Recurrence of spontaneous bacterial peritonitis in cirrhosis: novel predictors

Pathogenic spectrum and drug resistance of bloodstream infection in patients with acute myeloid leukaemia: a single centre retrospective study

Background

Bloodstream infection (BSI) represent a prevalent complication in haematological malignancies (HMs). Typically, Patients with BSI usually undergo empirical treatment pending pathogen identification. The timely and effective management of BSIs significantly influences patient prognosis. However, pathogen distribution in BSIs exhibits regional variation. In this study, we investigated the clinical characteristics, pathogen spectrum, drug resistance, risk factors of short-term prognosis and long-term prognostic factors of acute myeloid leukemia (AML) patients with BSI at Zhejiang Provincal People's Hospital.

Methods

From 2019 to 2021, a total of 56 AML patients with BSI were treated in the Department of Haematology at Zhejiang Province People's Hospital. Data regarding pathogen spectrum and drug resistance were collected for analysis. The patients were stratified into non-survivor cohort and survivor cohort within 30 days after BSI, and the predictors of 30-days mortality were identified through both univariate and multivariate Logistic regression analyses. Furthermore, Kaplan-Meier survival analysis and Cox regression analysis were employed to ascertain the risk factors associated with poor prognosis in AML patients complicated by BSI.

Results

A total of 70 strains of pathogenic bacteria were isolated from 56 AML patients with BSI. Gram-negative bacteria constituted the predominant pathogens (71.4%), with Klebsiella pneumoniae being the most prevalent (22.9%). Gram-positive bacteria and fungi accounted for 22.9% and 5.7%, respectively. Univariate and multivariate analyses revealed significant differences in total protein, albumin levels, and the presence of septic shock between the non-survivor cohort and the survior cohort 30 days post-BSI. COX regression analysis showed that agranulocytosis duration exceeding 20 days (HR:3.854; 95% CI: 1.451-10.242) and septic shock (HR:3.788; 95% CI: 1.729-8.299) were independent risk factors for poor prognosis in AML patients complicated by BSI. Notably, the mortality rate within 30 days after Stenotrophomonas maltophilia infection was up to 71.4%.

Conclusions

In this study, Gram-negative bacteria, predominantly Klebsiella pneumoniae, constituted the primary pathogens among AML patients with BSIs. Serum albumin levels and the presence of septic shock emerged as independent risk factors for mortality within 30 days among AML patients with BSI. In terms of long-term prognosis, extended agranulocytosis duration exceeding 20 days and septic shock were associated with elevated mortality rates in AML patients with BSI. Additionally, in our centre, Stenotrophomonas maltophilia infection was found to be associated with a poor prognosis. Early intervention for Stenotrophomonas maltophilia infection in our centre could potentially improve patient outcomes.

Spontaneous remission of Cronkhite-Canada syndrome without immunosuppressive medication in the context of decompensated cirrhosis: A case report

We present a case of Cronkhite-Canada syndrome in a patient with decompensated cirrhosis who had successful induction of remission with nutritional supplementation alone. We propose that early institution of high-protein, high-energy enteral supplementation should be offered to all patients, especially those with compelling contraindications to immunosuppression.

Liver Transplantation in Chronic Liver Disease and Acute on Chronic Liver Failure- Indication, Timing and Practices

Liver transplantation (LT) is the second most common solid organ transplantation worldwide. LT is considered the best and most definitive therapeutic option for patients with decompensated chronic liver disease (CLD), hepatocellular carcinoma (HCC), acute liver failure (ALF), and acute-on-chronic liver failure (ACLF). The etiology of CLD shows wide geographical variation, with viral hepatitis being the major etiology in the east and alcohol-related liver disease (ALD) in the west. Non-alcoholic fatty liver disease (NAFLD) is on an increasing trend and is expected to be the most common etiology on a global scale. Since the first successful LT, there have been radical changes in the indications for LT. In many circumstances, not just the liver disease itself but factors such as extra-hepatic organ dysfunction or failures necessitate LT. ACLF is a dynamic syndrome that has extremely high short-term mortality. Currently, there is no single approved therapy for ACLF, and LT seems to be the only feasible therapeutic option for selected patients at high risk of mortality. Early identification of ACLF, stratification of patients according to disease severity, aggressive organ support, and etiology-specific treatment approaches have a significant impact on post-transplant outcomes. This review briefly describes the indications, timing, and referral practices for LT in patients with CLD and ACLF.

Systematic review of the role of calprotectin in cirrhosis

BACKGROUND

Calprotectin is a calcium-binding-S100-protein synthetized mainly in neutrophils which has been demonstrated to be an accurate biomarker of the presence of these cells. Gut barrier dysfunction in patients with advanced chronic liver disease (ACLD), in addition to the lack of noninvasive tools for diagnosis and prognosis of cirrhosis decompensations, has raised interest in this biomarker.

AIMS

Our aim is to summarize the current evidence regarding the role of calprotectin in terms of its diagnostic and prognostic utility in ACLD.

METHODS

We performed a systematic search (PROSPERO registration no. CRD42023389069) of original articles published without any restrictions on the publication date until January 2023 providing information about calprotectin for the prognosis or diagnosis of ACLD and its decompensations in adult patients.

RESULTS

A total 227 articles were identified, and 26 observational studies finally met the inclusion criteria. In 14 studies, calprotectin was measured in ascitic fluid, all of which reported higher calprotectin values in spontaneous bacterial peritonitis, while cut-off points for its diagnosis were proposed in nine studies. Three studies reported higher faecal calprotectin levels in patients with hepatic encephalopathy and portal hypertension. Four studies evaluated faecal calprotectin and one plasma calprotectin as biomarkers for gut barrier integrity and bacterial translocation.

CONCLUSIONS

Calprotectin is emerging as a promising biomarker in ACLD, particularly for the management of bacterial infections and alcohol-related liver disease. Further research with better study designs should help to determine the feasibility of calprotectin measurement in routine clinical practice.

Effect of hypoalbuminemia on mortality in cirrhotic patients with spontaneous bacterial peritonitis

Objectives

The impact of hypoalbuminemia on the short-term and long-term mortality of cirrhotic patients with spontaneous bacterial peritonitis (SBP), both with and without renal function impairment, remains insufficiently elucidated based on population-based data.

Materials and Methods

We retrieved data from Taiwan's National Health Insurance Database encompassing 14,583 hospitalized patients diagnosed with both cirrhosis and SBP during the period from January 1, 2010, to December 31, 2013. Prognostic factors influencing 30-day and 3-year survival were computed. Furthermore, the impact of hypoalbuminemia on the mortality rate among SBP patients, with or without concurrent renal function impairment, was also assessed.

Results

The 30-day mortality rates for patients with SBP, comparing those with hypoalbuminemia and those without, were 18.3% and 29.4%, respectively (P < 0.001). Similarly, the 3-year mortality rates for SBP patients with hypoalbuminemia and those without were 73.7% and 85.8%, respectively (P < 0.001). Cox proportional hazard regression analysis, adjusted for patients' gender, age, and comorbid conditions, substantiated that individuals with hypoalbuminemia exhibit an inferior 30-day survival (hazard ratio [HR]: 1.62, 95% confidence interval [CI]: 1.51-1.74, P < 0.001) and reduced 3-year survival (HR: 1.57, 95% CI: 1.50-1.63, P < 0.001) in comparison to those lacking hypoalbuminemia. Among SBP patients with renal function impairment, those presenting hypoalbuminemia also experienced diminished 30-day survival (HR: 1.81, 95% CI 1.57-2.07, P < 0.001) as well as reduced 3-year survival (HR: 1.70, 95% CI 1.54-1.87, P < 0.001). Likewise, in SBP patients without renal function impairment, the presence of hypoalbuminemia was associated with poorer 30-day survival (HR: 1.54, 95% CI 1.42-1.67, P < 0.001) and 3-year survival (HR: 1.53, 95% CI 1.46-1.60, P < 0.001).

Conclusion

Among cirrhotic patients with SBP, the presence of hypoalbuminemia predicts inferior short-term and long-term outcomes, regardless of renal function.

Proton Pump Inhibitors Increases Longitudinal Risk of Mortality, Decompensation, and Infection in Cirrhosis: A Meta-Analysis

BACKGROUND/AIMS

Proton pump inhibitors (PPIs) are frequently prescribed to cirrhotic patients, but there is limited longitudinal evidence regarding their effects. This study aimed to assess the impact of PPIs on adverse events in cirrhotic patients.

METHODS

A comprehensive search was conducted using the Medline and Embase databases to identify relevant articles. Pooled hazard ratios (HRs) using DerSimonian and Laird random-effects model were calculated to evaluate the risk of adverse events such as long-term mortality, hepatic decompensation, hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), and overall infection in cirrhotic patients with PPI use.

RESULTS

The analysis included 28 studies with 260,854 cirrhotic patients. The prevalence of PPI use among cirrhotic patients was 55.93%. The use of PPIs was not significantly associated with short-term mortality in cirrhotic patients. However, long-term mortality (HR 1.321, 95% CI 1.103-1.581, P = 0.002), decompensation (HR 1.646, 95% CI 1.477-1.835, P < 0.001), HE (HR 1.968, 95% CI 1.372-2.822, P < 0.001), SBP (HR 1.751, 95% CI 1.649-1.859, P < 0.001), and infection (HR 1.370, 95% CI 1.148-1.634, P < 0.001) were significantly associated with PPI use. Sensitivity analysis with prospective studies yielded similar results.

CONCLUSION

PPIs should be reserved for appropriate indications at lowest effective dose for cirrhotic patients due to the potential harm.

Outcomes in patients with spontaneous bacterial peritonitis utilizing first-line or alternative agents for secondary prophylaxis

PURPOSE

The American Association for the Study of Liver Diseases guidelines recommend ciprofloxacin as a first-line option for spontaneous bacterial peritonitis (SBP) prophylaxis, citing literature that is over 30 years old. There is insufficient data and guidance for prophylaxis in cases of fluoroquinolone treatment failure or intolerance. This study aimed to evaluate outcomes in patients whose antimicrobial prophylaxis was switched from first-line therapies to an alternative agent versus those who were not switched following recurrent SBP.

METHODS

This study was an institutional review board-approved retrospective chart review of patients admitted to University of Kentucky HealthCare from 2014 through 2020. Patients included were 18 years of age or older with a diagnosis of recurrent SBP. The primary outcome examined was SBP recurrence rate following initial prophylaxis failure. Additional analyses targeted secondary outcomes, including 6-month mortality, development of SBP complications, development of an adverse drug reaction, and development of multidrug-resistant pathogens.

RESULTS

Fifty-three patients were identified with recurrent SBP and divided into 2 cohorts: 25 patients were switched from their original prophylactic agent while 28 patients continued on the same agent after SBP recurrence. Patients in the switch group had lower rates of recurrence (52% vs 100%). Additionally, these patients had lower 6-month mortality rates (24% vs 57.1%; P = 0.015). Thirteen patients in the no-switch group and 3 patients in the switch group required intensive care on a subsequent admission (46.4% vs 12%; P = 0.008). There were no significant differences between the groups in rates of other SBP complications.

CONCLUSION

Patients switched from their original prophylactic agent had lower rates of SBP recurrence with significantly lower 6-month mortality rates.

Consensus document on acute-on-chronic liver failure (ACLF) established by the Mexican Association of Hepatology

Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.

A risk score to predict 30-day hospital readmission rate in cirrhotic patients with spontaneous bacterial peritonitis

BACKGROUND AND AIM

There is lack of 30-day hospital readmission prediction score in patients with liver cirrhosis and SBP. The aim of this study is to recognize factors capable of predicting 30-day readmission and to develop a readmission risk score in patients with SBP.

METHODS

This study prospectively examined the 30-day hospital readmission for patients previously discharged with a diagnosis of SBP. Based on index hospitalization variables, a multivariable logistic regression model was implemented to recognize predictors of patient hospital readmission within 30 days. Consequently, Mousa readmission risk score was established to predict 30-day hospital readmission.

RESULTS

Of 475 patients hospitalized with SBP, 400 patients were included in this study. The 30-day readmission rate was 26.5%, with 16.03% of patients readmitted with SBP. Age ≥ 60, MELD > 15, serum bilirubin > 1.5 mg/dL, creatinine > 1.2 mg/dL, INR > 1.4, albumin < 2.5 g/dL, platelets count ≤ 74 (10³/dL) were found to be independent predictors of 30-day readmission. Incorporating these predictors, Mousa readmission score was established to predict 30-day patient readmissions. ROC curve analysis demonstrated that at a cutoff value ≥ 4, Mousa score had optimum discriminative power for predicting the readmission in SBP with sensitivity 90.6% and specificity 92.9%. However, at cutoff value ≥ 6 the sensitivity and specificity were 77.4% and 99.7%, respectively, while a cutoff value ≥ 2 had sensitivity of 99.1% and specificity of 31.6%.

CONCLUSIONS

The 30-day readmission rate of SBP was 25.6%. With the suggested simple risk assessment Mousa score, patients at high risk for early readmission can be easily identified so as to possibly prevent poorer outcomes.

Calprotectin as a diagnostic marker for sepsis: A meta-analysis

Introduction

Sepsis is a life-threatening condition, and biomarkers are needed to diagnose sepsis fast and accurately. We aimed to perform this meta-analysis to investigate the diagnostic value of calprotectin on sepsis in critically ill patients.

Methods

The investigators searched MEDLINE, Embase, Web of Science and Cochrane Library. Studies were included if they assessed the diagnostic accuracy of serum calprotectin for sepsis in intensive care unit (ICU). We estimated its diagnostic value and explored the source of heterogeneity. The bivariate model and the hierarchical summary receiver operating characteristic (HSROC) curve were used in the meta-analysis.

Results

Six records assessing 821 patients were included in this meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio (PLR), and diagnostic odds ratio (DOR) were separately as 0.77, 0.85, 5.20, 0.27, respectively. The Fagan's nomogram showed post-test probabilities of 91% and 35% for positive and negative outcomes, respectively. Subgroup analysis indicated that sepsis definition could be a possible source of heterogeneity, but there's no sufficient data to investigate sepsis-3 definition. Sensitivity analysis suggested that two studies could affect the stability of pooled results.

Conclusion

On the basis of our meta-analysis, calprotectin is a helpful marker for early diagnosis of sepsis on ICU admission.

The impact of proton pump inhibitors in liver diseases and the effects on the liver

In this systematic and comprehensive overview, we aimed to evaluate the impact of proton pump inhibitors (PPIs) on chronic liver diseases, especially on cirrhosis. A manual and comprehensive search of the PubMed database was conducted to obtain relevant literatures. PPIs altered the composition and function of the intestinal microflora and might lead to small intestinal bacterial overgrowth and bacterial translocation, which were associated with adverse effects in liver diseases. They might increase the risk of hepatic encephalopathy, spontaneous bacterial peritonitis, infections, and are related to an increased mortality in cirrhosis. PPIs might lead to an increased risk of hepatocellular carcinoma, although the mechanism is unknown, and the results are controversial. PPIs also had an impact on the direct-acting antiviral regimen in patients with chronic hepatitis C. They were associated with an increased risk of liver abscess and increased mortality. Additionally, PPIs might lead to metabolic risk events, such as liver steatosis and weight gain. PPIs are associated with several adverse outcomes in liver diseases. Cautious use of PPIs is recommended and clinicians should be aware of the indications for their use in patients with liver diseases.

Research Progress and Treatment Status of Liver Cirrhosis with Hypoproteinemia

Liver cirrhosis is the 14th leading cause of death in adults worldwide. The liver is an important organ for the metabolism of sugar, protein, and fat. Liver cirrhosis with hypoproteinemia (LCH) can lead to metabolic disorders of the nutrients such as sugar, protein, and fat, as well as insufficient protein intake, digestion and absorption disorders, and continuous leakage of plasma protein into the abdominal cavity. Severe hypoproteinemia leads to a poor prognosis in patients. For every 10 g/L decrease in peripheral blood albumin, the risk of secondary liver disease complications will increase by 89% and the mortality rate increased by 24%–56%. Therefore, it is necessary to take urgent measures to treat liver cirrhosis with hypoalbuminemia and effectively treat and reverse the deterioration of the disease caused by hypoalbuminemia, so as to reduce the burden of secondary liver disease. Emerging evidence suggests that protein balance disorders, auxin resistance, and hyperleptinemia are key steps in the development of cirrhosis and hypoproteinemia. This study comprehensively analyzed the common complications, pathogenic mechanisms, and treatment status of cirrhosis caused by hypoproteinemia and proposed research prospects for dealing with this increasingly serious problem.

Diagnostic Potential of Calprotectin for Spontaneous Bacterial Peritonitis in Patients Withliver Cirrhosis and Ascites

The development of spontaneous bacterial peritonitis (SBP) is a serious and life-threatening condition in patients with cirrhosis and ascites. The aim of this study was to determine the diagnostic potential of calprotectin in ascites, for SBP in patients with liver cirrhosis and ascites before and after antibiotic treatment and to compare the mean values of calprotectin in ascites in patients with and without SBP. This prospective-observational study was comprised of 70 patients with cirrhosis and ascites, divided into two groups, the SBP and the non-SBP group. Quantitative measurements of calprotectin in ascites was completed with the Quantum Blue Calprotectin Ascites test (LF-ASC25), using the Quantum Blue Reader. The average value of calprotectin in the SBP group was 1.5 ± 0.40 μg / mL, and in the non-SBP group it was lower (0.4 ± 0.30). The difference between the mean values was statistically significant with p <0.05. The mean value of calprotectin in ascites before therapy among the SBP group was 1.5 ± 0.4, and after antibiotic therapy, the value decreased significantly to 1.0 ± 0.6; the difference between the mean values was statistically significant with p <0.05. ROC analysis indicated that calprotectin contributed to the diagnosis of SBP with a 94.3% sensitivity rating (to correctly identify positives), and the specificity was 62.5%, which corresponded to the value of 0.275. Our research confirmed that ascitic calprotectin was a good predictor, and is significantly associated with the occurrence of SBP in patients with liver cirrhosis. By monitoring the value of calprotectin in ascites on the 7th day of antibiotic treatment, the effectiveness of antibiotic treatment in patients with SBP can be determined.

Hypoalbuminemia as Surrogate and Culprit of Infections

Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.

Factors Associated with Delayed Paracentesis in Patients with Spontaneous Bacterial Peritonitis

BACKGROUND AND AIM

In patients with spontaneous bacterial peritonitis (SBP), studies show that delayed paracentesis (DP) is associated with worse outcomes and mortality. We aimed to assess the rate of DP in the community setting and associated factors with early versus delayed paracentesis.

METHODS

Patients hospitalized with SBP were retrospectively studied between 12/2013 and 12/2018. DP was defined as paracentesis performed > 12 h from initial encounter. Data collected included: patient factors (i.e., age, race, symptoms, history of SBP, MELD) and physician factors (i.e., admission service, shift times, providers ordering and performing paracentesis). Logistic regression analysis was performed to assess for factors associated with DP.

RESULTS

DP occurred 82% of the time (n = 97). The most significant factors in predicting timing of paracentesis were ordering physician [emergency department (ED) physician was associated with early paracentesis (57% vs 8%, p < 0.001) and specialty of physician performing paracentesis (interventional radiology was associated with DP (88% vs 48%, p < 0.001)]. Younger patients were more likely to receive early paracentesis. In regression analysis, the factor most associated with early paracentesis was when the order was made by the ED provider (OR 0.07, 95% CI 0.02-0.22). No differences were observed in patients with prior history of SBP, abdominal pain, encephalopathy, or creatinine level.

CONCLUSIONS

Studies have suggested that DP is associated with increased mortality in patients with SBP. Despite this, DP is common in the community setting and is influenced by ordering physician and specialty of physician performing paracentesis. Future efforts should assess interventions to improve this important quality indicator.

Diagnostic and prognostic role of ascitic fluid calprotectin level: six-month outcome findings in cirrhotic patients

AIM

To assess the role of ascites calprotectin in early detection of SBP in patients with cirrhosis and to investigate its prognostic value in determination of the 6-month outcome. Methods and material: In this cross-sectional study, patients with liver cirrhosis who were consecutively referred to Imam Reza hospital, tertiary referral center in the northwest of Iran, underwent abdominal paracentesis. The samples were collected for measurement of calprotectin, albumin, total protein, WBCs, and PMNs.

RESULTS

The mean age of a total of 87 included patients was 56.86 (SD 16.05) years old with over half of the subjects (55.2%) being female. About 28.7% of performed paracenteses tested positive for SBP. Ascitic calprotectin was positively correlated to the PMN counts. Patients with SBP were found to have higher levels of ascites albumin, total protein, and calprotectin. Only 51 individuals survived the 6-month follow-up period and mortality outcomes were significantly related to the levels of aforementioned biochemical markers (p-value <.05).

CONCLUSION

Alongside with standard PMN counts, calprotectin measurement in the ascitic fluid could be used as an available test for early diagnosis of SBP. Calprotectin can also serve as a valuable prognostic marker in the evaluation of cirrhotic patients.

HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan

Approximately one half of patients develop ascites within 10 years of diagnosis of compensated cirrhosis. It is a poor prognostic indicator, with only 50% surviving beyond two years. Mortality worsens significantly to 20% to 50% at one year if the ascites becomes refractory to medical therapy. Pakistan has one of the highest prevalence of viral hepatitis in the world and patients with ascites secondary to liver cirrhosis make a major percentage of both inpatient and outpatient burden. Studies indicate that over 80% of patients admitted with ascites have liver cirrhosis as the cause.

This expert opinion suggests proper assessment of patients with ascites in the presence of underlying cirrhosis. This expert opinion includes appropriate diagnosis and management of uncomplicated ascites, refractory ascites and complicated ascites (including spontaneous bacterial peritonitis (SBP) ascites, hepatorenal syndrome (HRS) and hyponatremia. The purpose behind this expert opinion is to help consultants, postgraduate trainees, medical officers and primary care physicians optimally manage their patients with cirrhosis and ascites in a resource constrained setting as is often encountered in a developing country like Pakistan.

Use of proton pump inhibitors in dialysis patients: a double-edged sword?

Large cohort-based studies have shown that proton pump inhibitors (PPIs) are linked to rare but multiple and varied secondary events when used in the general population. Although clinicians accept the negative effects of PPIs on renal function, there is a lack of available data regarding the potential consequences of their use by dialysis patients in whom the risk of gastrointestinal bleeding is quite high. This review aims to highlight the risks and benefits of PPIs use in dialysis patients. To summarize, the benefit on the reduction of high digestive bleeding seems certain, but without any beneficial impact on overall survival. The impact on quality of life seems to be significant. The data on the occurrence of peritonitis during PPIs treatment are very contradictory. There is evidence regarding the occurrence of hypomagnesaemia in haemodialysis patients with PPIs; which may lead to increase bone fragility. New data show an increased cardiovascular risk and even a risk of death linked to the use of PPIs on dialysis. Several mechanisms of IPP toxicity are advanced to explain these findings.

Helicobacter pylori as an Initiating Factor of Complications in Patients With Cirrhosis: A Single-Center Observational Study

Background and Aim: The relationship between liver cirrhosis and Helicobacter pylori (H. pylori) is a debatable matter. The aim of this study is to evaluate the possible association between H. pylori infection and liver cirrhosis. Methods: A single-center prospective cohort pilot study of 558 patients with cirrhosis was followed up for 1 year. Serum C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), nitric oxide (NO), vascular endothelial growth factor (VEGF) levels and Fecal H. pylori antigen were evaluated by enzyme-linked immunosorbent assay (ELISA). All patients with positive H. pylori were treated and then followed up for 3 months. Participants with eradicated H. pylori were followed up for one further year. Results: H. pylori-positive patients (48.4%) were associated with increased levels of serum CRP, TNF-α, IL-6, NO, and VEGF, as well as increased incidence of varices, portal hypertensive gastropathy, gastric antral vascular ectasia, hepatocellular carcinoma (HCC), spontaneous bacterial peritonitis, hepatic encephalopathy, portal vein thrombosis (PVT), and hepatorenal syndrome (all P < 0.05). Multivariate analysis models revealed that the presence of H. pylori was an independent risk variable for the development of portal vein thrombosis and hepatocellular carcinoma (P = 0.043, P = 0.037) respectively. After treatment of H. pylori infection, there was a significant reduction in all measured biochemical parameters and reported cirrhotic complications (all P < 0.05). Conclusion: Incidence of PVT and HCC development increased with H. pylori infection through increased inflammatory markers and vascular mediators. Moreover, its eradication may reduce the incidence of these complications.

Limited effects of antibiotic prophylaxis in patients with Child-Pugh class A/B cirrhosis and upper gastrointestinal bleeding

Current guidelines recommend antibiotic prophylaxis for all patients with various degrees of cirrhosis and upper gastrointestinal (UGI) bleeding. This study assessed the need for antibiotic prophylaxis in patients with low Child–Pugh scores. We retrospectively screened all patients with cirrhosis who underwent upper endoscopies for UGI bleeding in a referral hospital in Taiwan between 2003 and 2014, from which 913 patients were enrolled after excluding patients with active bacterial infections, recent antibiotic use, early death, and Child–Pugh class C cirrhosis. Among them, 73 (8%) received prophylactic antibiotics, and 45 (4.9%) exhibited 14-day bacterial infection. Neither Child–Pugh score nor model for end stage liver disease score were optimal for predicting bacterial infection because their areas under the curves were 0.610 (95% confidence interval [CI]: 0.529–0.691) and 0.666 (95% CI: 0.591–0.742), respectively. Antibiotic prophylaxis did not reduce the risks of 14-day bacterial infection (relative risk [RR]: 0.932, 95% CI: 0.300–2.891, P = 0.902), 14-day rebleeding (RR: 0.791, 95% CI: 0.287–2.181, P = 0.650), or 42-day mortality (RR: 2.710, 95% CI: 0.769–9.524, P = 0.121). The results remained similar after propensity score adjustment. On-demand antibiotic treatment might suffice for patients with Child–Pugh class A/B cirrhosis and UGI bleeding.