1
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Kumar R, Lin S, Mehta G, Mesquita MD, Calvao JAF, Sheikh MF, Agarwal B, Mookerjee RP, Jalan R. Non-selective beta-blocker is associated with reduced mortality in critically ill patients with cirrhosis: A real-world study. Aliment Pharmacol Ther 2024. [PMID: 39091108 DOI: 10.1111/apt.18188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/08/2024] [Accepted: 07/15/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Apart from direct portal pressure reduction, non-selective beta-blockers (NSBB) modulate inflammatory response, which could be beneficial in patients with acute decompensation (AD). We therefore aimed to evaluate the effect of NSBB on 28-day mortality and markers of systemic inflammation in a propensity score-matched (PSM) cohort of AD patients requiring intensive care unit (ICU) admission. METHODS Patients were recruited from registry of AD patients requiring ICU admission. Out of total 445 patients, 108 patients on NSBB before admission (NSBB use group) were PSM for age, gender, pre-admission Child-Turcotte-Pugh score and history of previous decompensation to 108 patients not on NSBB (non-NSBB use group) which served as the control group. ICU parameters, markers of systemic inflammation and 28-day mortality were compared by standard statistical tests. RESULTS After PSM, no difference was observed in aetiology of cirrhosis, or precipitating event for AD between the groups. Pre-admission creatinine, bilirubin, international normalised ratio and haemoglobin were similar between the groups, whereas pre-admission white cell count (WCC) and neutrophil to lymphocyte ratio (NLR) was lower in NSBB-group. On admission to ICU, NSBB group had lower heart rate (p = 0.006), platelets (p = 0.012), WCC (p = 0.006), NLR (p = 0.039) and C-reactive protein (p = 0.007). Significantly more community acquired bacterial infections (p = 0.006), renal failure (p = 0.033) and higher grades of acute-on-chronic liver failure (ACLF; p = 0.012) were observed in non-NSBB group. Significantly lower 28-day (p = 0.001) and 90-day (p = 0.002) mortality was seen in NSBB group. Univariate and multivariable analysis for 28-day mortality showed that while ACLF at presentation and community acquired bacterial infection were independent negative predictors, prior NSBB use was positive predictors of survival. CONCLUSIONS Prior use of NSBB is associated with improved 28- and 90-day mortality in critically ill cirrhosis patients with AD which is mediated probably by blunting of the inflammatory response.
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Affiliation(s)
- Rahul Kumar
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke- NUS Academic Medical Centre, CGH Campus, Singapore
| | - Su Lin
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
- Liver Research Center of the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Gautam Mehta
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Monica D Mesquita
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
- Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Vila Real, Portugal
| | - Joana A F Calvao
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
- Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Vila Real, Portugal
| | - M Faisal Sheikh
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Banwari Agarwal
- Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Vila Real, Portugal
- Intensive Care Unit, Royal Free Hospital NHS Foundation Trust, London, UK
| | - R P Mookerjee
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
- Department of Hepatology and Gastroenterology, Aarhus University, Aarhus, Denmark
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
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2
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Incicco S, Angeli P, Piano S. Infectious Complications of Portal Hypertension. Clin Liver Dis 2024; 28:525-539. [PMID: 38945641 DOI: 10.1016/j.cld.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Patients with cirrhosis and clinically significant portal hypertension are at high risk of developing bacterial infections (BIs) that are the most common trigger of acute decompensation and acute-on-chronic liver failure. Furthermore, after decompensation, the risk of developing BIs further increases in an ominous vicious circle. BIs may be subtle, and they should be ruled out in all patients at admission and in case of deterioration. Timely administration of adequate empirical antibiotics is the cornerstone of treatment. Herein, we reviewed current evidences about pathogenesis, clinical implications and management of BIs in patients with cirrhosis and portal hypertension.
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Affiliation(s)
- Simone Incicco
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University and Hospital of Padova, via Giustiniani 2, Padova 35100, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University and Hospital of Padova, via Giustiniani 2, Padova 35100, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University and Hospital of Padova, via Giustiniani 2, Padova 35100, Italy.
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3
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Brujats A, Huerta A, Osuna-Gómez R, Guinart-Cuadra A, Ferrero-Gregori A, Pujol C, Soriano G, Poca M, Fajardo J, Escorsell A, Gallego A, Vidal S, Villanueva C, Alvarado-Tapias E. Immune Response and Risk of Decompensation following SARS-CoV-2 Infection in Outpatients with Advanced Chronic Liver Disease. Int J Mol Sci 2024; 25:8302. [PMID: 39125872 PMCID: PMC11312207 DOI: 10.3390/ijms25158302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Advanced chronic liver disease (ACLD) is associated with a wide spectrum of immune dysfunction. The clinical impact of SARS-CoV-2 on the development of decompensation and immune response in unvaccinated outpatients has not as yet been clearly defined. This study aimed to evaluate the clinical and immunological impact of SARS-CoV-2 on outpatients with ACLD. This is an observational case-control study, in which ACLD outpatients were included prospectively and consecutively and classified into two groups: SARS-CoV-2 infected and non-infected. Patients' baseline characteristics and infection data were collected and analyzed. Immunoglobulin G (IgG) levels against Spike 1 were evaluated. The primary endpoint was risk of liver decompensation during follow-up, assessed after propensity score matching and adjusted by Cox regression. Between October 2020 and July 2021, ACLD outpatients (n = 580) were identified, and 174 patients with clinical follow-up were included. SARS-CoV-2 infection incidence was 7.6% (n = 44). Risk of liver decompensation was significantly higher after infection (HR = 2.43 [1.01-5.86], p = 0.048) vs. non-infection. The time of IgG evaluation was similar in all patients (n = 74); IgG concentrations were significantly higher in compensated vs. decompensated patients (1.02 ± 0.35 pg/mL vs. 0.34 ± 0.16 pg/mL, p < 0.0001) and correlated with hemoglobin levels. The dysregulation of the innate immune response in patients with decompensated liver disease increased the risk of further decompensation following SARS-CoV-2, mainly due to a worsening of ascites.
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Affiliation(s)
- Anna Brujats
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
- Departament Medicina UAB, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Anna Huerta
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
| | - Rubén Osuna-Gómez
- Inflammatory Diseases Department, Institut Recerca Hospital de la Santa Creu i Sant Pau (IR Sant Pau), 08041 Barcelona, Spain; (A.G.-C.); (S.V.)
| | - Albert Guinart-Cuadra
- Inflammatory Diseases Department, Institut Recerca Hospital de la Santa Creu i Sant Pau (IR Sant Pau), 08041 Barcelona, Spain; (A.G.-C.); (S.V.)
| | - Andreu Ferrero-Gregori
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
| | - Clàudia Pujol
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
| | - German Soriano
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
- Departament Medicina UAB, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Maria Poca
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Javier Fajardo
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
| | - Angels Escorsell
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
- Departament Medicina UAB, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Adolfo Gallego
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
| | - Silvia Vidal
- Inflammatory Diseases Department, Institut Recerca Hospital de la Santa Creu i Sant Pau (IR Sant Pau), 08041 Barcelona, Spain; (A.G.-C.); (S.V.)
| | - Càndid Villanueva
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
- Departament Medicina UAB, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Edilmar Alvarado-Tapias
- Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Insitute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain; (A.B.); (A.H.); (A.F.-G.); (C.P.); (G.S.); (M.P.); (J.F.); (A.E.); (A.G.); (C.V.)
- Departament Medicina UAB, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Johansen S, Langkjær S, Rasmussen DN, Israelsen M, Torp N, Lindvig K, Kjærgaard M, Hansen JK, Hansen CD, Thorhauge K, Andersen P, Detlefsen S, Juel HB, Justesen US, Hansen T, Krag A, Thiele M. Infections increase the risk of decompensation and death in patients with early alcohol-related liver disease. JHEP Rep 2024; 6:101016. [PMID: 38486819 PMCID: PMC10937840 DOI: 10.1016/j.jhepr.2024.101016] [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: 12/08/2022] [Revised: 12/19/2023] [Accepted: 01/16/2024] [Indexed: 03/17/2024] Open
Abstract
Background & Aims Infections are frequent in patients with cirrhosis and worsen prognosis. We evaluated the incidence of infections and their impact on decompensation and death in patients with early alcohol-related liver disease (ALD) during long-term follow-up. Methods We performed a prospective cohort study of patients in secondary care with a history of excess alcohol intake, no prior decompensation, and with liver biopsies along with clinical investigations conducted at baseline. During follow-up, we reviewed the patients' electronic healthcare records for cases of infections, hospitalizations, transient elastography measurements, decompensations, all-cause mortality, and alcohol intake. Results We included 461 patients with a mean age of 56±10 years (76% males; fibrosis stage F0-1/F2/F3-4 = 259/107/93 [56%/23%/20%]). During a median follow-up of 4.5 years (IQR 2.9-6.3), 134 patients (29%) developed a total of 312 infections, most frequently pneumonia (106/312, 34%) and urinary tract infections (57/312, 18%). Excessive alcohol intake during follow-up, smoking ≥30 pack years, MELD score and elevated liver stiffness during follow-up were independent predictors of infections. Patients who developed at least one infection had a significantly increased risk of subsequent decompensation (hazard ratio 4.98, 95% CI 2.47-10.03) and death (hazard ratio 8.24, 95% CI 4.65-14.59). Infections increased the risk of decompensation and death independently of baseline fibrosis stage, age, gender, and MELD score. Conclusions Almost one-third of patients with early ALD develop an infection, which worsens their prognosis by increasing the risk of decompensation and death. The risk of infections increases with liver disease severity and ongoing harmful use of alcohol. Impact and implications This study reveals that infections significantly worsen the prognosis of patients with early alcohol-related liver disease (ALD), increasing the likelihood of decompensation and death by up to eight times. These findings, pertinent to healthcare providers, researchers, and policymakers, emphasize the importance of early prevention and management of infections in patients with ALD, even those in early stages who may be asymptomatic. It was observed that nearly one-third of patients with early-stage ALD developed infections over 4.5 years, with risk factors including alcohol overuse, smoking, and higher MELD scores. The research underscores the critical need to incorporate these insights into clinical practice and public health policies to improve patient outcomes and mitigate the impact of infections in patients with ALD.
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Affiliation(s)
- Stine Johansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Simon Langkjær
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ditlev Nytoft Rasmussen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mads Israelsen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Nikolaj Torp
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Lindvig
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Kjærgaard
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johanne Kragh Hansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Camilla Dalby Hansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Thorhauge
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Peter Andersen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Helene Bæk Juel
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Ulrik Stenz Justesen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Aleksander Krag
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maja Thiele
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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5
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Liu Y, Hu H, Li C, Zhang Y, Li M, Lu T, Wu Y, Yang Y, Li Y, Yang F, Shi X, Lin S. Impacts of the development of acute-on-chronic liver failure and bacterial infections on β-cell function and glucose homeostasis in patients with liver cirrhosis. Dig Liver Dis 2024; 56:648-655. [PMID: 37758609 DOI: 10.1016/j.dld.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The pathogenesis involved in glucose metabolism disorders (GMDs) in patients with liver cirrhosis remains unclear. AIMS We investigated the effects of acute-on-chronic liver failure (ACLF) development and bacterial infections (BIs) on pancreatic β-cell function and glucose homeostasis in individuals with liver cirrhosis. METHODS A retrospective analysis was conducted on 327 patients experiencing acute deterioration of liver cirrhosis. Oral glucose tolerance tests (OGTTs) and OGTT-based β-cell function indices were employed to assess β-cell function and glucose homeostasis. Univariate and multivariate logistic regression analyses were employed to identify GMD-associated risk factors. RESULTS Both the development of ACLF and BIs significantly increased the prevalence of GMDs. Both ACLF and BIs markedly elevated the homeostasis model of assessment 2-insulin resistance (HOMA2-IR). ACLF significantly impaired glucose-stimulated insulin secretion, as evidenced by reduced insulinogenic index (IGI). Patients with GMDs exhibited significantly lower IGI levels than those without GMDs. Independent risk factors associated with GMDs were prothrombin activity (odds ratio [OR]=0.981, 95% confidence interval [CI]: 0.960-0.995), HOMA2-IR (OR=1.749, 95% CI: 1.130-2.707), and IGI (OR=0.963, 95% CI: 0.947-0.978). CONCLUSIONS In liver cirrhosis, the onset of ACLF impairs glucose-stimulated insulin secretion from β-cells. Both liver impairment and BIs contribute to increased insulin resistance, ultimately disturbing glucose homeostasis.
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Affiliation(s)
- Yujuan Liu
- Suzhou Medical College of Soochow University, Suzhou 215325, China; Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China
| | - Han Hu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China
| | - Chuan Li
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China
| | - Yin Zhang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China
| | - Meichuan Li
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China
| | - Tao Lu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China
| | - Yunchong Wu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China
| | - Yanyan Yang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China
| | - Ying Li
- Department of Infectious Diseases, Second Affiliated Hospital of Zunyi Medical University, Guizhou, 563000, China
| | - Fangwan Yang
- Department of Infectious Diseases, Second Affiliated Hospital of Zunyi Medical University, Guizhou, 563000, China
| | - Xiuquan Shi
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Guizhou, 563006, China
| | - Shide Lin
- Suzhou Medical College of Soochow University, Suzhou 215325, China; Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Guizhou, 563003, China; College of Laboratory Medicine, Zunyi Medical University, Guizhou, 563003, China.
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6
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Feng G, Valenti L, Wong VWS, Fouad YM, Yilmaz Y, Kim W, Sebastiani G, Younossi ZM, Hernandez-Gea V, Zheng MH. Recompensation in cirrhosis: unravelling the evolving natural history of nonalcoholic fatty liver disease. Nat Rev Gastroenterol Hepatol 2024; 21:46-56. [PMID: 37798441 DOI: 10.1038/s41575-023-00846-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/07/2023]
Abstract
Recompensation has gained increasing attention in the field of cirrhosis, particularly in chronic liver disease with a definite aetiology. The current global prevalence of obesity and nonalcoholic fatty liver disease (NAFLD) is increasing, but there is currently a lack of a clear definition for recompensation in NAFLD-related cirrhosis. Here, we provide an up-to-date perspective on the natural history of NAFLD, emphasizing the reversible nature of the disease, summarizing possible mechanisms underlying recompensation in NAFLD, discussing challenges that need to be addressed and outlining future research directions in the field. Recompensation is a promising goal in patients with NAFLD-related cirrhosis, and further studies are needed to explore its underlying mechanisms and uncover its clinical features.
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Affiliation(s)
- Gong Feng
- Xi'an Medical University, Xi'an, China
- The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Precision Medicine, Biological Resource Center and Department of Transfusion Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yasser Mahrous Fouad
- Department of Endemic Medicine and Gastroenterology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Yusuf Yilmaz
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Won Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Zobair M Younossi
- Inova Medicine Services, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic Barcelona,-IDIBAPS, University of Barcelona, Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
- Key Laboratory of Diagnosis and Treatment for The Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China.
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7
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Arvanitakis K, Koufakis T, Kalopitas G, Papadakos SP, Kotsa K, Germanidis G. Management of type 2 diabetes in patients with compensated liver cirrhosis: Short of evidence, plenty of potential. Diabetes Metab Syndr 2024; 18:102935. [PMID: 38163417 DOI: 10.1016/j.dsx.2023.102935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 12/16/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND AIMS Treatment of type 2 diabetes (T2D) in patients with compensated cirrhosis is challenging due to hypoglycemic risk, altered pharmacokinetics, and the lack of robust evidence on the risk/benefit ratio of various drugs. Suboptimal glycemic control accelerates the progression of cirrhosis, while the frequent coexistence of nonalcoholic fatty liver disease (NAFLD) with T2D highlights the need for a multifactorial therapeutic approach. METHODS A literature search was performed in Medline, Google Scholar and Scopus databases till July 2023, using relevant keywords to extract studies regarding the management of T2D in patients with compensated cirrhosis. RESULTS Metformin, sodium-glucose co-transporter-2 inhibitors (SGLT2i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA) are promising treatment options for patients with T2D and compensated liver cirrhosis, offering good glycemic control with minimal risk of hypoglycemia, while their pleiotropic actions confer benefits on NAFLD and body weight, and decrease cardiorenal risk. Sulfonylureas cause hypoglycemia, thus should be avoided, while in specific studies, dipeptidyl peptidase-4 inhibitors have been correlated with increased risk of decompensation and variceal bleeding. Despite the benefits of thiazolidinediones in nonalcoholic steatohepatitis, concerns about edema and weight gain limit their use in compensated cirrhosis. Insulin does not exert hepatotoxic effects and can be administered safely in combination with other drugs; however, the risk of hypoglycemia should be considered. CONCLUSIONS The introduction of new hepatoprotective diabetes drugs into clinical practice, including tirzepatide, SGLT2i, and GLP-1 RA, sets the stage for future trials to investigate the ideal therapeutic regimen for people with T2D and compensated cirrhosis.
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Affiliation(s)
- Konstantinos Arvanitakis
- Division of Gastroenterology and Hepatology, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece; Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece
| | - Theocharis Koufakis
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, 54642, Thessaloniki, Greece
| | - Georgios Kalopitas
- Division of Gastroenterology and Hepatology, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece; Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece
| | - Stavros P Papadakos
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Georgios Germanidis
- Division of Gastroenterology and Hepatology, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece; Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece.
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8
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Tilg H, Zoller H. Pleiotropic prebiotic for liver disease. Nat Microbiol 2023; 8:1944-1945. [PMID: 37845317 DOI: 10.1038/s41564-023-01510-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Affiliation(s)
- Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medical University Innsbruck, Innsbruck, Austria.
| | - Heinz Zoller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medical University Innsbruck, Innsbruck, Austria
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9
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Chouik Y, Lebossé F, Plissonnier ML, Lega JC, Pradat P, Antonini T, Subic M, Hartig-Lavie K, Erard D, Villeret F, Guichon C, Payancé A, Radenne S, Rautou PE, Zoulim F, Levrero M. Circulating microRNAs improve bacterial infection diagnosis and overall survival prediction in acute decompensation of liver cirrhosis. iScience 2023; 26:107427. [PMID: 37575179 PMCID: PMC10415934 DOI: 10.1016/j.isci.2023.107427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/23/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
Bacterial infections are the most frequent precipitating event in patients with acute decompensation of cirrhosis (AD) and are associated with high mortality. Early diagnosis is challenging due to cirrhosis-related systemic inflammation. Here we investigated the potential of circulating microRNAs to diagnose bacterial infections and predict survival in cirrhotic patients with AD. High throughput profiling of circulating microRNAs was performed using the Nanostring technology in 57 AD patients and 24 patients with compensated cirrhosis (CC). Circulating miRs profiling showed that: (a) miRs differentially detected in AD vs. CC were mostly down-regulated; (b) a composite score including absolute neutrophil count, C reactive protein and miR-362-3p could diagnose bacterial infection with an excellent performance (AUC of 0.825 [95% CI = 0.671-0.980; p < 0.001]); (c) a composite score including miR-382-5p, miR-592 and MELD-Na improved 6-month survival prediction. Circulating miRs are strongly dysregulated in patients with AD and may help to improve bacterial infection diagnosis and survival prediction.
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Affiliation(s)
- Yasmina Chouik
- Cancer Research Center of Lyon (CRCL), INSERM U1052, CNRS UMR5286, Lyon, France
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- University of Lyon Claude Bernard 1 (UCLB1), Lyon, France
| | - Fanny Lebossé
- Cancer Research Center of Lyon (CRCL), INSERM U1052, CNRS UMR5286, Lyon, France
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- University of Lyon Claude Bernard 1 (UCLB1), Lyon, France
| | | | - Jean-Christophe Lega
- Department of Internal Medicine, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Pierre Pradat
- Clinical Research Center, GHN, Hospices Civils de Lyon, Lyon, France
| | - Teresa Antonini
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | | | - Kerstin Hartig-Lavie
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Domitille Erard
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - François Villeret
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- University of Lyon Claude Bernard 1 (UCLB1), Lyon, France
| | - Céline Guichon
- Department of Anesthesiology and Intensive Care, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Audrey Payancé
- Université Paris-Cité, Inserm, Centre de recherche sur l’inflammation, UMR 1149, Paris, France
| | - Sylvie Radenne
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l’inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Fabien Zoulim
- Cancer Research Center of Lyon (CRCL), INSERM U1052, CNRS UMR5286, Lyon, France
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- University of Lyon Claude Bernard 1 (UCLB1), Lyon, France
| | - Massimo Levrero
- Cancer Research Center of Lyon (CRCL), INSERM U1052, CNRS UMR5286, Lyon, France
- Department of Hepatology, Hôpital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- University of Lyon Claude Bernard 1 (UCLB1), Lyon, France
- Department of Medicine SCIAC and the Italian Institute of Technology (IIT) Center for Life Nanosciences (CLNS), University of Rome La Sapienza, Rome, Italy
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10
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Abraldes JG, Caraceni P, Ghabril M, Garcia-Tsao G. Update in the Treatment of the Complications of Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:2100-2109. [PMID: 36972759 PMCID: PMC11097249 DOI: 10.1016/j.cgh.2023.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/17/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
Abstract
Cirrhosis consists of 2 main stages: compensated and decompensated, the latter defined by the development/presence of ascites, variceal hemorrhage, and hepatic encephalopathy. The survival rate is entirely different, depending on the stage. Treatment with nonselective β-blockers prevents decompensation in patients with clinically significant portal hypertension, changing the previous paradigm based on the presence of varices. In patients with acute variceal hemorrhage at high risk of failure with standard treatment (defined as those with a Child-Pugh score of 10-13 or those with a Child-Pugh score of 8-9 with active bleeding at endoscopy), a pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) improves the mortality rate and has become the standard of care in many centers. In patients with bleeding from gastrofundal varices, retrograde transvenous obliteration (in those with a gastrorenal shunt) and/or variceal cyanoacrylate injection have emerged as alternatives to TIPS. In patients with ascites, emerging evidence suggests that TIPS might be used earlier, before strict criteria for refractory ascites are met. Long-term albumin use is under assessment for improving the prognosis of patients with uncomplicated ascites and confirmatory studies are ongoing. Hepatorenal syndrome is the least common cause of acute kidney injury in cirrhosis, and first-line treatment is the combination of terlipressin and albumin. Hepatic encephalopathy has a profound impact on the quality of life of patients with cirrhosis. Lactulose and rifaximin are first- and second-line treatments for hepatic encephalopathy, respectively. Newer therapies such as L-ornithine L-aspartate and albumin require further assessment.
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Affiliation(s)
- Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Paolo Caraceni
- Istituto di Ricerca e Cura a Carattere Scientifico Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Veterans Administration - Connecticut Healthcare System, West Haven, Connecticut.
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11
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Peng B, Li H, Liu K, Zhang P, Zhuang Q, Li J, Yang M, Cheng K, Ming Y. Intrahepatic macrophage reprogramming associated with lipid metabolism in hepatitis B virus-related acute-on-chronic liver failure. J Transl Med 2023; 21:419. [PMID: 37380987 DOI: 10.1186/s12967-023-04294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe syndrome with high short-term mortality, but the pathophysiology still remains largely unknown. Immune dysregulation and metabolic disorders contribute to the progression of ACLF, but the crosstalk between immunity and metabolism during ACLF is less understood. This study aims to depict the immune microenvironment in the liver during ACLF, and explore the role of lipid metabolic disorder on immunity. METHODS Single-cell RNA-sequencing (scRNA-seq) was performed using the liver non-parenchymal cells (NPCs) and peripheral blood mononuclear cells (PBMCs) from healthy controls, cirrhosis patients and ACLF patients. A series of inflammation-related cytokines and chemokines were detected using liver and plasma samples. The lipid metabolomics targeted free fatty acids (FFAs) in the liver was also detected. RESULTS The scRNA-seq analysis of liver NPCs showed a significant increase of monocytes/macrophages (Mono/Mac) infiltration in ACLF livers, whereas the resident Kupffer cells (KCs) were exhausted. A characterized TREM2+ Mono/Mac subpopulation was identified in ACLF, and showed immunosuppressive function. Combined with the scRNA-seq data from PBMCs, the pseudotime analysis revealed that the TREM2+ Mono/Mac were differentiated from the peripheral monocytes and correlated with lipid metabolism-related genes including APOE, APOC1, FABP5 and TREM2. The targeted lipid metabolomics proved the accumulation of unsaturated FFAs associated with α-linolenic acid (α-LA) and α-LA metabolism and beta oxidation of very long chain fatty acids in the ACLF livers, indicating that unsaturated FFAs might promote the differentiation of TREM2+ Mono/Mac during ACLF. CONCLUSIONS The reprogramming of macrophages was found in the liver during ACLF. The immunosuppressive TREM2+ macrophages were enriched in the ACLF liver and contributed to the immunosuppressive hepatic microenvironment. The accumulation of unsaturated FFAs in the ACLF liver promoted the reprogramming of the macrophages. It might be a potential target to improve the immune deficiency of ACLF patients through regulating lipid metabolism.
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Affiliation(s)
- Bo Peng
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China
| | - Hao Li
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China
| | - Kai Liu
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China
| | - Pengpeng Zhang
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China
| | - Quan Zhuang
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China
| | - Junhui Li
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China
| | - Min Yang
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China
| | - Ke Cheng
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China
| | - Yingzi Ming
- Transplantation Center, The Third Xiangya Hospital, Central South University, Hunan, 410013, Changsha, China.
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, Changsha, China.
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12
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Lantinga MA, van Kleef LA, den Hoed CM, De Knegt RJ. Spleen Stiffness Measurement Across the Spectrum of Liver Disease Patients in Real-World Practice. J Clin Exp Hepatol 2023; 13:414-427. [PMID: 37250876 PMCID: PMC10213849 DOI: 10.1016/j.jceh.2022.12.015] [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: 10/26/2022] [Accepted: 12/24/2022] [Indexed: 05/31/2023] Open
Abstract
Objectives Spleen stiffness measurement (SSM) provides a non-invasive surrogate marker for clinical significant portal hypertension (CSPH). Results obtained in highly selected populations were promising but require validation across the spectrum of liver disease. We aimed to investigate the clinical applicability of SSM in a real-world setting. Methods We prospectively enrolled patients referred for liver ultrasound (January-May 2021). Patients with a portosystemic shunt, liver transplant, or extrahepatic etiology of portal hypertension were excluded. We performed liver ultrasound, liver stiffness measurement (LSM) and SSM (dedicated software, 100 Hz-probe). Probable CSPH was established if ≥1 of the following items occurred: ascites, varices, encephalopathy, splenomegaly, recanalized umbilical vein, collaterals, dilated portal veins, hypertensive gastropathy, or LSM ≥25 kPa. Results We enrolled 185 patients (53% male; age 53years [37-64], 33% viral hepatitis, 21% fatty liver disease). Of them, 31% of patients had cirrhosis (68% Child-Pugh A) and 38% of patients had signs of portal hypertension. SSM (23.8 kPa [16.2-42.3]) and LSM (6.7 kPa [4.6-12.0]) were successful and met reliability criteria in 70% and 95%, respectively. Spleen size was inversely associated with SSM failure (odds ratio: 0.66 increment/cm, 95% confidence interval: 0.52-0.82). Optimal spleen stiffness cut-off to detect probable CSPH was >26.5 kPa (likelihood ratio: 4.5, sensitivity: 83%; specificity: 82%). Spleen stiffness did not outperform liver stiffness in detecting probable CSPH (P = 1.0). Conclusions In real-world practice, reliable SSM were obtained in 70% and could potentially stratify patients between high- and low-risk of probable CSPH. However, cut-offs for CSPH might be substantially lower than previously reported. Future studies validating these results are required. Clinical trial number Netherlands Trial Register (Registration number: NL9369).
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Affiliation(s)
- Marten A. Lantinga
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
| | - Laurens A. van Kleef
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Caroline M. den Hoed
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Robert J. De Knegt
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
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13
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Simbrunner B, Hartl L, Jachs M, Bauer DJ, Scheiner B, Hofer BS, Stättermayer AF, Marculescu R, Trauner M, Mandorfer M, Reiberger T. Dysregulated biomarkers of innate and adaptive immunity predict infections and disease progression in cirrhosis. JHEP Rep 2023; 5:100712. [PMID: 37035457 PMCID: PMC10074195 DOI: 10.1016/j.jhepr.2023.100712] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/15/2023] [Accepted: 02/09/2023] [Indexed: 04/11/2023] Open
Abstract
Background & Aims Cirrhosis-associated immune dysfunction (CAID) affects both innate and adaptive immunity. This study investigated the complement system, immunoglobulins, and acute-phase proteins and their prognostic relevance in patients with advanced chronic liver disease (ACLD). Methods Patients with ACLD (hepatic venous pressure gradient [HVPG] ≥6 mmHg) but without acute decompensation/infections were characterised by HVPG and by clinical EASL stages: compensated (cACLD; S0-2) vs. decompensated ACLD (dACLD) with previous variceal bleeding (S3), non-bleeding decompensation (S4), or further decompensation (S5). Complement factors (C3c, C4, CH50), immunoglobulins (IgA, IgM, IgG, IgG1-4), acute-phase proteins and systemic inflammation biomarkers (white blood cells, C-reactive protein, IL-6, procalcitonin) were measured. Results A total of 245 patients (median model for end-stage liver disease score: 11 [9-15], median HVPG: 17 [12-21] mmHg) were included with 150 (61%) presenting dACLD. Complement levels and activity significantly decreased in dACLD substages S4 and S5 (p <0.001). Total IgA/IgM/IgG and IgG1-4 subtype levels increased in patients with dACLD (all p <0.05). Complement and immunoglobulin levels correlated negatively and positively, respectively, with systemic inflammation (all p <0.05). High IgG-1 (adjusted hazard ratio per 100 mg/dl: 1.12, 1.04-1.19, p = 0.002) and IL-6 (adjusted hazard ratio: 1.03, 1.00-1.05, p = 0.023) levels predicted the development of infections during follow-up. High IgA (stratified by median; log-rank p <0.001), high IgG1 (log-rank p = 0.043) and low C3c (log-rank p = 0.003) indicated a higher risk of first/further decompensation or liver-related death (composite endpoint). Next to HVPG and IL-6, low C3c (adjusted hazard ratio per mg/dl: 0.99, 0.97-0.99, p = 0.040) remained independently associated with the composite endpoint on multivariate Cox regression analysis. Conclusions Complement levels and immunoglobulins may serve as surrogates of cirrhosis-associated immune dysfunction and associate with cirrhosis severity and systemic inflammation. Low complement C3c predicted decompensation and liver-related death, whereas high IgG-1 indicated an increased risk for infections. Impact and Implications Patients with cirrhosis are at increased risk for infections, which worsen their prognosis. We found a significant dysregulation of several essential components of the immune system that was linked to disease severity and indicated a risk for infections and other complications. Simple blood tests identify patients at particularly high risk, who may be candidates for preventive measures. Clinical Trials Registration This study is registered at ClinicalTrials.gov (NCT03267615).
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Affiliation(s)
- Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - David J.M. Bauer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rodrig Marculescu
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Corresponding author. Address: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria. Tel.: +43-1-40400-47440; Fax: +43-1-40400-47350
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14
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [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] [Indexed: 08/16/2023] Open
Abstract
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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Sharma S, Roy A. Recompensation in Cirrhosis: Current Evidence and Future Directions. J Clin Exp Hepatol 2023; 13:329-334. [PMID: 36950490 PMCID: PMC10025679 DOI: 10.1016/j.jceh.2022.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/07/2022] [Indexed: 02/17/2023] Open
Abstract
The natural history of cirrhosis has usually been conceptualized in the context of progression from compensated cirrhosis to subsequent stages of decompensation. While this unidirectional concept is the most common pathophysiological trajectory, there has been an emerging understanding of a subgroup of patients which undergo recompensation. While literature mostly based on transplant waitlist registries have indicated towards such a population who experience disease regression, the overall literature about this entity remains inexplicit. An effort to generate consensus on defining recompensation has been attempted which comes with its own nuances and limitations. We summarize the available literature on this emerging yet controversial concept of recompensation in cirrhosis and delve into future implications and impact on real-life practice.
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Key Words
- ALD, Alcoholic liver disease
- ALF, Acute liver failure
- APASL, Asia Pacific Association for the Study of Liver
- CAID, Cirrhosis associated immune dysfunction
- CSPH, Clinically significant portal hypertension
- CTP, Child-Turcotte-Pugh
- DC, Decompensated cirrhosis
- FAP, Familial amyloid polyneuropathy
- HBV, Hepatitis B Virus
- HCC, Hepatocellular carcinoma
- HCV, Hepatitis C Virus
- HE, Hepatic encephalopathy
- HVPG, Hepatic venous portal gradient
- INR, International normalized ratio
- LT, Liver transplantation
- MELD, Model for end-stage liver disease
- TIPSS, Transjugular intrahepatic porto-systemic shunt
- cACLD, Compensated advanced chronic liver disease
- liver disease
- portal hypertension
- recompensation
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Affiliation(s)
- Sanchit Sharma
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, OX39DU, United Kingdom
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, 700054, India
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Evaluation of CirrhoCare® - a digital health solution for home management of individuals with cirrhosis. J Hepatol 2023; 78:123-132. [PMID: 36087864 DOI: 10.1016/j.jhep.2022.08.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND & AIMS Individuals with cirrhosis discharged from hospital following acute decompensation are at high risk of new complications. This study aimed to assess the feasibility and potential clinical benefits of remote management of individuals with acutely decompensated cirrhosis using CirrhoCare®. METHODS Individuals with cirrhosis with acute decompensation were followed up with CirrhoCare® and compared with contemporaneous matched controls, managed with standard follow-up. Commercially available monitoring devices were linked to the smartphone CirrhoCare® app, for daily recording of heart rate, blood pressure, weight, % body water, cognitive function (CyberLiver Animal Recognition Test [CL-ART] app), self-reported well-being, and intake of food, fluid, and alcohol. The app had 2-way patient-physician communication. Independent external adjudicators assessed the appropriateness of CirrhoCare®-based decisions. RESULTS Twenty individuals with cirrhosis were recruited to CirrhoCare® (mean age 59 ± 10 years, 14 male, alcohol-related cirrhosis [80%], mean model for end-stage liver disease-sodium [MELD-Na] score 16.1 ± 4.2) and were not statistically different to 20 contemporaneous controls. Follow-up was 10.1 ± 2.4 weeks. Fifteen individuals showed good engagement (≥4 readings/week), 2 moderate (2-3/week), and 3 poor (<2/week). In a usability questionnaire, the median score was ≥9 for all questions. Five CirrhoCare®-managed individuals had 8 readmissions over a median of 5 (IQR 3.5-11) days, and none required hospitalisation for >14 days. Sixteen other CirrhoCare®-guided patient contacts were made, leading to clinical interventions that prevented further progression. Appropriateness was confirmed by adjudicators. Controls had 13 readmissions in 8 individuals, lasting a median of 7 (IQR 3-15) days with 4 admissions of >14 days. They had 6 unplanned paracenteses compared with 1 in the CirrhoCare® group. CONCLUSIONS This study demonstrates that CirrhoCare® is feasible for community management of individuals with decompensated cirrhosis with good engagement and clinically relevant alerts to new decompensating events. CirrhoCare®-managed individuals have fewer and shorter readmissions justifying larger controlled clinical trials. IMPACT AND IMPLICATIONS As the burden of cirrhosis grows worldwide, increasing demands are being placed on limited healthcare resources, necessitating the adoption of more sustainable care models that allow for at-home patient management. The CirrhoCare® management system was developed to fill this care gap, deploying a novel combination of hardware, apps, and algorithms, to monitor and intervene in individuals at risk of new decompensation. This study highlights the possibility of reducing hospital readmissions for cirrhosis by optimising specialist community care, reducing the need for interventions such as paracentesis, while providing a more sustainable care pathway that is acceptable to patients. However, given the pilot and non-randomised nature of this study, the outcomes require further validation in a larger randomised controlled trial, to assess both clinical effectiveness and cost-effectiveness. Moreover, the data generated will also facilitate data modelling and further research to refine the CirrhoCare® algorithms to increase their detection sensitivity and utility.
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Bacterial Infections Confer a Risk of Progression to Acute-on-Chronic Liver Failure in Patients with HBV-Related Compensated Cirrhosis During Severe Hepatitis Flares. Infect Dis Ther 2022; 11:1839-1851. [PMID: 36151452 DOI: 10.1007/s40121-022-00695-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/06/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The aims of this study were to investigate the risk factors for bacterial infections (BIs) and the association of BIs with the progression to acute-on-chronic liver failure (ACLF) in patients with hepatitis B virus (HBV)-related compensated liver cirrhosis and severe hepatitis flares. METHODS A total of 237 patients were retrospectively reviewed. Baseline biochemical characteristics were compared between patients with and without the occurrence of BIs and progression to ACLF. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for ACLF before and after 1:1 propensity score matching. RESULTS Forty-eight (20.3%) patients progressed to ACLF after admission. Additionally, 136 (57.4%) patients progressed to hepatic decompensation (HD) and 52 (21.9%) patients had BIs before the development of ACLF. Patients with BIs had significantly higher incidences of HD (84.6%) and ACLF (46.2%) than those without BIs (49.7% and 13.0%, respectively; P < 0.01). CTP score (OR 1.660, 95% CI 1.267-2.175) and MELD-Na score (OR 1.082, 95% CI 1.010-1.160) were independent risk factors for BIs. BIs (OR 4.037, 95% CI 1.808-9.061), CLIF-SOFA score (OR 2.007, 95% CI 1.497-2.691), and the MELD-Na score (OR 1.167, 95% CI 1.073-1.260) were independent risk factors for the progression to ACLF. BIs (OR 4.730, 95% CI 1.520-14.718) were also an independent risk factor for the progression to ACLF after propensity score matching. CONCLUSION High CTP and MELD-Na scores are risk factors for BIs, and BIs are risk factors for the progression to ACLF in patients with HBV-related compensated liver cirrhosis and severe hepatitis flares.
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The Role of Presepsin and Procalcitonin in Early Diagnosis of Bacterial Infections in Cirrhotic Patients with Acute-on-Chronic Liver Failure. J Clin Med 2022; 11:jcm11185410. [PMID: 36143057 PMCID: PMC9501308 DOI: 10.3390/jcm11185410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/04/2022] [Accepted: 09/12/2022] [Indexed: 11/27/2022] Open
Abstract
Background and Objectives: Bacterial infections represent one of the most frequent precipitating events of acute-on-chronic liver failure (ACLF) in a patient with liver cirrhosis (LC). Early diagnosis and treatment could influence the ACLF reversal rate and decrease the mortality rate in these patients. The study aimed to evaluate the role of presepsin, C-reactive protein (CRP), and procalcitonin (PCT) in the early diagnosis of bacterial infections in patients with LC and ACLF, defined according to the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. Material and Methods: We performed a prospective observational study including all consecutive cirrhotic patients with ACLF admitted to our tertiary university center. The patients were follow-up until discharge. All patients were screened for infection at admission, and we included patients with community-acquired or healthcare-associated bacterial infections. Results: In this study, we included 153 patients with a median age of 60 years, of whom 65.4% were male. Infections were diagnosed in 71 patients (46.4%). The presepsin, CRP, and PCT levels were higher in patients with infections than in those without infections (p < 0.001, p = 0.023, and p < 0.001, respectively). The ROC analysis results demonstrated that the best cut-offs values for infections diagnosis were for presepsin 2300 pg/mL (sensitivity of 81.7%, specificity of 92.7%, AUROC 0.959, p < 0.001), CRP 5.3 mg/dL (sensitivity of 54.9%, specificity of 69.6%, AUROC 0.648, p = 0.023), and PCT 0.9 ng/mL (sensitivity of 80.3%, specificity of 86.6%, AUROC 0.909, p < 0.001). Presepsin (OR 3.65, 95%CI 1.394−9.588, p = 0.008), PCT (OR 9.79, 95%CI 6.168−25.736, p < 0.001), and MELD score (OR 7.37, 95%CI 1.416−18.430, p = 0.018) were associated with bacterial infections in patients with ACLF. Conclusion: Presepsin level ≥2300 pg/mL and PCT level ≥0.9 ng/mL may be adequate non-invasive tools for the early diagnosis of infections in cirrhotics with ACLF.
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Characteristics of bacterial infections and prevalence of multidrug-resistant bacteria in hospitalized patients with liver cirrhosis in Germany. Ann Hepatol 2022; 27:100719. [PMID: 35460883 DOI: 10.1016/j.aohep.2022.100719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Bacterial infections are associated with a dismal prognosis in patients with liver cirrhosis. Data on their prevalence and the associated pathogen spectra in Germany are scarce. This study aimed to evaluate the impact of bacterial infections on mortality in hospitalized patients with liver cirrhosis and to analyze the prevalence of multidrug-resistant (MDR) bacteria in a German tertiary care center. PATIENTS AND METHODS Consecutive, non-electively hospitalized patients with liver cirrhosis were enrolled in this study between 03/2019-06/2021. All patients underwent clinical, laboratory and microbiological testing to detect potential bacterial infections. Patients were followed for 30 days regarding the composite endpoint of death or liver transplantation (mortality). RESULTS In total, 239 patients were recruited (median MELD 18). Bacterial infection was detected in 81 patients (33.9%) at study inclusion. A total of 70 patients (29.3%) developed a hospital-acquired infection. When comparing community-acquired and hospital-acquired infections, the pathogen pattern shifted from a gram-negative to a more gram-positive spectrum and showed an increase of Staphylococcus spp.. MDR bacteria were detected in seven infected patients (5.8%). 34 patients reached the composite endpoint during 30-days follow-up. In multivariable logistic regression analysis, the presence of infection during hospitalization remained independently associated with higher mortality (OR 2.522, 95% CI 1.044 - 6.091, p = 0.040). CONCLUSIONS This study demonstrates that bacterial infections are common in hospitalized patients with liver cirrhosis in Germany and are a major determinant of short-term mortality. Our data highlight the importance of regional differences in MDR bacteria and may guide physicians' decision-making regarding calculated antibiotic treatment.
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de Mattos ÂZ, Simonetto DA, Terra C, Farias AQ, Bittencourt PL, Pase THS, Toazza MR, de Mattos AA. Albumin administration in patients with cirrhosis: Current role and novel perspectives. World J Gastroenterol 2022; 28:4773-4786. [PMID: 36156923 PMCID: PMC9476855 DOI: 10.3748/wjg.v28.i33.4773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/05/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
Mortality in cirrhosis is mostly associated with the development of clinical decompensation, characterized by ascites, hepatic encephalopathy, variceal bleeding, or jaundice. Therefore, it is important to prevent and manage such complications. Traditionally, the pathophysiology of decompensated cirrhosis was explained by the peripheral arterial vasodilation hypothesis, but it is currently understood that decompensation might also be driven by a systemic inflammatory state (the systemic inflammation hypothesis). Considering its oncotic and nononcotic properties, albumin has been thoroughly evaluated in the prevention and management of several of these decompensating events. There are formal evidence-based recommendations from international medical societies proposing that albumin be administered in individuals with cirrhosis undergoing large-volume paracentesis, patients with spontaneous bacterial peritonitis, those with acute kidney injury (even before the etiological diagnosis), and those with hepatorenal syndrome. Moreover, there are a few randomized controlled trials and meta-analyses suggesting a possible role for albumin infusion in patients with cirrhosis and ascites (long-term albumin administration), individuals with hepatic encephalopathy, and those with acute-on-chronic liver failure undergoing modest-volume paracentesis. Further studies are necessary to elucidate whether albumin administration also benefits patients with cirrhosis and other complications, such as individuals with extraperitoneal infections, those hospitalized with decompensated cirrhosis and hypoalbuminemia, and patients with hyponatremia.
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Affiliation(s)
- Ângelo Zambam de Mattos
- Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Douglas Alano Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55902, United States
| | - Carlos Terra
- Department of Gastroenterology, State University of Rio de Janeiro, Rio de Janeiro 20550-170, Brazil
| | | | | | - Tales Henrique Soares Pase
- Internal Medicine Unit, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
| | - Marlon Rubini Toazza
- Gastroenterology and Hepatology Unit, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
| | - Angelo Alves de Mattos
- Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
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Igna R, Gîrleanu I, Cojocariu C, Muzîca C, Huiban L, Sfarti C, Cuciureanu T, Chiriac S, Sîngeap AM, Petrea OC, Stafie R, Zenovia S, Năstasă R, Stratina E, Rotaru A, Stanciu C, Trifan A, Blaj M. The Role of Presepsin in Diagnosing Infections in Patients with Liver Cirrhosis and Overt Hepatic Encephalopathy. Diagnostics (Basel) 2022; 12:diagnostics12092077. [PMID: 36140479 PMCID: PMC9497501 DOI: 10.3390/diagnostics12092077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/16/2022] [Accepted: 08/24/2022] [Indexed: 11/19/2022] Open
Abstract
Infections and sepsis represent severe liver cirrhosis (LC) complications and the precipitating factors of hepatic encephalopathy (HE). The early diagnosis and treatment of infections in patients with LC and HE can significantly increase their survival. Presepsin is a serum biomarker evaluated for the early diagnosis of infections and sepsis in the general and cirrhotic populations. This study aimed to evaluate the role of presepsin in the early diagnosis of infections in patients with LC and HE. This prospective observational study included all consecutive cirrhotic patients admitted to our tertiary university center with overt HE. The patients were follow-up until discharge. In this study, we included 365 patients with a median age of 59 years, of whom 61.9% were male. Infections were diagnosed in 134 patients (36.7%). The presepsin level was higher in patients with infections than those without infections (3167 vs. 500, p < 0.001). The ROC analysis results demonstrated that the best cut-off value for presepsin in infections detection was 980 pg/mL with a sensitivity of 80.17%, specificity of 82.5% (AUROC 0.869, CI 95%: 0.819−0.909, p < 0.001, Youden index J of 0.622), a positive predictive value of 40.63%, and a negative predictive value of 96.53%. In conclusion, in patients with LC and overt HE, presepsin levels >980 pg/mL could enhance the suspicion of bacterial infections. Presepsin may be an adequate non-invasive tool for the early diagnosis of infections in patients with LC and overt HE.
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Affiliation(s)
- Razvan Igna
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Intensive Care Unit, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Irina Gîrleanu
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
- Correspondence: (I.G.); (C.C.)
| | - Camelia Cojocariu
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
- Correspondence: (I.G.); (C.C.)
| | - Cristina Muzîca
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Laura Huiban
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Catalin Sfarti
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Tudor Cuciureanu
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Stefan Chiriac
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Ana-Maria Sîngeap
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Oana Cristina Petrea
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Remus Stafie
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Sebastian Zenovia
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Robert Năstasă
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Ermina Stratina
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Adrian Rotaru
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Carol Stanciu
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700115 Iasi, Romania
| | - Mihaela Blaj
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700111 Iasi, Romania
- Intensive Care Unit, “St. Spiridon” University Hospital, 700115 Iasi, Romania
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Bañares J, Manzano-Nuñez R, Prió A, Rivera-Esteban J, Camps-Relats L, Villarejo A, Ruiz-Ortega L, Pons M, Ciudin A, Salcedo MT, Vargas V, Genescà J, Pericàs JM. Risk of infections in patients with NAFLD and Type 2 Diabetes under treatment with SGLT2 inhibitors and relationship with liver outcomes: A retrospective case-control study. Front Endocrinol (Lausanne) 2022; 13:945626. [PMID: 36093073 PMCID: PMC9449723 DOI: 10.3389/fendo.2022.945626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in developed countries, with its incidence growing parallel to the epidemics of obesity and type 2 diabetes mellitus (T2DM). Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are becoming a cornerstone in the management of cardiovascular health and some studies suggest the potential role in NAFLD. However, patients under treatment with SGLT2i are at risk of developing genitourinary fungal infections (GFIs). Moreover, both NAFLD and SGLT2i have a strong influence on the immune system, and therefore the risk of infections other than GFIs could be increased in NAFLD patients treated with SGLT2i. We aimed to examine the possible association of SGLT2i with infections and hepatic outcomes in NAFLD patients. Methods We conducted a case-control study including NAFLD patients with T2DM visited at the Liver Unit outpatient clinic from 2016 to 2021 with a minimum follow-up of 6 months by selecting 65 patients receiving SGLT2i and 130 matched patients with other types of antidiabetic treatment. Results During follow-up, GFIs were significantly higher in the SGLT2i group (15.4% vs. 3.8%; p=0.008), whereas there were no differences in the occurrence of overall infections (41.5% vs. 30%; p=0.1) nor in other types of specific infections. In the multivariable analysis, treatment with SGLT2i was not independently associated with higher odds of overall infection. On the other hand, SGLT2i patients showed a significantly lower incidence of hepatic events (1.5% vs. 10.7%; p=0.02). There were no significant different in all-cause mortality between cases and controls. Conclusions NAFLD patients with T2DM receiving SGLT2i more frequently presented GFIs, whereas the incidence of other types of infections was not found to be higher than in other patients with NAFLD and T2DM treated with other drugs. Moreover, SGLT2i-treated patients had a lower occurrence of hepatic events. Further studies are warranted to validate our data.
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Affiliation(s)
- Juan Bañares
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Ramiro Manzano-Nuñez
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Alba Prió
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Jesús Rivera-Esteban
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Camps-Relats
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Ana Villarejo
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Lourdes Ruiz-Ortega
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Mònica Pons
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Instituto de Salud Carlos III, Madrid, Spain
| | - Andreea Ciudin
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDem), Instituto de Salud Carlos III, Madrid, Spain
| | - María Teresa Salcedo
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
- Pathology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Víctor Vargas
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Instituto de Salud Carlos III, Madrid, Spain
| | - Joan Genescà
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan M. Pericàs
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Instituto de Salud Carlos III, Madrid, Spain
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Xu X, Yu X, Gong K, Tu H, Yao J, Lan Y, Ye S, Weng H, Shi Y, Sheng J. Acute decompensation events differentially impact the risk of nosocomial infections and short-term outcomes in patients with cirrhosis. Front Med (Lausanne) 2022; 9:962541. [PMID: 36059822 PMCID: PMC9428487 DOI: 10.3389/fmed.2022.962541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/01/2022] [Indexed: 11/23/2022] Open
Abstract
Aims This research aimed to evaluate the influence of acute decompensation (AD) events upon admission on the subsequent risk of nosocomial infections (NIs) and the synergy between AD and the following NIs on the short-term outcome. Methods A total of 419 hospitalized individuals with cirrhosis and AD participated in the current study. Various AD events at admission and outcomes in patients with or without NIs were compared. The logistic regression and Cox proportional hazards models were designed for NIs development and liver transplant (LT)-free mortality at 28 and 90 days, respectively. Results During hospitalization, 91 patients developed NIs. Notably, a higher proportion of patients with NIs had jaundice (52.7 vs. 30.5%; p < 0.001) and bacterial infections (37.4 vs. 20.7%; p = 0.001) at admission compared to patients without NIs, while a lower proportion suffered gastrointestinal hemorrhage (16.5 vs. 36.6%; p < 0.001). Multivariate analysis revealed that jaundice was independently linked with the development of NIs (OR, 2.732; 95% CI: 1.104–6.762). The 28-day (16.5 vs. 7.3%; p = 0.008) and 90-day (27.5 vs. 15.9%; p = 0.011) LT-free mortality rates of patients with NIs were significantly higher than those without NIs. According to the Cox proportional hazards model, jaundice remained an independent risk factor for 90-day death (HR, 5.775; 95% CI: 1.217–27.397). The connection between total bilirubin and 90-day mortality was nonlinear, and a 6 mg/mL threshold was proposed. Conclusion The types of AD events differentially predispose to risk of NIs. Presenting jaundice at admission is independently associated with NIs occurrence and increased 90-day mortality of patients with NIs. Antibiotic prophylaxis may benefit this specific subset of patients.
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Caraceni P, O'Brien A, Gines P. Long-term albumin treatment in patients with cirrhosis and ascites. J Hepatol 2022; 76:1306-1317. [PMID: 35589252 DOI: 10.1016/j.jhep.2022.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 01/29/2023]
Abstract
Although proposed for the first time several decades ago, the possibility that long-term human albumin could be effective for the treatment of patients with cirrhosis and ascites has become a topic of scientific and clinical discussion in the last decade. Long-term albumin administration represents a completely different treatment perspective compared to acute or short-term uses of albumin. Results from the ANSWER and the MACHT studies indicate that long-term albumin treatment can be effective, safe and able to modify the course of the disease provided that albumin is given at a sufficient dose and for a sufficient time to restore physiological levels and functions of the circulating molecule, which are compromised, at least partially, in patients with decompensated cirrhosis. Further clinical studies and randomised trials are warranted to confirm the clinical benefits of long-term albumin therapy. Important areas for further research include determining the precise target population, the biomarkers of response, the optimal dose and frequency of albumin infusions, the stopping rules, and the cost-effectiveness of treatment in different healthcare systems across the world, particularly in those where the logistical issues and costs related to the periodic intravenous infusions may represent an important limitation to the implementation of this innovative approach in clinical practice. In this review, we will critically analyse the available data on long-term albumin treatment, focusing on the differences that exist between studies, the controversial issues and the future perspectives.
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Affiliation(s)
- Paolo Caraceni
- IRCCS Azienda Ospedaliera-Universitaria di Bologna, Italy; Department of Medical and Surgical Sciences and Center for Biomedical Applied Research, Alma Mater Studiorum University of Bologna, Italy.
| | - Alastair O'Brien
- UCL Institute for Liver and Digestive Health, Upper 3rd Floor, Division of Medicine, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Pere Gines
- Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBEReHD, Barcelona, Catalonia, Spain
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Inhibition of Galectin-3 Impairs Antifungal Immune Response in Fungal Keratitis. DISEASE MARKERS 2022; 2022:8316004. [PMID: 35437453 PMCID: PMC9013289 DOI: 10.1155/2022/8316004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/07/2022] [Indexed: 11/17/2022]
Abstract
Galectin-3 is one of the galectin family members which are master regulators of immune homeostasis, especially in infectious diseases. However, its mechanism of immune regulation in fungal keratitis has not been thoroughly studied. Our study is aimed at clarifying the role of galectin-3 in the fungal keratitis mouse model in vivo, thereby providing a new biomarker of antifungal therapy. In our study, aspergillus, the most common pathogenic fungi of fungal keratitis, was identified and isolated by corneal tissue fungus culture. Then, the RNA expression levels of galectin family members in corneas of the mouse model with aspergillus fumigatus keratitis were screened by transcriptome sequencing (RNA-seq). The expression of the galectin-3 was detected by quantitative real-time Polymerase Chain Reaction (qPCR), enzyme-linked immunosorbent assay (ELISA), and immunofluorescence in the corneal tissue of the fungal keratitis mouse model. Recruitment of neutrophils and the co-immunofluorescence of galectin-3 and related markers in corneal tissue were determined by flow cytometry analysis and immunofluorescence staining. The regulatory role of galectin-3 for proinflammatory cytokines and neutrophils was validated by the knockout mouse model. Galectin-3 knockout deteriorated the condition for the inhibition of galectin-3 was benefecial for fungi to survive and thrive in corneal lesions. These results demonstrated that in the ocular fungal infection, galectin-3 is capable of regulating the pathogenesis of fungal keratitis by modulating neutrophil recruitment. The deterioration of fungal keratitis and increased fungal load in corneal lesions of galectin-3 knockout mice proved the regulatory role of galectin-3 in fungal keratitis. In conclusion, galectin-3 is going to be an essential target to modulate neutrophil recruitment and its related antifungal immune response in fungal keratitis.
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Onorato L, Monari C, Capuano S, Grimaldi P, Coppola N. Prevalence and Therapeutic Management of Infections by Multi-Drug-Resistant Organisms (MDROs) in Patients with Liver Cirrhosis: A Narrative Review. Antibiotics (Basel) 2022; 11:232. [PMID: 35203834 PMCID: PMC8868525 DOI: 10.3390/antibiotics11020232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/11/2022] Open
Abstract
Bacterial infections are common events that significantly impact the clinical course of patients with cirrhosis. As in the general population, infections caused by multi-drug-resistant organisms (MDROs) are progressively increasing in cirrhotic patients, accounting for up to 30-35% of all infections. Nosocomial acquisition and prior exposure to antimicrobial treatment or invasive procedures are well-known risk factors for MDRO infections. Several studies have demonstrated that infections due to MDROs have a poorer prognosis and higher rates of treatment failure, septic shock, and hospital mortality. Due to the increasing rate of antimicrobial resistance, the approach to empirical treatment in cirrhotic patients with life-threatening infections has become significantly more challenging. In order to ensure a prompt administration of effective antibiotic therapy while avoiding unnecessary antibiotic exposure at the same time, it is of utmost importance to choose the correct antimicrobial therapy and administration schedule based on individual clinical characteristics and risk factors and rapidly adopt de-escalation strategies as soon as microbiological data are available. In the present paper, we aimed to provide an overview of the most frequent infections diagnosed in cirrhotic patients, the prevalence and impact of antimicrobial resistance, and potential therapeutic options in this population.
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Affiliation(s)
| | | | | | | | - Nicola Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (L.O.); (C.M.); (S.C.); (P.G.)
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27
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Hagström H, Thiele M, Simon TG, Sharma R, Röckert Tjernberg A, Roelstraete B, Söderling J, Ludvigsson JF. Risk of infections and their role on subsequent mortality in biopsy-proven alcohol-related liver disease. United European Gastroenterol J 2022; 10:198-211. [PMID: 35088575 PMCID: PMC8911538 DOI: 10.1002/ueg2.12200] [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: 10/23/2021] [Accepted: 01/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Aims The risk for infection in alcohol‐related liver disease (ALD) has rarely been investigated at a population level, nor if the underlying liver histopathology is associated with infection risk. We examined the rate of hospital‐based infections in a nationwide cohort of biopsy‐proven ALD, and the subsequent risk of death. Methods Population‐based cohort study in Sweden comparing 4028 individuals with an international classification of disease (ICD) code for ALD and a liver biopsy from 1969 to 2017 with 19,296 matched general population individuals. Swedish national registers were used to ascertain incident infections in secondary or tertiary care and subsequent mortality until 2019. We used Cox regression, adjusted for sex, age, education, country of birth, diabetes, and number of hospitalizations in the year preceding liver biopsy date, to estimate hazard ratios (HRs) in ALD and histopathological subgroups compared to reference individuals. Results Median age at ALD diagnosis was 59 years, 65% were men and 59% had cirrhosis at baseline. Infections were more common in patients with ALD (84 cases/1000 person‐years [PY]) compared to reference individuals (29/1000 PYs; adjusted hazard ratio [aHR] 3.06, 95% CI = 2.85–3.29). This excess risk corresponded to one additional infection per 18 ALD patients each year. The rate of infections was particularly high in individuals with cirrhosis (aHR = 3.46) and in those with decompensation (aHR = 5.20). Restricting our data to those with an infection, ALD (aHR = 3.63, 95%CI = 3.36–3.93), and especially ALD cirrhosis (aHR = 4.31, 95%CI = 3.89–4.78) were linked to subsequent death. Conclusions Individuals with biopsy‐proven ALD have a three‐fold increased rate of infections compared with the general population. The risk of death after an infection is also considerably higher in individuals with ALD.
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Affiliation(s)
- Hannes Hagström
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital and University of Southern Denmark, Odense, Denmark.,Department for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tracey G Simon
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Clinical and Translational Epidemiology Unit (CTEU), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rajani Sharma
- Center for Liver Disease and Transplantation, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Söderling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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D'Amico G, Bernardi M, Angeli P. Towards a new definition of decompensated cirrhosis. J Hepatol 2022; 76:202-207. [PMID: 34157322 DOI: 10.1016/j.jhep.2021.06.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 12/13/2022]
Abstract
There is a universal agreement that the occurrence of clinical complications, such as ascites, hepatic encephalopathy, gastrointestinal bleeding, and jaundice mark the transition from the compensated to the decompensated stage of cirrhosis. Decompensation is associated with a substantial worsening of patient prognosis and is therefore considered the most important stratification variable for the risk of death. However, this classification is an oversimplification, as it does not discriminate between the prognostic subgroups that characterise the course of decompensation, which depends on the type and number of decompensating events. A deeper insight into the clinical course of decompensated cirrhosis is provided by observational studies characterising acute decompensation (AD), which occurs mostly in patients who have already experienced decompensating events. Decompensation presents as AD in a portion of patients while in many others it presents as a slow development of ascites or mild grade 1 or 2 hepatic encephalopathy, or jaundice, not requiring hospitalisation. Thus, we propose that decompensation of cirrhosis occurs through 2 distinct pathways: a non-acute and an acute (which includes acute-on-chronic liver failure) pathway. Moreover, while non-acute decompensation is the most frequent pathway of the first decompensation, AD mostly represents further decompensation.
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Affiliation(s)
- Gennaro D'Amico
- Gastroenterology Unit, Ospedale V. Cervello, Clinica La Maddalena, Palermo, Italy
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paolo Angeli
- Department of Medicine, Unit of Internal Medicine and Hepatology (UIMH), University of Padova, Italy.
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First things first! Can bacterial infections be considered as decompensating events per se? J Hepatol 2021; 75:1241-1242. [PMID: 34107291 DOI: 10.1016/j.jhep.2021.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 12/13/2022]
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30
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Villanueva C, Bosch J. Reply to: "First things first! Can bacterial infections be considered as decompensating events per se?". J Hepatol 2021; 75:1242-1243. [PMID: 34358568 DOI: 10.1016/j.jhep.2021.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 12/04/2022]
Affiliation(s)
- Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), 08025 Barcelona, Universitat Autònoma de Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
| | - Jaume Bosch
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University, Switzerland
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