Bacterial infections complicating liver disease

Characteristics of patients with infective endocarditis and no underlying cardiac conditions

BACKGROUND

Infective endocarditis (IE) typically occurs in patients with underlying cardiac conditions (UCC). Little is known about IE in patients without UCC. We aimed to describe the clinical, microbiological and imaging characteristics, management, and in-hospital mortality of IE patients without UCC.

METHODS

We analysed the data of patients with definite IE included in an observatory between 1st January 2009 and 31st December 2019. We described patients without UCC compared to those with UCC.

RESULTS

Of 1502 IE patients, 475 (31.6%) had no UCC. They were younger (median 64.0 [19.0-101.0] vs. 70.0 [18.0-104.0] years, p < .001), more often on chronic haemodialysis (5.5% vs. 2.7%, p = .008), and had more often malignancy (22.5% vs. 17.3%, p = .017), immune deficiency (10.3% vs. 6.4%, p = .008), and an indwelling central venous line (14.5% vs. 7.0%, p < .001). They more often developed cerebral complications (34.7% vs. 27.5%, p = .004) and extracerebral embolism (48.6% vs. 36.1%, p < .001). Causative microorganisms were less often coagulase negative staphylococci (5.9% vs. 10.8%, p = .002) or enterococci (10.3% vs. 15.0%, p = .014) and more often group D streptococci (14.1% vs. 10.0%, p = 0.020). Vegetations were more common (92.8% vs. 77.0%, p < 0.001) and larger (14.0 [1.0-87.0], vs. 12.0 [0.5-60.0] mm, p = 0.002). They had more valve perforation or valve regurgitation (67.4% vs. 53.0%, p < 0.001) and underwent valve surgery more often (53.5% vs. 36.3%, p < 0.001). In-hospital mortality did not significantly differ between groups.

CONCLUSION

Patients with IE and no UCC were younger than those with UCC, had specific comorbidities and portals of entry, and a more severe disease course.

Bacterial meningitis after incomplete retrograde obliteration for duodenal varices with encephalopathy: A case report

We report a case of bacterial meningitis in a 72-year-old female with nonalcoholic steatohepatitis who underwent incomplete retrograde obliteration for duodenal varices with encephalopathy. Two months after incomplete retrograde obliteration, she became febrile, drowsy, and was transported to hospital. Her serum ammonia level was normal. Endoscopy revealed that previously embolized coil was partially migrated into the duodenal lumen. Cerebrospinal fluid examination confirmed the diagnosis of bacterial meningitis. She was treated with intravenous antibiotics. As there was a risk of bleeding, trans-ileocolic vein obliteration of duodenal varices was attempted. The patient slowly recovered and was discharged. This case indicated two problems could occur by coil migration after incomplete retrograde obliteration for duodenal varices with encephalopathy. One was bacterial meningitis and the other was risk of bleeding from duodenal varices. We conclude that cerebrospinal fluid examination is recommended for patients with high fever and abnormal mental status after incomplete retrograde obliteration, and immediate complete obliteration should be attempted for a risk of bleeding.

Foley catheters functionalised with a synergistic combination of antibiotics and silver nanoparticles resist biofilm formation

Foley catheters are inevitable in health care unit. Pathogens colonise and form biofilm on catheter causing catheter-associated urinary tract infection. Therefore, the authors aimed to functionalise catheter to resist biofilm formation. The authors impregnated urinary catheters with a synergistic combination of antibiotics and silver nanoparticles (SNPs) to evaluate antibiofilm efficacy in vitro and in vivo. SNPs were synthesised using Spirulina platensis. Synergy between the SNPs and antibiotics was determined by the checker-board method. In vivo efficacy of the functionalised catheters was assessed in mice. Liver and kidney function tests of mice were performed. The in vitro anti-adherence activity of the functionalised catheters was evaluated after 2 years. Nanoparticle sizes were 42-75 nm. Synergistic activity was observed among SNPs (2 µg/ml), amikacin (6.25 µg/ml), and nitrofurantoin (31.25 µg/ml). In mice, catheters functionalised with combinations of antibiotics and SNPs exhibited no colonisation until Day 14. Blood, liver, and kidney tests were normal. After 2 years, catheters functionalised with antibiotics exhibited 25% inhibition of bacterial adhesion, and catheters functionalised with the nanoparticle-antibiotic combination exhibited 90% inhibition. Impregnation of urinary catheters with a synergistic combination of antibiotics and SNPs is an efficient and promising method for preventing biofilm formation.

Anesthesia for the Patient with Concomitant Hepatic and Renal Impairment

Hepatic and renal disease are common comorbidities in patients presenting for intermediate- and high-risk surgery. With the evolution of perioperative medicine, anesthesiologists are encountering more patients who have significant hepatic and renal disease, both acute and chronic in nature. It is important that anesthesiologists have an in-depth understanding of the physiologic derangements seen with hepatic and renal disease to evaluate and manage these patients appropriately. Perioperative management requires an understanding of the physiologic perturbations associated with each disease process. This article elucidates the goals in the management and treatment of this complex patient population.

Macrophages from patients with cirrhotic ascites showed function alteration of host defense receptor

BACKGROUND

Patients with cirrhotic ascites (PCA) are susceptible to spontaneous bacterial peritonitis (SBP) which has increased morbidity and mortality. Since some host defense aspects of peritoneal macrophages (PMф) from PCA are altered this study examined factors related to receptor-mediated phagocytosis.

METHODS

Twelve PCA were studied. PMɸ were isolated from ascitic fluid (AF) samples removed from these patients. Uptake of mannose receptor (MR)-specific ligand, fluorescein isothiocyanate-mannosylated-bovine serum albumin (FITC-man-BSA), by patients' PMɸ and controls, a human monocytic cell line, was measured pre- and post-IL-4 treatment. Phagocytosis of FITC-labeled yeast particles by patients' PMɸ was measured pre- and post-IL-4 treatment. Fluorescence values were obtained using a spectrofuorometer. MRC1 gene was analyzed in blood samples from PCA and controls, healthy donors, using standard polymerase chain reaction (PCR) technique.

RESULTS

Past SBP episode(s) were reported in 58.3% of patients. Mean AF volume analyzed per patient was 1.3L. PMɸ ratio in cell yield was 53.73% (SD 18.1). Mean uptake absorbance of patients' PMф was 0.0841 (SD 0.077) compared to 0.338 (SD 0.34) of controls, P = 0.023. Following IL-4 treatment absorbance increased to 0.297 (SD 0.28) in patients' PMф (P = 0.018 on paired sample t-test), and to 0.532 (SD 0.398 in controls (P = 0.053 on independent sample t-test). Mean phagocytosis absorbance of patients' PMф was 0.1250 (SD 0.032) before IL-4 treatment compared to 0.2300 (SD 0.104) after (P = 0.026). PCR analysis for MRC1 gene was negative in all PCA samples compared to positive results in all controls.

CONCLUSION

Since decreased phagocytosis and MR uptake were enhanced post-IL-4 treatment MR downregulation pre-treatment is plausible. Negative PCR results for MRC1 might suggest an anomaly, but this awaits further ellucidation. These altered host defense findings are relevant to infection pathophysiology, and their relevance to SBP susceptibility in PCA is worth verifying.

Antibiotic prophylaxis in transarterial therapy of hepatocellular carcinoma: a meta-analysis

BACKGROUND

The use of prophylactic antibiotics against postprocedure infection in patients undergoing transarterial therapy for hepatocellular carcinoma is controversial.

AIM

To compare the effects of prophylactic antibiotic treatment and no prophylactic antibiotic treatment on infectious complications following transarterial procedures.

METHODS

Clinical trials fulfilling predefined selection criteria were identified by searching several bibliographic databases; a meta-analysis was performed where appropriate.

RESULTS

Four trials of inadequate quality consisting of 210 patients were included in the analysis. Only one case of possible postprocedure infection in each group was reported. The rate of patients developing fever (RR 0.91 [95% CI 0.61 to 1.35]), changes in peripheral white blood cell count or serum C-reactive protein levels, and the mean length of hospital stay (mean difference 0.20 [95% CI 0.75 to 1.14]) showed no significant intergroup differences between antibiotic and no antibiotic treatment. Furthermore, the results of the present study indicated that the incidence of bacteremia, septicemia, sepsis or hepatic abscess after transarterial therapy was rare.

CONCLUSION

Antibiotic prophylaxis in patients undergoing transarterial therapy for hepatocellular carcinoma may not be routinely necessary. However, a more judicious use of antibiotics is recommended for patients who are at an increased risk of infection. Nevertheless, prospective trials on a larger scale are clearly needed.

Bacterial infection-related morbidity and mortality in cirrhosis

OBJECTIVES

Bacterial infections are acknowledged causes of morbidity and mortality in cirrhotic patients; yet, apart from spontaneous bacterial peritonitis, other infection issues have been understudied. We evaluated the existing medical data on infectious risks and related preventive and treatment data for cirrhotic patients.

METHODS

Medical literature search through MEDLINE, using a variety of keywords focused on: (a) immunodeficiency parameters of cirrhosis and attempts at therapeutic reversal, (b) relative incidence of various focal infections and implications for prevention, and (c) specific pathogens posing a risk in cirrhosis and availability of preventive strategies.

RESULTS

Immunodeficiency in cirrhosis is multifactorial and might not be reversed by isolated interventions. Epidemiologic data on the incidence of specific infections and risk factors are scarce, only Child-Pugh stage C being a common denominator. A variety of common, such as Staphylococcus aureus, Streptococcus pneumoniae, and Mycobacterium tuberculosis, as well as uncommon pathogens possess significant risks in cirrhosis. Certain aspects of these risks remain though unrecognized.

CONCLUSIONS

To better understand the overall burden of bacterial infections on cirrhotic patients' survival, more data on preventive efficacy of pneumococcal vaccination, on the overall burden of tuberculosis, and the relative incidence of specific infections as endocarditis are warranted.

Frequency of urinary tract infection in pediatric liver transplantation candidates

An increased frequency of infections has been reported in patients with chronic liver disease. The tendency of patients in this population to acquire UTI is not completely understood. We aimed at investigating the incidence of UTI in children with cirrhosis, before liver transplantation. Twenty-six children (9 girls, 17 boys; mean age, 7.66 +/- 5.73 yr) with chronic liver disease who had undergone liver transplantation between 2002 and 2004 were included. On admission for liver transplantation, patients were examined for presence of UTI. Serum biochemistry, complete blood cell count, urinalysis and culture, glomerular filtration rate, and abdominal ultrasonography were performed prior to liver transplantation. Ten of 26 patients (38.5%) were found to have symptomatic UTI. Urine cultures revealed E. coli in five (50%), Klebsiella pneumoniae in three (30%), Enterococcus faecalis in one (10%), and Enterobacter aeruginosa in one (10%) patient(s), respectively, as etiologic factors. The etiologies of chronic liver disease in our patients with UTI were BA in five, PFIC in three, Wilson's disease in one, and alpha-1 antitrypsin deficiency in one patient. We found a significantly greater number of UTIs in patients with biliary atresia than in those without biliary atresia (p < 0.05). The mean age of the patients with UTI was 2.75 +/- 3.49 yr, which was significantly lower than in those without UTI (9.75 +/- 4.86 yr, p < 0.05). Levels for white blood cells, thrombocytes, ALT, and alkaline phosphatase were significantly higher in patients with UTI than in those without UTI. There were no significant differences between the groups with regard to serum albumin, bilirubin, AST, GGT, BUN, or creatinine levels, glomerular filtration rate, duration of disease, and PELD scores. In patients with bacteriuria, renal USG revealed normal findings in all, but except one patient who had pelvicalyceal dilatation. Scintigraphic findings demonstrated acute pyelonephritis in six (60%) patients with UTI. VCUG demonstrated vesicoureteral reflux in two patients. In conclusion, symptomatic UTI is common in children with cirrhosis. It occurs more frequently in patients with biliary atresia than it does in patients with other types of chronic liver disease. In febrile children with chronic liver disease, UTI should be considered in the differential diagnosis.

Long-term ursodeoxycholic acid therapy for primary biliary cirrhosis: a follow-up to 12 years

BACKGROUND

It is uncertain whether ursodeoxycholic acid therapy slows down the progression of primary biliary cirrhosis, according to two meta-analyses. However, the randomized trials evaluated had only a median of 24 months of follow-up.

AIM

To evaluate long-term ursodeoxycholic acid therapy in primary biliary cirrhosis.

METHODS

We evaluated 209 consecutive primary biliary cirrhosis patients, 69 compliant with ursodeoxycholic acid and 140 untreated [mean follow-up 5.79 (s.d. = 4.73) and 4.87 (s.d. = 5.21) years, respectively] with onset of all complications documented. Comparison was made following adjustment for baseline differences according to Cox modelling, Mayo and Royal Free prognostic models.

RESULTS

Bilirubin and alkaline phosphatase concentrations improved with ursodeoxycholic acid (at 36 months, P = 0.007 and 0.018, respectively). Unadjusted Kaplan-Meier analysis showed benefit (P = 0.028), as 44 (31%) untreated and 15 (22%) ursodeoxycholic acid patients died or had liver transplantation. However, there was no difference when adjusted by Cox modelling (P = 0.267), Mayo (P = 0.698) and Royal Free models (P = 0.559). New pruritus or fatigue or other complications were not different, either before or after adjustment for baseline characteristics.

CONCLUSIONS

Long-term ursodeoxycholic acid therapy did not alter disease progression in primary biliary cirrhosis patients despite a significant improvement in serum bilirubin and alkaline phosphatase consistent with, and similar to, those seen in ursodeoxycholic acid cohorts in randomized trials.

[Infective endocarditis in patients with chronic liver disease: clinical and prognostic assessment]

INTRODUCTION AND OBJECTIVES

Chronic liver disease increases the susceptibility to bacterial infections and infective endocarditis. Our aim was to determine the clinical and microbiological features and the prognosis in patients with chronic liver disease who also had infective endocarditis.

PATIENTS AND METHOD

One hundred and seventy-four consecutive inpatients at our institution were recruited and followed. Thirty of them had chronic liver disease. Clinical, microbiological and echocardiographic variables were analyzed and, in some cases, histological variables were also recorded.

RESULTS

Patients with chronic liver disease were younger (36 11 vs 54 18 years; p < 0.01) and had a larger proportion of intravenous drug users (73 vs 16%; p < 0.01), HIV infection (47 vs 10%; p < 0.01), right valve involvement and spleen enlargement, but heart failure appeared less often (7 vs 34%; p = 0.003). Thirty percent of the patients with and 51% of patients without chronic liver disease underwent surgery for infective endocarditis. Total mortality among patients with and without chronic liver disease was 40% and 31%, respectively. After adjustment for age and for the incidence of congestive heart failure, chronic liver disease doubled mid-term mortality with a RR = 2.45 (p = 0.015).

CONCLUSIONS

Chronic liver disease has a significant impact on the prognosis in patients with infective endocarditis, and these patients should therefore be considered a high risk group.

The influence of gingival margin recession on loss of clinical attachment in alcohol-dependent patients without medical disorders

BACKGROUND

The objective of this study was to examine the effects of alcohol and cocaine misuse on periodontal status in a group of alcohol-dependent patients.

METHODS

Forty verified alcoholics, either exclusively (n = 10) or with cocaine abuse (n = 30), and a matched comparison group of 25 non-alcoholic subjects, 14 of whom abused cocaine, were entered in the study. All subjects were free from systemic illnesses. Blood levels of gamma glutamyl transpeptidase (GGTP), a liver enzyme indicator of alcohol drinking, were determined. A comprehensive periodontal examination was performed on 6 sites per tooth. The gingival index (GI) and plaque index (PI) were recorded. Attachment levels (AL) were computed as probing depth (PD) plus gingival margin level (GM).

RESULTS

No statistically significant differences were noted between the groups for average AL, PD, GM, GI, and PI. In alcoholics, Pearson correlation showed a positive association between GGTP levels and loss of periodontal attachment (P<0.05). A series of regression analyses predicting AL from selected periodontal and demographic factors showed that alcoholics manifest AL by greater increases in GM than non-alcoholics (P<0.07). Severe alcohol use as measured by GGTP >51 iu/l worsens PI (P<0.07), which adversely impacts GM, GI, PD, and ultimately AL. No significant associations were found between cocaine use and AL.

CONCLUSIONS

The results suggest that persistent alcohol abuse increases periodontitis development by heightening the loss of attachment through recession of gingival margins.

Granulocyte colony-stimulating factor improves deficient in vitro neutrophil transendothelial migration in patients with advanced liver disease

Bacterial infections are frequent complications in patients with liver cirrhosis. Cirrhotic patients present abnormalities in both innate and adaptive immune responses, including a deficient neutrophil recruitment to infected sites. The purpose of this study was to assess neutrophil-endothelium interactions in cirrhotic patients and evaluate the effects of G-CSF on this process. We studied neutrophil adhesion and transendothelial migration in 14 cirrhotic patients and 14 healthy controls. We also analyzed neutrophil expression of the adhesion molecules CD62L and CD11b in whole blood by flow cytometry. Cirrhotic patients expressed higher levels of CD11b than healthy controls, whereas CD62L expression was significantly lower, suggesting exposure of neutrophils to activating agents within the bloodstream. Neutrophils from cirrhotic patients showed increased adhesion to both resting and tumor necrosis factor alpha-stimulated microvascular endothelial cells and decreased transendothelial migration. Granulocyte colony-stimulating factor (G-CSF) (100 ng/ml) significantly enhanced neutrophil adhesion to microvascular endothelial cells in healthy controls but not in cirrhotic patients. G-CSF also significantly improved neutrophil transmigration in cirrhotic patients and healthy controls. In conclusion, cirrhotic patients exhibit increased neutrophil adhesion to microvascular endothelium and deficient transendothelial migration. G-CSF enhances neutrophil transendothelial migration in cirrhotic patients despite having no effect on neutrophil adhesion. Therefore, G-CSF may be able to increase neutrophil recruitment into infected sites in these patients.

Infections in cirrhosis

Infection is a well-described complication of cirrhosis and is a major cause of death in this population. This article examines the types of infections related with cirrhosis, such as bacteremia, urinary tract infections, meningitis, and others.

Pneumolysin-induced complement depletion during experimental pneumococcal bacteremia

To quantify complement depletion by pneumolysin during Streptococcus pneumoniae bacteremia, cirrhotic and control rats were infected intravenously with one of three isogenic mutant strains of S. pneumoniae expressing different forms of pneumolysin. Outcome measures included clearance of the organisms from the bloodstream, alterations in 50% serum hemolytic complement (CH(50)) activity and complement C3 levels during infection, and serum opsonic capacity at 18 h postinfection. Cirrhotic rats had significantly lower CH(50) and C3 levels than control rats, both before and after infection. However, initial complement levels did not predict bacterial load after 18 h of infection. Changes in CH(50) and C3 levels over the 18-h period correlated with numbers of H+C+ but not H+C- or PLY- organisms in the bloodstream at 18 h postinfection. The sera of cirrhotic rats infected with the H+C+ strain had significantly decreased levels of C3 and showed significantly lower opsonizing activity for S. pneumoniae than sera from H+C+-infected control rats. These studies suggest that under limiting concentrations of complement, the expression of pneumolysin by pneumococci has a significant, negative effect on serum complement levels and reduces serum opsonic activity.

Vegetative infection of transjugular intrahepatic portosystemic shunts

BACKGROUND & AIMS

The occurrence of and the clinical picture of infection of transjugular intrahepatic portosystemic shunts (TIPS) has not been described previously. We describe the clinical features, associated pathogens, results of treatment of a previously unreported complication of TIPS, and primary infection of TIPS occurring after formation of the neointima.

METHODS

Patients with TIPS and fever were evaluated to exclude other sources of infection. The diagnosis was based on the occurrence of fever with positive blood cultures and either a thrombus or vegetations on the stent or persistent bacteremia in a patient with a TIPS and no other detectable source of infection despite an extensive search.

RESULTS

Eight patients met diagnostic criteria. Two of 8 cases occurred within 10 days of TIPS manipulation despite antibiotic administration before the procedure. The clinical features included fever (8 patients), tender hepatomegaly (5 of 8), hypoxemia (2 of 8), septic pulmonary emboli (1 of 8), septic shock (2 of 8), neutrophilia (5 of 8), and subsequent development of necrotizing fasciitis (1 of 8). Blood cultures were positive in all cases. The organisms included oral and enteric aerobic gram-negative bacteria in 7 of 8 patients and Candida in 1 patient. All 8 responded to administration of antibiotics. Two patients died of myocardial infarction and alcoholic hepatitis, respectively.

CONCLUSIONS

Infective endotipsitis is an uncommon complication of TIPS. Recognition of its clinical features will facilitate diagnosis. Most patients responded to antibiotic therapy.

Primary biliary cirrhosis in patients with breast cancer: studying the link

Primary biliary cirrhosis (PBC) is a liver disease of unknown etiology characterized by chronic nonsuppurative destructive cholangitis (CNSDC) of intrahepatic septal and interlobular bile ducts. It is generally defined as an autoimmune disease. Characteristically, patients with PBC have a cholestatic serum hepatic profile and circulating antimitochondrial antibodies (AMA). PBC is progressive and ultimately leads to biliary cirrhosis and liver failure. It occurs at least three times more often in women than in men and it is the most common indication for liver transplantation in women around the world. There is no known cure for PBC. Despite the remarkable progress elucidating the genetics of breast cancer, and the effort placed on breast cancer education and screening methods, the mortality of breast cancer remains unacceptably high. In this essay, we describe the similarities between breast cancer and PBC and how their pathogenesis may be related. The hypothesis stated herein has evolved from reports from the early 1980s that linked an increased risk for breast cancer with PBC, and from the author's clinical experience with patients who suffer from both diseases. The association between these two diseases in the USA merits further investigation. If it is confirmed, risk factors involved in their pathogenesis will be identified.

Spontaneous bacterial empyema in cirrhotic patients: a prospective study

Spontaneous bacterial empyema (SBEM) is an infection of a preexisting hydrothorax in cirrhotic patients and has seldom been reported. To determine its incidence and primary characteristics, all cirrhotic patients with pleural effusion underwent thoracentesis at our hospital either on admission or when an infection was suspected. Pleural fluid (PF) study included biochemical analysis, polymorphonuclear (PMN) leukocyte count, and culture by two methods: conventional and modified (inoculation of 10 mL of PF into a blood culture bottle at the bedside). SBEM was defined according to previously reported criteria: PF culture positive or PMN count greater than 500 cells/micro L, and exclusion of parapneumonic effusions. Sixteen of the 120 (13 percent) cirrhotic patients admitted with hydrothorax had 24 episodes of SBEM. In 10 of the 24 episodes (43 percent), SBEM was not associated with spontaneous bacterial peritonitis (SBP). PF culture was positive by the conventional method in 8 episodes (33 percent) and by the modified method (blood culture inoculation) in 18 (75 percent) (P = .004, McNemar). The microorganisms identified in PF were Escherichia coli in 8 episodes, Streptococcus species in 4, Enterococcus species in 3, Klebsiella pneumoniae in 2, and Pseudomonas stutzeri in 1. All episodes were treated with antibiotics without inserting a chest tube in any case. Mortality during treatment was 20 percent. We conclude that SBEM is a common complication of cirrhotic patients with hydrothorax. Almost half of the episodes were not associated with SBP; thus, thoracentesis should be performed in patients with cirrhosis, pleural effusion, and suspected infection. Culture of PF should be performed by inoculating 10 mL into a blood culture bottle at the bedside.

Mediators, cytokines, and growth factors in liver-lung interactions

Multiple mediators have been implicated in the interactions between the liver and the lungs in various disease states. The best characterized mediator of liver-lung interaction is alpha 1-antitrypsin. Several cytokines and mediators may be involved in the pathogenesis of the hepatopulmonary syndrome and in the cytokine cascades that are activated in systemic inflammatory states such as acute respiratory distress syndrome. Hepatocyte growth factor or scatter factor is a recently described peptide with a broad range of biologic effects that may mediate lung-liver interactions.

Transarterial embolization for hepatocellular carcinoma. Antibiotic prophylaxis and clinical meaning of postembolization fever

BACKGROUND/AIMS

The aim of this prospective randomized controlled trial was to investigate the need for prophylactic antibiotherapy in patients with cirrhosis and hepatocellular carcinoma who underwent transarterial embolization and to establish the parameters that determine the development of fever > 38 degrees C after this procedure.

METHODS

Sixty-one consecutive patients with cirrhosis undergoing 75 procedures were randomized into Group I [(n = 37) allocated to receive prophylactic antibiotics (Cefotaxime + Metronidazole)] and Group II [(n = 38) allocated to receive no antibiotic treatment].

RESULTS

Twelve of the 37 patients (32%) in Group I and 13 of the 38 patients (34%) in Group II developed fever > 38 degrees C after treatment. However, none of them developed bacterial infection, and all biological fluid cultures were negative. A logistic regression analysis disclosed that the obtention of an extensive tumor necrosis was the unique parameter independently associated with the development of fever.

CONCLUSIONS

Antibiotic prophylaxis is therefore not necessary in patients with cirrhosis and hepatocellular carcinoma undergoing transarterial embolization. The appearance of fever after this procedure does not indicate bacterial infection; it rather represents a clinical marker of extensive tumor necrosis and thus of a favorable response to treatment.

The current spectrum of infectious glomerulonephritis. Experience with 76 patients and review of the literature

To identify the demographic, clinical, and pathologic features and the prognosis of renal disease in a series of patients with infectious or postinfectious proliferative glomerulonephritis (GN), data were collected from records of 76 adult patients admitted from 1976 to 1993 to 2 neighboring suburban hospital nephrology units, whose catchment population consists of patients living in a suburban borough of Paris with a below-average socioeconomic status. Thirty-four patients (45%) were alcoholics, diabetics, or intravenous illicit-drug users. Sixty-six patients presented with acute nephritic and/or nephrotic syndrome. Acute renal failure was present in 56 (76%) and required dialysis in 14. The diagnostic workup comprised at least 1 renal biopsy in each case. The patient's background, site of infection, clinical course, laboratory variables, and, when available, bacteriologic findings were analyzed in each case to interpret the evolution of the disease. Initial renal biopsy disclosed endocapillary GN in 44 patients, crescentic GN in 26, and membranoproliferative GN in 6. Ten patients had endocarditis. Staphylococci and Gram-negative strains, not streptococci, were the most common bacteria identified. The origin of sepsis was mainly the oropharynx (21), the skin (19) and the lung (14); 19 cases involved multiple sites of infection. Eight patients died (11%), and 20 (26%) recovered renal function, but GN followed a chronic course in 38 (50%), rapidly requiring maintenance dialysis in 6. Poor prognostic factors included age over 50 years, purpura, endocarditis, and glomerular extracapillary proliferation. Twenty-six patients underwent repeat renal biopsy 1 month to 11 years after the initial presentation. The main finding, irrespective of the interval since the first biopsy, was that ongoing or new iatrogenic infection acquired during hospitalization was almost invariably acquired during hospitalization was almost invariably associated with developing glomerular proliferative changes. This study shows that infectious proliferative GN remains common, but that its epidemiology has changed from what was observed until 2 decades ago. The responsible bacteria, when identified, now comprise a majority of staphylococci and Gram-negative strains, in contrast to the streptococci which predominated 3 decades ago. Infectious GN affects with increasing frequency patients with an underlying condition responsible for immunosuppression, especially alcoholism, even in the absence of cirrhosis. Destructive glomerular proliferation persists, especially but not exclusively until infection has been eradicated, and despite rescue treatment with corticosteroids and/or cytostatic drugs. Thus, the prognosis is poor, and infectious GN often ends in renal death. Infection continues in this decade to represent a frequent and probably often overlooked cause of end-stage renal failure.(ABSTRACT TRUNCATED AT 400 WORDS)

Serum IgE levels in liver cirrhosis. Contrasting results in alcoholic and non-alcoholic patients

Hypergammaglobulinemia is a well-known feature of liver cirrhosis, but studies on serum IgE in this setting are limited. The present study evaluates serum IgE concentration in a group of cirrhotic patients and examines their relationship with aetiological, clinical and analytical parameters (including liver function tests and hepatic phagocytic activity). The presence of specific IgE against common dietary antigens was also investigated. Total serum IgE was determined by enzyme immunoassay (EIA) in 52 cirrhotics (27 alcoholic and 25 non-alcoholic, including eight virus B and seven virus C-related cirrhosis, three primary biliary cirrhosis, three cryptogenic, three haemochromatosis and one Wilson's disease) and 34 healthy subjects (used as controls). Serum IgE (IU/ml) in controls was not significantly different from that of cirrhotic patients (median 42, range 2-726 vs median 86, range 2- > 1000, respectively) (P = NS). However, serum IgE among alcoholics (median 199, range 19- > 1000) was higher than that of controls (P < 0.001), virus B-related cirrhotics (median 25, range 3- > 1000) (P < 0.05), virus C-related cirrhotics (median 47, range 2-170) (P < 0.05), or non-alcoholic cirrhotics as a whole (median 23, range 2- > 1000) (P < 0.01). High IgE levels (> or = 170 IU/ml) were detected in 55.5% of alcoholics compared with only 12% of non-alcoholic cirrhotics (P < 0.01). Moreover, IgE levels were very high (> 1000 IU/ml) in six patients of the alcoholic group (22.2%) compared with only one non-alcoholic patient (4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Endotoxin-induced nitric oxide synthesis in the perfused rat liver: effects of L-arginine and ammonium chloride

We used the single-pass-perfused rat liver model to study short-term regulation of endotoxin-inducible nitric oxide synthesis by following the release of nitrite and nitrate, the oxidation products of nitric oxide, into the effluent perfusate. In endotoxin-pretreated livers, the basal nitrite+nitrate release was 5.3 +/- 1.2 nmol.gm liver-1.min-1. Nitrite and nitrate release was stimulated by L-arginine in a dose-dependent and saturable fashion. Maximal nitrite+nitrate release with 1 mmol/L L-arginine infused to the influent perfusate was 10.2 +/- 1.1 nmol.gm liver-1.min-1, with a half-maximal effect at 53 mumol/L L-arginine. In the absence of molecular oxygen, nitric oxide synthesis was inhibited. Ammonium chloride infusion also stimulated nitrite and nitrate release to a maximal rate of 9.2 +/- 0.8 nmol.gm liver-1.min-1 with half-maximal effects at 60 mumol/L ammonium chloride. Ammonium chloride-stimulated nitrite and nitrate release was abolished when urea synthesis was inhibited by bicarbonate-free liver perfusion. Citrulline and ornithine (200 mumol/L each) were without effect on nitrite and nitrate release. L-Nitroarginine methyl ester inhibited both, L-arginine-and ammonium chloride-induced nitrite and nitrate release. Stimulation of nitric oxide synthesis by L-arginine and ammonium chloride addition (1 mmol/L each) was accompanied by a threefold-to-fourfold increase of cyclic GMP release into the effluent perfusate. In livers of endotoxin-pretreated rats the urea production from L-arginine was higher than that in untreated livers, suggesting induction of an L-arginine transport system in hepatocytes by endotoxin.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial translocation in acute liver failure induced by 90 per cent hepatectomy in the rat

Bacterial infection and bacteraemia have been observed in patients with acute liver failure. The exact source of bacteria and nature of pathophysiological mechanisms explaining the development of infection remain unclear. In the present study, acute liver failure was induced by 90 per cent hepatectomy in the rat. The mesenteric lymph nodes and organs were harvested aseptically for bacteriological culture after sham operation or 90 per cent hepatectomy. Function of the liver and reticuloendothelial system (RES) was assayed; gut oxygen extraction was also measured. Translocation of enteric bacteria occurred 2 h after operation and increased with time following hepatectomy. Overgrowth of Escherichia coli in the distal small intestine started 2 h after operation. RES function decreased immediately after 90 per cent hepatectomy; uptake rates per gram tissue in other organs increased significantly. These results indicate that bacterial translocation occurred early after 90 per cent hepatectomy, associated with a decrease in RES function and gut oxygen extraction, and overgrowth of intestinal bacteria.

Review article: the pathophysiology and pharmacological treatment of portal hypertension

The pathogenesis of portal hypertension remains poorly understood. Similarly, pharmacological manipulation for the prevention and treatment of variceal haemorrhage has not fulfilled the promise of the 1980s. This article reviews current concepts in the pathophysiology of portal hypertension and considers pharmacotherapy for the treatment of variceal bleeding.

Hyperdynamic circulation in cirrhosis: a role for nitric oxide?

Hypotension, low systemic vascular resistance, and a reduced sensitivity to vasoconstrictors are features of cirrhosis. These cardiovascular changes might be the result of increased synthesis of a vasodilator. Nitric oxide (NO), a potent vasodilator, is synthesised in and released from peripheral blood-vessels in man. Studies in animals indicate that bacterial endotoxin and cytokines induce NO synthase expression in vessel walls, with sustained NO release and consequent hypotension. Endotoxaemia is a common feature of cirrhosis; persistent induction of NO synthase may account for the associated haemodynamic changes.