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Shinde AS, Kapoor D. Infections After Liver Transplant -Timeline, Management and Prevention. J Clin Exp Hepatol 2024; 14:101316. [PMID: 38264574 PMCID: PMC10801311 DOI: 10.1016/j.jceh.2023.101316] [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: 02/13/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024] Open
Abstract
Liver transplantation (LT) is the standard treatment for end- stage liver disease. Patient and graft survival have improved significantly in the last three decades owing to improvement in surgical technique, better perioperative management and better immunosuppressive regimens. However, LT recipients are at increased risk of infections, particularly in the first year after transplantation. The risk of infection is directly proportional to immunosuppressive regimen and graft function. In this review, we will briefly discuss the timeline of infections after liver transplant, preventive strategies and management of infectious complications.
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Affiliation(s)
- Ajay S. Shinde
- Consultant Gastroenterologist and Hepatologist, Yashoda Hospitals, Secunderabad, Telangana, India
| | - Dharmesh Kapoor
- Consultant Hepatologist, Yashoda Hospitals, Secunderabad, Telangana, India
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2
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Lim C, Turco C, Goumard C, Jeune F, Perdigao F, Savier E, Rousseau G, Soubrane O, Scatton O. Perceptions of surgical difficulty in liver transplantation: A European survey and development of the Pitié-Salpêtrière classification. Surgery 2023; 174:979-993. [PMID: 37543467 DOI: 10.1016/j.surg.2023.06.041] [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: 03/24/2023] [Revised: 06/01/2023] [Accepted: 06/18/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Significant variations exist regarding the definition of difficult liver transplantation. The study goals were to investigate how liver transplant surgeons evaluate the surgical difficulty of liver transplantation and to use the identified factors to classify liver transplantation difficulty. METHODS A Web-based online European survey was presented to liver transplant surgeons. The survey was divided into 3 parts: (1) participant demographics and practices; (2) various situations based on recipient, liver disease, tumor treatment, and technical factors; and (3) 8 real-life clinical vignettes with different levels of complexity. In part 3 of the survey, respondents were asked whether they would perform liver transplantation but were not aware that these patients eventually underwent liver transplantation. RESULTS A total of 143 invites were sent out, and 97 (67.8%) participants completed the survey. Most participants considered previous spontaneous bacterial peritonitis, previous supra-mesocolic surgery, hypertrophy of segment I, and obesity to be recipient factors for high-difficulty liver transplantation. Most participants considered liver transplantation to be challenging in patients with Budd-Chiari syndrome, Kasai surgery, polycystic liver disease, diffuse portal vein thrombosis, and a history of open hepatectomy. The proportion of participants indicating that liver transplantation was warranted varied across the 8 cases, from 69% to 100%. Our classification of the surgical difficulty of liver transplantation employed these recipient-related, surgical history-related, and liver disease-related variables and 3 difficulty groups were identified: low, intermediate, and high difficulty groups. CONCLUSION This survey provides an overview of the surgical difficulty of various situations in liver transplantation that could be useful for further benchmark and textbook outcome studies.
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Affiliation(s)
- Chetana Lim
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Célia Turco
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Centre de Recherche de Saint-Antoine, INSERM, UMRS-938, Paris, France
| | - Claire Goumard
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris, France; Centre de Recherche de Saint-Antoine, INSERM, UMRS-938, Paris, France
| | - Florence Jeune
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Fabiano Perdigao
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Savier
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Centre de Recherche de Saint-Antoine, INSERM, UMRS-938, Paris, France
| | - Géraldine Rousseau
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Olivier Soubrane
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Olivier Scatton
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris, France; Centre de Recherche de Saint-Antoine, INSERM, UMRS-938, Paris, France.
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3
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Incicco S, Tonon M, Zeni N, Gambino C, Gagliardi R, Calvino V, Barone A, Zilio G, Feltracco P, Burra P, Cillo U, Angeli P, Piano S. Impact of bacterial infections prior to liver transplantation on post-transplant outcomes in patients with cirrhosis. JHEP Rep 2023; 5:100808. [PMID: 37534231 PMCID: PMC10393541 DOI: 10.1016/j.jhepr.2023.100808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 08/04/2023] Open
Abstract
Background & Aims Bacterial infections are frequent in patients with cirrhosis and increase the risk of death and drop-out from liver transplant (LT) waiting list. In patients with bacterial infections, LT is frequently delayed because of the fear of poor outcomes. We evaluated the impact of pre-LT infections on post-LT complications and survival. Methods From 2012 to 2018, consecutive patients transplanted at the Hospital of Padua were identified and classified in two groups: patients surviving an episode of bacterial infection within 3 months before LT (study group) and patients without infections before LT (control group). Post-LT outcomes (complications, new infections, survival) were collected. Results A total of 466 LT recipients were identified (study group n = 108; control group n = 358). After LT, the study group had a higher incidence of new bacterial (57% vs. 20%, p <0.001) and fungal infections (14% vs. 5%, p = 0.001) and of septic shock (8% vs. 2%, p = 0.004) than the control group. Along with the model for end-stage liver disease (MELD) score and alcohol-related cirrhosis, bacterial infection pre-LT was an independent predictor of post-LT infections (odds ratio = 3.92; p <0.001). Nevertheless, no significant difference was found in 1-year (88% vs. 89%, p = 0.579) and 5-year survival rates (76% vs. 75%, p = 0.829) between the study group and control group. Within the study group, no association was found between the time elapsed from infection improvement/resolution to LT and post-LT outcomes. Conclusions Patients with pre-LT infections have a higher risk of new bacterial and fungal infections and of septic shock after LT. However, post-LT survival is excellent. Therefore, as soon as the bacterial infection is improving/resolving, transplant should not be delayed, but patients with pre-transplant bacterial infections require active surveillance for infections after LT. Impact and Implications Bacterial infections increase mortality and delay transplant in patients with cirrhosis awaiting liver transplantation (LT). Little is known about the impact of adequately treated infections before LT on post-transplant complications and outcomes. The study highlights that pre-LT infections increase the risk of post-LT infections, but post-LT survival rates are excellent despite the risk. These findings suggest that physicians should not delay LT because of concerns about pre-LT infections, but instead should actively monitor these patients for infections after surgery.
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Affiliation(s)
- Simone Incicco
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Nicola Zeni
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Carmine Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Roberta Gagliardi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Anna Barone
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Gianluca Zilio
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Paolo Feltracco
- Anesthesiology and Intensive Care Unit, Department of Medicine (DIMED), University and Hospital of Padova, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University and Hospital of Padova, Padua, Italy
| | - Umberto Cillo
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padua, Italy
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Ausania F, Borin A, Martinez-Perez A, Blasi A, Landi F, Colmenero J, Fuster J, Garcia-Valdecasas JC. Development of a preoperative score to predict surgical difficulty in liver transplantation. Surgery 2022; 172:1529-1536. [PMID: 36055816 DOI: 10.1016/j.surg.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/13/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND A difficulty score to predict intraoperative surgical complexity in liver transplantation has never been developed. The aim of this study was to assess factors associated with a difficult liver transplant and develop a score to predict difficult surgery. METHODS All patients undergoing deceased donor whole liver transplantation from 2012 to 2019 at a single center were included. Estimated intraoperative blood loss (mL/kg) and surgery duration (skin-to-arterial reperfusion time) were used as surrogates of difficulty. Based on these variables, the study population was divided into 2 groups: high risk and standard risk of difficulty. Univariate and multivariate analyses were performed to identify predictors associated with a demanding liver transplantation and develop a difficulty score. RESULTS A total of 515 patients were included in the study population, and 101 (20%) were considered difficult operations. Patients with a higher risk of difficulty showed a significantly higher rate of Clavien-Dindo ≥III complications (50.5% vs 24.4%, P = .001) and a longer hospital stay (19 vs 16 days, P = .001). Preoperative factors associated with difficulty were retransplantation (odds ratio 4.34, P = .001), preoperative portal vein thrombosis (odds ratio 3.419, P = .001), previous upper abdominal surgery (odds ratio 2.161, P = .003), spontaneous bacterial peritonitis (odds ratio 1.985, P < .02), and prior variceal bleeding (odds ratio 1.401, P = .051). A 10-point difficulty score was created, showing a negative predictive value of 84% at 4 points. CONCLUSION Difficult liver transplantation surgery, as assessed by skin-to-arterial reperfusion time and estimated blood loss, is associated with worse perioperative outcomes. We developed a simple score with clinical preoperative variables that predicts difficult surgery, and therefore, it may help to optimize allocation policies and perioperative logistics.
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Affiliation(s)
- Fabio Ausania
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain. https://twitter.com/fabio_ausania
| | - Alex Borin
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain; Department of General Surgery and Dentistry, Liver Transplant Unit, University and Hospital Trust of Verona, Italy.
| | | | - Anabel Blasi
- Department of Anesthesia, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
| | - Filippo Landi
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
| | - Jordi Colmenero
- Liver Unit, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Spain
| | - Josep Fuster
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
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Nikam V, Srivastava M. The outcome of living donor liver transplant recipients with recent episodes of spontaneous bacterial peritonitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:251-254. [PMID: 33207887 DOI: 10.17235/reed.2020.6780/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND spontaneous bacterial peritonitis (SBP) is a common complication in patients with cirrhosis and is associated with a high mortality rate. Only a few reports have analyzed the impact of treated SBP that occurs in the immediate pre-operative period on outcome after a living donor liver transplantation (LDLT). The results of whether post-transplant patients are dependent on pre-transplant infections are still debatable and unclear. Therefore, this study examined the outcomes of LDLT recipients with recent episodes of SBP and LDLT recipients without prior episodes of SBP. PATIENTS the records of 62 LDLT recipients who underwent LDLT were retrospectively reviewed. Twenty-four (36 %) recipients had at least one episode of SBP before LDLT. However, active SBP was not present in any of the recipients at the time of LDLT. Both recipient groups were compared in terms of demographic profile, perioperative and postoperative variables and outcomes. RESULTS higher pre-operative Child-Turcotte-Pugh (CTP) score (mean [SD] 11.77 [1.37] vs 10.5 [1.22], p < 0.001) and prior history of renal dysfunction (mean serum creatinine [SD] 1.715 [1.08] vs 1.02 [0.479] mg/dl, p = 0.002) were more commonly associated with the SBP group as compared to the non-SBP group. However, there was no statistically significant difference between the two groups in terms of the following variables: previous diabetes mellitus (3 [12.5 %] vs 6 [15.8 %]), pre-operative model for end-stage liver disease (MELD) score (median [IQR] 21 [10-37] vs 22 [9-39]), operative time (mean [SD] 789.57 [153.49] vs 800.86 [138.69] min), total number of blood transfusion (median [IQR] 10 [2-19] vs 8 [1-18]), hospital stay (median 21 vs 20 days), re-exploration (4 [16.6 %] vs 2 [5.3 %]), postoperative sepsis (8 [33 %] vs 5 [13 %]) and 30-day mortality (3 [12.5 %] vs 2 [5.3 %]). CONCLUSIONS the presence of previous episodes of pre-operative SBP in LDLT recipients does not result in adverse post-operative short-term outcomes.
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Affiliation(s)
- Vinayak Nikam
- Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, India
| | - Manish Srivastava
- Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, India
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6
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Nafea MA, Alsebaey A, Abd El Aal Sultan A, Goda MH, Salman A, Rashed HS, Soliman A, Elshenoufy M, Abdelrahman M. Predictors of early recipient mortality after living donor liver transplantation in a tertiary care center in Egypt. Ann Saudi Med 2019; 39:337-344. [PMID: 31580715 PMCID: PMC6832315 DOI: 10.5144/0256-4947.2019.337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Living donor liver transplantation (LDLT) has evolved into a widely accepted therapeutic option. Many different risk factors may affect early mortality after LDLT. OBJECTIVES Analyze risk factors that can affect early (<6 months) mortality of patients after LDLT in a single center. DESIGN Retrospective chart review of patients who underwent LDLT. SETTING University hospital. PATIENTS AND METHODS Adult cirrhotic patients who underwent LDLT were classified by early (first 6 months) or late mortality. A full pre, intra- and post-operative evaluation had been done on all patients including a full history, examination and investigations to identify risk factors that might affect mortality post-LDLT. MAIN OUTCOME MEASURES Determination of pre-, intra- or postoperative factors that might affect recipient mortality post-LDLT. SAMPLE SIZE 123. RESULTS Pre-operative factors that increased early mortality in a univariate analysis were higher model for end-stage liver disease (MELD) scores, lower graft-recipient weigh ratio (GRWR), older donor age, and recurrent spontaneous bacterial peritonitis. Intraoperative factors included more transfusion units of blood, plasma, platelets and cryoprecipitate, a longer time for cold and warm ischemia, and a longer anhepatic phase among others. Postoperative factors included a longer ICU or hospital stay and abnormal postoperative laboratory data. In the final logistic regression model, the most significant factors were pre-operative GRWR, length of hospital stay, units of intraoperative blood transfusion, postoperative alanine aminotransferase, postoperative total leukocyte count, and MELD score. CONCLUSION LDLT outcomes might be improved by attempting to resolve clinical factors that have been identified as contributors to early post-LDLT mortality. LIMITATIONS More risk factors, such as those relevant to patient portal vein hemodynamics, should be included in an analysis of predictors of early mortality. CONFLICT OF INTEREST None.
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Affiliation(s)
- Mohammed A. Nafea
- From the Department of General Surgery, Al-Azhar University, Cairo, Egypt
| | - Ayman Alsebaey
- From the Department of Gastroenterology and Hepatology, National Liver Institute, Shebin El-Kom, Egypt
| | | | | | - Ahmed Salman
- From the Department of Internal Medicine, Faculty of Medicine University Kasr, Cairo, Egypt
| | - Hanaa Said Rashed
- From the Department of Anesthesia, National Liver Institute, Shebin El-Kom, Egypt
| | - Ahmed Soliman
- From the Department of Internal Medicine, Faculty of Medicine University Kasr, Cairo, Egypt
| | - Mai Elshenoufy
- From the Department of Internal Medicine, Faculty of Medicine University Kasr, Cairo, Egypt
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Ferrarese A, Vitale A, Sgarabotto D, Russo FP, Germani G, Gambato M, Cattelan AM, Angeli P, Cillo U, Burra P, Senzolo M. Outcome of a First Episode of Bacterial Infection in Candidates for Liver Transplantation. Liver Transpl 2019; 25:1187-1197. [PMID: 31021050 DOI: 10.1002/lt.25479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/22/2019] [Indexed: 12/13/2022]
Abstract
Bacterial infection (BI) is a major cause of worsening of liver function and death in patients with cirrhosis who are awaiting liver transplantation (LT). This study aimed to evaluate the outcome of LT candidates after a first episode of BI between January 2006 and December 2014 at Padua University Hospital. Among 876 LT candidates with cirrhosis, 114 (13%) experienced an episode of BI. Of the 114 patients, 79 were male and 35 were female, and the median (interquartile range) age and Model for End-Stage Liver Disease scores were 58 (12) years and 19 (8), respectively. When compared with matched LT candidates who experienced no BI, they had a higher probability of death (P = 0.004) and a lower probability of undergoing LT (P = 0.01). Considering only patients who recovered from BI within 30 days, their probabilities of death and of undergoing LT were similar to those of matched controls (P = 0.34 and P = 0.43, respectively). The 90-day post-LT mortality was equal between groups (P = 0.90). BI was a strong predictor of early death on the waiting list for LT. Conversely, patients who fully recovered from a BI episode within 30 days did not have a higher mortality risk than matched controls without infection.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplant Center, Padua University Hospital, Padua, Italy
| | - Dino Sgarabotto
- Tropical and Infectious Diseases Unit, Padua University Hospital, Padua, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Anna Maria Cattelan
- Tropical and Infectious Diseases Unit, Padua University Hospital, Padua, Italy
| | - Paolo Angeli
- Internal Medicine, Padua University Hospital, Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Center, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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8
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Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24:4311-4329. [PMID: 30344417 PMCID: PMC6189843 DOI: 10.3748/wjg.v24.i38.4311] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/11/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.
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Affiliation(s)
- Elda Righi
- Department of Infectious Diseases, Santa Maria della Misericordia University Hospital, Udine 33100, Italy
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9
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Linecker M, Krones T, Berg T, Niemann CU, Steadman RH, Dutkowski P, Clavien PA, Busuttil RW, Truog RD, Petrowsky H. Potentially inappropriate liver transplantation in the era of the "sickest first" policy - A search for the upper limits. J Hepatol 2018; 68:798-813. [PMID: 29133246 DOI: 10.1016/j.jhep.2017.11.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/11/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.
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Affiliation(s)
- Michael Linecker
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Tanja Krones
- Division of Clinical Ethics, University Hospital Zurich, Switzerland; Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Thomas Berg
- Division of Hepatology, University of Leipzig, Germany
| | - Claus U Niemann
- Department of Anesthesiology, University of California, San Francisco, USA; Department of Surgery, University of California San Francisco, USA
| | - Randolph H Steadman
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA
| | - Philipp Dutkowski
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ronald W Busuttil
- Dumont-UCLA Transplant Center, Ronald Reagan Medical Center, University of California Los Angeles, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, USA; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, USA
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
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10
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Ferrarese A, Zanetto A, Becchetti C, Sciarrone SS, Shalaby S, Germani G, Gambato M, Russo FP, Burra P, Senzolo M. Management of bacterial infection in the liver transplant candidate. World J Hepatol 2018; 10:222-230. [PMID: 29527258 PMCID: PMC5838441 DOI: 10.4254/wjh.v10.i2.222] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 12/29/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection (BI) is a common cause of impairment of liver function in patients with cirrhosis, especially in the liver transplant candidates. These patients share an immunocompromised state and increased susceptibility to develop community and hospital-acquired infections. The changing epidemiology of BI, with an increase of multidrug resistant strains, especially in healthcare-associated settings, represents a critical issue both in the waiting list and in the post-operative management. This review focused on the role played by BI in patients awaiting liver transplantation, evaluating the risk of drop-out from the waiting list, the possibility to undergo liver transplantation after recovery from infection or during a controlled infection.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Salvatore Stefano Sciarrone
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Sarah Shalaby
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
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11
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Hung TH, Tsai CC, Hsieh YH, Tsai CC, Tseng CW, Tseng KC. The Effect of the First Spontaneous Bacterial Peritonitis Event on the Mortality of Cirrhotic Patients with Ascites: A Nationwide Population-Based Study in Taiwan. Gut Liver 2017; 10:803-7. [PMID: 27563023 PMCID: PMC5003205 DOI: 10.5009/gnl13468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 03/06/2014] [Accepted: 03/10/2014] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Spontaneous bacterial peritonitis (SBP) contributes to poorer short-term mortality in cirrhotic patients with ascites. However, it is unknown how long the effect of the first SBP event persists in these patients. Methods The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify and enroll 7,892 cirrhotic patients with ascites who were hospitalized between January 1 and December 31, 2007. All patients were free from episodes of SBP from 1996 to 2006. Results The study included 1,176 patients with SBP. The overall 30-day, 90-day, 1-year, and 3-year mortality rates in this group were 21.8%, 38.9%, 57.5%, and 73.4%, respectively. The overall 30-day, 90-day, 1-year, and 3-year mortality rates in the non-SBP group were 15.7%, 32.5%, 53.3%, and 72.5%, respectively. After adjusting for gender, age, and other medical comorbidities, the adjusted hazard ratios of SBP for 30-day, 30- to 90-day, 90-day to 1-year, and 1- to 3-year mortality were 1.49 (95% confidence interval [CI], 1.30 to 1.71), 1.19 (95% CI, 1.02 to 1.38), 1.04 (95% CI, 0.90 to 1.20), and 0.90 (95% CI, 0.77 to 1.05), respectively, compared with the non-SBP group. Conclusions The effect of SBP on the mortality of cirrhotic patients with ascites disappeared in those surviving more than 90 days after the first SBP event.
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Affiliation(s)
- Tsung-Hsing Hung
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chen-Chi Tsai
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Hsi Hsieh
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
| | - Chih-Wei Tseng
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kuo-Chih Tseng
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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12
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Leong J, Huprikar S, Schiano T. Outcomes of spontaneous bacterial peritonitis in liver transplant recipients with allograft failure. Transpl Infect Dis 2017; 18:545-51. [PMID: 27261101 DOI: 10.1111/tid.12565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 01/30/2016] [Accepted: 03/19/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) carries appreciable morbidity and mortality in the pre-liver transplant (LT) setting. However, the occurrence of SBP and its consequences in the post-LT setting have not been well characterized. METHODS This is a retrospective study of SBP occurring in post-LT patients between January 2007 and December 2012. Outcomes were compared to a cohort of post-LT patients with allograft failure and ascites without SBP. RESULTS The most common indication for liver transplantation in this cohort was hepatitis C. A total of 29 episodes of SBP in 21 patients were identified. Escherichia coli (19%) and Klebsiella pneumoniae (10%) were the most frequent pathogens identified. Six patients died during their first episode of SBP. Ten patients were eventually listed for liver re-transplantation (re-LT) after their first episode of SBP; 5 of these patients were transplanted and the other 5 died. Of the 5 who were transplanted, 2 died shortly after re-transplant, and 3 are still alive. The cause of death in the majority of patients was infection (83.3%). The median time from onset of ascites to death was 214 days (range: 10-1085 days) and from the first episode of SBP to death was 50.5 days (range: 4-549 days). In contrast, the median time from onset of ascites to death in patients with allograft failure and ascites without SBP was 331.5 days (45-2400 days). CONCLUSIONS Allograft failure with ascites is a poor prognostic factor and these patients should be considered high risk for re-LT. SBP may accelerate the time to mortality.
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Affiliation(s)
- J Leong
- Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - S Huprikar
- Division of Infectious Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - T Schiano
- Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
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13
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Verna EC, Pereira MR. Transplanting patients with active bacterial infection. Clin Liver Dis (Hoboken) 2017; 9:81-85. [PMID: 30992965 PMCID: PMC6467147 DOI: 10.1002/cld.624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/28/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Medical Center622 West 168th Street New YorkNY, 10032
| | - Marcus R. Pereira
- Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center622 West 168th Street New YorkNY, 10032
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14
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Shah NL, Intagliata NM, Henry ZH, Argo CK, Northup PG. Spontaneous bacterial peritonitis prevalence in pre-transplant patients and its effect on survival and graft loss post-transplant. World J Hepatol 2016; 8:1617-1622. [PMID: 28083084 PMCID: PMC5192553 DOI: 10.4254/wjh.v8.i36.1617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/22/2016] [Accepted: 11/17/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the incidence of spontaneous bacterial peritonitis (SBP) in pre-transplant patients and its effect on post transplant mortality and graft failure.
METHODS We conducted a retrospective cohort study of patient records from the organ procurement and transplant network data set. Patients were identified by the presence of SBP pre-transplant. Univariate post-transplant survival models were constructed using the Kaplan-Meier technique and multivariate models were constructed using the Cox proportional hazards model. Variables that affected post-transplant graft survival were identified in the SBP population.
RESULTS Forty-seven thousand eight hundred and eighty patient records were included in the analysis for both groups, and 1966 (4.11%) patients were identified in the data set as having pre-transplant SBP. Patients that had pre-transplant SBP had higher rates of graft loss from recurrent hepatitis C virus (HCV) (3.6% vs 2.0%, P < 0.0001), infections leading to graft loss (1.9% vs 1.3%, P = 0.02), primary non-function (4.3% vs 3.0%, P < 0.0001) and chronic rejection (1.1% vs 0.7%, P = 0.04). Kaplan-Meier survival analysis showed a statistically significant difference in all-cause survival in patients with a history of SBP vs those without (P < 0.0001). Pre-transplant history of SBP was independently predictive of mortality due to recurrent HCV (HR = 1.11, 95%CI: 1.02-1.21, P < 0.017) after liver transplantation.
CONCLUSION HCV patients prior to the advent of directing acting anti-viral agents had a higher incidence of pre-transplant SBP than other patients on the liver transplant wait list. SBP history pre-transplant resulted in a higher rate of graft loss due to recurrent HCV infection and chronic rejection.
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15
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Kim IK, Park JS, Ju MK. Impact of Pre-Transplant Bacterial Infections on Post-Operative Outcomes in Patients after Liver Transplantation. Surg Infect (Larchmt) 2016; 18:170-175. [PMID: 27929923 DOI: 10.1089/sur.2016.109] [Citation(s) in RCA: 2] [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 In contrast to studies evaluating the negative effect of bacterial infections on clinical outcomes after liver transplantation, there is little evidence with regard to pre-transplant bacterial infections. We aimed to investigate the impact of pre-transplant bacterial infections on post-transplant outcomes in patients after liver transplantation. PATIENTS AND METHODS We retrospectively analyzed clinical data from 33 consecutive patients who underwent primary liver transplantations. Patients were divided into two groups based on the occurrence of a bacterial infection within the 30 days before transplantation. RESULTS Of the 33 patients, 23 patients did not have pre-transplant bacterial infections, while 10 patients did have pre-transplant bacterial infections. Pre-transplant bacterial infections were urinary tract infections (n = 4), spontaneous bacterial peritonitis (n = 3), and one each of pneumonia, bacteremia, and cellulitis. There were no differences in clinical characteristics between the two groups. Post-operative clinical outcomes, including post-operative bacterial infection, intensive-care unit re-admission, 30-day re-hospitalization, and 90-day mortality rate were not significantly different between the two groups. The two-year overall survival rate was 76.7% in patients with pre-transplant infections and 80.0% in those without pre-transplant infections. CONCLUSIONS Patients with pre-transplant bacterial infections did not have inferior clinical outcomes, compared with those without pre-transplant bacterial infections.
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Affiliation(s)
- Im-Kyung Kim
- Department of Surgery, Gangnam Severance Hospital , Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital , Yonsei University College of Medicine, Seoul, Korea
| | - Man Ki Ju
- Department of Surgery, Gangnam Severance Hospital , Yonsei University College of Medicine, Seoul, Korea
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16
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Karagozian R, Rutherford AE, Christopher KB, Brown RS. Spontaneous bacterial peritonitis is a risk factor for renal failure requiring dialysis in waitlisted liver transplant candidates. Clin Transplant 2016; 30:502-7. [DOI: 10.1111/ctr.12712] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Raffi Karagozian
- Columbia University College of Physicians & Surgeons; New York NY USA
| | | | | | - Robert S. Brown
- Columbia University College of Physicians & Surgeons; New York NY USA
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Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther 2015; 41:1116-31. [PMID: 25819304 DOI: 10.1111/apt.13172] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 02/02/2015] [Accepted: 03/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection in patients with cirrhosis and ascites. AIM To review the known and changing bacteriology, risk factors, ascitic fluid interpretation, steps in performing paracentesis, treatment, prophylaxis and evolving perspectives related to SBP. METHODS Information was obtained from reviewing medical literature accessible on PubMed Central. The search term 'spontaneous bacterial peritonitis' was cross-referenced with 'bacteria', 'risk factors', 'ascites', 'paracentesis', 'ascitic fluid analysis', 'diagnosis', 'treatment', 'antibiotics', 'prophylaxis', 'liver transplantation' and 'nutrition'. RESULTS Gram-positive cocci (GPC) such as Staphylococcus, Enterococcus as well as multi-resistant bacteria have become common pathogens and have changed the conventional approach to treatment of SBP. Health care-associated and nosocomial SBP infections should prompt greater vigilance and consideration for alternative antibiotic coverage. Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals. CONCLUSIONS Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment. Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy. For uncomplicated SBP, early oral switch therapy is reasonable. Alternative antibiotics such as pipercillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens. Selective albumin supplementation remains an important adjunct in SBP treatment. Withholding acid suppressive medication deserves strong consideration, and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites is standard care. Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications.
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Affiliation(s)
- J B Dever
- Department of Gastroenterology, VA San Diego Healthcare System, San Diego, CA, USA
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18
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Lim KHJ, Potts JR, Chetwood J, Goubet S, Verma S. Long-term outcomes after hospitalization with spontaneous bacterial peritonitis. J Dig Dis 2015; 16:228-40. [PMID: 25564761 DOI: 10.1111/1751-2980.12228] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the determinants of long-term outcome in patients with spontaneous bacterial peritonitis (SBP). METHODS This study was conducted retrospectively. Kaplan-Meier (KM) and Cox proportional hazards survival analyses were performed. RESULTS Altogether, 93 patients with SBP were identified, with their mean age of 57.9 ± 12.9 years, Child-Pugh score 10.4 ± 1.9 and model for end-stage liver disease (MELD) score 20.2 ± 6.8. The etiology of chronic liver disease (CLD) was alcohol-related liver disease (ARLD) (n = 58) and viral hepatitis/non-alcoholic steatohepatitis (n = 28). SBP was the index presentation of cirrhosis in 26 (28.0%) patients. Overall mortality was 80.6%; among them 81.3% were liver-related, and 33 (35.5%) died during index hospitalization. In total, 70.0% of patients who survived index hospitalization died during follow-up, with a median survival of 12.5 months. Estimated survival at 3 months, 1 year and 5 years was 54.8%, 34.4% and 15.2%, respectively. Non-ARLD etiology for CLD was an independent predictor of overall mortality (HR 3.484, 95% CI 1.802-6.757, P < 0.001) and mortality in those surviving hospitalization (HR 2.319, 95% CI 1.210-4.444, P = 0.011). Hepatorenal syndrome did not predict outcomes. Two (3.3%) patients surviving hospitalization underwent liver transplantation (LT). CONCLUSIONS One-year survival after hospitalization with SBP remains poor (34.4%) with unacceptably low LT rates. Non-ARLD etiology for CLD is an independent predictor of both overall mortality and mortality after discharge. In view of the projected increase in non-alcoholic steatohepatitis-related CLD, screening strategies for timely CLD diagnosis are warranted.
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Affiliation(s)
- Kok Haw Jonathan Lim
- Department of Gastroenterology & Hepatology, Brighton & Sussex University Hospitals NHS Trust, Brighton, United Kingdom
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Mattos AAD, Costabeber AM, Lionço LC, Tovo CV. Multi-resistant bacteria in spontaneous bacterial peritonitis: A new step in management? World J Gastroenterol 2014; 20:14079-14086. [PMID: 25339797 PMCID: PMC4202339 DOI: 10.3748/wjg.v20.i39.14079] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 05/04/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is the most typical infection observed in cirrhosis patients. SBP is responsible for an in-hospital mortality rate of approximately 32%. Recently, pattern changes in the bacterial flora of cirrhosis patients have been observed, and an increase in the prevalence of infections caused by multi-resistant bacteria has been noted. The wide-scale use of quinolones in the prophylaxis of SBP has promoted flora modifications and resulted in the development of bacterial resistance. The efficacy of traditionally recommended therapy has been low in nosocomial infections (up to 40%), and multi-resistance has been observed in up to 22% of isolated germs in nosocomial SBP. For this reason, the use of a broad empirical spectrum antibiotic has been suggested in these situations. The distinction between community-acquired infectious episodes, healthcare-associated infections, or nosocomial infections, and the identification of risk factors for multi-resistant germs can aid in the decision-making process regarding the empirical choice of antibiotic therapy. Broad-spectrum antimicrobial agents, such as carbapenems with or without glycopeptides or piperacillin-tazobactam, should be considered for the initial treatment not only of nosocomial infections but also of healthcare-associated infections when the risk factors or severity signs for multi-resistant bacteria are apparent. The use of cephalosporins should be restricted to community-acquired infections.
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Percutaneous placement and management of the Denver shunt for portal hypertensive ascites. AJR Am J Roentgenol 2012; 199:W449-53. [PMID: 22997394 DOI: 10.2214/ajr.12.9203] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Many patients with cirrhotic effusions in the peritoneal and pleural spaces lead a difficult existence. In addition to their decreased mobility and physical discomfort, they spend hours in the hospital or an outpatient facility undergoing peritoneal and pleural drainage. Liver transplantation is the ultimate solution for those with cirrhotic effusions refractory to medical management; however, most are on a long waiting list, forcing them to undergo a year or more of percutaneous centesis. Transjugular intrahepatic portosystemic shunts offer relief to those with cirrhotic ascites but at the cost of accelerated hepatic failure and hepatic encephalopathy. This article will review the development of the peritoneovenous and pleurovenous shunt, discuss reasons for its loss of favor, and suggest its current role in the armamentarium of the interventional radiologist. CONCLUSION Peritoneovenous and pleurovenous shunt creation is a procedure that has the potential to significantly improve the quality of life of the patient by controlling the fluid collections, reducing dependence on frequent drainage procedures, improving renal function, and reducing protein loss.
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Current world literature. Curr Opin Organ Transplant 2011; 16:650-60. [PMID: 22068023 DOI: 10.1097/mot.0b013e32834dd969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Acute-on-Chronic Liver Failure Before Liver Transplantation: Impact on Posttransplant Outcomes. Transplantation 2011; 92:952-7. [DOI: 10.1097/tp.0b013e31822e6eda] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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23
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Viñuela EF, Mirza DF. Preparation of the patient for liver transplantation. INDIAN JOURNAL OF TRANSPLANTATION 2011. [DOI: 10.1016/s2212-0017(11)60001-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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