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Zanetto A, Campello E, Senzolo M, Simioni P. The evolving knowledge on primary hemostasis in patients with cirrhosis: A comprehensive review. Hepatology 2024; 79:460-481. [PMID: 36825598 DOI: 10.1097/hep.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 02/25/2023]
Abstract
Patients with cirrhosis develop complex alterations in primary hemostasis that include both hypocoagulable and hypercoagulable features. This includes thrombocytopenia, multiple alterations of platelet function, and increased plasma levels of von Willebrand factor. Contrary to the historical view that platelet dysfunction in cirrhosis might be responsible for an increased bleeding tendency, the current theory posits a rebalanced hemostasis in patients with cirrhosis. Severe thrombocytopenia is not indicative of the bleeding risk in patients undergoing invasive procedures and does not dictate per se the need for pre-procedural prophylaxis. A more comprehensive and individualized risk assessment should combine hemostatic impairment, the severity of decompensation and systemic inflammation, and the presence of additional factors that may impair platelet function, such as acute kidney injury and bacterial infections. Although there are multiple, complex alterations of platelet function in cirrhosis, their net effect is not yet fully understood. More investigations evaluating the association between alterations of platelet function and bleeding/thrombosis may improve risk stratification in patients with decompensated cirrhosis. Besides hemostasis, the assessment of von Willebrand factor Ag and ADP-induced, whole-blood platelet aggregation normalized by platelet count (VITRO score and PLT ratio) are promising biomarkers to predict the risk of hepatic decompensation and survival in both compensated and decompensated patients. Further investigations into the in vivo interplay between platelets, circulating blood elements, and endothelial cells may help advance our understanding of cirrhotic coagulopathy. Here, we review the complex changes in platelets and primary hemostasis in cirrhosis and their potential clinical implications.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Padova, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Elena Campello
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Padova, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Paolo Simioni
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
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Saner FH, Scarlatescu E, Broering DC, Bezinover D. The Yin and the Yang of Hemostasis in End-Stage Liver Disease. J Clin Med 2023; 12:5759. [PMID: 37685826 PMCID: PMC10488973 DOI: 10.3390/jcm12175759] [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: 07/11/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Patients with end-stage liver disease (ESLD) undergoing liver transplantation (LT) are prone to thromboses both while on the waiting list and in the perioperative period. This hypercoagulability is associated with significant endothelial dysfunction (ED) due to nitric oxide dysregulation. ED and increased thrombin generation are the main factors responsible for this hypercoagulability. Sepsis alone can significantly alter a patient's coagulation profile. In combination with ESLD, however, sepsis or septic shock are responsible for very complex changes. This makes both the assessment and management of coagulation in septic patients with ESLD very challenging. Viscoelastic testing (VET) is the preferred method of coagulation management in patients with cirrhosis because, as with standard laboratory testing, VET can assess the entire coagulation system including the interaction between both pro- and anticoagulants and platelets.
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Affiliation(s)
- Fuat H. Saner
- King Faisal Specialist Hospital & Research Center, Organ Transplant Center of Excellence, Riyadh 11564, Saudi Arabia;
| | - Ecaterina Scarlatescu
- Department of Anesthesia and Intensive Care Medicine III, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Anesthesia and Intensive Care Department, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Dieter Clemens Broering
- King Faisal Specialist Hospital & Research Center, Organ Transplant Center of Excellence, Riyadh 11564, Saudi Arabia;
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
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3
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Bai Z, Méndez-Sánchez N, Romeiro FG, Mancuso A, Philips CA, Tacke F, Basaranoglu M, Primignani M, Ibrahim M, Wong YJ, Nery FG, Teschke R, Ferreira CN, Muñoz AE, Pinyopornpanish K, Thevenot T, Singh SP, Mohanty A, Satapathy SK, Ridola L, Maruyama H, Cholongitas E, Levi Sandri GB, Yang L, Shalimar, Yang Y, Villa E, Krag A, Wong F, Jalan R, O’Brien A, Bernardi M, Qi X. Use of albumin infusion for cirrhosis-related complications: An international position statement. JHEP Rep 2023; 5:100785. [PMID: 37456673 PMCID: PMC10339261 DOI: 10.1016/j.jhepr.2023.100785] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 07/18/2023] Open
Abstract
Background & Aims Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. Methods Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. Results Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. Conclusions Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. Impact and implications Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion.
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Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico
| | | | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Metin Basaranoglu
- Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Massimo Primignani
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Filipe Gaio Nery
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Alberto E. Muñoz
- Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina
| | - Kanokwan Pinyopornpanish
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thierry Thevenot
- Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d’Hépatologie et de Soins Intensifs Digestifs, Besançon, France
| | | | - Arpan Mohanty
- Section of Gastroenterology, Boston Medical Center, Boston, MA, USA
| | - Sanjaya K. Satapathy
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Li Yang
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Yongping Yang
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Erica Villa
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Aleksander Krag
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK
| | | | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - the Liver Cirrhosis-related Complications (LCC)-International Special Interest Group
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico
- Internal Medicine Department, Botucatu Medical School, São Paulo, Brazil
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
- Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d’Hépatologie et de Soins Intensifs Digestifs, Besançon, France
- Kalinga Gastroenterology Foundation, Odisha, India
- Section of Gastroenterology, Boston Medical Center, Boston, MA, USA
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
- Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK
- Division of Medicine, Royal Free Campus, London, UK
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Zanetto A, Northup P, Roberts L, Senzolo M. Haemostasis in cirrhosis: Understanding destabilising factors during acute decompensation. J Hepatol 2023; 78:1037-1047. [PMID: 36708812 DOI: 10.1016/j.jhep.2023.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
Hospitalised patients with decompensated cirrhosis are in a rebalanced haemostatic state due to a parallel decline in both pro- and anti-haemostatic pathways. However, this rebalanced haemostatic state is highly susceptible to perturbations and may easily tilt towards hypocoagulability and bleeding. Acute kidney injury, bacterial infections and sepsis, and progression from acute decompensation to acute-on-chronic liver failure are associated with additional alterations of specific haemostatic pathways and a higher risk of bleeding. Unfortunately, there is no single laboratory method that can accurately stratify an individual patient's bleeding risk and guide pre-procedural prophylaxis. A better understanding of haemostatic alterations during acute illness would lead to more rational and individualised management of hospitalised patients with decompensated cirrhosis. This review will outline the latest findings on haemostatic alterations driven by acute kidney injury, bacterial infections/sepsis, and acute-on-chronic liver failure in these difficult-to-treat patients and provide evidence supporting more tailored management of bleeding risk.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Patrick Northup
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, NYU Transplant Institute, New York, NY, USA
| | - Lara Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.
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5
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Kaur A, Verma N, Singh B, Kumar A, Kumari S, De A, Sharma RR, Singh V. Quantitative liver SPECT/CT is a novel tool to assess liver function, prognosis, and response to treatment in cirrhosis. Front Med (Lausanne) 2023; 10:1118531. [PMID: 37035316 PMCID: PMC10073445 DOI: 10.3389/fmed.2023.1118531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/03/2023] [Indexed: 04/11/2023] Open
Abstract
Background Functional liver reserve is an important determinant of survival in cirrhosis. The traditional indocyanine green test (ICG) is cumbersome. Hence, we developed and validated a novel liver imaging, a hybrid of SPECT and CT (Q-SPECT/CT), for evaluating disease severity, outcomes, and response to treatment in decompensated cirrhosis (DC). Methods We recruited a cohort of DC patients at a tertiary institute between 2016-2019. First, we standardized the Q-SPECT/CT across a predefined range of volumes through phantom experiments. Then we performed clinical and laboratory evaluations, ICG test (retention at 15 min), and Q-SPECT/CT at baseline and 12 months of granulocyte colony-stimulating factor (G-CSF) and standard medical treatment (SMT). Results In 109 DC patients, 87.1% males, aged 51 ± 10 years, MELD: 14 (7-21), the percent quantitative liver uptake (%QLU) on Q-SPECT/CT exhibited a strong correlation with CTP (r = -0.728, p < 0.001), MELD (r = -0.743; p < 0.001) and ICG-R-15 (r = -0.720, p < 0.001) at baseline. %QLU had the maximum discrimination (AUC: 0.890-0.920), sensitivity (88.9-90.3%), specificity (81.2-90.7%), and accuracy (85.8-89.4%) than liver volumes on Q-SPECT/CT or ICG test for classifying patients in CTP/MELD based prognostic categories. A significant increase in %QLU (26.09 ± 10.06 to 31.2 ± 12.19, p = 0.001) and improvement in CTP/MELD correlated with better survival of G-CSF treated DC patients (p < 0.05). SMT did not show any improvement in Q-SPECT/CT or clinical severity scores (p > 0.05). %QLU > 25 (adj.H.R.: 0.234, p = 0.003) and G-CSF treatment (adj.H.R.: 0.414, p = 0.009) were independent predictors of better 12-months survival in DC. Conclusion Q-SPECT/CT (%QLU) is a novel non-invasive, diagnostic, prognostic, and theragnostic marker of liver reserve and its functions in cirrhosis patients. Clinical trial registration Clinicaltrials.gov, NCT02451033 and NCT03415698.
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Affiliation(s)
- Amritjyot Kaur
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- *Correspondence: Nipun Verma,
| | - Baljinder Singh
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Baljinder Singh,
| | - Ajay Kumar
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunita Kumari
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ratti Ram Sharma
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Lee K, Ryu D, Kim H, Jeon CH, Kim JH, Park CY, Yeom SR. Validity of the scoring system for traumatic liver injury: a generalized estimating equation analysis. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: The scoring system for traumatic liver injury (SSTLI) was developed in 2015 to predict mortality in patients with polytraumatic liver injury. This study aimed to validate the SSTLI as a prognostic factor in patients with polytrauma and liver injury through a generalized estimating equation analysis. Methods: The medical records of 521 patients with traumatic liver injury from January 2015 to December 2019 were reviewed. The primary outcome variable was in-hospital mortality. All the risk factors were analyzed using multivariate logistic regression analysis. The SSTLI has five clinical measures (age, Injury Severity Score, serum total bilirubin level, prothrombin time, and creatinine level) chosen based on their predictive power. Each measure is scored as 0–1 (age and Injury Severity Score) or 0–3 (serum total bilirubin level, prothrombin time, and creatinine level). The SSTLI score corresponds to the total points for each item (0–11 points). Results: The areas under the curve of the SSTLI to predict mortality on post-traumatic days 0, 1, 3, and 5 were 0.736, 0.783, 0.830, and 0.824, respectively. A very good to excellent positive correlation was observed between the probability of mortality and the SSTLI score (γ=0.997, P<0.001). A value of 5 points was used as the threshold to distinguish low-risk (<5) from high-risk (≥5) patients. Multivariate analysis using the generalized estimating equation in the logistic regression model indicated that the SSTLI score was an independent predictor of mortality (odds ratio, 1.027; 95% confidence interval, 1.018–1.036; P<0.001). Conclusions: The SSTLI was verified to predict mortality in patients with polytrauma and liver injury. A score of ≥5 on the SSTLI indicated a high-risk of post-traumatic mortality.
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Liao JN, Kuo L, Liu CM, Chen SA, Chao TF. Non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients with advanced chronic kidney and liver diseases. Eur Heart J Suppl 2022; 24:A11-A18. [PMID: 35185405 PMCID: PMC8850708 DOI: 10.1093/eurheartj/suab154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Advanced chronic kidney disease (CKD) or chronic liver disease (CLD) is frequent in patients with atrial fibrillation (AF) because of their common risk factors. Chronic kidney disease and CLD superimposed on AF are associated with increased risks of thrombosis and bleeding, which further complicates the use of oral anticoagulants (OACs). Because currently approved non-vitamin K antagonist oral anticoagulants (NOACs) undergo certain degrees of metabolism and clearance in the liver and kidney, increased exposure to medications and risk of bleeding are major concerns with the use of NOACs in patients with advanced CKD and CLD. Besides, these patients were mostly excluded from landmark trials of NOACs and related cohort studies are also limited. Therefore, the optimal strategy for the use of NOACs in this population remains unclear. This review would go through current evidence regarding the safety and efficacy of NOACs in AF patients with advanced CKD and CLD and provide a comprehensive discussion for clinical practices.
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Affiliation(s)
- Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Zoratti C, Moretti R, Rebuzzi L, Albergati IV, Di Somma A, Decorti G, Di Bella S, Crocè LS, Giuffrè M. Antibiotics and Liver Cirrhosis: What the Physicians Need to Know. Antibiotics (Basel) 2021; 11:antibiotics11010031. [PMID: 35052907 PMCID: PMC8772826 DOI: 10.3390/antibiotics11010031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 12/13/2022] Open
Abstract
The liver is the primary site of drug metabolism, which can be altered by a variety of diseases affecting the liver parenchyma, especially in patients with liver cirrhosis. The use of antibiotics in patients with cirrhosis is usually a matter of concern for physicians, given the lack of practical knowledge for drug choice and eventual dose adjustments in several clinical scenarios. The aim of the current narrative review is to report, as broadly as possible, basic, and practical knowledge that any physician should have when approaching a patient with liver cirrhosis and an ongoing infection to efficiently choose the best antibiotic therapy.
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Affiliation(s)
- Caterina Zoratti
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Rita Moretti
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Lisa Rebuzzi
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Irma Valeria Albergati
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Antonietta Di Somma
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Giuliana Decorti
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy;
| | - Stefano Di Bella
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Lory Saveria Crocè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
- Italian Liver Foundation, 34149 Trieste, Italy
| | - Mauro Giuffrè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
- Italian Liver Foundation, 34149 Trieste, Italy
- Correspondence: ; Tel.: +39-0403994044
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Incidence of spontaneous bacterial peritonitis among asymptomatic cirrhosis patients undergoing outpatient paracentesis: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2021; 33:e851-e857. [PMID: 34432678 DOI: 10.1097/meg.0000000000002279] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is a common complication of decompensated cirrhosis with high morbidity and mortality rate. There is a paucity of evidence regarding the incidence of SBP in asymptomatic liver cirrhosis patients undergoing routine out-patient large-volume paracentesis (LVP). The aim of this study was to perform a systematic review and meta-analysis to determine the incidence of SBP among asymptomatic decompensated cirrhosis patients undergoing routine outpatient LVP. METHODS A systematic search of Ovid Medline, Embase, Web of Science and CENTRAL electronic databases was performed in January 2021, along with a manual search of reference lists of retrieved articles. Data were extracted to determine the incidence of SBP [polymorphonuclear cells (PMNs) greater than 250 PMNs/mm3 with or without positive culture] and the incidence of all positive paracentesis (SBP or bacterascites-positive ascitic culture but no elevation in PMNs). RESULTS A total of 504 studies were retrieved with 16 studies being included in the review. A total of 1532 patients were included with a total of 4016 paracentesis performed. The incidence of a positive paracentesis (SBP and/or bacterascitis) was 4% [95% confidence interval (CI), 3-6%]. However, the incidence of definite SBP was 2% (95% CI, 1-3%). CONCLUSION The incidence of SBP in asymptomatic outpatients with decompensated cirrhosis requiring LVP is low. The benefit of routine analysis of all paracentesis samples in this population is questionable. Further studies are required to determine the cost-effectiveness of routine analysis and to determine if certain subgroups are at higher risk of SBP that require routine analysis.
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10
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Tapadia A, Jain M, Reddy MS, Mahadevan B, Varghese J, Venkataraman J. Serum C-reactive protein and neutrophil-to-lymphocyte ratio as predictors of survival in cirrhotic patients with systemic inflammatory response syndrome and bacterial infection. Indian J Gastroenterol 2021; 40:265-271. [PMID: 33974227 DOI: 10.1007/s12664-020-01134-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cirrhotic patients are prone to infections due to underlying immune dysfunction in them. We aimed to study the role of inflammatory markers, serum C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR), in predicting infection, blood culture positivity, and short-term (1 month) mortality in hospitalized cirrhotic patients. METHODS This prospective study was done over a period of 14 months (October 2017 to November 2018). Patient data included age, gender, etiology of cirrhosis, reason for admission, and comorbidity. Laboratory tests included blood chemistry and blood cell counts, and blood and urine culture. The specific tests included were CRP and NLR. Survival of patients in the following 1 month was noted. Area under receiver operating characteristic curve (AUROC), sensitivity, specificity, predictive values, diagnostic accuracy were calculated and logistic regression analysis performed. A p-value < 0.05 was considered significant. RESULTS Two hundred and eight patients formed the study cohort. The median age was 51.5 years and male predominance was noted. Alcohol-related liver disease (49%) was the commonest etiology. The infection rate was 62%, culture positivity was 58.5%, and mortality was 30.8%. NLR and CRP were significantly higher in those with documented infection (culture positive or negative) and among nonsurvivors. Optimal cutoffs for NLR and CRP to predict infection were 5.86 and 33.7, respectively. The risk of having an infection was 7.5 times and about 15 times if NLR and CRP were above the cutoffs. The risk of 1-month mortality was 2-3 times higher if patients had NLR and CRP above the cutoffs. The combination of NLR and CRP (≥ 5.86 and ≥ 33.7, respectively) increased specificity and diagnostic accuracy for infection. CONCLUSION NLR and CRP were independently good predictors of infection and 1-month survival among the patients with cirrhosis of liver included in this study.
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Affiliation(s)
- Ashishkumar Tapadia
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India
| | - Mayank Jain
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India.
- Department of Gastroenterology, Arihant Hospital and Research Centre, Indore, 452 009, India.
| | - Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Dr. Rela's Institute of Medical Sciences, Chennai 600 044, India
| | - B Mahadevan
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India
| | - Joy Varghese
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India
| | - Jayanthi Venkataraman
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India
- Department of Hepatology, Sri Ramachandra Medical College, Porur, Chennai 600 116, India
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11
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Willmann S, Coboeken K, Kapsa S, Thelen K, Mundhenke M, Fischer K, Hügl B, Mück W. Applications of Physiologically Based Pharmacokinetic Modeling of Rivaroxaban-Renal and Hepatic Impairment and Drug-Drug Interaction Potential. J Clin Pharmacol 2021; 61:656-665. [PMID: 33205449 PMCID: PMC8048900 DOI: 10.1002/jcph.1784] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
The non–vitamin K antagonist oral anticoagulant rivaroxaban is used in several thromboembolic disorders. Rivaroxaban is eliminated via both metabolic degradation and renal elimination as unchanged drug. Therefore, renal and hepatic impairment may reduce rivaroxaban clearance, and medications inhibiting these clearance pathways could lead to drug‐drug interactions. This physiologically based pharmacokinetic (PBPK) study investigated the pharmacokinetic behavior of rivaroxaban in clinical situations where drug clearance is impaired. A PBPK model was developed using mass balance and bioavailability data from adults and qualified using clinically observed data. Renal and hepatic impairment were simulated by adjusting disease‐specific parameters, and concomitant drug use was simulated by varying enzyme activity in virtual populations (n = 1000) and compared with pharmacokinetic predictions in virtual healthy populations and clinical observations. Rivaroxaban doses of 10 mg or 20 mg were used. Mild to moderate renal impairment had a minor effect on area under the concentration‐time curve and maximum plasma concentration of rivaroxaban, whereas severe renal impairment caused a more pronounced increase in these parameters vs normal renal function. Area under the concentration‐time curve and maximum plasma concentration increased with severity of hepatic impairment. These effects were smaller in the simulations compared with clinical observations. AUC and Cmax increased with the strength of cytochrome P450 3A4 and P‐glycoprotein inhibitors in simulations and clinical observations. This PBPK model can be useful for estimating the effects of impaired drug clearance on rivaroxaban pharmacokinetics. Identifying other factors that affect the pharmacokinetics of rivaroxaban could facilitate the development of models that approximate real‐world pharmacokinetics more accurately.
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Affiliation(s)
| | | | - Stefanie Kapsa
- Clinical Pharmacokinetics Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Kirstin Thelen
- Clinical Pharmacokinetics Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Markus Mundhenke
- Medical Affairs Cardiovascular, Bayer Vital GmbH, Leverkusen, Germany
| | | | - Burkhard Hügl
- Clinic for Cardiology and Rhythmology, Marienhaus Klinikum St Elisabeth Neuwied, Neuwied, Germany
| | - Wolfgang Mück
- Clinical Pharmacokinetics Cardiovascular, Bayer AG, Wuppertal, Germany
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Casulleras M, Zhang IW, López-Vicario C, Clària J. Leukocytes, Systemic Inflammation and Immunopathology in Acute-on-Chronic Liver Failure. Cells 2020; 9:E2632. [PMID: 33302342 PMCID: PMC7762372 DOI: 10.3390/cells9122632] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/20/2020] [Accepted: 12/01/2020] [Indexed: 02/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a complex syndrome that develops in patients with cirrhosis and is characterized by acute decompensation, organ failure(s) and high short-term mortality. ACLF frequently occurs in close temporal relationship to a precipitating event, such as acute alcoholic, drug-induced or viral hepatitis or bacterial infection and, in cases without precipitating events, probably related to intestinal translocation of bacterial products. Dysbalanced immune function is central to its pathogenesis and outcome with an initial excessive systemic inflammatory response that drives organ failure and mortality. This hyperinflammatory state ultimately impairs the host defensive mechanisms of immune cells, rendering ACLF patients immunocompromised and more vulnerable to secondary infections, and therefore to higher organ dysfunction and mortality. In this review, we describe the prevailing characteristics of the hyperinflammatory state in patients with acutely decompensated cirrhosis developing ACLF, with special emphasis on cells of the innate immune system (i.e., monocytes and neutrophils), their triggers (pathogen- and damage-associated molecular patterns [PAMPs and DAMPs]), their effector molecules (cytokines, chemokines, growth factors and bioactive lipid mediators) and the consequences on tissue immunopathology. In addition, this review includes a chapter discussing new emerging therapies based on the modulation of leukocyte function by the administration of pleiotropic proteins such as albumin, Toll-like receptor 4 antagonists, interleukin-22 or stem cell therapy. Finally, the importance of finding an appropriate intervention that reduces inflammation without inducing immunosuppression is highlighted as one of the main therapeutic challenges in cirrhosis.
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Affiliation(s)
- Mireia Casulleras
- Biochemistry and Molecular Genetics Service, Hospital Clínic-IDIBAPS, 08036 Barcelona, Spain; (M.C.); (I.W.Z.)
- European Foundation for the Study of Chronic Liver Failure (EF Clif) and Grifols Chair, 08021 Barcelona, Spain
| | - Ingrid W. Zhang
- Biochemistry and Molecular Genetics Service, Hospital Clínic-IDIBAPS, 08036 Barcelona, Spain; (M.C.); (I.W.Z.)
- European Foundation for the Study of Chronic Liver Failure (EF Clif) and Grifols Chair, 08021 Barcelona, Spain
| | - Cristina López-Vicario
- Biochemistry and Molecular Genetics Service, Hospital Clínic-IDIBAPS, 08036 Barcelona, Spain; (M.C.); (I.W.Z.)
- European Foundation for the Study of Chronic Liver Failure (EF Clif) and Grifols Chair, 08021 Barcelona, Spain
| | - Joan Clària
- Biochemistry and Molecular Genetics Service, Hospital Clínic-IDIBAPS, 08036 Barcelona, Spain; (M.C.); (I.W.Z.)
- European Foundation for the Study of Chronic Liver Failure (EF Clif) and Grifols Chair, 08021 Barcelona, Spain
- Department of Biomedical Sciences, School of Medicine and Health Sciences, Universitat de Barcelona, 08036 Barcelona, Spain
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Diagnostic Value of Presepsin for Bacterial Infection in Cirrhosis: A Pilot Study. Transplant Proc 2020; 52:1593-1600. [PMID: 32305204 DOI: 10.1016/j.transproceed.2020.02.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/28/2020] [Accepted: 02/05/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Presepsin (or sCD14) has been identified as a protein whose levels increase specifically in the blood of patients with bacterial infections. In this study, we evaluated the clinical performance of sCD14 and its usefulness in the early diagnosis of bacterial infection in decompensated cirrhotic patients. MATERIALS Seventy patients were enrolled in this study. The mean age of patients was 49.5 years, and 21 were women and 49 men. The heparinized whole blood for the PATHFAST test was used in the evaluation of bacterial infection (T0). The test was repeated after 48 hours (T1); at 96 hours (T2); at 144 hours (T3); then at 15 days (T4) to monitor the clinical responses to therapeutic interventions. RESULTS Forty-nine patients tested positive for sCD14. The mean sCD14 level was 1854 ± 1744 pg/mL. Microbiological findings confirmed the presence of bacterial infections within 84 ± 4.8 h from enrollment in all 49 positive patients. Thirty-eight patients were considered responders to empirical antibiotic therapy with a decrease of presepsin at the different time points, while an increased level of sCD14 was highlighted in 11 patients. When the test was performed, 45% of the patients showed no signs or symptoms of bacterial infection. At 30 days of follow-up 43 patients survived, and 6 patients died from septic shock. CONCLUSIONS The PATHFAST test highlighted the presence of infection in a very short time (15 minutes), and the presepsin could be considered an early biomarker in patients with cirrhosis. A greater number of patients are necessary to confirm these data.
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Martin Mateos R, Albillos A. Sepsis in Patients With Cirrhosis Awaiting Liver Transplantation: New Trends and Management. Liver Transpl 2019; 25:1700-1709. [PMID: 31408581 DOI: 10.1002/lt.25621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023]
Abstract
Bacterial infections are more frequent and severe in patients with advanced liver disease and, therefore, in liver transplant candidates. The increased risk of infection in these patients parallels the severity of the immune dysfunction associated with cirrhosis, which is related to systemic inflammation and progressive immunodeficiency. Other factors contribute to this risk, such as genetic polymorphisms, proton pump inhibitor overuse, the numerous invasive procedures and hospitalizations these patients go through, or the immunosuppressive effects of malnutrition or alcohol abuse. Bacterial infections have a great impact on disease progression and significantly increase mortality rates before and after liver transplantation. Mechanisms leading to organ failure in sepsis are associated not only with the hemodynamic derangement but also with an excessive inflammatory response triggered by infection. Furthermore, prophylactic and empirical antibiotic treatment strategies in patients with cirrhosis are being modified according to the growing prevalence of multidrug-resistant bacteria in the past decade. Also, new criteria have been introduced for the diagnosis of sepsis and septic shock. These new definitions have been validated in patients with cirrhosis and show a better accuracy to predict in-hospital mortality than previous criteria based on systemic inflammatory response syndrome. Accurate prophylaxis and early identification and treatment of bacterial infections are key to reducing the burden of sepsis in patients with cirrhosis awaiting liver transplantation.
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Affiliation(s)
- Rosa Martin Mateos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
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Metwally K, Fouad T, Assem M, Abdelsameea E, Yousery M. Predictors of Spontaneous Bacterial Peritonitis in Patients with Cirrhotic Ascites. J Clin Transl Hepatol 2018; 6:372-376. [PMID: 30637213 PMCID: PMC6328737 DOI: 10.14218/jcth.2018.00001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 06/07/2018] [Accepted: 06/22/2018] [Indexed: 12/14/2022] Open
Abstract
Background and Aims: Spontaneous bacterial peritonitis (SBP) is a serious complication of liver cirrhosis and a prognostic model to predict it is needed. This study was designed to test the ability of different laboratory tests and the new scoring system by Wehmeyer and colleagues (consisting of age, C-reactive protein (CRP) and platelet count) to predict it. Methods: Three-hundred patients admitted to the National Liver Institute, University of Menoufia, Egypt (2015-2016) with liver cirrhosis and ascites were included in our study. SBP was diagnosed if ascetic neutrophil count was ≥250/µL with no sign of secondary peritonitis. Results: The patient population had age range of 29-81 years old, was 60% men and showed a majority (91.7%) with primary cause of liver disease being hepatitis C. By univariate analysis, associations with age, total bilirubin, aspartate aminotransferase level, creatinine level, international normalized ratio, model for end-stage liver disease score, total leucocytic count, platelet count and CRP level were significant. By multivariate analysis, independent predictors were age, platelet count and CRP level (p = 0.004, 0.013 and <0.001, respectively). CRP at a cut-off point ≥13.5 mg/L could predict SBP (sensitivity of 86.4% and specificity of 66.0%). Wehmeyer's SBP scoring system was predictive (p < 0.001); only 4% of patients with 0 score developed SBP (CRP cut-off of 30 mg/L), while 92.8% with score of 3 or 4 developed SBP. By using our modified Wehmeyer score with CRP cut-off value of 13.5 mg/L, no patient with 0 score developed SBP. Conclusions: Age, CRP level and platelet count are independent predictors for SBP and a scoring system including them could easily predict the condition. SBP diagnosis could be excluded in patients with 0 score, using CRP cut-off value of 13.5 mg/L.
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Affiliation(s)
- Khaled Metwally
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
- *Correspondence to: Khaled Metwally, Liver and Gastroenterology Unit, National Liver Institute, University of Menoufyia, Menofyia Governorate, Egypt. Tel: +20-100-0486019, Fax: + 20-48-2222740, E-mail:
| | - Tamer Fouad
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
| | - Medhat Assem
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
| | - Eman Abdelsameea
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
| | - Mohamed Yousery
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
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Li Y, Chaiteerakij R, Kwon JH, Jang JW, Lee HL, Cha S, Ding XW, Thongprayoon C, Ha FS, Nie CY, Zhang Q, Yang Z, Giama NH, Roberts LR, Han T. A model predicting short-term mortality in patients with advanced liver cirrhosis and concomitant infection. Medicine (Baltimore) 2018; 97:e12758. [PMID: 30313084 PMCID: PMC6203558 DOI: 10.1097/md.0000000000012758] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Infection is a common cause of death in patients with advanced cirrhosis. We aimed to develop a predictive model in Child-Turcotte-Pugh (CTP) class C cirrhotics hospitalized with infection for optimizing treatment and improving outcomes.Clinical information was retrospectively abstracted from 244 patients at Tianjin Third Central Hospital, China (cohort 1). Factors associated with mortality were determined using logistic regression. The model for predicting 90-day mortality was then constructed by decision tree analysis. The model was further validated in 91 patients at Mayo Clinic, Rochester, MN (cohort 2) and 82 patients at Seoul St. Mary's Hospital, Korea (cohort 3). The predictive performance of the model was compared with that of the CTP, model for end-stage liver disease (MELD), MELD-Na, Chronic Liver Failure-Sequential Organ Failure Assessment, and the North American consortium for the Study of End-stage Liver Disease (NACSELD) models.The 3-month mortality was 58%, 58%, and 54% in cohort 1, 2, and 3, respectively. In cohort 1, respiratory failure, renal failure, international normalized ratio, total bilirubin, and neutrophil percentage were determinants of 3-month mortality, with odds ratios of 16.6, 3.3, 2.0, 1.1, and 1.03, respectively (P < .05). These parameters were incorporated into the decision tree model, yielding area under receiver operating characteristic (AUROC) of 0.804. The model had excellent reproducibility in the U.S. (AUROC 0.808) and Korea cohort (AUROC 0.809). The proposed model has the highest AUROC and best Youden index of 0.488 and greatest overall correctness of 75%, compared with other models evaluated.The proposed model reliably predicts survival of advanced cirrhotics with infection in both Asian and U.S.
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Affiliation(s)
- Ying Li
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Roongruedee Chaiteerakij
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jung Hyun Kwon
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon
| | - Jeong Won Jang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hae Lim Lee
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Stephen Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN
| | - Xi Wei Ding
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Charat Thongprayoon
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Fu Shuang Ha
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
| | - Cai Yun Nie
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
| | - Qian Zhang
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
| | - Zhen Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Nasra H. Giama
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Lewis R. Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Tao Han
- Department of Hepatology and Gastroenterology, Tianjin Third Central Hospital Affiliated to Tianjin Medical University, Tianjin Key Laboratory of Artificial Cells, Tianjin, China
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Elefsiniotis I, Tsakiris SA, Barla G, Tasovasili A, Vrachatis D, Mavrogiannis C. Presepsin levels in cirrhotic patients with bacterial infections and/or portal hypertension-related bleeding, presenting with or without acute kidney injury. Ann Gastroenterol 2018; 31:604-612. [PMID: 30174398 PMCID: PMC6102455 DOI: 10.20524/aog.2018.0292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/25/2018] [Indexed: 12/28/2022] Open
Abstract
Background Bacterial infections in cirrhotic patients remain a challenge. Presepsin has been proposed as a valuable sepsis biomarker. We aimed to assess plasma presepsin levels in uncomplicated cirrhotic patients and to correlate them with liver disease severity and complicating events, defined as documented bacterial infection with or without concomitant portal hypertension-related bleeding, or bleeding without documented bacterial infection, with or without acute kidney injury. Methods We prospectively evaluated the presepsin levels of 108 consecutive uncomplicated cirrhotic patients with compensated (55, 50.9%) or decompensated (53, 49.1%) cirrhosis. During the follow up, 20 patients were reevaluated for a complicating event. Results Mean baseline presepsin levels of the entire population were 440.4 pg/mL. Patients with decompensated cirrhosis exhibited significantly higher baseline levels than patients with compensated cirrhosis (599.1±492.2 vs. 287.5±130.5 pg/mL, P<0.001). In complicated cirrhotic patients, admission levels were remarkably higher than baseline (1438.0±1247.2 vs. 725.3±602.8 pg/mL, P<0.001), especially in those who developed acute kidney injury compared to those who did not (1827.3±1118.8 vs. 1048.7±1302.1 pg/mL, P<0.05). Baseline presepsin levels, using a cutoff of 607.5 pg/mL, could predict liver disease-related 3-month mortality with 77.8% sensitivity and 86.9% specificity: area under the receiver operating characteristic curve 0.825; 95% confidence interval 0.684-0.967; P<0.01. Conclusions Plasma presepsin levels are elevated in uncomplicated cirrhotic patients, especially in those with advanced liver disease, and rise further in those complicated by an event. Baseline presepsin levels in cirrhotic patients could be used as an additional marker, along with the model for end-stage liver disease score, to predict short-term outcomes.
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Affiliation(s)
- Ioannis Elefsiniotis
- Academic Department of Internal Medicine, Hepatogastroenterology Unit, "Agioi Anargyroi" General and Oncology Hospital of Kifisia, National and Kapodistrian University of Athens, Greece, The study was partially supported by an unrestricted research grant from AbbVie Pharmaceuticals S.A. The authors state that AbbVie Pharmaceuticals S.A. had no involvement in the study design, collection, analysis, interpretation of data, writing of the report or the decision to submit the manuscript for publication
| | - Stefanos A Tsakiris
- Academic Department of Internal Medicine, Hepatogastroenterology Unit, "Agioi Anargyroi" General and Oncology Hospital of Kifisia, National and Kapodistrian University of Athens, Greece, The study was partially supported by an unrestricted research grant from AbbVie Pharmaceuticals S.A. The authors state that AbbVie Pharmaceuticals S.A. had no involvement in the study design, collection, analysis, interpretation of data, writing of the report or the decision to submit the manuscript for publication
| | - Georgia Barla
- Academic Department of Internal Medicine, Hepatogastroenterology Unit, "Agioi Anargyroi" General and Oncology Hospital of Kifisia, National and Kapodistrian University of Athens, Greece, The study was partially supported by an unrestricted research grant from AbbVie Pharmaceuticals S.A. The authors state that AbbVie Pharmaceuticals S.A. had no involvement in the study design, collection, analysis, interpretation of data, writing of the report or the decision to submit the manuscript for publication
| | - Athanasia Tasovasili
- Academic Department of Internal Medicine, Hepatogastroenterology Unit, "Agioi Anargyroi" General and Oncology Hospital of Kifisia, National and Kapodistrian University of Athens, Greece, The study was partially supported by an unrestricted research grant from AbbVie Pharmaceuticals S.A. The authors state that AbbVie Pharmaceuticals S.A. had no involvement in the study design, collection, analysis, interpretation of data, writing of the report or the decision to submit the manuscript for publication
| | - Dimitrios Vrachatis
- Academic Department of Internal Medicine, Hepatogastroenterology Unit, "Agioi Anargyroi" General and Oncology Hospital of Kifisia, National and Kapodistrian University of Athens, Greece, The study was partially supported by an unrestricted research grant from AbbVie Pharmaceuticals S.A. The authors state that AbbVie Pharmaceuticals S.A. had no involvement in the study design, collection, analysis, interpretation of data, writing of the report or the decision to submit the manuscript for publication
| | - Christos Mavrogiannis
- Academic Department of Internal Medicine, Hepatogastroenterology Unit, "Agioi Anargyroi" General and Oncology Hospital of Kifisia, National and Kapodistrian University of Athens, Greece, The study was partially supported by an unrestricted research grant from AbbVie Pharmaceuticals S.A. The authors state that AbbVie Pharmaceuticals S.A. had no involvement in the study design, collection, analysis, interpretation of data, writing of the report or the decision to submit the manuscript for publication
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18
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Ferrarese A, Zanetto A, Becchetti C, Sciarrone SS, Shalaby S, Germani G, Gambato M, Russo FP, Burra P, Senzolo M. Management of bacterial infection in the liver transplant candidate. World J Hepatol 2018; 10:222-230. [PMID: 29527258 PMCID: PMC5838441 DOI: 10.4254/wjh.v10.i2.222] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 12/29/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection (BI) is a common cause of impairment of liver function in patients with cirrhosis, especially in the liver transplant candidates. These patients share an immunocompromised state and increased susceptibility to develop community and hospital-acquired infections. The changing epidemiology of BI, with an increase of multidrug resistant strains, especially in healthcare-associated settings, represents a critical issue both in the waiting list and in the post-operative management. This review focused on the role played by BI in patients awaiting liver transplantation, evaluating the risk of drop-out from the waiting list, the possibility to undergo liver transplantation after recovery from infection or during a controlled infection.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Salvatore Stefano Sciarrone
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Sarah Shalaby
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
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Clària J, Arroyo V, Moreau R. The Acute-on-Chronic Liver Failure Syndrome, or When the Innate Immune System Goes Astray. THE JOURNAL OF IMMUNOLOGY 2017; 197:3755-3761. [PMID: 27815438 DOI: 10.4049/jimmunol.1600818] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/24/2016] [Indexed: 12/20/2022]
Abstract
The acute-on-chronic liver failure (ACLF) syndrome is characterized by acute decompensation of cirrhosis, organ failure, and high 28-d mortality. ACLF displays key features of systemic inflammation and its poor outcome is closely associated with exacerbated systemic inflammatory responses. In this review, we describe the prevailing characteristics of systemic inflammation in patients with decompensated cirrhosis and ACLF, with special emphasis on the principal features of the cytokine storm the mechanisms underlying this intense systemic inflammatory response (i.e., presence of circulating pathogen- and damage-associated molecular patterns), and their implication in tissue and organ damage in this condition.
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Affiliation(s)
- Joan Clària
- Servei de Bioquímica i Genètica Molecular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona 08036, Spain; .,Department of Biomedical Sciences, University of Barcelona, Barcelona 08036, Spain
| | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure, Barcelona 08021, Spain; and
| | - Richard Moreau
- INSERM, Université Paris Diderot, Centre de Recherche sur l'Inflammation, Paris 75018, France
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Short article: Impact of genetic variation in the vasopressin 1a receptor on the development of organ failure in patients admitted for acute decompensation of liver cirrhosis. Eur J Gastroenterol Hepatol 2017; 29:535-538. [PMID: 28350742 DOI: 10.1097/meg.0000000000000834] [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] [Indexed: 12/10/2022]
Abstract
BACKGROUND Vasopressin receptor-mediated vasoconstriction is considered to be involved in the pathogenesis of organ failure in acute-on-chronic liver failure (ACLF). PATIENTS AND METHODS We studied the association between six single nucleotide polymorphisms (SNPs) of the vasopressin 1a receptor gene and the development of organ failure in 826 patients admitted for acute decompensation of liver cirrhosis (n=641) or ACLF (n=185). RESULTS No associations were found for SNPs with the presence of circulatory or renal failure. A C>T mutation in SNP rs7308855 and a T>A mutation in SNP rs7298346 showed an association with the presence of coagulation failure in the entire population (n=61, P=0.024 and 0.060, respectively) and in the subgroup of patients with ACLF (n=44, P=0.081 and 0.056, respectively). CONCLUSION Genetic variation in the vasopressin 1a receptor was found not to be associated with circulatory or renal failure, but with the presence of coagulation failure in patients with acute decompensation of liver cirrhosis and ACLF.
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Wong F, Pappas SC, Boyer TD, Sanyal AJ, Bajaj JS, Escalante S, Jamil K. Terlipressin Improves Renal Function and Reverses Hepatorenal Syndrome in Patients With Systemic Inflammatory Response Syndrome. Clin Gastroenterol Hepatol 2017; 15:266-272.e1. [PMID: 27464593 DOI: 10.1016/j.cgh.2016.07.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/24/2016] [Accepted: 07/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with systemic inflammatory response syndrome (SIRS) along with decompensated cirrhosis and renal dysfunction have a poor prognosis and a lower response to treatment. We evaluated the effect of SIRS on the response of hepatorenal syndrome type 1 (HRS-1) to terlipressin. METHODS We performed a retrospective study of data from a trial of the effects of terlipressin (1 mg every 6 hours or placebo with concomitant albumin) in 198 patients with HRS-1, performed at 50 investigational sites in the United States and 2 in Canada from October 2010 through February 2013. We identified patients with 2 or more criteria for SIRS, without untreated infections (28 received terlipressin and 30 received placebo), and patients with less than 2 criteria for SIRS (control subjects). Primary endpoints included HRS reversal (a decrease in serum level of creatinine to ≤1.5 mg/dL), confirmed HRS reversal (defined as 2 serum creatinine levels ≤1.5 mg/dL, ≥ 48 hours apart), and survival for 90 days after treatment. RESULTS Baseline characteristics were similar between groups, apart from slightly higher white blood cell counts and heart rates, and slightly lower serum levels of bicarbonate in patients with SIRS versus without SIRS. HRS was reversed in 42.9% of patients who received terlipressin with SIRS (12/28) versus 6.7% of patients who received placebo (2/30) (P = .0018); confirmed HRS reversal occurred in 32.1% of patients who received terlipressin with SIRS (9/28) versus 3.3% who received placebo (1/30) (P = .0048). A larger proportion of patients with SIRS who received terlipressin survived for 90 days without a transplant (13/28; 46.4%) than patients with SIRS who received placebo (7/30; 23.3%) (P = .076). CONCLUSIONS In an analysis of data from a placebo-controlled study, we found that terlipressin improved renal function and reversed HRS in a higher proportion of patients with HRS-1 and SIRS than patients who received albumin plus placebo. ClincialTrials.gov, number NCT 01143246.
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Affiliation(s)
- Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | | | - Thomas D Boyer
- Department of Medicine, University of Arizona, Tucson, Arizona
| | - Arun J Sanyal
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | | | - Khurram Jamil
- Ikaria Therapeutics LLC/a Mallinckrodt Company, Hampton, New Jersey
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Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference. Dig Liver Dis 2016; 48:455-467. [PMID: 27012444 DOI: 10.1016/j.dld.2016.02.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.
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The usefulness of C-reactive protein and neutrophil-to-lymphocyte ratio for predicting the outcome in hospitalized patients with liver cirrhosis. BMC Gastroenterol 2015; 15:146. [PMID: 26498833 PMCID: PMC4619077 DOI: 10.1186/s12876-015-0378-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 10/15/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The role of clinical parameters such as systemic inflammatory response syndrome (SIRS) criteria in predicting the infection remains unclear in cirrhosis patients. The aim was to evaluate the usefulness of inflammatory markers including C-reactive protein (CRP) and the neutrophil-to-lymphocyte ratio (NLR) for diagnosis of infection and predicting the outcomes in hospitalized cirrhotic patients. METHODS The study included 184 cirrhotic patients consecutively hospitalized from 2011 to 2012. The presence of overt infection and survival was evaluated. CRP concentration, NLR, Model for End-Stage Liver Disease (MELD) score and the presence of SIRS were assessed. RESULTS The main cause of admission was uncontrolled ascites (36.4 %), followed by varix bleeding (23.9 %), and hepatic encephalopathy (13.6 %). Fifty-eight patients (31.5 %) had overt infection during hospitalization and thirty-two patients (17.4 %) expired during the follow up period (median 38 months). Ninety-two patients (52.2 %) fulfilled the SIRS criteria and among them, only 32 patients (38.5 %) had the overt infection. For diagnose of the infection, baseline CRP concentration was a significant factor compared to the presence of SIRS (odds ratio 1.202, P = 0.003). For predicting one-month short-term survival, MELD score, NLR and WBC count were significant factors but in Child-Pugh class C patients, NLR was only an independent factor. CONCLUSIONS CRP was a significant indicator of infection in hospitalized cirrhotic patients and a NLR was a useful predictor of 1-month survival, particularly in Child-Pugh class C patients. This study suggests that the inflammatory markers such as CRP and NLR can help identify cirrhotic patients at risk of unfavorable outcomes.
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Mendell J, Johnson L, Chen S. An open-label, phase 1 study to evaluate the effects of hepatic impairment on edoxaban pharmacokinetics and pharmacodynamics. J Clin Pharmacol 2015; 55:1395-405. [PMID: 26011596 DOI: 10.1002/jcph.550] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/13/2015] [Indexed: 12/31/2022]
Abstract
Edoxaban, a once-daily, oral, direct factor Xa inhibitor, is approved for stroke prevention in nonvalvular atrial fibrillation and venous thromboembolism treatment. This study examined the effects of mild or moderate hepatic impairment on the pharmacokinetics of edoxaban and its metabolite M4. Thirty-three subjects enrolled in 4 treatment cohorts-mild hepatic impairment (n = 8), moderate hepatic impairment (n = 9), and 2 cohorts of healthy controls matched for age, sex, and weight (each n = 8)-and received a single 15-mg dose of edoxaban. Plasma pharmacokinetics for edoxaban and M4, prothrombin time (PT), activated partial thromboplastin time (aPTT), and safety data were measured over 72 hours. Edoxaban and M4 exposures were similar in subjects with mild or moderate hepatic impairment compared with matched controls. Higher PT and aPTT values were observed at baseline and after edoxaban dosing in the hepatic impairment groups compared with healthy controls. Edoxaban 15 mg was well tolerated in all cohorts. These results suggest that edoxaban exposure does not significantly increase in patients with mild or moderate hepatic impairment. However, because of the potential for underlying coagulopathy, edoxaban is not recommended for use in patients with moderate or severe hepatic impairment. No dose reduction is recommended for patients with mild hepatic impairment.
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Affiliation(s)
| | | | - Shuquan Chen
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
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Scoring system for traumatic liver injury (SSTLI) in polytraumatic patients: a predictor of mortality. Eur J Trauma Emerg Surg 2015; 41:375-85. [PMID: 26037988 DOI: 10.1007/s00068-014-0454-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to examine prognostic factors in polytraumatic patients with liver injury and to develop a scoring system for traumatic liver injury (SSTLI) to predict mortality. METHODS The medical records of 175 patients treated for traumatic liver injury from July 2009 to April 2013 were reviewed. The primary outcome variable was hospital mortality. All risk factors were analyzed by multivariate logistic regression analysis. The SSTLI was created based on the predictive power of each factor. RESULTS Age, injury severity score (ISS), trauma and injury severity score, the shock index, and the volume of packed red blood cells transfused were strong predictors of mortality. We hypothesized that the SSTLI would use five clinical measures (total bilirubin, prothrombin time, serum creatinine, age, and ISS). Each measure was scored 0-1 (age and ISS) or 0-3 (total bilirubin, prothrombin time, and creatinine), with 3 indicating the most severe derangement. The receiver-operating characteristic curve of the SSTLI was significant at post-traumatic days 0, 1, 3, and 5 [area under the curve (AUC), 0.830; AUC, 0.912; AUC, 0.941; and AUC, 0.930, respectively]. A value of 5 points was the threshold for reliability dividing low-risk (<5) from high-risk (≥5) patients. CONCLUSIONS The SSTLI may be available to predict mortality in polytraumatic patients with liver injury, although external validation is needed before widespread implementation.
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Wu Q, Ren J, Wang G, Gu G, Hu D, Liu S, Li G, Chen J, Li R, Hong Z, Ren H, Wu X, Li Y, Yao M, Zhao Y, Li J. Evaluating the safety and efficacy of recombinant human thrombopoietin among severe sepsis patients with thrombocytopenia: study protocol for a randomized controlled trial. Trials 2015; 16:220. [PMID: 25986785 PMCID: PMC4488939 DOI: 10.1186/s13063-015-0746-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 05/06/2015] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is still a major health problem that causes high mortality in all populations. Organ dysfunction including sepsis-associated thrombocytopenia is prevalent among sepsis patients, resulting in increasing mortality rates. Considering the clinical role of platelets, thrombocytopenia in sepsis has led to a large spend in research activity and clinical trials in this area, yet there is no consensus upon which treatment should be administered. As a result, platelet transfusion is often indicated to resolve low platelet counts, leading to an increasing risk of the multiple risks transfusion brings, such as infectious or immune system complications. Given the role of thrombopoietin in stimulating proliferation and differentiation of megakaryocytes, our previous study investigated the potential benefits of recombinant human thrombopoietin in severe sepsis patients with thrombocytopenia. However, there are several limitations in the study, which may have led to bias in our conclusion. Thus, we are conducting this study in order to evaluate the safety and efficacy of recombinant human thrombopoietin in a large, varied population. Methods/Design The study is designed as a randomized, open-label, placebo-controlled, multi-center study in tertiary academic centers for evaluating the safety and efficacy of recombinant human thrombopoietin over placebo. An established total of 708 patients with sepsis and thrombocytopenia will undergo prospective random assignment to recombinant human thrombopoietin or placebo (a 1:1 ratio). The primary endpoint is 7-day all-cause mortality and 28-day all-cause mortality. Discussion To our knowledge, this is the first study to evaluate the safety and efficacy of recombinant human thrombopoietin among severe sepsis patients with thrombocytopenia in a varied population. With our study, the level of evidence for the treatment of these patients will be significantly raised. Trial registration ClinicalTrials.gov: NCT02094248. Registration date: 23 March 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0746-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qin Wu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Jianan Ren
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Gefei Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Guosheng Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Dong Hu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Song Liu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Gunawei Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Jun Chen
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Ranran Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Zhiwu Hong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Huajian Ren
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Xiuwen Wu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Yuan Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Min Yao
- Department of Surgery, VA Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA.
| | - Yunzhao Zhao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhong Shan Road, Nanjing, 210002, China.
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Sureka B, Bansal K, Patidar Y, Kumar S, Arora A. Thoracic perspective revisited in chronic liver disease. Gastroenterol Rep (Oxf) 2015; 3:194-200. [PMID: 25969457 PMCID: PMC4527268 DOI: 10.1093/gastro/gov017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
A variety of chest manifestations are seen in patients with chronic liver diseases, namely hepatopulmonary syndrome, portopulmonary hypertension, intrathoracic portosystemic collaterals, hepatic hydrothorax, infections, drug-induced changes, manifestations of hepatocellular carcinoma, gynecomastia, acute respiratory distress syndrome, autoimmune changes, aspiration pneumonitis and changes due to α1-antitrypsin deficiency. Gastroenterologists and radiologists should be aware of these entities; knowledge of the imaging findings specific to each condition is of prime importance for managing such patients.
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Affiliation(s)
- Binit Sureka
- Department of Radiology/Interventional Radiology and
| | | | | | - Sachin Kumar
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Arora
- Department of Radiology/Interventional Radiology and
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Interleukin-6 as an early diagnostic marker for bacterial sepsis in patients with liver cirrhosis. J Crit Care 2015; 30:732-8. [PMID: 25891645 DOI: 10.1016/j.jcrc.2015.03.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 03/25/2015] [Accepted: 03/28/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Liver cirrhosis is associated with frequent bacterial infections that increase the mortality rate. However, the early diagnosis and treatment of these infections are often difficult. In this retrospective-prospective observational study, the serum levels of interleukin-6 (IL-6) and procalcitonin (PCT) were measured in 233 cirrhotic patients to evaluate the early diagnostic and prognostic values of IL-6 and PCT for cirrhotic patients. METHODS Cirrhotic patients admitted to the Liver Research Center of the First Affiliated Hospital of Fujian Medical University between 1 October 2012 and 30 June 2014 were enrolled. They showed no evidence of infection on admission, and all had first onset of fever and met the systemic inflammatory response syndrome criteria 72 hours after admission. The serum IL-6 and PCT levels were determined on admission, at the onset of fever (0 hour) and 24 and 48 hours after fever onset. RESULTS A total of 233 cirrhotic patients, including 183 men and 50 women, with a median age of 56 (46-65) years were enrolled. A training group of 159 patients was retrospectively enrolled from 1 October 2012 to 31 December 2013, and a validation group of 74 patients was prospectively enrolled from 1 January 2014 to 30 June 2014. Among these patients, 134 were diagnosed with bacterial sepsis, 96 of whom were in the training group and 38 of whom were in the validation group; infections were ultimately ruled out in 99 patients: 63 training patients and 36 validation patients. At 0 hour, the IL-6 and PCT levels as well as the proportion of neutrophils were much higher in septic patients than in nonseptic ones. The IL-6 level and proportion of neutrophils peaked upon the onset of fever, 24 hours before the PCT levels and white blood cell count, and then sharply declined. The area under the receiver operating characteristic curve of IL-6 for diagnosing sepsis was largest at the onset of fever (area under the receiver operating characteristic curve, 0.983; 95% confidence interval, 0.967-0.999). The threshold of IL-6 for diagnosis was 135 pg/mL, with a sensitivity of 94.8% and a specificity of 93.7%. These diagnostic values were also confirmed in the validation group, with a sensitivity of 97.4% and specificity of 80.6%. Eleven (11.5%) patients died, and 85 (88.5%) patients recovered in the sepsis group of training patients after a 4-week follow-up. The IL-6 level was significantly higher in the nonsurvival group than that in the survival group (1813.00 vs 472.10 pg/mL, P = .004) at the onset of sepsis. The cutoff value for predicting prognosis was 1105 pg/mL, with a sensitivity of 81.8% and a specificity of 76.5%. CONCLUSIONS The serum IL-6 levels increased earlier than the PCT in septic cirrhotic patients. The direct measurement of the serum IL-6 level can help to rapidly detect bacterial infection, thus allowing for early therapeutic decisions and prognostic predictions.
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Gustot T, Felleiter P, Pickkers P, Sakr Y, Rello J, Velissaris D, Pierrakos C, Taccone FS, Sevcik P, Moreno C, Vincent JL. Impact of infection on the prognosis of critically ill cirrhotic patients: results from a large worldwide study. Liver Int 2014; 34:1496-503. [PMID: 24606193 DOI: 10.1111/liv.12520] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 02/26/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infections are a leading cause of death in patients with advanced cirrhosis, but there are relatively few data on the epidemiology of infection in intensive care unit (ICU) patients with cirrhosis. AIMS We used data from the Extended Prevalence of Infection in Intensive Care (EPIC) II 1-day point-prevalence study to better define the characteristics of infection in these patients. METHODS We compared characteristics, including occurrence and types of infections in non-cirrhotic and cirrhotic patients who had not undergone liver transplantation. RESULTS The EPIC II database includes 13,796 adult patients from 1265 ICUs: 410 of the patients had cirrhosis. The prevalence of infection was higher in cirrhotic than in non-cirrhotic patients (59 vs. 51%, P < 0.01). The lungs were the most common site of infection in all patients, but abdominal infections were more common in cirrhotic than in non-cirrhotic patients (30 vs. 19%, P < 0.01). Infected cirrhotic patients more often had Gram-positive (56 vs. 47%, P < 0.05) isolates than did infected non-cirrhotic patients. Methicillin-resistant Staphylococcus aureus (MRSA) was more frequent in cirrhotic patients. The hospital mortality rate of cirrhotic patients was 42%, compared to 24% in the non-cirrhotic population (P < 0.001). Severe sepsis and septic shock were associated with higher in-hospital mortality rates in cirrhotic than in non-cirrhotic patients (41% and 71% vs. 30% and 49%, respectively, P < 0.05). CONCLUSIONS Infection is more common in cirrhotic than in non-cirrhotic ICU patients and more commonly caused by Gram-positive organisms, including MRSA. Infection in patients with cirrhosis was associated with higher mortality rates than in non-cirrhotic patients.
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Affiliation(s)
- Thierry Gustot
- Department of Gastroenterology and Hepatopancreatology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Ding H, Cao XY, Ma XG, Zhou WJ. Endothelial cell injury with inflammatory cytokine and coagulation in patients with sepsis. World J Emerg Med 2014; 4:285-9. [PMID: 25215134 DOI: 10.5847/wjem.j.issn.issn.1920-8642.2013.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 10/11/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Current studies on CD62P have focused mainly on cardiovascular diseases, while only few studies have evaluated the effects of CD62P on the development of sepsis and the association between endothelial cell injury with inflammation and coagulation. This study attended to explore the association between endothelial cell injury with inflammation and coagulation by evaluating the expression of soluble CD62P (s-CD62P) in plasma and its mechanism in patients with sepsis, thus to provide the evidence of effective treatment of sepsis with anti-adhesion therapy targeted CD62P. METHODS A total of 70 critically ill patients with systemic inflammatory response syndrome (SIRS) admitted to intensive care unit (ICU) between September 2009 and February 2010 were enrolled for a prospective and control study. According to the diagnostic criteria of sepsis/SIRS, the patients were divided into two groups: a sepsis group (n=38) and a SIRS group (n=32). Another 20 healthy volunteers served as a control group. Patients in the sepsis group and SIRS group were matched by clinical signs of high blood pressure, diabetes and its complications. The demographics of the patients including age, sex, body mass index (BMI), smoking and alcohol addict were compared among the groups. Six mL peripheral blood samples were collected within 24-hour admission in ICU for enzymelinked immunosorbent assay (ELISA) to detect the plasma levels of s-CD62P, TNF-α, and hs-CRP. And variables of coagulation function such as platelet (PLT), prothrombin (PT), activated partial thromboplastin time (APTT), D-dimer and antithrombin-III (AT-III) were analyzed during 24 hours after admission to ICU. Meanwhile sequential organ failure assessment (SOFA) score of critically ill patients was evaluated. Data were expressed as mean±standard deviation and were statistically analyzed by using SPSS 17.0 statistical software. The differences in plasma levels of s-CD62P of patients in each group were analyzed by ANOVA and the Kruskal-Wallis test. The relations between s-CD62P and inflammatory cytokines as well as with coagulation were determined by Pearson's product moment correlation coefficient analysis. Changes were considered as statistically significant if P value was less than 0.05. RESULTS Compared with the control group and SIRS group, the sepsis group demonstrated significantly higher levels of s-CD62P, TNF-α and highly sensitive C-reactive protein (hs-CRP) (P<0.05). The plasma levels of D-dimer, PT, and APTT in the sepsis and SIRS groups were significantly higher than those in the control group, while the platelet count and the activity of AT-III were obviously lower (P<0.05). In the sepsis group, the plasma levels of hs-CRP and TNF-α were positively correlated with PT, APTT, and D-dimer, and negatively correlated with AT-III and PLT (P<0.05). The plasma levels of s-CD62P were significantly correlated with the plasma levels of TNF-α, hs-CRP, D-dimer, PT, and APTT, whereas they were correlated negatively well with PLT and AT-III (P<0.05). CONCLUSIONS The concentration of plasma s-CD62P is elevated as a early biomarker in patients with sepsis, and it serves as one of the pathogenic factors responsible for endothelial cell damage. Coagulation and mediators of inflammation promote each other, aggravating the severity of sepsis. Plasma s-CD62P may be an important factor for the development of coagulation and inflammatory reaction.
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Affiliation(s)
- Huan Ding
- Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xiang-Yuan Cao
- Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xi-Gang Ma
- Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Wen-Jie Zhou
- Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan 750004, China
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Abstract
OBJECTIVE To determine the evolution of the outcome of patients with cirrhosis and septic shock. DESIGN A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data. SETTING The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area. PATIENTS Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p < 0.0001) and higher prevalence of renal (71.5% vs 54.8%, p < 0.0001) and neurological (26.1% vs 19.5%, p < 0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p < 0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p < 0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04). CONCLUSIONS The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.
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Abstract
Coagulopathy in cirrhosis is a composite condition where liver synthetic deficit rebalances coagulation to a parallel reduction of both pro- and anticoagulant factors. Cirrhosis is therefore no longer considered a hypocoagulable state but rather a more unstable hemostatic balance with a lower threshold for tipping toward thrombosis or bleeding. Tendency to bleeding in cirrhosis is due to the reduction in the synthesis of procoagulants and a low platelet count as well as hyperfibrinolysis. Variceal hemorrhage is a frequent bleeding complication in decompensated cirrhosis. However, the possible contribution of coagulopathy as a precipitant or an aggravating factor is poorly documented and further data are required to clarify its real contributing role. Moreover, apart from the gastrointestinal tract, the occurrence of spontaneous and procedure-related bleeding elsewhere in the body, whilst not uncommon, is less than would be expected. By contrast, a large-scale population-based study has shown the propensity towards venous thrombosis in patients with liver diseases. Portal vein thrombosis (PVT) is a critical but frequent event occurring in up to 40% of patients with liver cirrhosis. PVT causes deterioration of the clinical course, the complications of portal hypertension and an increase in post-transplant mortality. The pathogenesis of PVT includes both local alterations, like blood flow reduction and endothelial activation, and systemic derangement. Systemic prohemostatic alterations include high von Willebrand factor, low ADAMTS-13, low levels of anticoagulants (antithrombin, proteins C and S) and increases in procoagulants like factor VIII. Low-molecular-weight heparin such as enoxaparin has proven to be safe and effective in both the treatment and prevention of PVT. In addition, patients in prophylaxis with enoxaparin showed a lower rate of decompensation and a better survival without bleeding complications. In such patients, circulating bacterial DNA, endotoxemia and markers of inflammation were attenuated compared to controls. These results therefore suggest a possible connection between enoxaparin, decrease of endotoxemia and reduction of portal hypertension. The approach to the coagulopathy in patients with liver diseases is changing: while the main goal for clinicians so far has been to reduce the risk of bleeding, the results of these new studies highlight the importance of preventing or treating thrombophilic disorders like PVT to avoid microcirculatory damage and eventually liver decompensation.
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Affiliation(s)
- Marcello Bianchini
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Abstract
Disseminated intravascular coagulation (DIC) is a complex abnormality of hemostasis with dramatic consequences and long described as associated with tumors. Yet the diagnosis and management of paraneoplastic DIC are poorly defined. The purpose of this paper is to review DIC associated with solid tumors, at the pathophysiological and therapeutic levels in particular. We also report data from a recent retrospective series of patients with DIC in the context of a solid tumor, to illustrate the epidemiological, clinical and prognostic.
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Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, Stadlbauer V, Gustot T, Bernardi M, Canton R, Albillos A, Lammert F, Wilmer A, Mookerjee R, Vila J, Garcia-Martinez R, Wendon J, Such J, Cordoba J, Sanyal A, Garcia-Tsao G, Arroyo V, Burroughs A, Ginès P. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol 2014; 60:1310-24. [PMID: 24530646 DOI: 10.1016/j.jhep.2014.01.024] [Citation(s) in RCA: 598] [Impact Index Per Article: 59.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/30/2013] [Accepted: 01/26/2014] [Indexed: 02/08/2023]
Abstract
Bacterial infections are very common and represent one of the most important reasons of progression of liver failure, development of liver-related complications, and mortality in patients with cirrhosis. In fact, bacterial infections may be a triggering factor for the occurrence of gastrointestinal bleeding, hypervolemic hyponatremia, hepatic encephalopathy, kidney failure, and development of acute-on-chronic liver failure. Moreover, infections are a very common cause of repeated hospitalizations, impaired health-related quality of life, and increased healthcare costs in cirrhosis. Bacterial infections develop as a consequence of immune dysfunction that occurs progressively during the course of cirrhosis. In a significant proportion of patients, infections are caused by gram-negative bacteria from intestinal origin, yet gram-positive bacteria are a frequent cause of infection, particularly in hospitalized patients. In recent years, infections caused by multidrug-resistant bacteria are becoming an important clinical problem in many countries. The reduction of the negative clinical impact of infections in patients with cirrhosis may be achieved by a combination of prophylactic measures, such as administration of antibiotics, to reduce the occurrence of infections in high-risk groups together with early identification and management of infection once it has developed. Investigation on the mechanisms of altered gut microflora, translocation of bacteria, and immune dysfunction may help develop more effective and safe methods of prevention compared to those that are currently available. Moreover, research on biomarkers of early infection may be useful in early diagnosis and treatment of infections. The current manuscript reports an in-depth review and a position statement on bacterial infections in cirrhosis.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, Royal Free Hospital, UK
| | - Javier Fernandez
- Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Reiner Wiest
- Department of Gastroenterology, UVCM, Inselspital, 3010 Bern, Switzerland
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Richard Moreau
- INSERM U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, UMRS 773, Université Paris-Diderot Paris, Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy, France
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, University of Padova, Italy
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Austria
| | - Thierry Gustot
- Department of Gastroenterology and Hepato-Pancreatology, Erasme Hospital, Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Rafael Canton
- Department of Microbiology, Hospital Universitario Ramón y Cajal and Intituto Ramon y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Agustin Albillos
- Gastroenterology Service, University Hospital Ramon y Cajal, Madrid, Spain
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Alexander Wilmer
- Medical Intensive Care Unit, University Hospital Gasthuisberg, Leuven, Belgium
| | - Rajeshwar Mookerjee
- Liver Failure Group, UCL Institute for Liver and Digestive Health, Royal Free Hospital, UK
| | - Jordi Vila
- Department of Microbiology, Hospital Clínic, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Rita Garcia-Martinez
- Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Julia Wendon
- Institute of Liver Studies and Critical Care, Kings College London, Kings College Hospital, UK
| | - José Such
- Department of Clinical Medicine, Miguel Hernández University, Alicante, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Cordoba
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Arun Sanyal
- Charles Caravati Professor of Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Guadalupe Garcia-Tsao
- Department of Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Andrew Burroughs
- The Royal Free Shelia Sherlock Liver Centre and University Department of Surgery, University College London and Royal Free Hospital, UK
| | - Pere Ginès
- Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain.
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Wu Q, Ren J, Wu X, Wang G, Gu G, Liu S, Wu Y, Hu D, Zhao Y, Li J. Recombinant human thrombopoietin improves platelet counts and reduces platelet transfusion possibility among patients with severe sepsis and thrombocytopenia: A prospective study. J Crit Care 2014; 29:362-6. [DOI: 10.1016/j.jcrc.2013.11.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 10/27/2013] [Accepted: 11/28/2013] [Indexed: 12/12/2022]
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Levesque E, Saliba F, Ichaï P, Samuel D. Outcome of patients with cirrhosis requiring mechanical ventilation in ICU. J Hepatol 2014; 60:570-8. [PMID: 24280294 DOI: 10.1016/j.jhep.2013.11.012] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 10/25/2013] [Accepted: 11/18/2013] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Mortality rate of patients with cirrhosis admitted to the intensive care unit (ICU) and requiring mechanical ventilation varies between 60 and 91%. The aim of our study is to assess the prognosis of these patients, their 1-year outcome and to analyze predictive factors of long-term mortality. METHODS From May 2005 to May 2011, we studied 246 consecutive patients with cirrhosis requiring mechanical ventilation either at admission or during their ICU stay. RESULTS Alcohol was the most common etiology of the cirrhosis (69%). Bleeding related to portal hypertension (30%) and severe sepsis (33%) were the most common reasons for admission. ICU and hospital mortality were respectively 65.9% and 70.3%. Prognostic severity scores, the need for other organ support therapy, infection, and total bilirubin value at ICU admission were significantly associated with ICU mortality. Eighty-four patients (34.1%) were discharged from the ICU. Among these patients, the one-year survival was only of 32%. Logistic regression analysis, using survival at one year as the endpoint, identified two independent risk factors: the length of ventilation (odds ratio [OR] = 1.1; 95% CI, 1.0-1.2; p = 0.02) and total bilirubin at ICU discharge (OR = 1.3; 95% CI, 1.1-1.5; p = 0.006). CONCLUSION Patients with cirrhosis admitted to the liver ICU and who required mechanical ventilation have a poor prognosis with a 1-year mortality of 89%. At ICU discharge, a total bilirubin level higher than 64.5 μmol/L and length of ventilation higher than 9 days could help the hepatologists to identify patients at risk of death in the year following the ICU discharge.
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Affiliation(s)
- Eric Levesque
- AP-HP Hôpital Henri Mondor, Anesthésie et Réanimations Chirurgicales, Créteil, France; AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Univ Paris-Sud, UMR-S 785, Villejuif, France; Inserm, Unité 785, 94800 Villejuif, France.
| | - Philippe Ichaï
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Univ Paris-Sud, UMR-S 785, Villejuif, France; Inserm, Unité 785, 94800 Villejuif, France
| | - Didier Samuel
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Univ Paris-Sud, UMR-S 785, Villejuif, France; Inserm, Unité 785, 94800 Villejuif, France
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Kubitza D, Roth A, Becka M, Alatrach A, Halabi A, Hinrichsen H, Mueck W. Effect of hepatic impairment on the pharmacokinetics and pharmacodynamics of a single dose of rivaroxaban, an oral, direct Factor Xa inhibitor. Br J Clin Pharmacol 2014; 76:89-98. [PMID: 23294275 DOI: 10.1111/bcp.12054] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 11/25/2012] [Indexed: 12/14/2022] Open
Abstract
AIM This study investigated the effects of hepatic impairment on the pharmacokinetics and pharmacodynamics of a single dose of rivaroxaban (10 mg), an oral, direct Factor Xa inhibitor. METHOD This single centre, non-randomized, non-blinded study included subjects with mild (n = 8) or moderate hepatic impairment (n = 8), according to the Child-Pugh classification, and gender-matched healthy subjects (n = 16). RESULTS Rivaroxaban was well tolerated irrespective of hepatic function. Mild hepatic impairment did not significantly affect the pharmacokinetics or pharmacodynamics of rivaroxaban, compared with healthy subjects. However, in subjects with moderate hepatic impairment, total body clearance was decreased, leading to a significant increase in the area under the plasma concentration-time curve (AUC). The least-squares (LS)-mean values for AUC were 1.15-fold [90% confidence interval (CI) 0.85, 1.57] and 2.27-fold (90% CI 1.68, 3.07) higher in subjects with mild and moderate hepatic impairment, respectively, than in healthy subjects. Consequently, the pharmacodynamic responses were significantly enhanced in subjects with moderate hepatic impairment. For inhibition of Factor Xa, increases in the area under the effect-time curve and the maximum effect were observed, with LS-mean ratios of 2.59 and 1.24, respectively, vs. healthy subjects. Prolongation of prothrombin time was similar in healthy subjects and those with mild hepatic impairment, but was significantly enhanced in those with moderate hepatic impairment. CONCLUSION Moderate (but not mild) hepatic impairment reduced total body clearance of rivaroxaban after a single 10 mg dose, leading to increased rivaroxaban exposure and pharmacodynamic effects.
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Affiliation(s)
- Dagmar Kubitza
- Clinical Pharmacology, Bayer Pharma AG, Wuppertal, Germany.
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Galbois A, Das V, Carbonell N, Guidet B. Prognostic scores for cirrhotic patients admitted to an intensive care unit: which consequences for liver transplantation? Clin Res Hepatol Gastroenterol 2013; 37:455-66. [PMID: 23773487 DOI: 10.1016/j.clinre.2013.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 05/03/2013] [Indexed: 02/06/2023]
Abstract
Mortality is increased in cirrhotic patients admitted in ICU whatever the admission reason. Prognosis scores assessed in critically ill cirrhotic patients in ICU can be classified in three main categories: liver-specific (CTP and MELD) scores, general (SAPS II and APACHE) scores, and organ failure (OSF and SOFA) scores. The components of the liver-specific scores can be influenced by the acute disease indicating the admission to ICU but those of the non liver-specific scores can be influenced by the underlying liver cirrhosis. Many studies reported that organ failure scores are the best predictors of outcome in cirrhotic patients in ICU. We may wonder if cirrhotic patients with acute organ failures should receive prioritization for organ allocation to save their life or should be denied for a potential futile LT. According to recent studies, the SOFA score is associated with a higher risk of death for patients waiting for LT but could not be associated with a worse outcome after LT. It becomes of paramount importance to correctly identify the cirrhotic patients who will maximally benefit from LT after admission to ICU. The EASL-CLIF Consortium defines the CLIF-SOFA score, redefining the SOFA score with cut-off levels based on mortality prediction. The CLIF-SOFA could represent the ideal score in ICU since it is based on organ failures with cut-off values specifically identified in cirrhotic patients. The validation of the CLIF-SOFA score in critically ill cirrhotic patients admitted to ICU and its usefulness to identify patients who could benefit from LT should be the next steps.
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Affiliation(s)
- Arnaud Galbois
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, 75012 Paris, France; UPMC, Université Paris 06, Sorbonne Universités, 75006 Paris, France; INSERM, UMR_S 938, CdR Saint-Antoine, 75012 Paris, France.
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Yi SG, Sadhu AR, Jones SL, Turner K, Monsour H, Donahue K, Xia X, Gaber AO, Ghobrial RM, Burroughs SG. The Effect of Adrenal Replacement Therapy on Rates of Fungal Colonization and Mortality in Critically Ill Patients Awaiting Liver Transplantation. J Clin Transl Hepatol 2013; 1:2-8. [PMID: 26355432 PMCID: PMC4521274 DOI: 10.14218/jcth.2013.00007] [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: 05/14/2013] [Revised: 06/26/2013] [Accepted: 06/28/2013] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The effect of adrenal replacement therapy (ART) with hydrocortisone on critical endpoints such as infection and mortality in critically ill patients with cirrhosis remains unclear. We evaluated our indications for ART in patients with cirrhosis with clinical symptoms of adrenal insufficiency (AI), and examined the rate of peri-transplant fungal colonization and mortality associated with ART. METHODS Seventy-eight patients with cirrhosis admitted to our institution's surgical intensive care unit (ICU) over a 4-year period met criteria for AI by vasopressor requirement and baseline cortisol levels. Outcomes included disposition at 90-days, fungal colonization, and fungal infection in the presence or absence of ART. RESULTS In total, 56 patients received hydrocortisone (HC+) while 22 did not (HC-). The HC+ and HC- groups had comparable median Model for End-stage Liver Disease (MELD) scores (26.5 vs. 25, respectively; p=0.93), median ICU lengths of stay (23 vs. 20 days, respectively; p=0.54) and median cortisol levels (18 μg/dL for both, p=0.87). Fungal cultures (FC) from blood, urine or bronchoalveolar lavage/sputum were positive for 44% of HC+, and 40.9% of HC- (p=0.77) had mortality rates between HC+ and HC- groups that were not significantly different (60.7% vs. 50%, respectively; p=0.39; α=0.05). The 90-day outcomes for HC+ vs. HC- (39.3% vs. 50% discharged, respectively; p=0.39; α=0.05) and those surviving to transplant (17.9% vs. 36.4%, respectively; p=0.08; α=0.05) were not significantly different between the two groups. CONCLUSION In this small single-center series, we found that steroid administration for AI does not affect the rate of fungal colonization/infection or mortality. Further prospective studies are required to determine the utility of ART and factors affecting the rate of FC and mortality in these patients.
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Affiliation(s)
- Stephanie G. Yi
- Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, Houston, TX
| | - Archana R. Sadhu
- Division of Endocrinology, Department of Medicine, The Methodist Hospital, Houston, TX
| | - Stephen L. Jones
- Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, Houston, TX
| | - Krista Turner
- Department of Surgery, University of New Mexico at Albuquerque, Albuquerque, NM
| | - Howard Monsour
- Hepatology and Transplant Medicine, Department of Medicine, The Methodist Hospital, Houston, TX
| | - Kevin Donahue
- Department of Pharmacy, The Methodist Hospital, Houston, TX
| | - Xuefeng Xia
- The Methodist Hospital Research Institute, The Methodist Hospital, Houston, TX
| | - A. Osama Gaber
- Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, Houston, TX
| | - R. Mark Ghobrial
- Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, Houston, TX
| | - Sherilyn Gordon Burroughs
- Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, Houston, TX
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Ozier Y, Cadic A, Dovergne A. Prise en charge des troubles de l’hémostase chez l’insuffisant hépatique. Transfus Clin Biol 2013; 20:249-54. [DOI: 10.1016/j.tracli.2013.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Gandoura S, Weiss E, Rautou PE, Fasseu M, Gustot T, Lemoine F, Hurtado-Nedelec M, Hego C, Vadrot N, Elkrief L, Lettéron P, Tellier Z, Pocidalo MA, Valla D, Lebrec D, Groyer A, Monteiro RC, de la Grange P, Moreau R. Gene- and exon-expression profiling reveals an extensive LPS-induced response in immune cells in patients with cirrhosis. J Hepatol 2013; 58:936-48. [PMID: 23321315 DOI: 10.1016/j.jhep.2012.12.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 12/26/2012] [Accepted: 12/28/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Lipopolysaccharide (LPS)-expressing bacteria cause severe inflammation in cirrhotic patients. The global gene response to LPS is unknown in cirrhotic immune cells. METHODS Gene-expression profiling using Affymetrix Human Exon Array analyzed the expression of 14,851 genes in LPS-stimulated peripheral blood mononuclear cells (PBMCs) from 4 patients with cirrhosis and 4 healthy subjects. We performed validation studies using RT-qPCR in LPS-stimulated PBMCs from 52 patients and 9 healthy subjects and investigated the association of gene induction with mortality in 26 patients. RESULTS Gene-expression profiling of LPS-stimulated cirrhotic cells showed 509 upregulated genes and 1588 downregulated genes. In LPS-stimulated "healthy" cells, 952 genes were upregulated and 838 genes downregulated. The 741 LPS-regulated genes shared by cirrhotic and "healthy" cells were involved in cytokine production/activity and induction of "immune paralysis". Comparison of functions associated with the 1356 genes, specifically regulated by LPS in cirrhotic cells, to functions of the 1049 genes, specifically regulated in "healthy" cells, allowed to define a cirrhosis-specific phenotype. Unlike in "healthy" cells, LPS failed to induce an interferon-mediated program in cirrhotic cells. In cirrhotic PBMCs, LPS specifically induced certain molecules involved in apoptosis and downregulated molecules involved in endocytic trafficking. RT-qPCR experiments showed that LPS-stimulated cirrhotic PBMCs had an enhanced induction of certain proinflammatory cytokines and chemokines. In the prognosis study, higher ex vivo LPS-induction of the inflammatory genes IL6 and CXCL5 was a significant predictor of mortality. CONCLUSIONS Our results show that LPS-stimulated cirrhotic PBMCs exhibit an extensive and often unexpected transcriptional response.
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Affiliation(s)
- Sonia Gandoura
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Clichy and Paris, France
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Reuken PA, Stallmach A, Bruns T. Mortality after urinary tract infections in patients with advanced cirrhosis - Relevance of acute kidney injury and comorbidities. Liver Int 2013; 33:220-30. [PMID: 23295053 DOI: 10.1111/liv.12029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 10/22/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Bacterial infections increase mortality four-fold in patients with decompensated cirrhosis. However, specific mortality associated with urinary tract infections (UTI) in cirrhosis is not known. METHODS Retrospective single-centre analysis of all hospitalized patients with cirrhosis and ascites who underwent first paracentesis between 2006 and 2011 to determine 90-day mortality associated with UTI defined as pyuria with significant bacteriuria using Cox proportional hazard models. RESULTS A total of 108 patients with at least one episode of UTI and 291 with exclusion of UTI were identified. Bacterial infections other than UTI were diagnosed in 136 (34%) of patients at the time of urine analysis. Female gender, Child-Pugh stage C, higher grade of ascites and systemic inflammatory response syndrome were associated with UTI. After adjustment for liver function and co-morbidity, the hazard ratios (HR) of death within 90 days after urine analysis were 2.08 (95% CI 1.28-3.38) in patients with UTI, 2.93 (1.90-4.52) in patients with other bacterial infections and 3.39 (2.03-5.65) in patients with UTI and concomitant infection. Independent predictors of death after UTI were renal dysfunction at presentation (HR 2.52; 95% CI 2.52), subsequent acute kidney injury within 48 h after diagnosis (4.57; 2.54-8.24), concomitant bacterial infection (1.77; 1.04-3.00) and malignant comorbidity (1.85; 1.03-3.30). The combination of these factors was more accurate in predicting 90-day mortality than the MELD score or C-reactive protein. CONCLUSIONS The presence of UTI indicates an increased risk of 90-day mortality in patients with advanced cirrhosis. Renal dysfunction and comorbidities are predictors of death in these patients.
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Affiliation(s)
- Philipp A Reuken
- Division of Gastroenterology, Hepatology and Infectious Diseases, Department of Internal Medicine II, Jena University Hospital, Friedrich Schiller University, Jena, Germany
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Ding H, Cao XY, Ma XG, Zhou WJ. Endothelial cell injury with inflammatory cytokine and coagulation in patients with sepsis. World J Emerg Med 2013. [DOI: 10.5847/wjem.j.issn.1920-8642.2013.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Tsai MH, Chen YC, Yang CW, Jenq CC, Fang JT, Lien JM, Hung CC, Weng HH, Wu CS, Peng YS, Shen CH, Tung SY, Tian YC. Acute renal failure in cirrhotic patients with severe sepsis: value of urinary interleukin-18. J Gastroenterol Hepatol 2013; 28:135-41. [PMID: 23034155 DOI: 10.1111/j.1440-1746.2012.07288.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIM Acute renal failure (ARF) is a common complication of liver cirrhosis and severe sepsis. Differentiating functional renal failure from acute tubular necrosis (ATN) has been difficult in this clinical setting. It has been shown that urinary interleukin 18 (IL-18) can serve as a sensitive marker for ARF and ATN. This study was aimed to investigate the diagnostic and prognostic values of urinary IL-18 in ARF associated with liver cirrhosis and severe sepsis. METHODS We prospectively evaluated the relationship between urinary IL-18 and clinical outcomes in 168 consecutive cirrhotic patients with severe sepsis. RESULTS One hundred and eight patients (64.3%) developed ARF at admission to the intensive care unit. ARF was associated with higher urinary IL-18 and impaired effective arterial volume. Renal failure was functional in 64 (59.2%), due to acute tubular necrosis (ATN) in 30 (27.7%), and mixed type in 14 (12.9%). Patients with ATN had significantly higher levels of urinary IL-18, rates of vasopressor dependency, and hospital mortality than those with functional renal failure. By using the areas under receiver operating characteristic (AUROC) curve, urinary IL-18 demonstrated an excellent discriminative power (AUROC 0.882) for diagnosing tubular injury in those with ARF. Meanwhile, hospital survivors had significantly lower urinary and serum IL-18 levels, compared to non-survivors. In multivariate analysis, urinary IL-18, international normalized ratio, and mean arterial pressure were independent factors to predict hospital mortality. CONCLUSIONS Urinary IL-18 can serve as a diagnostic and prognostic marker in cirrhotic patients with severe sepsis.
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Affiliation(s)
- Ming-Hung Tsai
- Division of Digestive Therapeutic Endoscopy, Chang Gung Memorial Hospital, Taipei, Taiwan
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Villa E, Cammà C, Marietta M, Luongo M, Critelli R, Colopi S, Tata C, Zecchini R, Gitto S, Petta S, Lei B, Bernabucci V, Vukotic R, De Maria N, Schepis F, Karampatou A, Caporali C, Simoni L, Del Buono M, Zambotto B, Turola E, Fornaciari G, Schianchi S, Ferrari A, Valla D. Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis. Gastroenterology 2012; 143:1253-1260.e4. [PMID: 22819864 DOI: 10.1053/j.gastro.2012.07.018] [Citation(s) in RCA: 478] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 07/05/2012] [Accepted: 07/09/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a randomized controlled trial to evaluate the safety and efficacy of enoxaparin, a low-molecular-weight heparin, in preventing portal vein thrombosis (PVT) in patients with advanced cirrhosis. METHODS In a nonblinded, single-center study, 70 outpatients with cirrhosis (Child-Pugh classes B7-C10) with demonstrated patent portal veins and without hepatocellular carcinoma were assigned randomly to groups that were given enoxaparin (4000 IU/day, subcutaneously for 48 weeks; n = 34) or no treatment (controls, n = 36). Ultrasonography (every 3 months) and computed tomography (every 6 months) were performed to check the portal vein axis. The primary outcome was prevention of PVT. Radiologists and hepatologists that assessed outcomes were blinded to group assignments. Analysis was by intention to treat. RESULTS At 48 weeks, none of the patients in the enoxaparin group had developed PVT, compared with 6 of 36 (16.6%) controls (P = .025). At 96 weeks, no patient developed PVT in the enoxaparin group, compared with 10 of 36 (27.7%) controls (P = .001). At the end of the follow-up period, 8.8% of patients in the enoxaparin group and 27.7% of controls developed PVT (P = .048). The actuarial probability of PVT was lower in the enoxaparin group (P = .006). Liver decompensation was less frequent among patients given enoxaparin (11.7%) than controls (59.4%) (P < .0001); overall values were 38.2% vs 83.0%, respectively (P < .0001). The actuarial probability of liver decompensation was lower in the enoxaparin group (P < .0001). Eight patients in the enoxaparin group and 13 controls died. The actuarial probability of survival was higher in the enoxaparin group (P = .020). No relevant side effects or hemorrhagic events were reported. CONCLUSIONS In a small randomized controlled trial, a 12-month course of enoxaparin was safe and effective in preventing PVT in patients with cirrhosis and a Child-Pugh score of 7-10. Enoxaparin appeared to delay the occurrence of hepatic decompensation and to improve survival.
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Affiliation(s)
- Erica Villa
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy.
| | - Calogero Cammà
- Sezione di Gastroenterologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Marco Marietta
- Department of Haematology, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Monica Luongo
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Rosina Critelli
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Colopi
- Department of Radiology, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Cristina Tata
- Department of Radiology, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Ramona Zecchini
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Gitto
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Salvatore Petta
- Sezione di Gastroenterologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Barbara Lei
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Veronica Bernabucci
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Ranka Vukotic
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola De Maria
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Filippo Schepis
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Aimilia Karampatou
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Cristian Caporali
- Department of Radiology, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Luisa Simoni
- Haematology Laboratory, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Mariagrazia Del Buono
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Beatrice Zambotto
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Turola
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Anna Ferrari
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Dominique Valla
- Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy, France; Université Paris-Diderot, Paris, France; INSERM U773-CRB3, Paris, France
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Acevedo J, Silva A, Prado V, Fernández J. The new epidemiology of nosocomial bacterial infections in cirrhosis: therapeutical implications. Hepatol Int 2012. [PMID: 26201623 DOI: 10.1007/s12072-012-9396-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cirrhotic patients are at increased risk of developing infection, sepsis and death. Enterobacteriaceae and nonenterococcal streptococci are the main bacteria responsible for spontaneous and urinary infections in this population. Prompt and appropriate treatment is basic in the management of cirrhotic patients with infection. Third-generation cephalosporins continue to be the gold-standard antibiotic treatment of the majority of infections acquired in the community because responsible strains are usually susceptible to β-lactams. By contrary, nosocomial infections are nowadays frequently caused by multiresistant bacteria (extended-spectrum β-lactamase-producing Enterobacteriaceae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci among others) that are nonsusceptible to the main antibiotics. Treatment of these infections requires the use of broader spectrum antibiotics (carbapenems) or of antibiotics that are active against specific resistant bacteria (glycopeptides, linezolid, daptomycin, amikacin and colistin). Empirical antibiotic schedules must be adapted to the local epidemiological pattern of antibiotic resistance. Careful restriction of antibiotic prophylaxis to the high-risk population is also mandatory to reduce the spread of multiresistant bacteria in cirrhosis.
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Affiliation(s)
- Juan Acevedo
- Liver Unit, Hospital Clinic, University of Barcelona, Villarroel 170, 08036, Barcelona, Catalunya, Spain
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Hospital Sant Jaume de Calella, Calella, Spain
| | - Aníbal Silva
- Liver Unit, Hospital Clinic, University of Barcelona, Villarroel 170, 08036, Barcelona, Catalunya, Spain
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Verónica Prado
- Liver Unit, Hospital Clinic, University of Barcelona, Villarroel 170, 08036, Barcelona, Catalunya, Spain
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Javier Fernández
- Liver Unit, Hospital Clinic, University of Barcelona, Villarroel 170, 08036, Barcelona, Catalunya, Spain.
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.
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Microbial translocation in chronic liver diseases. Int J Microbiol 2012; 2012:694629. [PMID: 22848224 PMCID: PMC3405644 DOI: 10.1155/2012/694629] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 06/18/2012] [Indexed: 02/08/2023] Open
Abstract
The intestinal microflora is not only involved in the digestion of nutrients, but also in local immunity, forming a barrier against pathogenic microorganisms. The derangement of the gut microflora may lead to microbial translocation, defined as the passage of viable microorganisms or bacterial products (i.e., LPS, lipopeptides) from the intestinal lumen to the mesenteric lymph nodes and other extraintestinal sites. The most recent evidence suggests that microbial translocation (MT) may occur not only in cirrhosis, but also in the early stage of several liver diseases, including alcoholic hepatopathy and nonalcoholic fatty liver disease. Different mechanisms, such as small intestinal bacterial overgrowth, increased permeability of intestinal mucosa, and impaired immunity, may favor MT. Furthermore, MT has been implicated in the pathogenesis of the complications of cirrhosis, which are a significant cause of morbidity and mortality in cirrhotic subjects. Therapeutic strategies aiming at modulating the gut microflora and reducing MT have focused on antibiotic-based options, such as selective intestinal decontamination, and nonantibiotic-based options, such as prokinetics and probiotics. In particular, probiotics may represent an attractive strategy, even though the promising results of experimental models and limited clinical studies need to be confirmed in larger randomized trials.
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Affiliation(s)
| | - Nicola Maria
- Gastroenterology; University of Modena; Modena; Italy
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