Renal Dysfunction Induced by Bacterial Infection other than Spontaneous Bacterial Peritonitis in Patients with Cirrhosis: Incidence and Risk Factor

Common musculoskeletal disorders in chronic liver disease patients

Chronic liver disease (CLD) is the commonest ailment affecting the hepatobiliary system. Six significant pathologies related to CLD include hepatic osteodystrophy (HO), increased infection susceptibility, sarcopenia, osteonecrosis of the femoral head (OFH), increased risk of periprosthetic complications and fracture. Hepatic osteodystrophy, which comprises osteopenia, osteoporosis, and osteomalacia, refers to alterations in bone mineral metabolism found in patients with CLD. The HO prevalence ranges from 13 to 95%. Low complement levels, poor opsonization capacity, portosystemic shunting, decreased albumin levels, and impaired reticuloendothelial system make the cirrhotic patients more susceptible to developing infectious diseases. Septic arthritis, osteomyelitis, prosthetic joint infection, and cellulitis were common types of CLD-associated infectious conditions. The incidence of septic arthritis is 1.5 to 2-fold higher in patients with cirrhosis. Sarcopenia, also known as muscle wasting, is one of the frequently overlooked manifestations of CLD. Sarcopenia has been shown to be independent predictor of longer mechanical ventilation, hospital stay, and 12-month mortality of post-transplantation. Alcohol and steroid abuse commonly associated with CLD are the two most important contributory factors for non-traumatic osteonecrosis. However, many studies have identified cirrhosis alone to be an independent cause of atraumatic osteonecrosis. The risk of developing OFH in cirrhosis patients increases by 2.4 folds and the need for total hip arthroplasty increases by 10 folds. Liver disease has been associated with worse outcomes and higher costs after arthroplasty. Cirrhosis is a risk factor for arthroplasty complications and is associated with a prolonged hospital stay, higher costs, readmission rates, and increased mortality after arthroplasty. Greater physician awareness of risk factors associated with musculoskeletal complications of CLD patients would yield earlier interventions, lower healthcare costs, and better overall clinical outcomes for this group of patients.

Hemodynamic Changes of Hepatic & Renal Vessels in Systemic Bacterial Infection with Fever in HCV Related Cirrhosis

OBJECTIVES

To study the hemodynamic changes of hepatic & renal vessels in systemic bacterial infection with fever in HCV related cirrhosis with possible complications.

METHODS

Three groups of patients with systemic bacterial infection with fever were included in the study; group І included 15 patients with decompensated cirrhosis, group ІІ included 15 patients with compensated cirrhosis and group ІІІ included 10 patients without liver affection. Laboratory parameters and Doppler US of hepatic and renal vessels were evaluated during and after subsidence of fever in all patients.

RESULTS

Forty patients were enrolled in this prospective study. There were 22 male and 18 female patients. We found that the direction of blood flow in the portal and splenic veins was hepatopetal and the veins were non pulsatile in all cases with no change during and after subsidence of infection. There was no significant difference in portal or splenic vein diameters during and after subsidence of infection in the three studied groups. However, the mean values of portal and splenic veins peak velocities were significantly lower during infection in cirrhotic groups. The mean value of hepatic artery resistive index during fever was significantly higher than after fever in cirrhotic groups. Renal resistive and pulsatility indices were significantly higher during fever in cirrhotic groups.

CONCLUSION

Systemic bacterial infection with fever can affect hepatic haemodynamics leading to aggravation of portal hypertension and increasing the risk of complications as variceal bleeding and hepatic encephalopathy and can also affect renal haemodynamics with increased risk of renal impairment.

Effects of poor hepatic reserve in cirrhotic patients with bacterial infections: A population-based study

Objective:

Ascites, hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis, and esophageal variceal bleeding are major complications associated with cirrhosis. The presence of these complications indicates poor hepatic reserve. This study aimed to identify the effects of poor hepatic reserve on mortality in cirrhotic patients with bacterial infections.

Patients and Methods:

The Taiwan National Health Insurance Database was used to identify 43,042 cirrhotic patients with bacterial infections hospitalized between January 1, 2010, and December 31, 2013, after propensity score matching analysis. Of these, 21,521 cirrhotic patients had major cirrhotic-related complications and were considered to have poor hepatic reserve.

Results:

Mortality rates at 30 and 90 days were 24.2% and 39.5% in the poor hepatic reserve group and 12.8% and 21.7% in the good hepatic reserve group, respectively (P < 0.001 for each group). The cirrhotic patients with poor hepatic reserve (hazard ratio [HR], 2.10; 95% confidence interval [CI] = 2.03–2.18; P < 0.001) had significantly increased mortality at 90 days. The mortality HRs in patients with one, two, and three or more complications compared to patients without complications were 1.92 (95% CI = 1.85–1.99, P < 0.001), 2.61 (95% CI = 2.47–2.77, P < 0.001), and 3.81 (95% CI = 3.18–4.57, P < 0.001), respectively.

Conclusion:

In cirrhotic patients with bacterial infections, poor hepatic reserve is associated with a poor prognosis. The presence of three or more cirrhotic-related complications increases mortality almost four folds.

Clinical predictors and impact of bacteremia in cirrhotic patients with acute skin and skin structure infection

OBJECTIVE

Acute bacterial skin and skin structure infection (ABSSSI) is a common cause of acute admissions in patients with cirrhosis worldwide, but the disease is not well-understood epidemiologically with respect to factors that determine positive blood cultures or patient mortality. The aim of this study was to understand the utility of blood cultures and the association between bacteremia and mortality in cirrhotic patients with ABSSSI. We conducted a retrospective study to investigate factors associated with positive blood cultures and mortality in cirrhotic patients with ABSSSI.

METHODS

A retrospective cohort study of hospitalized adult cirrhotic patients with ABSSSI was conducted in a tertiary hospital in Taiwan between March 2015 and December 2016.

RESULTS

A total of 122 hospitalized cirrhotic patients with ABSSSI were included. The overall mortality rate was 9% (11/122), and 23 patients had positive blood culture results. Comorbidities that were significant risk factors for a positive blood culture included diabetes mellitus, acute kidney injury (AKI), and acute-on-chronic liver failure (ACLF). Significant risk factors evident in laboratory evaluations included higher model for end-stage liver disease (MELD) score, higher serum lactate, and lower serum albumin level. Bacteremia was also a significant factor associated with mortality.

CONCLUSION

A blood culture should be considered for cirrhotic patients with ABSSSI with diabetes mellitus, AKI, ACLF or those exhibiting abnormal albumin, lactate levels, or high MELD score because of the positive correlation between bacteremia and mortality.

Are there differences in risk factors, microbial aspects, and prognosis of cellulitis between compensated and decompensated hepatitis C virus-related cirrhosis?

Background/Aims

Cellulitis is a common infection in patients with liver cirrhosis. We aimed to compare risk factors, microbial aspects, and outcomes of cellulitis in compensated and decompensated hepatitis C virus (HCV)-related cirrhosis.

Methods

Six hundred twenty consecutive HCV-related cirrhotic patients were evaluated for cellulitis. Demographic and clinical data were evaluated, along with blood and skin cultures. Severity of cirrhosis was assessed using Child-Pugh score. In-hospital mortality was assessed.

Results

Seventy-seven (12.4%) cirrhotic patients had cellulitis (25 with compensated and 52 with decompensated disease). Smoking and venous insufficiency were risk factors of cellulitis in compensated cirrhosis. Leg edema, ascites, hyperbilrubinemia and hypoalbuminemia were risk factors in decompensated cirrhosis. Gram-positive bacteria (Staphylococcus spp. and Streptococcus pyogenes) were the infective organisms in compensated patients, while gram negative bacteria (Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa) were the predominant organisms in decompensated cirrhosis. Fungi (Candida albicans and Aspergillus niger) were detected in 3 decompensated cases. In-hospital mortality in patients with cellulitis was 27.3%, approaching 100% in decompensated patients with gram-negative cellulitis. Prolonged hospitalization, higher model for end-stage liver disease (MELD)-Na score, septic shock, local complication, and recurrent cellulitis were predictors of mortality.

Conclusions

Cellulitis in compensated cirrhosis is different from that of decompensated patients regarding microorganisms, pathogenesis, and prognosis. Cellulitis has a poor prognosis, with mortality rates approaching 100% in decompensated patients with gram-negative cellulitis. Stratifying patients according to severity of cirrhosis is important to identify the proper empirical antibiotic and to decide the proper means of care.

Primary Klebsiella pneumoniae Osteomyelitis with Bacteremia and Sepsis in a Patient with Cirrhosis

Osteomyelitis is commonly caused by Staphylococci, Streptococci, Escherichia coli, and anaerobes. There have been cases of rare organisms like Klebsiella pneumoniae (Kp) being initially overlooked as causes of osteomyelitis. We report a case of an elderly cirrhotic adult male transferred for further management of liver failure, who was subsequently diagnosed with Kp osteomyelitis and sepsis. He had a history of blunt leg trauma, and MRI of the leg revealed osteomyelitis, with a negative workup for other sources of infection. Kp osteomyelitis is reported in less than 100 cases, mainly in pediatric and sickle-cell patients. There are no pathognomonic imaging findings. Lesions may be metastatic, with rapid widespread destruction and exuberant periosteal reaction. Kp is a rare, under recognized cause of osteomyelitis in immune-suppressed adults. Given its pathogenicity, early identification is critical.

Cellulitis in liver cirrhosis - a series of 25 cases from southern India

Introduction

Cirrhosis of the liver predisposes patients to serious bacterial infections including cellulitis. The aim of the study was to determine the clinical and bacteriological profile of cellulitis in patients with liver cirrhosis.

Material and methods

In this prospective study, consecutive cirrhotic patients hospitalized between February and September 2017 were enrolled. Data retrieved included demographics, aetiology, co-morbidity, cirrhosis-related complications, site of cellulitis, baseline investigations, and wound and blood culture.

Results

Three hundred and thirty-eight patients were admitted, of whom 25 had cellulitis (mean age 52.8 ± 10.4 years, men 88.0%, median MELD [model of end-stage liver disease] 18.8 ± 10.4). Non-alcoholic steatohepatitis and alcohol were each the cause of cirrhosis in 40% of cases. Nine patients (36%) had diabetes mellitus. Cultures were positive in 13 cases (52%; 1 - blood, 11 - wound, 1 - both blood and skin). The majority of the cultures showed monomicrobial growth (9; 70%). Escherichia coli was the commonest isolate (6/13), followed by Klebsiella (4). 61% of isolates had multidrug resistant organisms. The outcome was favourable.

Conclusions

Prevalence of cellulitis was 7.4% in hospitalised cirrhotics. Culture positivity was 52%. Escherichia coli and Klebsiella were the most common isolates and three fifths of isolates were multidrug resistant.

New Insights About Albumin and Liver Disease

Decompensated liver cirrhosis has a dismal prognosis, with an overall survival of 2-4 years, which is worse than for many oncological diseases. Albumin is an important tool in the management of patients with cirrhosis, since it decreases for less than half the risk for post-paracentesis cardiocirculatory dysfunction and mortality associated with spontaneous bacterial infection, as well as, it triplicates the response to terlipressin in patients with hepatorenal syndrome. Recently, research on albumin has been a hot topic, with important new insights such as the characterization of the pleiotropic effects of albumin (which surpass its oncotic properties) and the concept of effective albumin concentration. In fact, patients with liver cirrhosis present posttranslational modifications on albumin that compromises its function. Those modified albumin forms were proved to have prognostic value and its knowledge may change the paradigm of albumin treatment. In this review, we critically summarize the latest evidence on the potential benefits of albumin in patients with end-stage liver disease.

Incidence, predictive factors and impacts of acute kidney injury in cirrhotic patients hospitalized for cellulitis

BACKGROUND & AIMS

Cellulitis is a common infection in patients with cirrhosis but its impact on progression of liver disease has been hardly addressed. This study examines the incidence of acute kidney injury (AKI), predictive factors and its impacts on mortality in cirrhotic patients hospitalized for cellulitis.

METHODS

Retrospective data from cirrhotic patients hospitalized for cellulitis over the period January 2006 to September 2015 were analysed. AKI was defined according to revised criteria of the International Club of Ascites.

RESULTS

A total of 101 episodes of cellulitis were examined (70.3% men; mean age 60.6 ± 13.6 years). Of patients, 27% met criteria for acute on chronic liver failure (ACLF) (grade 1: 63%; grade 2: 22%; grade 3: 15%). AKI was recorded in 50.5% (type 1: 67%; type 2: 19%; type 3: 14%). AKI was present on admission in 21 of the 51 patients (41%) who developed it. In the remaining 30 patients (59%), AKI appeared during hospitalization and its development was associated with a MELD score >14 (70% vs 30%, P=.024). In-hospital mortality was 10% and all patients who died had AKI. A high MELD score on admission, AKI and ACLF were associated with in-hospital mortality (P<.05). One-month transplant-free survival was 84% (70% vs 98% in patients with and without AKI, P=.001).

CONCLUSIONS

In cirrhotic patients, cellulitis is a serious infection that often leads to AKI and ACLF. AKI is a strong predictor of mortality in this setting.

Impact of renal dysfunction in cirrhotic patients with bacterial infections other than spontaneous bacterial peritonitis

AIM

The impact of renal dysfunction has not been well evaluated among cirrhotic patients having bacterial infections other than spontaneous bacterial peritonitis (SBP). We aimed to examine the impact of renal function impairment (RFI) among cirrhotic patients with non-SBP bacterial infections.

METHODS

Data of 7134 cirrhotic patients with non-SBP bacterial infections extracted from the Taiwan National Health Insurance Database, derived from the Taiwan National Health Insurance Program, in 2004 were analyzed.

RESULTS

A total of 579 (8.1%) patients had renal dysfunction. Of these, 223 patients had acute renal failure (ARF), and 141 had end-stage renal disease (ESRD) requiring hemodialysis before admission. The overall 30-day, 1-year and 3-year mortalities were 15.8%, 39.3% and 54.5%, respectively. Compared with the non-RFI group, the adjusted hazard ratios (HR) of 30-day mortality for RFI, ARF and ESRD were 3.20 (P < 0.001), 4.81 (P < 0.001) and 1.59 (P = 0.015); the adjusted HR of 1-year mortality for RFI, ARF and ESRD were 2.68 (P < 0.001), 3.50 (P < 0.001) and 1.84 (P < 0.001), and adjusted HR of 3-year mortality for RFI, ARF and ESRD were 2.34 (P < 0.001), 2.97 (P < 0.001) and 1.76 (P < 0.001). The adjusted HR of 30-day, 1-year and 3-year mortalities for the ARF group were 2.98 (P < 0.001), 1.74 (P < 0.001) and 1.58 (P = 0.001) compared with the ESRD group, respectively.

CONCLUSION

This population-based cohort study shows that RFI, especially ARF, is an independent poor prognostic factor in cirrhotic patients with non-SBP bacterial infections.

Prevalence and in-hospital mortality trends of infections among patients with cirrhosis: a nationwide study of hospitalised patients in the United States

BACKGROUND

Data on bacterial infections in hospitalised patients in the US with cirrhosis are derived largely from single centre data. Countrywide data in this population are lacking.

AIM

To assess prevalence of infections among hospitalised patients in the US and examine their impact on in-hospital mortality and health care resources utilisation.

METHODS

Nationwide Inpatient Sample (1998-2007) was queried for hospitalisations with cirrhosis and examined for infections including spontaneous bacterial peritonitis (SBP), urinary tract infection (UTI), skin and soft tissue infections, pneumonia and Clostridium difficile infections (CDI). In-hospital mortality, length of stay (LOS) and total charges were analysed.

RESULTS

Of 742,391 admissions with cirrhosis, 168,654 (23%) had discharge diagnosis of any infection. Between 1998 and 2007, there was a trend towards increasing prevalence of infections (21-25%). Higher rates of infection were associated with ascites (22-25%) and renal insufficiency (RI) (38-43%). Infection with RI increased from 13% in 1998 to 27% in 2007. UTI was the most common infection (9-12%) followed by subcutaneous tissue infections (5-6%) and SBP (2-3%, around 12% in patients with ascites). Infection rate was similar among teaching and nonteaching hospitals with CDI and SBP being more common in teaching hospitals. In-hospital mortality was about 5%, over fivefold higher in infected cirrhotics, and associated with higher LOS and charges. Sepsis (38-42%), pneumonia (23-30%), SBP (16-23%) and CDI (11-16%) contributed most to in-hospital mortality.

CONCLUSIONS

The prevalence of infections among hospitalised patients with cirrhosis in the US is increasing and is associated with in-hospital mortality, renal insufficiency and costs.

The frequency of complications and the etiology of disease in patients with liver cirrhosis in erzurum

OBJECTIVE

This study included 100 patients diagnosed with liver cirrhosis who presented at Atatürk University Faculty of Medicine Gastroenterology clinic and polyclinic.

MATERIALS AND METHODS

The etiology of liver cirrhosis and the incidence of its complications have been investigated.

RESULTS

The etiological classification of liver cirrhosis in our patients was as follows: 47 hepatitis B virus hepatitis, 11 hepatitis C virus hepatitis, 5 HBV+HDV hepatitis, 4 Budd Chiari syndrome, 2 chronic alcohol abuse, 2 ischemic heart disease, 1 autoimmune hepatitis, 1 sclerosing cholangitis, 1 hydatid cyst. In 26 patients we could not find any etiological condition. These patients were called cryptogenic cirrhosis patients.When we examined the complications of liver cirrhosis, it appeared that there were ascites in 83 patient. In 56 patients, esophageal variceal bleeding occurred. There was spontaneous bacterial peritonitis in 42 patients. Hepatorenal syndrome occurred in 26 patients. Finally, in 3 patients we detected hepatorenal syndrome.

CONCLUSION

The most common causes in the etiology of liver cirrhosis are viral, especially HBV. Many of the patients were in decompensated phase when diagnosed. We found that there was a close relation between the frequency of complications and mortality in liver cirrhosis.

Risk factors of cellulitis in cirrhosis and antibiotic prophylaxis in preventing recurrence

BACKGROUND

Cellulitis is a commonly encountered bacterial infection among cirrhotic patients apart from spontaneous bacterial peritonitis, urinary tract and respiratory infections. This study aimed to determine the risk factors of cellulitis in cirrhosis and whether antibiotic prophylaxis helps prevent recurrence of cellulitis.

METHODS

The study was conducted in two phases. In phase 1, all cirrhotic patients admitted with cellulitis from August 2011 to August 2013 were taken as cases (n=70) and cirrhotic patients without cellulitis were included as controls (n=73). Baseline demographic data, comorbidities and investigations were noted and compared. In phase 2, the cases of phase 1 were divided into two groups, based on initiation of antibiotic prophylaxis at the time of discharge and were followed up for six months for recurrence of cellulitis.

RESULTS

The main etiology of cirrhosis was alcohol and 68% of cases were Child C. Factors which showed significance in univariate analysis were presence of diabetes mellitus, hepatic encephalopathy, platelet count, albumin level and model for end-stage liver disease (MELD) score. Using logistic regression, hepatic encephalopathy (OR 2.95, CI 1.01-8.45), albumin level <2.5 g/dL (OR 2.80, CI 1.32-5.92) and MELD >15 (OR 2.95, CI 1.39-6.27) emerged as significant factors associated with cellulitis. Cellulitis recurred in 20% and recurrence was significantly low among antibiotic prophylaxis group (15% vs. 50% P=0.048).

CONCLUSIONS

Hypoalbuminemia, and high MELD score are the risk factors for cellulitis in cirrhosis. Antibiotic prophylaxis can reduce the recurrence of cellulitis as in the case of spontaneous bacterial peritonitis.

Mortality after urinary tract infections in patients with advanced cirrhosis - Relevance of acute kidney injury and comorbidities

BACKGROUND

Bacterial infections increase mortality four-fold in patients with decompensated cirrhosis. However, specific mortality associated with urinary tract infections (UTI) in cirrhosis is not known.

METHODS

Retrospective single-centre analysis of all hospitalized patients with cirrhosis and ascites who underwent first paracentesis between 2006 and 2011 to determine 90-day mortality associated with UTI defined as pyuria with significant bacteriuria using Cox proportional hazard models.

RESULTS

A total of 108 patients with at least one episode of UTI and 291 with exclusion of UTI were identified. Bacterial infections other than UTI were diagnosed in 136 (34%) of patients at the time of urine analysis. Female gender, Child-Pugh stage C, higher grade of ascites and systemic inflammatory response syndrome were associated with UTI. After adjustment for liver function and co-morbidity, the hazard ratios (HR) of death within 90 days after urine analysis were 2.08 (95% CI 1.28-3.38) in patients with UTI, 2.93 (1.90-4.52) in patients with other bacterial infections and 3.39 (2.03-5.65) in patients with UTI and concomitant infection. Independent predictors of death after UTI were renal dysfunction at presentation (HR 2.52; 95% CI 2.52), subsequent acute kidney injury within 48 h after diagnosis (4.57; 2.54-8.24), concomitant bacterial infection (1.77; 1.04-3.00) and malignant comorbidity (1.85; 1.03-3.30). The combination of these factors was more accurate in predicting 90-day mortality than the MELD score or C-reactive protein.

CONCLUSIONS

The presence of UTI indicates an increased risk of 90-day mortality in patients with advanced cirrhosis. Renal dysfunction and comorbidities are predictors of death in these patients.

The risk of cellulitis in cirrhotic patients: a nationwide population-based study in taiwan

Background/Aims

Cellulitis is a common infectious disease. However, the risk of cellulitis in cirrhotic patients is not well established, and whether liver cirrhosis is a risk factor for cellulitis remains unknown. This study evaluated the relationship between cellulitis and liver cirrhosis.

Methods

The National Health Insurance Database, which was derived from the Taiwan National Health Insurance program, was used to identify patients. The study group consisted of 39,966 patients with liver cirrhosis, and the comparison group consisted of 39,701 randomly selected age- and sex-matched patients.

Results

During the 3-year follow-up period, 2,674 (6.7%) patients with liver cirrhosis developed cellulitis, and 1,587 (4.0%) patients without liver cirrhosis developed cellulitis (p<0.001). Following a Cox's regression analysis adjusted for age, sex, and underlying medical disorders, the cirrhotic patients demonstrated a greater risk for the occurrence of cellulitis than the non-cirrhotic patients during the 3-year period (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.55 to 1.77; p<0.001). Additionally, cirrhotic patients with complications also had a greater risk for the occurrence of cellulitis than those patients without complications (HR, 1.23; 95% CI, 1.14 to 1.33; p<0.001).

Conclusions

We conclude that cirrhotic patients have a greater risk of cellulitis than non-cirrhotic patients.

Renal failure and hyponatremia in patients with cirrhosis and skin and soft tissue infection. A retrospective study

BACKGROUND & AIMS

Skin and soft tissue infection in cirrhosis is considered a non-severe infection, but specific information is lacking. This study aimed at assessing the characteristics, occurrence of renal failure, and outcome of cirrhotic patients with skin and soft tissue infection.

METHODS

Ninety-two patients with cirrhosis and skin and soft tissue infection admitted to hospital within a 6-year period were retrospectively analyzed. A control group matched by severity of liver disease, admitted for reasons other than infection, was also studied.

RESULTS

Resolution of the infection was achieved in 96% of patients. Twenty (21.7%) patients with skin and soft tissue infection developed renal failure, compared to only five patients (5.4%) of the control group (p=0.001). Renal failure was persistent despite infection resolution in 10 of the 20 patients vs. none of the control group. Renal failure was associated with poor prognosis. Hyponatremia developed in 40% and 25% of the infection and control group, respectively (p=0.028). Within a 3-month follow-up period, 25 patients (23%) with skin and soft tissue infection died or were transplanted compared to only four patients (4%) of the control group (p<0.001). Factors independently associated with mortality in the infection group were: site of acquisition of the infection and MELD-sodium score at diagnosis.

CONCLUSIONS

Skin and soft tissue infection is a severe complication of cirrhosis with high frequency of renal failure and hyponatremia that may persist despite resolution of the infection. MELD-sodium score is useful to assess 3-month mortality in these patients.

Acute renal dysfunction in patients with alcoholic hepatitis

Acute renal dysfunction is common in patients with alcoholic hepatitis (AH). Its presence leads to higher mortality in these patients. Despite advances in medical care, the outcome has changed little over the past decades. Studies using Pentoxifylline and molecular adsorbent recirculation system have shown encouraging data in small studies. Further larger well designed studies are needed to assess these modalities of treatment for the treatment of AH.