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Jan MY, Patidar KR, Ghabril MS, Kubal CA. Optimization of Kidney Health in Liver Transplant Candidates: Pretransplant Considerations and Modalities. Transplantation 2024; 108:1542-1550. [PMID: 38192019 PMCID: PMC11188627 DOI: 10.1097/tp.0000000000004851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 08/11/2023] [Accepted: 08/24/2023] [Indexed: 01/10/2024]
Abstract
Patients with decompensated end-stage liver disease (ESLD) are at increased risk for mortality, and only liver transplantation (LT) offers meaningful hope for survival. These patients are at risk for kidney dysfunction through the continuum of care for ESLD including LT. We discuss the role of accurate estimation and measurement of baseline glomerular filtration rate in assessment of kidney dysfunction among those with ESLD. Optimizing kidney function is a vital goal in the management of these patients before LT. In this review, we summarize salient aspects of assessing and optimizing kidney function in this patient population. Precipitating factors and different causes of acute kidney injury are discussed, including hepatorenal syndrome. We further review treatment options for acute kidney injury including volume management. The role of vasopressor therapy, renal replacement therapy, and transjugular intrahepatic portosystemic shunting are discussed.
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Affiliation(s)
- Muhammad Y. Jan
- Division of Transplant Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Kavish R. Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Marwan S. Ghabril
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Chandrashekhar A. Kubal
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Shafiq M, Amin MK, Khan MA. Prudent Use of Blood Cultures for Hospitalized Patients With Cirrhosis. Cureus 2024; 16:e65389. [PMID: 39184588 PMCID: PMC11344699 DOI: 10.7759/cureus.65389] [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] [Accepted: 07/25/2024] [Indexed: 08/27/2024] Open
Abstract
Background No reliable risk stratification method is available to guide the extent of infectious work-up among hospitalized patients with cirrhosis. Therefore, we aimed to create a risk stratification method for obtaining blood cultures from hospitalized patients with cirrhosis. Methods This was a retrospective cohort study using the Healthcare Cost and Utilization Project - National Readmission Database 2019. Adult patients who were not immunocompromised comprised the final cohort. The primary outcome was the incidence of bacteremia among hospitalized patients with cirrhosis. Secondary outcomes included length of hospital stay, inpatient mortality, and 30-day readmission rate among cirrhosis patients with and without bacteremia. After propensity score matching, the χ2 test was used to assess the primary outcome and inpatient mortality. The Wilcoxon signed-rank test was used to compare the length of hospital stay. Readmission rates were compared via survival analysis. Concomitant bacterial infection, cirrhosis causes, and complications were assessed as potential risk factors for bacteremia using binomial regression. Results The risk ratio (RR) of bacteremia was 1.66 (95% confidence interval (CI): 1.55-1.78) among patients with cirrhosis compared to those without cirrhosis. A concomitant bacterial infection was found to have a strong association with bacteremia in patients with cirrhosis (RR: 3.3, 95% CI: 3.03-3.59). Among cirrhosis patients without concomitant bacterial infection, the incidence of bacteremia was 0.76% (<1%). Among the causes of cirrhosis, primary sclerosing cholangitis was found to have a strong association with bacteremia (RR: 3.88, 95% CI: 2.3-6.04, P < 0.001). Patients with cirrhosis who had bacteremia were hospitalized three days longer than those without bacteremia. There was no difference in inpatient mortality or 30-day readmission rates between cirrhotic patients with and without bacteremia. Conclusion This study suggests that, in the absence of another concomitant bacterial infection and primary sclerosing cholangitis, we can avoid unnecessary blood cultures among immunocompetent patients with cirrhosis. However, given some inherent limitations associated with the database (such as the unavailability of vitals or laboratory values), additional studies are needed to validate its findings.
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Affiliation(s)
- Muhammad Shafiq
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Muhammad K Amin
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Muhammad A Khan
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
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3
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Kosuta I, Premkumar M, Reddy KR. Review article: Evaluation and care of the critically ill patient with cirrhosis. Aliment Pharmacol Ther 2024; 59:1489-1509. [PMID: 38693712 DOI: 10.1111/apt.18016] [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: 01/15/2024] [Revised: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. AIM Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. METHODS We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. RESULTS Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. CONCLUSIONS Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Lan NTN, Lieu DQ, Anh TN, Thuong LH, Tuong TTK, Bang MH. Characteristics and Related Factors of Bacterial Infection Among Patients With Cirrhosis. Mater Sociomed 2024; 36:90-96. [PMID: 38590588 PMCID: PMC10999149 DOI: 10.5455/msm.2024.36.90-96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/25/2024] [Indexed: 04/10/2024] Open
Abstract
Background Infection causes cirrhosis to decompensate, affecting liver function and resulting in several complications, including esophageal variceal hemorrhage, hepatic encephalopathy, and hepatorenal syndrome. Objective: This study aimed to identify the prevalence, essential features, and related factors of bacterial infection among patients with cirrhosis in Vietnam. Methods This retrospective study included 317 patients diagnosed with cirrhosis, who were divided into two groups: group 1 including 125 patients with bacterial infection and group 2 including 192 patients without bacterial infection. Infection was diagnosed on the basis of its localization. Results Spontaneous bacterial peritonitis (SBP; 31.2%) and pneumonia (28.8%) were the most common infections identified. The procalcitonin (PCT) level had a strong diagnostic value with an area under the curve value of 0.868. The most common type of gram-negative bacteria was Escherichia coli, while the gram-positive bacteria seen were Staphylococcus, Enterococcus, and Streptococcus among the patients with infection. In the logistic regression analysis, Child-Pugh class B and C (p<0.001, OR=4.14, CI=1.90-9.03; OR=4.76, CI=2.03-11.16, respectively) and the presence of acute kidney injury (p=0.009, OR=2.57, CI=1.27-5.22) and gastrointestinal hemorrhage (p=0.035, OR=0.39, CI=0.16-0.94) significantly differed between the groups. Conclusion The most prevalent type of bacterial infection in patients with cirrhosis is SBP, with gram-negative bacteria being the most common cause. The PCT level is useful in identifying infection in patients with cirrhosis. Decompensated cirrhosis is linked to a higher risk of infection.
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Affiliation(s)
| | - Dau Quang Lieu
- Department of Internal Medicine, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Tran Ngoc Anh
- Department of Internal Medicine, Hanoi Medical University Hospital, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Le Hoai Thuong
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Tran-Thi Khanh Tuong
- Department of Internal Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Mai Hong Bang
- Department of Gastroenterology, 108 Military Central Hospital, Hanoi, Vietnam
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5
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Zheng J, Li J, Zhang Z, Yu Y, Tan J, Liu Y, Gong J, Wang T, Wu X, Guo Z. Clinical Data based XGBoost Algorithm for infection risk prediction of patients with decompensated cirrhosis: a 10-year (2012-2021) Multicenter Retrospective Case-control study. BMC Gastroenterol 2023; 23:310. [PMID: 37704966 PMCID: PMC10500933 DOI: 10.1186/s12876-023-02949-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/07/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVES To appraise effective predictors for infection in patients with decompensated cirrhosis (DC) by using XGBoost algorithm in a retrospective case-control study. METHODS Clinical data were retrospectively collected from 6,648 patients with DC admitted to five tertiary hospitals. Indicators with significant differences were determined by univariate analysis and least absolute contraction and selection operator (LASSO) regression. Further multi-tree extreme gradient boosting (XGBoost) machine learning-based model was used to rank importance of features selected from LASSO and subsequently constructed infection risk prediction model with simple-tree XGBoost model. Finally, the simple-tree XGBoost model is compared with the traditional logical regression (LR) model. Performances of models were evaluated by area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. RESULTS Six features, including total bilirubin, blood sodium, albumin, prothrombin activity, white blood cell count, and neutrophils to lymphocytes ratio were selected as predictors for infection in patients with DC. Simple-tree XGBoost model conducted by these features can predict infection risk accurately with an AUROC of 0.971, sensitivity of 0.915, and specificity of 0.900 in training set. The performance of simple-tree XGBoost model is better than that of traditional LR model in training set, internal verification set, and external feature set (P < 0.001). CONCLUSIONS The simple-tree XGBoost predictive model developed based on a minimal amount of clinical data available to DC patients with restricted medical resources could help primary healthcare practitioners promptly identify potential infection.
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Affiliation(s)
- Jing Zheng
- Operation Management Office, Affiliated Banan Hospital of Chongqing Medical University, Chongqing, 401320, China
| | - Jianjun Li
- Department of Cardiothoracic Surgery, Affiliated Banan Hospital of Chongqing Medical University, Chongqing, 401320, China
| | - Zhengyu Zhang
- Medical Records Department, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Yue Yu
- Senior Bioinformatician Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, 55905, US
| | - Juntao Tan
- Operation Management Office, Affiliated Banan Hospital of Chongqing Medical University, Chongqing, 401320, China
| | - Yunyu Liu
- Medical Records Department, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Jun Gong
- Department of Information Center, the University Town Hospital of Chongqing Medical University, Chongqing, 401331, China
| | - Tingting Wang
- College of Medical Informatics, Chongqing Medical University, Chongqing, 400016, China
| | - Xiaoxin Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Centre for Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, 310003, Zhejiang, China.
| | - Zihao Guo
- Department of Gastroenterology, Chongqing Banan Cancer Hospital, Chongqing, 400054, China.
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Nosocomial infections in female compared with male patients with decompensated liver cirrhosis. Sci Rep 2022; 12:3285. [PMID: 35228572 PMCID: PMC8885665 DOI: 10.1038/s41598-022-07084-9] [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] [Received: 11/10/2021] [Accepted: 01/27/2022] [Indexed: 11/09/2022] Open
Abstract
There are considerable differences between males and females regarding the etiology, progression and outcome of liver diseases. Infections are a frequent and severe complication in these patients. This study aimed to examine sex specific differences in the incidence and clinical course of nosocomial infections in patients with decompensated liver cirrhosis. A number of 556 consecutive hospitalized patients with decompensated liver cirrhosis and ascites were analyzed. The patients were followed up for the incidence of nosocomial infections, acute kidney injury (AKI), acute-on-chronic liver failure (ACLF) as well as liver transplantation and death (LTx-free survival). A number of 285 patients (111 women and 174 men) developed a nosocomial infection. Incidence was numerically lower in men (P = 0.076). While the frequency of a nosocomial spontaneous bacterial peritonitis was similar between males and females, the incidence of a nosocomial urinary tract infection was significantly higher in women (P < 0.001). No sex specific differences were documented regarding the outcome of an infection as indicated by a similar incidence of, AKI, ACLF as well as LTx-free survival. There seem to be no major differences in the incidence and outcome of nosocomial infections between male and female patients.
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7
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Atteberry P, Biederman B, Jesudian A, Lucero C, Brown RS, Verna E, Sundaram V, Fortune B, Rosenblatt R. Mortality, sepsis, and organ failure in hospitalized patients with cirrhosis vary by type of infection. J Gastroenterol Hepatol 2021; 36:3363-3370. [PMID: 34293211 DOI: 10.1111/jgh.15633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Infection is associated with substantial morbidity and mortality in cirrhosis, but presumably, not all infections carry the same risk of mortality. We compared outcomes of different sites of infection in a nationally representative sample of inpatients with cirrhosis. METHODS We queried the Nationwide Readmissions Database for patients with cirrhosis from 2011 to 2014. Cirrhosis and infection diagnoses were identified by previously used algorithms of ICD-9 codes. The following infections were compared: urinary tract infection (UTI), pneumonia, cellulitis, spontaneous bacterial peritonitis (SBP), and Clostridium difficile infection (CDI). The primary outcome was inpatient mortality. Secondary outcomes included sepsis, any organ failure, multiple organ failures, and 30-day readmission. Outcomes were analyzed using logistic regression and included a priori covariates. RESULTS A total of 1 798 830 weighted index admissions were identified. Infection was present in 29.2% overall-including UTI (13.7%), pneumonia (8.9%), cellulitis (5.2%), CDI (2.8%), and SBP (2.0%). Mortality was significantly higher in pneumonia (19.6%), SBP (18.6%), and CDI (17.4%) compared with cellulitis (7.6%) and UTI (11.8%). Sepsis, any, and multiple organ failures were most commonly seen in pneumonia, SBP, and CDI. Multivariable analysis demonstrated that pneumonia had the highest associated mortality (odds ratio [OR] 2.73, confidence interval [CI] 2.68-2.80) and multiple organ failures (OR 3.59, CI 3.50-3.68). Significantly increased 30-day readmission was seen only with SBP (24.9%). CONCLUSIONS Outcomes of inpatients with cirrhosis vary significantly depending on the type of infection. The severity and epidemiology of infection in cirrhosis appears to be shifting with pneumonia, not SBP, having the highest prevalence of multiple organ failures and inpatient mortality.
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Affiliation(s)
- Preston Atteberry
- New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Benjamin Biederman
- New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Arun Jesudian
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Catherine Lucero
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Robert S Brown
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Elizabeth Verna
- Center for Liver Disease and Transplantation, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Vinay Sundaram
- Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Brett Fortune
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Russell Rosenblatt
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
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Niehaus CE, Strunz B, Cornillet M, Falk CS, Schnieders A, Maasoumy B, Hardtke S, Manns MP, Kraft ARM, Björkström NK, Cornberg M. MAIT Cells Are Enriched and Highly Functional in Ascites of Patients With Decompensated Liver Cirrhosis. Hepatology 2020; 72:1378-1393. [PMID: 32012321 DOI: 10.1002/hep.31153] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Patients with advanced liver cirrhosis have an increased susceptibility to infections. As part of the cirrhosis-associated immune dysfunction, mucosal-associated invariant T (MAIT) cells, which have the capacity to respond to bacteria, are severely diminished in circulation and liver tissue. However, MAIT cell presence and function in the peritoneal cavity, a common anatomical site for infections in cirrhosis, remain elusive. In this study, we deliver a comprehensive investigation of the immune compartment present in ascites of patients with decompensated liver cirrhosis, and focus especially on MAIT cells. APPROACH AND RESULTS To study this, matched peripheral blood and ascites fluid were collected from 35 patients with decompensated cirrhosis, with or without spontaneous bacterial peritonitis (SBP). MAIT cell phenotype and function were analyzed using high-dimensional flow cytometry, and the obtained data were compared with the blood samples of healthy controls (n = 24) and patients with compensated cirrhosis (n = 11). We found circulating MAIT cells to be severely decreased in patients with cirrhosis as compared with controls. In contrast, in ascites fluid, MAIT cells were significantly increased together with CD14+ CD16+ monocytes, innate lymphoid cells, and natural killer cells. This was paralleled by elevated levels of several pro-inflammatory cytokines and chemokines in ascites fluid as compared with plasma. Peritoneal MAIT cells displayed an activated tissue-resident phenotype, and this was corroborated by increased functional responses following stimulation with E. coli or interleukin (lL)-12 + IL-18 as compared with circulating MAIT cells. During SBP, peritoneal MAIT cell frequencies increased most among all major immune cell subsets, suggestive of active homing of MAIT cells to the site of infection. CONCLUSIONS Despite severely diminished MAIT cell numbers and impaired phenotype in circulation, peritoneal MAIT cells remain abundant, activated, and highly functional in decompensated cirrhosis and are further enriched in SBP. This suggests that peritoneal MAIT cells could be of interest for immune-intervention strategies in patients with decompensated liver cirrhosis and SBP.
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Affiliation(s)
- Christian E Niehaus
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Benedikt Strunz
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Martin Cornillet
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Christine S Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research, Partner-Site Hannover-Braunschweig, Hannover, Germany
| | - Ansgar Schnieders
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research, Partner-Site Hannover-Braunschweig, Hannover, Germany
| | - Svenja Hardtke
- German Center for Infection Research, HepNet Study-House German Liver Foundation, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research, Partner-Site Hannover-Braunschweig, Hannover, Germany
| | - Anke R M Kraft
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research, Partner-Site Hannover-Braunschweig, Hannover, Germany
| | - Niklas K Björkström
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research, Partner-Site Hannover-Braunschweig, Hannover, Germany.,Centre for Individualised Infection Medicine (CiiM), Hannover, Germany.,TWINCORE, Centre for Experimental and Clinical Infection Research, a joint venture between the Hanover Medical School and the Helmholtz Centre for Infection Research, Braunschweig, Germany.,Cluster of Excellence RESIST (EXC 2155), Hannover Medical School, Hannover, Germany
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Milovanovic T, Dumic I, Veličkovic J, Lalosevic MS, Nikolic V, Palibrk I. Epidemiology and risk factors for multi-drug resistant hospital-acquired urinary tract infection in patients with liver cirrhosis: single center experience in Serbia. BMC Infect Dis 2019; 19:141. [PMID: 30755176 PMCID: PMC6373165 DOI: 10.1186/s12879-019-3761-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 01/30/2019] [Indexed: 12/14/2022] Open
Abstract
Background Cirrhosis-associated immune dysfunction syndrome (CAIDS) has been identified in patients with liver cirrhosis (LC), predisposing them to a wide variety of infections. In patients with LC, healthcare-associated infections involving multi-drug resistant (MDR) bacteria have increased significantly over the last decades. Among them, hospital-acquired urinary tract infections (HA-UTI) are the most common. This study aimed to investigate the rates of antimicrobial resistance among patients with LC and HA-UTI and to determine risk factors associated with their development among patients hospitalized in tertiary care facility in Serbia. Methods This retrospective study included 65 hospitalized patients with LC who had developed HA-UTI. We examined the epidemiology of these infections concerning resistance to the most commonly used antimicrobials and patient-specific risk factors associated with HA-UTI development by MDR pathogens. Results The most frequently isolated organisms were Enterococcus spp. (n = 34, 52.3%), Klebsiella spp. (n = 10, 15.4%), and E.coli (n = 6, 9.2%). Thirty-five isolates (53.8%) were identified as MDR, and 30 (46.2%) were non-MDR.We found a statistically significant difference in the distribution of MDR and non-MDR strains, based on Gram staining, with the majority of Gram-negative pathogens being MDR (p = 0.005). We identified age ≥ 65 years (p = 0.007), previous use of cephalosporins as empiric therapy (p = 0.042), and the presence of hepatic encephalopathy (p = 0.011) as independent risk factors for the development of MDR UTIs. Conclusion This is the first study from Serbia and the Balkans concerning the changing epidemiology of MDR UTI in patients with LC. Our study showed that more than half of HA-UTI was caused by MDR and the most common pathogen was Enterococcus spp. The overall resistance to ceftriaxone was 92%. Our findings underscore the need for institutions to individualize protocols for treatment of hospital-acquired infections, particularly in immunocompromised populations.
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Affiliation(s)
- Tamara Milovanovic
- School of Medicine, University of Belgrade, Belgrade, Serbia. .,Department of Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia.
| | - Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA.,Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jelena Veličkovic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Anesthesiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Milica Stojkovic Lalosevic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Ivan Palibrk
- Department of Anesthesiology, Clinical Center of Serbia, Belgrade, Serbia
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10
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Safi W, Elnegouly M, Schellnegger R, Umgelter K, Geisler F, Reindl W, Saugel B, Hapfelmeier A, Umgelter A. Infection and Predictors of Outcome of Cirrhotic Patients after Emergency Care Hospital Admission. Ann Hepatol 2018; 17:948-958. [PMID: 30600289 DOI: 10.5604/01.3001.0012.7195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIMS We aimed to explore the impact of infection diagnosed upon admission and of other clinical baseline parameters on mortality of cirrhotic patients with emergency admissions. MATERIAL AND METHODS We performed a prospective observational monocentric study in a tertiary care center. The association of clinical parameters and established scoring systems with short-term mortality up to 90 days was assessed by univariate and multivariable Cox regression analysis. Akaike's Information Criterion (AIC) was used for automated variable selection. Statistical interaction effects with infection were also taken into account. RESULTS 218 patients were included. 71.2% were male, mean age was 61.1 ± 10.5 years. Mean MELD score was 16.2 ± 6.5, CLIF-consortium Acute on Chronic Liver Failure-score was 34 ± 11. At 28, 90 and 365 days, 9.6%, 26.0% and 40.6% of patients had died, respectively. In multivariable analysis, respiratory organ failure [Hazard Ratio (HR) = 0.15], albumin substitution (HR = 2.48), non-HCC-malignancy (HR = 4.93), CLIF-C-ACLF (HR = 1.10), HCC (HR = 3.70) and first episode of ascites (HR = 0.11) were significantly associated with 90-day mortality. Patients with infection had a significantly higher 90-day mortality (36.3 vs. 20.1%, p = 0.007). Cultures were positive in 32 patients with resistance to cephalosporins or quinolones in 10, to ampicillin/sulbactam in 14 and carbapenems in 6 patients. CONCLUSION Infection is common in cirrhotic ED admissions and increases mortality. The proportion of resistant microorganisms is high. The predictive capacity of established scoring systems in this setting was low to moderate.
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Affiliation(s)
- Wajima Safi
- 4th Medical Department, Klinikum Süd, Friedrich-Alexander-University Erlangen-Nuremberg, Germany
| | - Mayada Elnegouly
- 2nd Medical Department, Technische Universität München, Klinikum rechts der Isar, Germany
| | | | - Katrin Umgelter
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany, Klinik für operative Intensivmedizin, Vivantes Humboldt Klinikum, Berlin, Germany
| | - Fabian Geisler
- 2nd Medical Department, Technische Universität München, Klinikum rechts der Isar, Germany
| | - Wolfgang Reindl
- 2nd Medical Department, Universitätsmedizin Mannheim, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Statistics and Epidemiology, Technische Universität München, Germany
| | - Andreas Umgelter
- 2nd Medical Department, Technische Universität München, Klinikum rechts der Isar, Germany
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Papp M, Tornai T, Vitalis Z, Tornai I, Tornai D, Dinya T, Sumegi A, Antal-Szalmas P. Presepsin teardown - pitfalls of biomarkers in the diagnosis and prognosis of bacterial infection in cirrhosis. World J Gastroenterol 2016; 22:9172-9185. [PMID: 27895404 PMCID: PMC5107598 DOI: 10.3748/wjg.v22.i41.9172] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the diagnostic and prognostic value of presepsin in cirrhosis-associated bacterial infections.
METHODS Two hundred and sixteen patients with cirrhosis were enrolled. At admission, the presence of bacterial infections and level of plasma presepsin, serum C-reactive protein (CRP) and procalcitonin (PCT) were evaluated. Patients were followed for three months to assess the possible association between presepsin level and short-term mortality.
RESULTS Present 34.7 of patients had bacterial infection. Presepsin levels were significantly higher in patients with infection than without (median, 1002 pg/mL vs 477 pg/mL, P < 0.001), increasing with the severity of infection [organ failure (OF): Yes vs No, 2358 pg/mL vs 710 pg/mL, P < 0.001]. Diagnostic accuracy of presepsin for severe infections was similar to PCT and superior to CRP (AUC-ROC: 0.85, 0.85 and 0.66, respectively, P = NS for presepsin vs PCT and P < 0.01 for presepsin vs CRP). At the optimal cut-off value of presepsin > 1206 pg/mL sensitivity, specificity, positive predictive values and negative predictive values were as follows: 87.5%, 74.5%, 61.8% and 92.7%. The accuracy of presepsin, however, decreased in advanced stage of the disease or in the presence of renal failure, most probably because of the significantly elevated presepsin levels in non-infected patients. 28-d mortality rate was higher among patients with > 1277 pg/mL compared to those with ≤ 1277 pg/mL (46.9% vs 11.6%, P < 0.001). In a binary logistic regression analysis, however, only PCT (OR = 1.81, 95%CI: 1.09-3.01, P = 0.022) but neither presepsin nor CRP were independent risk factor for 28-d mortality after adjusting with MELD score and leukocyte count.
CONCLUSION Presepsin is a valuable new biomarker for defining severe infections in cirrhosis, proving same efficacy as PCT. However, it is not a useful marker of short-term mortality.
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Urologische Aspekte bei Patienten mit Leberzirrhose. Urologe A 2016; 55:63-7. [DOI: 10.1007/s00120-015-3978-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ye C, Kumar D, Carbonneau M, Keough A, Ma M, Tandon P. Asymptomatic bacteriuria is an independent predictor of urinary tract infections in an ambulatory cirrhotic population: a prospective evaluation. Liver Int 2014; 34:e39-44. [PMID: 24325582 DOI: 10.1111/liv.12435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 12/03/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Asymptomatic bacteriuria (ASB) is a risk factor for urinary tract infections (UTIs) in many patients without liver disease. It remains unclear whether a diagnosis of ASB in an outpatient with cirrhosis could be utilized to predict the subsequent development of a UTI. We undertook this study to determine the prevalence and incidence of ASB in an outpatient population and its association with UTI. METHODS We prospectively evaluated 108 adult outpatients with cirrhosis over a 6-month period. Monthly midstream urines (MSU) were performed to detect the occurrence of UTI and ASB (culture of ≥10(8) CFU/L of a urinary pathogen in the absence of UTI symptoms). RESULTS Of 108 patients enrolled, 99 completed at least one MSU, for a total of 489 MSUs. Total follow-up was 44 person-years. The incidences of ASB and UTI were 181 and 250 per 1000 person-years, respectively. The prevalences of ASB and UTI on the first MSU were 5 and 1%, respectively. In total, 8% of patients developed an episode of ASB and 11% developed a UTI during the study period. Univariate predictors of UTI were female gender, primary biliary cirrhosis, number of previous UTIs and preceding ASB. Preceding ASB was the only independent predictor of UTI on multivariate analysis, with an odds ratio of 6.2 (1.1-34.3), P = 0.04. CONCLUSIONS Cirrhotic patients have higher rates of ASB and UTI than reported in the general population. ASB is an independent predictor of UTI. Further studies are necessary to determine whether routine screening and antimicrobial treatment of ASB is warranted.
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Affiliation(s)
- Carrie Ye
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Abstract
Cirrhosis patients’ comorbidities are their other diseases than cirrhosis. Comorbidities are neither causes nor consequences of cirrhosis, but they can increase mortality and are therefore clinically important. They are also an important source of confounding in epidemiologic studies. Comorbidity scoring systems have been developed as tools to measure the cirrhosis patient’s total burden of comorbidity, and they are useful in the clinic and for epidemiologic studies. The recently developed CirCom score is the only comorbidity scoring system developed specifically for cirrhosis patients, and it may be preferred over the older, generic, and more complex Charlson comorbidity index. Studies of individual comorbid diseases can provide insight into the interactions between cirrhosis and other diseases and thus into the pathophysiology of cirrhosis. This article reviews the literature on comorbidity in cirrhosis.
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Bruns T, Zimmermann HW, Stallmach A. Risk factors and outcome of bacterial infections in cirrhosis. World J Gastroenterol 2014; 20:2542-2554. [PMID: 24627590 PMCID: PMC3949263 DOI: 10.3748/wjg.v20.i10.2542] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/05/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Viable and non-viable pathological bacterial translocation promote a self-perpetuating circle of dysfunctional immune activation and systemic inflammation facilitating infections and organ failure in advanced cirrhosis. Bacterial infections and sepsis are now recognized as a distinct stage in the natural progression of chronic liver disease as they accelerate organ failure and contribute to the high mortality observed in decompensated cirrhosis. The increasing knowledge of structural, immunological and hemodynamic pathophysiology in advanced cirrhosis has not yet translated into significantly improved outcomes of bacterial infections over the last decades. Therefore, early identification of patients at the highest risk for developing infections and infection-related complications is required to tailor the currently available measures of surveillance, prophylaxis and therapy to the patients in need in order to improve the detrimental outcome of bacterial infections in cirrhosis.
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Zimmermann HW, Reuken PA, Koch A, Bartneck M, Adams DH, Trautwein C, Stallmach A, Tacke F, Bruns T. Soluble urokinase plasminogen activator receptor is compartmentally regulated in decompensated cirrhosis and indicates immune activation and short-term mortality. J Intern Med 2013; 274:86-100. [PMID: 23432143 DOI: 10.1111/joim.12054] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Patients with decompensated cirrhosis are susceptible to bacterial infections, which are associated with organ failure and a high mortality rate. Reliable biomarkers are needed to identify patients who require intensified treatment. Our objective was to study the regulation and prognostic relevance of elevated concentrations of soluble urokinase plasminogen activator receptor (suPAR) in patients with advanced cirrhosis. DESIGN, SETTING AND PARTICIPANTS We examined the associations between serum and ascitic fluid (AF) suPAR and liver function, bacterial infection, and short-term mortality in 162 consecutive patients with decompensated cirrhosis undergoing diagnostic paracentesis in a tertiary health care centre in Germany. MAIN OUTCOME MEASURE Twenty-eight-day mortality. RESULTS Circulating suPAR levels were increased in patients with decompensated cirrhosis and correlated with the severity of liver dysfunction and systemic inflammation but were not indicative of bacterial infection. Circulating suPAR levels >14.4 ng mL(-1) predicted 28-day mortality, even after adjustment for liver function and confounders [HR = 3.05 (1.35-6.90); P = 0.0076] equal to the MELD score (AUC = 0.71; 95% CI = 0.61-0.81; P < 0.001). Cut-off levels derived from cohorts without liver disease were not applicable due to the low specificity. AF suPAR levels were elevated during spontaneous bacterial peritonitis (SBP), but not during episodes in which bacteria or bacterial DNA was translocated into the ascites. AF suPAR levels correlated poorly with systemic suPAR but were associated with a more severe course of SBP and a worse outcome. In vitro experiments revealed that monocytes, and to a lesser extent neutrophils, secrete suPAR after Toll-like-receptor ligation, which led to rapid urokinase plasminogen activator receptor cleavage followed by increased synthesis. CONCLUSION Blood and ascitic suPAR levels provide distinct, but relevant prognostic information on the severity of complications in patients with end-stage liver disease.
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Affiliation(s)
- H W Zimmermann
- Department of Medicine III, University Hospital Aachen, Aachen, Germany
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