1
|
Yoon JS, Lee JH. Letter: Risks of proton pump inhibitor treatment in cirrhotic patients-Authors' reply. Aliment Pharmacol Ther 2024; 60:546-547. [PMID: 38997811 DOI: 10.1111/apt.18167] [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] [Indexed: 07/14/2024]
Abstract
LINKED CONTENTThis article is linked to Yoon et al papers. To view these articles, visit https://doi.org/10.1111/apt.17909 and https://doi.org/10.1111/apt.17954
Collapse
Affiliation(s)
- Jun Sik Yoon
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
2
|
Bettinger D, Thimme R, Sturm L. Editorial: Novel insights into the prognostic relevance of high-dose PPI treatment in patients with cirrhosis. Aliment Pharmacol Ther 2024; 59:1282-1283. [PMID: 38652787 DOI: 10.1111/apt.17928] [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] [Indexed: 04/25/2024]
Abstract
LINKED CONTENTThis article is linked to Yoon et al paper. To view this article, visit https://doi.org/10.1111/apt.17909
Collapse
Affiliation(s)
- Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Sturm
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
3
|
Yoon JS, Hong JH, Park SY, Kim SU, Kim HY, Kim JY, Hur MH, Park MK, Lee YB, Lee HA, Kim GA, Sinn DH, Park SJ, Lee YJ, Kim YJ, Yoon JH, Lee JH. High-dose proton pump inhibitor treatment is associated with a higher mortality in cirrhotic patients: A multicentre study. Aliment Pharmacol Ther 2024; 59:973-983. [PMID: 38389319 DOI: 10.1111/apt.17909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/11/2023] [Accepted: 02/07/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Proton pump inhibitors (PPI) are frequently used in patients with cirrhosis. AIMS This study aimed to determine whether PPI use is associated with the prognosis of cirrhotic patients. METHODS We conducted a multicentre retrospective cohort study involving 1485 patients who had experienced hepatic encephalopathy (HE) from 7 referral centres in Korea. The primary outcome was overall survival and secondary outcomes included the development of cirrhotic complications, including recurrent HE, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and gastrointestinal bleeding. Patients treated with PPI with a mean defined daily dose (mDDD) ≥0.5 (high-dose PPI group) were compared to those treated with PPI of an mDDD < 0.5 (No or low-dose PPI group) for each outcome. RESULTS Among 1485 patients (median age, 61 years; male, 61%), 232 were assigned to the high-dose PPI group. High-dose PPI use was independently associated with a higher risk of death (adjusted HR [aHR] = 1.71, 95% confidence interval [CI] = 1.38-2.11, p < 0.001). This result was reproducible after propensity score-matching (PSM) (aHR = 1.90, 95% CI = 1.49-2.44, p < 0.001). High-dose PPI use was an independent risk factor of recurrent HE (before PSM: aHR = 2.04, 95% CI = 1.66-2.51, p < 0.001; after PSM: aHR = 2.16, 95% CI = 1.70-2.74, p < 0.001), SBP (before PSM: aHR = 1.87, 95% CI = 1.43-2.43, p < 0.001; after PSM: aHR = 1.76, 95% CI = 1.31-2.36, p = 0.002), HRS (before PSM: aHR = 1.48, 95% CI = 1.02-2.15, p = 0.04; after PSM: aHR = 1.47, 95% CI = 0.95-2.28, p = 0.09), and gastrointestinal bleeding (before PSM: aHR = 1.46, 95% CI = 1.12-1.90, p = 0.006; after PSM: aHR = 1.74, 95% CI = 1.28-2.37, p < 0.001). CONCLUSIONS The use of high-dose PPI was independently associated with increased risks of mortality and cirrhotic complications.
Collapse
Affiliation(s)
- Jun Sik Yoon
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Ji Hoon Hong
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Soo Young Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Seung Up Kim
- Department of Internal Medicine and Yonsei Liver Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hwi Young Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ju Yeon Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Moon Haeng Hur
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Min Kyung Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yun Bin Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Gi-Ae Kim
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Jae Park
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Youn Jae Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
4
|
Low EXS, Wang YP, Lu CL. Risks of Proton Pump Inhibitors in Patients with Cirrhosis: Please Peruse the Indications. Dig Dis Sci 2024; 69:7-9. [PMID: 37968555 DOI: 10.1007/s10620-023-08153-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/09/2023] [Indexed: 11/17/2023]
Abstract
The use of proton pump inhibitor (PPI) in cirrhotic patients can be associated with increased risks of long-term mortality, decompensation, hepatic encephalopathy, spontaneous bacterial peritonitis, and infection, but not with short-term mortality. Ensure clear indications at lowest effective dose of is mandatory for the use of PPI among cirrhotic patients.
Collapse
Affiliation(s)
- En Xian Sarah Low
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Po Wang
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Liang Lu
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
- Institute of Brain Science, National Yang Ming Chiao Tung Univeristy, Taipei, Taiwan.
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| |
Collapse
|
5
|
Wong ZY, Koh JH, Muthiah M, Koh B, Ong EYH, Ong CEY, Ou KQ, Lim WH, Tan DJH, Chee D, Siah KTH, Wong Y, Kaewdech A, Wijarnpreecha K, Kulkarni AV, Nah B, Huang DQ, Noureddin M, Ng CH, Teng M. Proton Pump Inhibitors Increases Longitudinal Risk of Mortality, Decompensation, and Infection in Cirrhosis: A Meta-Analysis. Dig Dis Sci 2024; 69:289-297. [PMID: 37968557 DOI: 10.1007/s10620-023-08150-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 10/09/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND/AIMS Proton pump inhibitors (PPIs) are frequently prescribed to cirrhotic patients, but there is limited longitudinal evidence regarding their effects. This study aimed to assess the impact of PPIs on adverse events in cirrhotic patients. METHODS A comprehensive search was conducted using the Medline and Embase databases to identify relevant articles. Pooled hazard ratios (HRs) using DerSimonian and Laird random-effects model were calculated to evaluate the risk of adverse events such as long-term mortality, hepatic decompensation, hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), and overall infection in cirrhotic patients with PPI use. RESULTS The analysis included 28 studies with 260,854 cirrhotic patients. The prevalence of PPI use among cirrhotic patients was 55.93%. The use of PPIs was not significantly associated with short-term mortality in cirrhotic patients. However, long-term mortality (HR 1.321, 95% CI 1.103-1.581, P = 0.002), decompensation (HR 1.646, 95% CI 1.477-1.835, P < 0.001), HE (HR 1.968, 95% CI 1.372-2.822, P < 0.001), SBP (HR 1.751, 95% CI 1.649-1.859, P < 0.001), and infection (HR 1.370, 95% CI 1.148-1.634, P < 0.001) were significantly associated with PPI use. Sensitivity analysis with prospective studies yielded similar results. CONCLUSION PPIs should be reserved for appropriate indications at lowest effective dose for cirrhotic patients due to the potential harm.
Collapse
Affiliation(s)
- Zhen Yu Wong
- Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jia Hong Koh
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Benjamin Koh
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Elden Yen Hng Ong
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Christen En Ya Ong
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Kai Qi Ou
- Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Douglas Chee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Kewin Tien Ho Siah
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Yujun Wong
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Apichat Kaewdech
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Benjamin Nah
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
- Division of Gastroenterology, NAFLD Research Center, University of California at San Diego, La Jolla, CA, USA
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | | | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore.
| | - Margaret Teng
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| |
Collapse
|
6
|
Sturm L, Hirose M, Stolz L, Schultheiss M, Zoldan K, Reincke M, Huber JP, Kaeser R, Boettler T, Thimme R, Albert E, Busch H, Künstner A, Bettinger D. Proton pump inhibitor treatment aggravates bacterial translocation in patients with advanced cirrhosis and portal hypertension. mBio 2023; 14:e0049223. [PMID: 37623323 PMCID: PMC10653923 DOI: 10.1128/mbio.00492-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 08/26/2023] Open
Abstract
IMPORTANCE Long-term prescription of proton pump inhibitors (PPIs) in patients with cirrhosis is common practice. However, in recent years, several observational studies have reported increased complications and negative prognostic effects of PPI treatment in these patients. Judging the significance of these associations is complicated by the fact that a plausible underlying pathomechanism has not been identified so far. In the present study, we address this important issue by investigating the impact of PPI treatment on subclinical bacterial translocation from the gut into the blood stream in patients with advanced cirrhosis and portal hypertension. Indeed, we report significantly aggravated bacterial translocation in cirrhosis patients receiving PPI treatment. This finding is highly relevant, as bacterial translocation is known to promote the development of complications and impair prognosis in patients with cirrhosis. Hence, the present study could establish a plausible link between PPI treatment and adverse effects in cirrhosis.
Collapse
Affiliation(s)
- Lukas Sturm
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Misa Hirose
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
| | - Laura Stolz
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Zoldan
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Marlene Reincke
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Jan Patrick Huber
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Rafael Kaeser
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- IMM-PACT-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Boettler
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Elisabeth Albert
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
| | - Hauke Busch
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
- Institute for Cardiogenetics, University of Luebeck, Luebeck, Germany
| | - Axel Künstner
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
- Institute for Cardiogenetics, University of Luebeck, Luebeck, Germany
| | - Dominik Bettinger
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| |
Collapse
|
7
|
Tergast TL, Schulte B, Griemsmann M, Kahlhöfer J, Dörge P, Hinrichs JB, Kraft ARM, Schmidt JJ, Behrendt P, Wedemeyer H, Cornberg M, Maasoumy B. Application of CT contrast medium is not associated with an increased risk for acute kidney injury in patients with decompensated cirrhosis. Aliment Pharmacol Ther 2023; 57:136-145. [PMID: 36352768 DOI: 10.1111/apt.17289] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/09/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent complication in patients with decompensated cirrhosis. Studies reported conflicting results regarding the nephrotoxic potential of iodinated contrast medium (CM) for computer tomography (CT). AIM To investigate the impact of diagnostic CM application on kidney function in patients with decompensated cirrhosis. METHODS First, we evaluated the impact of diagnostic CM-CT on AKI incidence in a cross-sectional approach. Second, we analysed 28-day AKI incidence post-CM-CT in patients with impaired kidney function (i.e., creatinine >133 μmoL/L). Third, we excluded all patients with relevant interventions besides CM-CT. All remaining patients were matched via propensity score matching (PPSM) and further analysed. Last, we validated the results in an independent dataset of prospectively collected registry data of 118 patients with decompensated cirrhosis. Here, plasma samples were analysed regarding neutrophil-gelatinase-associated-lipocalin (NGAL). RESULTS Of the 611 included patients, 98 (16%) received CM-CT. CM-CT was not associated with AKI in the cross-sectional approach (CM-CT:8% vs. no CM-CT:15%; p = 0.08). Furthermore, CM-CT was not associated with higher 28-day AKI incidence among patients with impaired kidney function (HR:0.79; 95% CI 0.45-1.38; p = 0.40). The PPSM cohort revealed no association between CM-CT and AKI or severe AKI (HR:1.28, p = 0.45 and HR:1.62; p = 0.43). Moreover, CM-CT did not result in worsening of kidney function after CM application. In the validation cohort, CM-CT was also not linked to AKI (p = 0.85) and NGAL levels were not increased in those with CM-CT (CM-CT:309 ng/ml vs. No CM-CT:266 ng/ml, p = 0.35). CONCLUSION Decompensated cirrhosis per se should not preclude diagnostic CM-CT.
Collapse
Affiliation(s)
- Tammo L Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Benjamin Schulte
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marie Griemsmann
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Julia Kahlhöfer
- German Centre for Infection Research, HepNet Study-House of the German Liver Foundation, Hannover, Germany
| | - Petra Dörge
- German Centre for Infection Research, HepNet Study-House of the German Liver Foundation, Hannover, Germany
| | - Jan B Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Anke R M Kraft
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,Centre for Individualised Infection Medicine (CiiM), Hannover, Germany
| | - Julius J Schmidt
- Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Patrick Behrendt
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,Twincore, Centre for Experimental and Clinical Infection Research, Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Centre for Infection Research, HepNet Study-House of the German Liver Foundation, Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Centre for Infection Research, HepNet Study-House of the German Liver Foundation, Hannover, Germany.,Centre for Individualised Infection Medicine (CiiM), Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Centre for Infection Research, HepNet Study-House of the German Liver Foundation, Hannover, Germany
| |
Collapse
|
8
|
Association Between Proton Pump Inhibitor Therapy and Spontaneous Bacterial Peritonitis Occurrence in Cirrhotic Patients: A Clinical Review. Curr Med Sci 2022; 42:673-680. [DOI: 10.1007/s11596-022-2607-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 01/20/2022] [Indexed: 11/26/2022]
|
9
|
Liu YB, Chen MK. The impact of proton pump inhibitors in liver diseases and the effects on the liver. J Dig Dis 2022; 23:196-208. [PMID: 35357775 DOI: 10.1111/1751-2980.13093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/09/2022] [Accepted: 03/29/2022] [Indexed: 12/11/2022]
Abstract
In this systematic and comprehensive overview, we aimed to evaluate the impact of proton pump inhibitors (PPIs) on chronic liver diseases, especially on cirrhosis. A manual and comprehensive search of the PubMed database was conducted to obtain relevant literatures. PPIs altered the composition and function of the intestinal microflora and might lead to small intestinal bacterial overgrowth and bacterial translocation, which were associated with adverse effects in liver diseases. They might increase the risk of hepatic encephalopathy, spontaneous bacterial peritonitis, infections, and are related to an increased mortality in cirrhosis. PPIs might lead to an increased risk of hepatocellular carcinoma, although the mechanism is unknown, and the results are controversial. PPIs also had an impact on the direct-acting antiviral regimen in patients with chronic hepatitis C. They were associated with an increased risk of liver abscess and increased mortality. Additionally, PPIs might lead to metabolic risk events, such as liver steatosis and weight gain. PPIs are associated with several adverse outcomes in liver diseases. Cautious use of PPIs is recommended and clinicians should be aware of the indications for their use in patients with liver diseases.
Collapse
Affiliation(s)
- Yuan Bin Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Ming Kai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| |
Collapse
|
10
|
Stockhoff L, Muellner-Bucsics T, Markova AA, Schultalbers M, Keimburg SA, Tergast TL, Hinrichs JB, Simon N, Gerbel S, Manns MP, Mandorfer M, Cornberg M, Meyer BC, Wedemeyer H, Reiberger T, Maasoumy B. Low Serum Cholinesterase Identifies Patients With Worse Outcome and Increased Mortality After TIPS. Hepatol Commun 2022; 6:621-632. [PMID: 34585537 PMCID: PMC8870033 DOI: 10.1002/hep4.1829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/29/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension-related complications. However, careful selection of patients is crucial. The aim of this study was to evaluate the prognostic value of serum cholinesterase (CHE) for outcomes and mortality after TIPS insertion. In this multicenter study, 389 consecutive patients with cirrhosis receiving a TIPS at Hannover Medical School, University Hospital Essen, or Medical University of Vienna were included. The Hannover cohort (n = 200) was used to initially explore the role of CHE, whereas patients from Essen and Vienna served as a validation cohort (n = 189). Median age of the patients was 58 years and median Model for End-Stage Liver Disease (MELD) score was 12. Multivariable analysis identified MELD score (hazard ratio [HR]: 1.16; P < 0.001) and CHE (HR: 0.61; P = 0.008) as independent predictors for 1-year survival. Using the Youden Index, a CHE of 2.5 kU/L was identified as optimal threshold to predict post-TIPS survival in the Hannover cohort (P < 0.001), which was confirmed in the validation cohort (P = 0.010). CHE < 2.5 kU/L was significantly associated with development of acute-on-chronic liver failure (P < 0.001) and hepatic encephalopathy (P = 0.006). Of note, CHE was also significantly linked to mortality in the subgroup of patients with refractory ascites (P = 0.001) as well as in patients with high MELD scores (P = 0.012) and with high-risk FIPS scores (P = 0.004). After propensity score matching, mortality was similar in patients with ascites and CHE < 2.5 kU/L if treated by TIPS or by paracentesis. Contrarily, in patients with CHE ≥ 2.5 kU/L survival was significantly improved by TIPS as compared to treatment with paracentesis (P < 0.001). Conclusion: CHE is significantly associated with mortality and complications after TIPS insertion. Therefore, we suggest that CHE should be evaluated as an additional parameter for selecting patients for TIPS implantation.
Collapse
Affiliation(s)
- Lena Stockhoff
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Theresa Muellner-Bucsics
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Antoaneta A Markova
- Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Marie Schultalbers
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Simone A Keimburg
- Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Tammo L Tergast
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Jan B Hinrichs
- Institute for Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Nicolas Simon
- Center for Information Management (ZIMt)Hannover Medical SchoolHannoverGermany
| | - Svetlana Gerbel
- Center for Information Management (ZIMt)Hannover Medical SchoolHannoverGermany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Mattias Mandorfer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Bernhard C Meyer
- Institute for Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany.,Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Thomas Reiberger
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| |
Collapse
|
11
|
Rajan P, Iglay K, Rhodes T, Girman CJ, Bennett D, Kalantar-Zadeh K. Risk of bias in non-randomized observational studies assessing the relationship between proton-pump inhibitors and adverse kidney outcomes: a systematic review. Therap Adv Gastroenterol 2022; 15:17562848221074183. [PMID: 35173802 PMCID: PMC8841917 DOI: 10.1177/17562848221074183] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Proton-pump inhibitors (PPIs) are widely prescribed as acid-suppression therapy. Some observational studies suggest that long-term use of PPIs is potentially associated with certain adverse kidney outcomes. We conducted a systematic literature review to assess potential bias in non-randomized studies reporting on putative associations between PPIs and adverse kidney outcomes (acute kidney injury, acute interstitial nephritis, chronic interstitial nephritis, acute tubular necrosis, chronic kidney disease, and end-stage renal disease). METHODS We searched the medical literature within 10 years of 17 December 2020. Pre-specified criteria guided identification of relevant English language articles for assessment. Risk of bias on an outcome-specific basis was evaluated using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool by two independent reviewers. RESULTS Of 620 initially identified records, 26 studies met a priori eligibility criteria and underwent risk of bias assessment. Nineteen studies were judged as having a moderate risk of bias for reported adverse kidney outcomes, while six studies were judged as having a serious risk of bias (mainly due to inadequate control of confounders and selection bias). We were unable to determine the overall risk of bias in two studies (one of which was assessed as having a moderate risk of bias for a different adverse kidney outcome) due to insufficient information presented. Effect estimates for PPIs in relation to adverse kidney outcomes varied widely (0.24-7.34) but associations mostly showed increased risk. CONCLUSION Using ROBINS-I, we found that non-randomized observational studies suggesting kidney harm by PPIs have moderate to serious risk of bias, making it challenging to establish causality. Additional high-quality, real-world evidence among generalizable populations are needed to better understand the relation between PPI treatment and acute and chronic kidney outcomes, accounting for the effects of varying durations of PPI treatment, self-treatment with over-the-counter PPIs, and potential critical confounders.
Collapse
Affiliation(s)
| | - Kristy Iglay
- CERobs Consulting, LLC, Wrightsville Beach, NC, USA
| | | | | | - Dimitri Bennett
- Global Evidence and Outcomes, Takeda Pharmaceuticals USA, Inc., Cambridge, MA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension & Kidney Transplantation, School of Medicine, University of California, Irvine, Irvine, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
- Tibor Rubin Veterans Administration Long Beach Healthcare System, Long Beach, CA, USA
| |
Collapse
|
12
|
Jacques RDOC, Massignan LDS, Winkler MS, Balbinot RS, Balbinot SS, Soldera J. ACUTE-ON-CHRONIC LIVER FAILURE IS INDEPENDENTLY ASSOCIATED WITH LOWER SURVIVAL IN PATIENTS WITH SPONTANEOUS BACTERIAL PERITONITIS. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:344-352. [PMID: 34705969 DOI: 10.1590/s0004-2803.202100000-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a decompensation of cirrhosis with an in-hospital mortality ranging from 20% to 40%. OBJECTIVE The purpose of this study is to analyze if EASL-CLIF definition of acute-on-chronic liver failure (ACLF) is able to predict mortality in cirrhotic patients with SBP. METHODS Historical cohort study conducted in a public tertiary care teaching hospital. Data from medical records from January 2009 to July 2016 were obtained by searching the hospital electronic database for samples of ascites collected in the period. Electronic and physical medical records were analyzed and patients were included if they were over 18-years old, with cirrhosis and an ascites fluid compatible with SBP: 69 patients were included. Liver-specific scores were calculated and Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis. RESULTS All cause mortality was 44%, 56.5% and 74% for 28-, 90- and 365-day, respectively. The prevalence of ACLF was 58%. Of these, 65% grade 1, 17.5% grade 2 and 17.5% grade 3. In multivariate analysis, the use of proton-pump inhi-bitors, alanine transaminase lower than 40 U/L, hemoglobin higher than 9 g/dL, absence of ACLF and lower CLIF-SOFA and MELD scores were independently associated with higher survival for both 28- and 90-day interval. CONCLUSION The presence of ACLF and higher CLIF-SOFA scores were independently associated with higher 28- and 90-day mortality in cirrhotic patients admitted due to SBP.
Collapse
Affiliation(s)
- Raquel de Oliveira Coberllini Jacques
- Hospital Geral, Medicina Interna, Caxias do Sul, RS, Brasil.,Universidade Federal de Santa Catarina, Departamento de Gastroenterologia, Florianópolis, SC, Brasil
| | - Lais da Silva Massignan
- Hospital Geral, Medicina Interna, Caxias do Sul, RS, Brasil.,Universidade Federal de Santa Catarina, Departamento de Gastroenterologia Clínica, Florianópolis, SC, Brasil
| | | | - Rafael Sartori Balbinot
- Universidade Federal de Ciências da Saúde de Porto Alegre, Medicina Interna, Porto Alegre, RS, Brasil
| | - Silvana Sartori Balbinot
- Universidade de Caxias do Sul, Departamento de Gastroenterologia Clínica, Caxias do Sul, RS, Brasil.,Universidade de São Paulo, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Jonathan Soldera
- Universidade de Caxias do Sul, Departamento de Gastroenterologia Clínica, Caxias do Sul, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Hepatologia, Programa de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| |
Collapse
|
13
|
Stockhoff L, Schneider H, Tergast TL, Cornberg M, Maasoumy B. Freiburg index of post-TIPS survival (FIPS) a valid prognostic score in patients with cirrhosis but also an advisor against TIPS? J Hepatol 2021; 75:487-489. [PMID: 33716088 DOI: 10.1016/j.jhep.2021.02.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 02/25/2021] [Accepted: 02/28/2021] [Indexed: 02/09/2023]
Affiliation(s)
- Lena Stockhoff
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Hannah Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Tammo Lambert Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany.
| |
Collapse
|
14
|
Dai R, Sag AA, Martin JG, Befera NT, Pabon-Ramos WM, Suhocki PV, Smith TP, Kim CY, Muir AJ, Ronald J. Proton pump inhibitor use is associated with increased rates of post-TIPS hepatic encephalopathy: Replication in an independent patient cohort. Clin Imaging 2021; 77:187-192. [PMID: 33940357 DOI: 10.1016/j.clinimag.2021.04.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/18/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Proton pump inhibitor (PPI) use is a potential risk factor for hepatic encephalopathy (HE), but few studies have examined the effect on post-TIPS HE. The purpose of this study was to determine whether PPIs are associated with increased rates of post-TIPS HE in an independent patient cohort. MATERIALS AND METHODS This single-institution retrospective study analyzed 86 patients (54 male, mean age 58.2) following TIPS from 1/1/2017 to 12/31/2019. Dates of PPI usage and episodes of new or worsening HE were recorded. Poisson regression with generalized estimating equations was used to test for association between PPI use and post-TIPS HE and to test for dose dependence. Post-TIPS HE was also analyzed using the Andersen-Gill survival model for recurrent events. RESULTS There were 1.88 episodes of new or worsening post-TIPS HE per person-year among 35 patients on uninterrupted PPIs therapy, 1.95 on PPIs and 0.94 off PPIs among 35 patients on intermittent therapy, and 0.47 among 16 patients never on PPIs. PPI use was significantly associated with post-TIPS HE in both univariable (incidence rate ratio (IRR) = 2.62; CI = 1.41-4.84; p = 0.002) and multivariable (IRR = 2.31; CI = 1.37-3.89; p = 0.002) regression. Analysis of only those patients on PPIs showed increased rates of HE with higher doses (IRR = 1.17 per 10 mg omeprazole equivalent; CI = 1.04-1.33; p = 0.011). Recurrent events survival analysis supported the association between PPI use and HE in univariable (hazard ratio (HR) = 2.17; CI = 1.19-3.95; p = 0.011) and multivariable (HR = 1.87; CI = 1.12-3.13; p = 0.017) analysis. CONCLUSION In an independent patient cohort PPI use was associated with increased rates of new or worsening post-TIPS HE.
Collapse
Affiliation(s)
- Rui Dai
- Duke University School of Medicine, DUMC 3710, Durham, NC 27710, USA
| | - Alan A Sag
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Jonathan G Martin
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Nicholas T Befera
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Waleska M Pabon-Ramos
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Paul V Suhocki
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Tony P Smith
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Charles Y Kim
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, DUMC 3913, Durham, NC 27710, USA
| | - James Ronald
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA.
| |
Collapse
|
15
|
Proton pump inhibitor use and mortality in patients with cirrhosis: a meta-analysis of cohort studies. Biosci Rep 2021; 40:224145. [PMID: 32406491 PMCID: PMC7276520 DOI: 10.1042/bsr20193890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Proton pump inhibitor (PPI) is commonly used in patients with cirrhosis. However, some studies demonstrated that PPI use was associated with adverse outcome in patients with cirrhosis. We aimed to perform a meta-analysis of cohort studies to evaluate the association between PPI use and mortality in cirrhotic patients. Methods: Relevant studies were obtained via search of PubMed and Embase databases. A randomized-effect model was used to pool the results. Subgroup analyses were performed to evaluate the source of heterogeneity. Results: Overall, 21 cohort studies with 20,899 patients and 7457 death events were included. The pooled results with a randomized-effect model showed that PPI use was associated with significantly increased risk of mortality in patients with cirrhosis (adjusted relative risk [RR] = RR: 1.39, P<0.001) with considerable heterogeneity (I2=73%). Subgroup analyses showed that characteristics such as patient ethnicity, sample size, definition of PPI use, and complications of patients did not affect the association. However, the association between PPI use and mortality was independent of study characteristics including patient ethnicity, sample size, complications, definition of PPI use, and follow-up duration. However, the association between PPI use and mortality in cirrhotic patients was significant in retrospective studies (RR: 1.40, P<0.001), but not in prospective studies (RR: 1.34, P=0.33). Conclusions: PPI use may be associated with moderately increased mortality in cirrhotic patients. Although prospective cohort studies are needed to validate our findings, PPI should only prescribed to cirrhotic patients with indications for the treatment.
Collapse
|
16
|
Beyaz Coşkun A, Sağdiçoğlu Celep AG. Therapeutic modulation methods of gut microbiota and gut-liver axis. Crit Rev Food Sci Nutr 2021; 62:6505-6515. [PMID: 33749411 DOI: 10.1080/10408398.2021.1902263] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Liver diseases are considered global health problems that cause more than 1 million deaths each year. Due to the increase in the prevalence of liver diseases worldwide, studies on different treatment methods have increased. Some of these methods is diagnostic and therapeutic applications based on the examination of the intestinal and intestinal microbiota. In this study, research articles, systematic review and review in the literature were examined in order to determine gut-liver axis relationship and treatment methods for liver diseases with gut modulation methods. Studies related to the subject have been searched in Google Scholar and Pubmed databases. The keywords "liver disease" and "gut-liver axis" and "microbiota" and "gut modulation methods" or "probiotic" or "prebiotic" or "symbiotic" or "antibiotic" or "bile acid regulation" or "adsorbent" or "fecal microbiota transplantation" were used in the searches. Improvements have been achieved in biomarkers of liver diseases by providing intestinal modulation with probiotic, prebiotic, symbiotic, antibiotic and adsorbents applications, bile acid regulation and fecal microbiota transplantation. In the results of experimental and clinical studies, it was seen that the therapeutic potential of the treatments performed by applying probiotics, prebiotics and symbiotics was higher.
Collapse
Affiliation(s)
- Ayfer Beyaz Coşkun
- Department of Nutrition and Dietetics, Faculty of Health Science, Fırat University, Elazığ, Turkey
| | | |
Collapse
|
17
|
Terres AZ, Balbinot RS, Muscope ALF, Longen ML, Schena B, Cini BT, Luis Rost G, Balensiefer JIL, Eberhardt LZ, Balbinot RA, Balbinot SS, Soldera J. Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:25-39. [PMID: 33746028 DOI: 10.1016/j.gastrohep.2021.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/22/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients. METHODS An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis. RESULTS The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality. CONCLUSION The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.
Collapse
Affiliation(s)
- Alana Zulian Terres
- Internal Medicine, Hospital Pompeia, Caxias do Sul, RS, Brazil; Gastroenterology, Hospital Geral de Caxias do Sul (RS), Brazil
| | - Rafael Sartori Balbinot
- Residency in Internal Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil; Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | | | | | - Bruna Schena
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | - Bruna Teston Cini
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | - Gilberto Luis Rost
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | | | | | - Raul Angelo Balbinot
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Department of Gastroenterology, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Silvana Sartori Balbinot
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Department of Gastroenterology, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Jonathan Soldera
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
| |
Collapse
|
18
|
Lu Z, Sun X, Han J, Jin B, Zhang W, Han J, Ma X, Liu B, Yu X, Wu Q, Wang Y, Li H. Characteristics of peptic ulcer bleeding in cirrhotic patients with esophageal and gastric varices. Sci Rep 2020; 10:20068. [PMID: 33208832 PMCID: PMC7674460 DOI: 10.1038/s41598-020-76530-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 10/14/2020] [Indexed: 02/07/2023] Open
Abstract
Upper gastrointestinal bleeding (UGIB) is common in liver cirrhosis. Although esophageal and gastric varices (EGV) is the main bleeding source, there were still a proportion of patients with peptic ulcer bleeding. Thus, this study aimed to analyze the characteristic of variceal bleeding and peptic ulcer bleeding in liver cirrhosis. Cirrhotic patients with confirmed UGIB by urgent endoscopy from July 2012 to June 2018 were enrolled, and classified into peptic ulcer bleeding group (n = 248) and variceal bleeding group (n = 402). Clinical and endoscopic characteristics, therapeutic efficacy and prognosis were evaluated, and independent risk factors for 42-day morality were determined. The mean age and gender ratio of peptic ulcer bleeding group were higher than those in variceal bleeding group (55.58 ± 11.37 vs. 52.87 ± 11.57, P < 0.01; 4.51:1 vs. 2.87:1, P = 0.023). Variceal bleeding group most commonly presented as red blood emesis and coffee grounds (67.16%), while peptic ulcer group primarily manifested as melena (62.10%). Hepatocellular carcinoma was more prevalent in peptic ulcer group (141 vs. 119, P < 0.01). Albumin level in variceal bleeding group was lower higher (P < 0.01), but serum bilirubin, creatinine and prothrombin time were significantly higher (all P < 0.01). Success rate of endoscopic hemostasis for variceal bleeding and peptic ulcer bleeding was 89.05% and 94.35% (P = 0.021). Univariate and multivariate analysis identified prothrombin time (P = 0.041, OR [95% CI] 0.884 [0.786–0.995]), MELD score (P = 0.000, OR [95% CI] 1.153 [1.073–1.240]), emergency intervention (P = 0.002, OR [95% CI] 8.656 [2.219–33.764]), hepatic encephalopathy before bleeding (P = 0.003, OR [95% CI] 8.119 [2.084–31.637]) and hepatic renal syndrome before bleeding (P = 0.029, OR [95% CI] 3.877 [1.152–13.045]) as the independent predictors for 42-day mortality. Peptic ulcer bleeding should be distinguished from variceal bleeding by clinical and endoscopic characteristics.
Collapse
Affiliation(s)
- Zheng Lu
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xiaotian Sun
- Departement of Internal Medicine, Beijing South Medical District of Chinese PLA General Hospital, No. 1 North Liuli Bridge, Beijing, 100161, China
| | - Jingjing Han
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Bo Jin
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Wenhui Zhang
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Jun Han
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xuemei Ma
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Bo Liu
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xiaoli Yu
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Qin Wu
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Yanling Wang
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Hanwei Li
- Liver Cirrhosis Diagnosis and Treatment Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China.
| |
Collapse
|
19
|
Kabbani AR, Schultalbers M, Tergast T, Kimmann M, Stahmeyer J, Manns MP, Cornberg M, Maasoumy B, Becker H. [Influence of a spontaneous bacterial peritonitis, nosocomial infections and acute-on-chronic liver failure on treatment revenues in patients with decompensated cirrhosis in Germany]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:855-867. [PMID: 32947631 DOI: 10.1055/a-1217-7549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The economic effects of spontaneous bacterial peritonitis (SBP), nosocomial infections (nosInf) and acute-on-chronic liver failure (ACLF) have so far been poorly studied. We analyzed the impact of these complications on treatment revenues in hospitalized patients with decompensated cirrhosis. METHODS 371 consecutive patients with decompensated liver cirrhosis, who received a paracentesis between 2012 and 2016, were included retrospectively. DRG (diagnosis-related group), "ZE/NUB" (additional charges/new examination/treatment methods), medication costs, length of hospital stay as well as different kinds of specific treatments (e. g., dialysis) were considered. Exclusion criteria included any kind of malignancy, a history of organ transplantation and/or missing accounting data. RESULTS Total treatment costs (DRG + ZE/NUB) were higher in those with nosInf (€ 10,653 vs. € 5,611, p < 0.0001) driven by a longer hospital stay (23 d vs. 12 d, p < 0.0001). Of note, revenues per day were not different (€ 473 vs. € 488, p = 0.98) despite a far more complicated treatment with a more frequent need for dialysis (p < 0.0001) and high-complex care (p = 0.0002). Similarly, SBP was associated with higher total revenues (€ 10,307 vs. € 6,659, p < 0.0001). However, the far higher effort for the care of SBP patients resulted in lower daily revenues compared to patients without SBP (€ 443 vs. € 499, p = 0.18). ACLF increased treatment revenues to € 10,593 vs. €6,369 without ACLF (p < 0.0001). While treatment of ACLF was more complicated, revenue per day was not different to no-ACLF patients (€ 483 vs. € 480, p = 0.29). CONCLUSION SBP, nosInf and/or ACLF lead to a significant increase in the effort, revenue and duration in the treatment of patients with cirrhosis. The lower daily revenue, despite a much more complex therapy, might indicate that these complications are not yet sufficiently considered in the German DRG system.
Collapse
Affiliation(s)
- Abdul-Rahman Kabbani
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany
| | - Marie Schultalbers
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany
| | - Tammo Tergast
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany
| | - Markus Kimmann
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany
| | - Jona Stahmeyer
- Institut für Epidemiologie Sozialmedizin und Gesundheitssystemforschung, Medizinische Hochschule Hannover, Germany
| | - Michael P Manns
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany.,Deutsche Leberstiftung, Hannover, Germany.,Deutsches Zentrum für Infektionsforschung e.V., Standort Hannover-Braunschweig, Germany
| | - Markus Cornberg
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany.,Deutsche Leberstiftung, Hannover, Germany.,Deutsches Zentrum für Infektionsforschung e.V., Standort Hannover-Braunschweig, Germany
| | - Benjamin Maasoumy
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany.,Deutsche Leberstiftung, Hannover, Germany
| | - Hans Becker
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany.,Deutsche Leberstiftung, Hannover, Germany
| |
Collapse
|
20
|
Stockhoff L, Schultalbers M, Tergast TL, Hinrichs JB, Gerbel S, Meine TC, Manns MP, Simon N, Cornberg M, Meyer BC, Maasoumy B. Safety and feasibility of transjugular intrahepatic portosystemic shunt in elderly patients with liver cirrhosis and refractory ascites. PLoS One 2020; 15:e0235199. [PMID: 32584874 PMCID: PMC7316253 DOI: 10.1371/journal.pone.0235199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/10/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND & AIMS The management of patients with refractory ascites (RA) is challenging, particularly at higher age. Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for RA, but safety data in elderly patients are rare. Our aim was to evaluate the safety and feasibility of TIPS in elderly patients with RA. METHODS Overall, 160 consecutive cirrhotic patients receiving a TIPS for RA at Hannover Medical School between 2012 and 2018 were considered for this retrospective analysis. Periinterventional complications such as acute-on-chronic liver failure (ACLF) as well as survival were compared between patients <65 and ≥65 years. Propensity score matching was conducted to match elderly TIPS patients and patients treated with paracentesis. RESULTS A number of 53 out of the 160 patients were ≥65 years (33%). Periinterventional course in those ≥65 years appeared to be slightly more complicated than in <65 years as reflected by a significantly longer hospital stay (p = 0.030) and more ACLF-episodes (21% vs. 9%; p = 0.044). 28-day mortality was similar between both groups (p = 0.350), whereas survival of the younger patients was significantly higher at 90 days (p = 0.029) and numerically higher at 1 year (p = 0.171). In the multivariate analysis age ≥65 years remained an independent predictor for 90-day mortality (HR: 2.58; p = 0.028), while it was not associated with 28-day and 1-year survival. Importantly, after matching for potential confounders 1-year survival was similar in elderly patients if treated with TIPS or paracentesis (p = 0.419). CONCLUSIONS TIPS placement in elderly patients with RA appears to be slightly more complicated compared to younger individuals, but overall feasible and at least not inferior to paracentesis.
Collapse
Affiliation(s)
- Lena Stockhoff
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marie Schultalbers
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Tammo L. Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Svetlana Gerbel
- Centre for Information Management (ZIMt), Hannover Medical School, Hannover, Germany
| | - Timo C. Meine
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektions-forschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
| | - Nicolas Simon
- Centre for Information Management (ZIMt), Hannover Medical School, Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektions-forschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
| | - Bernhard C. Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektions-forschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
- * E-mail:
| |
Collapse
|
21
|
Lin L, Hou L, Deng Y, Zhao T, Wang B, Sun C. Acid suppression therapy and its association with spontaneous bacterial peritonitis incidence: A systemic review and meta-analysis. Hepatol Res 2020; 50:233-245. [PMID: 31667938 DOI: 10.1111/hepr.13447] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 12/16/2022]
Abstract
AIM It is well known that the use of proton pump inhibitor (PPI) is widespread in patients with liver cirrhosis. PPI counteracts H2 receptor inhibitor (H2 RA) with its strong acid suppression effect. However, there is always a concern that PPI use may increase spontaneous bacteria peritonitis (SBP) development in cirrhotic patients. We aimed to investigate the association between acid suppression therapy (i.e. PPI or H2 RA) and SBP through meta-analysis. METHODS We searched PubMed, Medline, Web of Science, Cochrane library, and Embase for relevant studies published up to April 2019. Pooled OR and 95% CI were calculated by a random-effects model. Funnel plots and Egger's tests were performed for the evaluation of publication bias. Non-parametric "trim-and-fill" tests were conducted for sensitivity analysis. RESULTS A total of 20 original articles including 9566 cirrhotic patients were analyzed. The overall meta-analysis highlighted that PPI use was associated with the risk of SBP (pooled OR 1.77, 95% CI 1.49-2.11). The conclusion was irrespective of study methods, whereas the result was inconsistent only in South America. However, the conclusion might not be stable enough and should be extrapolated with caution. Unlike PPI, we found H2 RA was not associated with SBP (pooled OR 1.06, 95% CI 0.75-1.48). CONCLUSIONS In conclusion, PPI use, but not H2 RA, will increase the incidence of SBP in cirrhotic patients. In addition, H2 RA might be beneficial for patients who require long-term acid suppression therapy.
Collapse
Affiliation(s)
- Lin Lin
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Lijun Hou
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - You Deng
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Tianming Zhao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Bangmao Wang
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China.,Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| |
Collapse
|
22
|
Abstract
A substantial volume of literature exists linking proton pump inhibitor (PPI) use with a multitude of serious adverse events. There is uncertainty, however, over whether these associations are clinically important. Excessive concern about PPI-related adverse events may leave patients at risk of harm by leaving acid-related upper gastrointestinal disease untreated. Conversely, the risk of treatments may outweigh the benefits if any of the purported adverse events are directly caused by PPI use; this is of particular concern where indications for PPI use are not present. In this paper, we review the studies which have reported associations between adverse events and PPI use, discuss the proposed mechanisms of action, grade the confidence in whether these associations are truly causal, and provide advice regarding balancing the benefits of PPI use against their possible harms.
Collapse
Affiliation(s)
- Evan Elias
- Section of Gastroenterology, Department of Internal Medicine, Rady School of Medicine, University of Manitoba, 805G-715 McDermot Avenue, Winnipeg, MB, R3E 3P4, Canada
| | - Laura E Targownik
- Section of Gastroenterology, Department of Internal Medicine, Rady School of Medicine, University of Manitoba, 805G-715 McDermot Avenue, Winnipeg, MB, R3E 3P4, Canada.
| |
Collapse
|
23
|
Properly prescribed, proton pump inhibitors are largely safe, but precautions are needed to prevent potential problems, overuse and misuse. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00671-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
24
|
Tergast TL, Kimmann M, Laser H, Gerbel S, Manns MP, Cornberg M, Maasoumy B. Systemic arterial blood pressure determines the therapeutic window of non-selective beta blockers in decompensated cirrhosis. Aliment Pharmacol Ther 2019; 50:696-706. [PMID: 31373713 DOI: 10.1111/apt.15439] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/10/2019] [Accepted: 07/05/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The safety of non-selective β-blockers in patients with advanced cirrhosis has been questioned in recent years. It was hypothesised that there is a particular therapeutic window. However, the specific limits still need to be determined. AIM To evaluate potential limits of the therapeutic window of non-selective β-blocker therapy in patients with cirrhosis and ascites METHODS: The impact of non-selective β-blockers on 28-day transplant-free survival was analysed in a cohort of 624 consecutive patients with decompensated cirrhosis and ascites. Three potential limits were investigated: spontaneous bacterial peritonitis, acute-on-chronic liver failure, mean arterial blood pressure ≤ 82 and < 65 mm Hg. RESULTS Treatment with non-selective β-blockers was associated with a higher 28-day transplant-free survival in the overall cohort (hazard ratio: 0.621; P = .035) as well as in patients with acute-on-chronic liver failure (hazard ratio: 0.578; P = .031) and those with spontaneous bacterial peritonitis (hazard ratio: 0.594; P = .073). In contrast, survival benefits were markedly attenuated in patients with a mean arterial blood pressure ≤ 82 mm Hg and completely lost in those with mean arterial blood pressure < 65 mm Hg (P = .536). In spontaneous bacterial peritonitis patients with a mean arterial blood pressure < 65 mm Hg non-selective β-blocker treatment was associated with renal impairment. Of note, among those with a mean arterial blood pressure ≥ 65 mm Hg non-selective β-blocker intake was consistently associated with superior transplant-free survival (hazard ratio: 0.582; P = .029) irrespective of the presence of spontaneous bacterial peritonitis (hazard ratio: 0.435; P = .028) or acute-on-chronic liver failure (hazard ratio: 0.480 P = .034). CONCLUSIONS Ascites, acute-on-chronic liver failure and spontaneous bacterial peritonitis do not limit the safe use of non-selective β-blockers in patients with cirrhosis. Mean arterial blood pressure might represent a better indicator to determine the therapeutic window of non-selective β-blocker treatment.
Collapse
Affiliation(s)
- Tammo L Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Markus Kimmann
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Hans Laser
- Hannover Medical School, Centre for Information Management (ZIMt), Hannover, Germany
| | - Svetlana Gerbel
- Hannover Medical School, Centre for Information Management (ZIMt), Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany.,Centre for Individualised Infection Medicine (CIIM), Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany.,Centre for Individualised Infection Medicine (CIIM), Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
| |
Collapse
|
25
|
Kabbani AR, Tergast TL, Manns MP, Maasoumy B. [Treatment strategies for acute-on-chronic liver failure]. Med Klin Intensivmed Notfmed 2019; 116:3-16. [PMID: 31463674 PMCID: PMC7095250 DOI: 10.1007/s00063-019-00613-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 12/15/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is a newly defined syndrome in patients with liver cirrhosis characterized by acute hepatic decompensation (jaundice, ascites, hepatic encephalopathy, bacterial infection and gastrointestinal bleeding), single or multiple organ failure and a high mortality (>15% within 28 days). The affected organ systems include not only the liver but also the circulation, lungs, kidneys, brain and/or coagulation. Pathophysiologically decisive is an uncontrolled inflammation that is induced by specific triggers and on the basis of previously (possibly not diagnosed) compensated as well as already decompensated liver cirrhosis leads to a severe systemic clinical syndrome, ACLF. The course during the first 72 h is decisive for the prognosis. In addition to treatment of the respective organ or system failure, the underlying triggers should be quickly identified and if necessary specifically treated. Often, however, these cannot (no longer) be determined with any certainty, in particular recent alcohol consumption as well as bacterial and viral infections play an important role. A specific treatment for the ACLF is (currently) not established. Some experimental approaches are currently being tested, including administration of granulocyte colony-stimulating factor (GCSF). Additionally, suitable patients should be presented to a liver transplantation center in a timely manner.
Collapse
Affiliation(s)
| | | | | | - B Maasoumy
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| |
Collapse
|
26
|
Kimmann M, Tergast TL, Schultalbers M, Laser H, Gerbel S, Manns MP, Cornberg M, Maasoumy B. Sustained impact of nosocomial-acquired spontaneous bacterial peritonitis in different stages of decompensated liver cirrhosis. PLoS One 2019; 14:e0220666. [PMID: 31374111 PMCID: PMC6677299 DOI: 10.1371/journal.pone.0220666] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND & AIMS Bacterial infections, in particular a spontaneous bacterial peritonitis (SBP), are a major threat in patients with liver cirrhosis. Recently, it has been shown that the impact on mortality might be underestimated by established risk-scores. Onset of infection was suggested to define a distinct stage of cirrhosis. However, it remains unclear whether all stages of decompensated cirrhosis are equally affected. Moreover, if there is such a distinct stage, it must be determined whether it is reversible after the infection has resolved. In this study we aimed to further analyze the impact of a current as well as a resolved SBP in different stages of decompensated liver cirrhosis. METHODS A number of 579 patients with liver cirrhosis and ascites were included. MELD-score was used to determine the stage of liver disease. Low (<15), intermediate (15-25) and high (>25) MELD-groups were compared. Patients were followed up for 90 days. Primary endpoint was overall mortality. Statistical analyses were performed using the log-rank test, Cox regression and competing risk analysis. RESULTS Mortality was significantly higher in patients with nosocomial-acquired SBP (nSBP) compared to patients without SBP (p<0.001;HR = 2.05). However, the most prominent difference in mortality was documented in the intermediate MELD-group (nSBP: p = 0.02;HR = 2.10). Importantly, mortality in nSBP patients remained increased even after the initial nSBP episode had resolved (p<0.01;HR = 1.90). Again, this was only significant in those with intermediate MELD-scores (p = 0.02;HR = 2.28). While a current as well as a resolved nSBP were significantly linked to a higher mortality, neither of them did increase the likelihood for liver transplantation. CONCLUSIONS Development of nSBP is independently associated with increased mortality supporting the concept of a distinct status of cirrhosis. Importantly, the prognosis remains unfavorable even after resolution of nSBP. This could be particularly relevant for patients with intermediate MELD-scores, who have limited chances for a donor liver.
Collapse
Affiliation(s)
- Markus Kimmann
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Tammo Lambert Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marie Schultalbers
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Hans Laser
- Centre for Information Management (ZIMT), Hannover Medical School, Hannover, Germany
| | - Svetlana Gerbel
- Centre for Information Management (ZIMT), Hannover Medical School, Hannover, Germany
| | - Michael Peter Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
| |
Collapse
|
27
|
Wellhöner F, Döscher N, Tergast TL, Vital M, Plumeier I, Kahl S, Potthoff A, Manns MP, Maasoumy B, Wedemeyer H, Cornberg M, Pieper DH, Heidrich B. The impact of proton pump inhibitors on the intestinal microbiota in chronic hepatitis C patients. Scand J Gastroenterol 2019; 54:1033-1041. [PMID: 31361979 DOI: 10.1080/00365521.2019.1647280] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objectives: Proton pump inhibitors (PPI), a class of drugs commonly used, are known to be associated with changes in the intestinal microbiota. Published studies were done in heterogeneous cohorts which could hamper conclusions drawn as effects of diseases were not taken into consideration. We aimed to elucidate differences in the intestinal microbiota being associated to the use of PPI in a cohort study of patients with chronic hepatitis C. Material and Methods: The 16S rDNA gene was analyzed in stool samples of patients with and without PPI use. Patients with concomitant medication influencing the microbiota were excluded. Results were compared with the clinical course of hepatitis C patients with decompensated liver cirrhosis. Results: No differences in alpha diversity could be observed, while the microbial community structure differed significantly, especially in patients with liver cirrhosis. The relative abundance of Streptococcus spp., Enterobacter spp. and Haemophilus spp. was significantly increased in patients with PPI use irrespectively of the stage of liver disease. Finally, in patients with decompensated liver cirrhosis due to chronic HCV infection only in these using PPI bacterial phylotypes were isolated. Conclusions: PPI use was associated with significant alterations in the microbial community in patients with chronic hepatitis C, which were even pronounced in patients with liver cirrhosis. In patients with decompensated liver cirrhosis due to chronic HCV infection, the use of PPI may promote infections either directly or indirectly through changes in the microbial community structure. Future studies should further investigate long-term impact on the microbiota and the clinical outcome.
Collapse
Affiliation(s)
- Freya Wellhöner
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany
| | - Nico Döscher
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany
| | - Tammo Lambert Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany
| | - Marius Vital
- Helmholtz Center for Infection Research, Microbial Interactions and Processes Research Group , Braunschweig , Germany
| | - Iris Plumeier
- Helmholtz Center for Infection Research, Microbial Interactions and Processes Research Group , Braunschweig , Germany
| | - Silke Kahl
- Helmholtz Center for Infection Research, Microbial Interactions and Processes Research Group , Braunschweig , Germany
| | - Andrej Potthoff
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany
| | - Michael Peter Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany.,German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig , Braunschweig , Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany.,German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig , Braunschweig , Germany.,Department of Gastroenterology and Hepatology, Essen University Hospital , Essen , Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany.,German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig , Braunschweig , Germany
| | - Dietmar Helmut Pieper
- Helmholtz Center for Infection Research, Microbial Interactions and Processes Research Group , Braunschweig , Germany.,German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig , Braunschweig , Germany
| | - Benjamin Heidrich
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School , Hannover , Germany.,Helmholtz Center for Infection Research, Microbial Interactions and Processes Research Group , Braunschweig , Germany.,German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig , Braunschweig , Germany
| |
Collapse
|
28
|
Proton Pump Inhibitor Therapy and Hepatic Encephalopathy Risk in Cirrhotic Patients: A Systematic Review with Meta-analysis. Clin Drug Investig 2019; 39:847-856. [DOI: 10.1007/s40261-019-00810-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
29
|
Tantai XX, Yang LB, Wei ZC, Xiao CL, Chen LR, Wang JH, Liu N. Association of proton pump inhibitors with risk of hepatic encephalopathy in advanced liver disease: A meta-analysis. World J Gastroenterol 2019; 25:2683-2698. [PMID: 31210719 PMCID: PMC6558434 DOI: 10.3748/wjg.v25.i21.2683] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Several studies have explored the association between the use of proton pump inhibitors (PPIs) and the risk of developing hepatic encephalopathy (HE) in patients with advanced liver disease. However, the evidence-based conclusions are controversial. We hypothesized that using PPIs may increase the risk of HE in patients with advanced liver disease. If confirmed, clinicians must strictly adhere to the indications for PPI treatment in this population.
AIM To evaluate the pooled risk of HE in patients with advanced liver disease who use PPIs.
METHODS Three electronic databases (PubMed, EMBASE, and the Cochrane Library) were searched from the date of database inception through January 8, 2019 to identify comparative studies evaluating the association between PPI use and the risk of HE. Data from the included studies were extracted. The random-effects model was used for pooling risk estimates and the corresponding 95% confidence intervals (CIs). Subgroup and sensitivity analyses were also performed.
RESULTS In total, 4342 patients from five case-control studies and 188053 patients from four cohort studies were included in this analysis. In patients with advanced liver disease, PPI use was associated with an elevated risk of developing HE, with significant heterogeneity. The pooled odds ratio for case-control studies was 2.58 (95%CI: 1.68-3.94, I2 = 72%). The pooled RR for cohort studies was 1.67 (95%CI: 1.30-2.14, I2 = 67%). The results of the subgroup analyses suggested that the heterogeneity may be the result of differences in the study designs and the definitions of PPI use. The sensitivity and subgroup analyses did not alter our findings.
CONCLUSION In patients with advanced liver disease, PPI use is associated with an elevated risk of HE. Future large prospective studies are needed to confirm this association.
Collapse
Affiliation(s)
- Xin-Xing Tantai
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Long-Bao Yang
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Zhong-Cao Wei
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Cai-Lan Xiao
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Li-Rong Chen
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Jin-Hai Wang
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Na Liu
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| |
Collapse
|
30
|
Ma YJ, Cao ZX, Li Y, Feng SY. Proton pump inhibitor use increases hepatic encephalopathy risk: A systematic review and meta-analysis. World J Gastroenterol 2019; 25:2675-2682. [PMID: 31210718 PMCID: PMC6558435 DOI: 10.3748/wjg.v25.i21.2675] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/24/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Several studies have been conducted to explore the association between the use of proton pump inhibitors (PPIs) and hepatic encephalopathy (HE) risk in patients with liver cirrhosis. However, their results are controversial.
AIM To perform a systematic review and meta-analysis to evaluate the HE risk among PPI users.
METHODS A systematic search on PubMed, Web of Science, EMBase, and ScienceDirect databases was conducted up to December 31, 2018 for eligible studies involving PPI use and HE risk. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the fixed or random effects model. Publication bias was evaluated using Begg’s test, Egger’s test, and trim-and-fill method.
RESULTS Seven studies with 4574 patients were included in the present meta-analysis. The meta-analysis results indicated a significant association between the PPI use and HE risk (OR = 1.50; 95%CI: 1.25-1.75) with low heterogeneity (I2 = 14.2%, P = 0.321). Although publication bias existed when Egger’s tests were used (P = 0.005), the trim-and-fill method verified the stability of the pooled result. Sensitivity analyses suggested that the results of this meta-analysis were robust.
CONCLUSION The current evidence indicates that PPI use increases HE risk in patients with liver cirrhosis. Further studies with a large data set and well-designed models are needed to validate our findings.
Collapse
Affiliation(s)
- Yun-Jie Ma
- Emergency Department, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Zong-Xun Cao
- Emergency Department, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Yong Li
- Emergency Department, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Shun-Yi Feng
- Emergency Department, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| |
Collapse
|
31
|
Ribiere S, Guillaumot MA, Barré A, Abou Ali E, Barret M, Chaussade S, Coriat R. Quel est le VRAI risque au long cours des inhibiteurs de la pompe à protons ? Presse Med 2019; 48:503-510. [DOI: 10.1016/j.lpm.2019.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/11/2019] [Indexed: 11/30/2022] Open
|
32
|
Okura Y, Namisaki T, Sato S, Moriya K, Akahane T, Kitade M, Kawaratani H, Kaji K, Takaya H, Sawada Y, Shimozato N, Seki K, Saikawa S, Nakanishi K, Furukawa M, Fujinaga Y, Kubo T, Kaya D, Tsuji Y, Ozutsumi T, Kitagawa K, Mashitani T, Ogawa H, Ishida K, Mitoro A, Yamao J, Yoshiji H. Proton pump inhibitor therapy does not increase serum endotoxin activity in patients with cirrhosis. Hepatol Res 2019; 49:232-238. [PMID: 30198141 DOI: 10.1111/hepr.13249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/16/2018] [Accepted: 09/02/2018] [Indexed: 12/17/2022]
Abstract
AIM Proton pump inhibitors (PPIs) are frequently prescribed in patients with cirrhosis, but this therapy entails potential complications. We aimed to investigate the influence of PPI use on intestinal permeability in patients with cirrhosis. METHODS We recruited 228 patients with cirrhosis and divided them into four groups. Group (Gp)1 comprised patients receiving a PPI with concurrent neomycin (NEO) (PPI-NEO group, n = 14 [6.1%]), Gp2 and Gp3 comprised those receiving either PPI or NEO (PPI group, n = 91 [39.9%]; and NEO group, n = 11 [4.4%]), and Gp4 comprised those receiving neither of these medications (control group; n = 112 [49.1%]). We assessed the intestinal permeability by measuring endotoxin activity (EA) using a luminol chemiluminescence method. RESULTS Endotoxin activity levels were significantly higher in patients with Child B cirrhosis than in those with Child A cirrhosis, but we found no significant differences in EA levels between patients with Child C cirrhosis and those with either Child A or B cirrhosis. We observed no significant differences in EA levels among groups 1-4. Patients without antibiotic exposure (n = 203), comprising 91 patients on PPI therapy (Gp2) and 112 no-PPI-therapy controls (Gp4), were subdivided according to Child-Pugh (CP) classification. We found no significant differences in EA levels between Gp2 and Gp4 in either CP class. CONCLUSION Our results suggest that PPI usage does not have a significant impact on serum levels of gut-derived endotoxins, which are already elevated because of the increased intestinal permeability in patients with cirrhosis.
Collapse
Affiliation(s)
- Yasushi Okura
- Department of Endoscopy, Nara Medical University Hospital, Nara, Japan
| | - Tadashi Namisaki
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Shinya Sato
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Kei Moriya
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Takemi Akahane
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Mitsuteru Kitade
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Hideto Kawaratani
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Kosuke Kaji
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Hiroaki Takaya
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Yasuhiko Sawada
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Naotaka Shimozato
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Kenichiro Seki
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Soichiro Saikawa
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Keisuke Nakanishi
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Masanori Furukawa
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Yukihisa Fujinaga
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Takuya Kubo
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Daisuke Kaya
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Yuki Tsuji
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Takahiro Ozutsumi
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Koh Kitagawa
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Tsuyoshi Mashitani
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Hiroyuki Ogawa
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Koji Ishida
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Akira Mitoro
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Junichi Yamao
- Department of Endoscopy, Nara Medical University Hospital, Nara, Japan
| | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| |
Collapse
|
33
|
Tergast TL, Laser H, Gerbel S, Manns MP, Cornberg M, Maasoumy B. Association Between Type 2 Diabetes Mellitus, HbA1c and the Risk for Spontaneous Bacterial Peritonitis in Patients with Decompensated Liver Cirrhosis and Ascites. Clin Transl Gastroenterol 2018; 9:189. [PMID: 30250034 PMCID: PMC6155293 DOI: 10.1038/s41424-018-0053-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/06/2018] [Accepted: 08/11/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction Type 2 diabetes mellitus (DM) is a frequent comorbidity among patients with liver cirrhosis. However, data regarding the impact of DM on spontaneous bacterial peritonitis (SBP) are quite limited. Our aim was to analyze the impact of DM and HbA1c values on the incidence of SBP and mortality in patients with liver cirrhosis and ascites. Methods A number of 475 consecutive patients with liver cirrhosis and ascites were analyzed. Presence of DM as well as HbA1c was assessed at the time of the first paracentesis. Patients were followed up for a mean of 266 days. Primary endpoints were SBP development and mortality. Results Overall, 118 (25%) patients were diagnosed with DM. DM patients had an increased risk for developing a SBP during follow-up (HR: 1.51; p = 0.03). SBP incidence was particularly high in DM patients with HbA1c values ≥6.4%, significantly higher than in DM patients with HbA1c values <6.4% (HR: 4.21; p = 0.0002). Of note, DM patients with HbA1c <6.4% at baseline had a similar risk for SBP as those without DM (HR: 0.93; p = 0.78, respectively). After excluding all patients who were eligible for secondary antibiotic prophylaxis, HbA1c ≥6.4% but neither bilirubin nor ascites protein level were associated with primary SBP development in the multivariate analysis (p = 0.003). Conclusions Individuals with liver cirrhosis and concomitant DM have a higher risk for developing a SBP. HbA1c values may be useful to further stratify the risk for SBP among DM patients, which may help to identify those who benefit from antibiotic prophylaxis.
Collapse
Affiliation(s)
- Tammo L Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany
| | - Hans Laser
- Centre for Information Management (ZIMt), Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany
| | - Svetlana Gerbel
- Centre for Information Management (ZIMt), Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany.,German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany.,Centre for Individualised Infection Medicine (CIIM), c/o CRC Hannover, Feodor-Lynen-Str. 15, 30625, Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany. .,German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany. .,Centre for Individualised Infection Medicine (CIIM), c/o CRC Hannover, Feodor-Lynen-Str. 15, 30625, Hannover, Germany.
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany. .,German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany.
| |
Collapse
|