There were no gender-related differences in the studied biomarker levels. Both NE and MPO correlated with routine markers of inflammation, while NE with MELD and mDF scores. Patients with a severe ALD course i.e. MELD>20 or mDF>32, presented with significantly higher NE blood concentrations. CONCLUSIONS Our results point out the critical role of neutrophils in the pathogenesis of ALD. NE and MPO correlated with the intensity of inflammation, and NE was related to the severity of liver dysfunction.
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Affiliation(s)
| | - Bartosz Zygo
- Department of Gastroenterology with Endoscopy Unit, Independent Public Academic Hospital No. 4 in Lublin, Lublin, Poland
| | - Anna Rycyk-Bojarzynska
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, Lublin, Poland
| | - Agata Surdacka
- Department of Clinical Immunology, Medical University of Lublin, Lublin, Poland
| | - Jacek Rolinski
- Department of Clinical Immunology, Medical University of Lublin, Lublin, Poland
| | - Halina Cichoz-Lach
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, Lublin, Poland
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Wang C, Li Y, Liu L, Liu M, Chen X, Zhou S, Cui P, Du X, Qiu L, Wang J, Jiang P, Xia J. Antimicrobial nanozyme-enzyme complex catalyzing cascade reaction of glucose to hydroxyl radical to combat bacterial infection. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bonavia A, Stiles N. Renohepatic crosstalk: a review of the effects of acute kidney injury on the liver. Nephrol Dial Transplant 2021; 37:1218-1228. [PMID: 33527986 DOI: 10.1093/ndt/gfaa297] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 12/13/2022] Open
Abstract
Several theories regarding acute kidney injury (AKI)-related mortality have been entertained, although mounting evidence supports the paradigm that impaired kidney function directly and adversely affects the function of several remote organs. The kidneys and liver are fundamental to human metabolism and detoxification, and it is therefore hardly surprising that critical illness complicated by hepatorenal dysfunction portends a poor prognosis. Several diseases can simultaneously impact the proper functioning of the liver and kidneys, although this review will address the impact of AKI on liver function. While evidence for this relationship in humans remains sparse, we present supportive studies and then discuss the most likely mechanisms by which AKI can cause liver dysfunction. These include 'traditional' complications of AKI (uremia, volume overload and acute metabolic acidosis, among others) as well as systemic inflammation, hepatic leukocyte infiltration, cytokine-mediated liver injury and hepatic oxidative stress. We conclude by addressing the therapeutic implications of these findings to clinical medicine.
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Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.,Department of Pharmacology, Penn State College of Medicine, Hershey, PA, USA
| | - Nicholas Stiles
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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