Prognostic role of serum ammonia in patients with sepsis-associated encephalopathy without hepatic failure

Objectives

Our previous study shows that serum ammonia in sepsis patients without hepatic failure is associated with a poor prognosis. The relationship between serum ammonia level and the prognosis of sepsis-associated encephalopathy (SAE) patients without hepatic failure remains unclear. We aimed to explore the relationship between serum ammonia levels and the prognosis of patients with SAE.

Materials and methods

This study is a retrospective cohort study. We collected 465 patients with SAE admitted to the intensive care unit (ICU) from Medical Information Mart for Intensive Care IV (MIMIC IV) from 2008 to 2019. Patients with SAE were divided into a survival group (369 patients) and a non-survival group (96 patients). We used the Wilcoxon signed-rank test and the multivariate logistic regression analysis to analyze the relationship between serum ammonia levels and the prognosis of patients with SAE. R software was used to analyze the dataset.

Results

The primary outcome was the relationship between serum ammonia level and hospital mortality of SAE. The secondary outcomes were the relationship between serum ammonia level and hospital stays, simplified acute physiology score (SAPS II), Charlson, Glasgow coma scale (GCS), sequential organ failure assessment (SOFA), and lactate level of SAE. The mortality of patients with SAE was 20.6%. The serum ammonia level was not significantly associated with hospital mortality, longer hospital stays, higher SAPS II and Charlson scores, and lower GCS of patients with SAE. The serum ammonia level was associated with higher SOFA scores and lactate levels in patients with SAE. The SAPS II and Charlson scores were independent risk factors for death in patients with SAE.

Conclusion

Serum ammonia level was associated with higher SOFA scores and lactate levels in patients with SAE. In addition, the SAPS II and Charlson scores can be used to assess the prognosis of patients with SAE. Therefore, we should closely monitor serum ammonia, SAPS II, and Charlson levels in patients with SAE.

Lactobacillus reuteri DSM 17938 alleviates d-galactosamine-induced liver failure in rats

Liver failure is a serious hepatic dysfunction with high mortality. This work aimed to investigate the effect of a famous probiotic and drug, Lactobacillus reuteri DSM 17938, on liver failure in rats. Sprague-Dawley rats were gavaged with 3 × 109 CFU of DSM 17938 for 7 days. d-galactosamine was intraperitoneally injected to induce acute liver failure on the eighth day. Samples were collected to determine the liver function, serum cytokines levels, terminal ileum and liver histology, gut microbiota, metabolome and transcriptome. Our results showed that pretreatment with DSM 17938 not only reduced the elevation in serum alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, IL-1α, IL-2, IL-18, M-CSF, and MIP-3α levels but also alleviated histological abnormalities of both the terminal ileum and liver induced by d-galactosamine. Additionally, DSM 17938 reduced d-galactosamine-induced enrichment of some taxa of gut Actinobacteria or Firmicutes, including abundant pathogens such as Actinomycetales, Coriobacteriaceae, Staphylococcaceae and Enterococcaceae. Furthermore, DSM 17938 reduced the d-galactosamine-induced increase in not only fecal metabolites such as trisaminol and lithocholic acid but also the transcription of liver inflammatory genes, such as Ccl2, Ccl7, Ccl11, Ccl12, Il6, Il11, Il20rb, Mmp3 and Mmp10. Downregulation of retinol metabolism and PPAR signaling pathway as well as upregulation of viral protein interaction with cytokine and cytokine receptor and central carbon metabolism in cancer signaling pathway were involved in the mechanism of L. reuteri DSM 17938 alleviating liver failure. Our findings suggested that DSM 17938 is a potential probiotic for the prevention or treatment of liver failure.

Vitamin D deficiency is associated with hepatic decompensation and inflammation in patients with liver cirrhosis: A prospective cohort study

Background

Vitamin D is required to maintain the integrity of the intestinal barrier and inhibits inflammatory signaling pathways.

Objective

Vitamin D deficiency might be involved in cirrhosis-associated systemic inflammation and risk of hepatic decompensation in patients with liver cirrhosis.

Methods

Outpatients of the Hepatology Unit of the University Hospital Frankfurt with advanced liver fibrosis and cirrhosis were prospectively enrolled. 25-hydroxyvitamin D (25(OH)D₃) serum concentrations were quantified and associated with markers of systemic inflammation / intestinal bacterial translocation and hepatic decompensation.

Results

A total of 338 patients with advanced liver fibrosis or cirrhosis were included. Of those, 51 patients (15%) were hospitalized due to hepatic decompensation during follow-up. Overall, 72 patients (21%) had severe vitamin D deficiency. However, patients receiving vitamin D supplements had significantly higher 25(OH)D₃ serum levels compared to patients without supplements (37 ng/mL vs. 16 ng/ml, P<0.0001). Uni- and multivariate analyses revealed an independent association of severe vitamin D deficiency with the risk of hepatic decompensation during follow-up (multivariate P = 0.012; OR = 3.25, 95% CI = 1.30–8.2), together with MELD score, low hemoglobin concentration, low coffee consumption, and presence of diabetes. Of note, serum levels of C-reactive protein, IL-6 and soluble CD14 were significantly higher in patients with versus without severe vitamin D deficiency, and serum levels of soluble CD14 levels declined in patients with de novo supplementation of vitamin D (median 2.15 vs. 1.87 ng/mL, P = 0.002).

Conclusions

In this prospective cohort study, baseline vitamin D levels were inversely associated with liver-cirrhosis related systemic inflammation and the risk of hepatic decompensation.

Impacts of pretransplant infections on clinical outcomes of patients with acute-on-chronic liver failure who received living-donor liver transplantation

Background

Liver transplantation is the only therapeutic modality for patients with acute-on chronic liver failure (ACLF). These patients are at high risk for bacterial infections while awaiting transplantation. The aim of this study was to elucidate whether an adequately treated bacterial infection influences the outcomes after transplantation in this patient population.

Methodology/Principal Findings

54 recipients (median age, 49.5 years [range, 22–60]) of adult-to-adult living donor liver transplant (LDLT) for ACLF were categorized as those with pretransplant infection (Group 1, n = 34) or without pretransplant infection (Group 2, n = 20) for retrospective analyses. With the exception of a higher male-female ratio (P = 0.046) and longer length of pretransplant hospital stay (P = 0.026) in Group 1, similar demographic, laboratory and clinical features were found in both groups. Patients in Group 1 (totally 42 pretransplant infection episodes) were adequately treated with effective antibiotic(s) before receiving LDLT. All included patients were followed up until one year after transplantation or death. Sixty-one posttransplant infection episodes were found in an overall of 44 ACLF patients (27 in Group 1 vs. 15 in Group 2; P = 0.352). Frequently encountered posttransplant infections were intraabdominal infection, pneumonia, bloodstream infection and urinary tract infection. Two patients died in each group (P = 0.622). No significant difference was found in the length of posttransplant ICU stay, and in one-year survival, graft rejection, and posttransplant infection rate between both groups. The longer overall hospital stay (mean day, 89.0 vs. 65.5, P = 0.024) found in Group 1 resulted from a longer pretransplant hospital stay receiving treatment for pretransplant infection(s) and/or awaiting transplantation.

Conclusions

These data suggested that an adequately treated pretransplant infection do not pose a significant risk for clinical outcomes including posttransplant fatality in recipients in adult-to-adult LDLT for ACLF.

Nephrotoxic effects from chronic toxic cyanobacterial blooms in fishes with different trophic levels in a large Chinese lake

Physiological and biochemical responses in kidneys of fishes with different trophic levels to toxic cyanobacterial blooms were studied. We sampled four fishes: the phytoplanktivorous Hypophthalmichthys molitrix and Aristichthys nobilis, the omnivorous Carassius auratus, and the carnivorous Culter ilishaeformis. Alterations of the antioxidant (GSH) and the major antioxidant enzymes (CAT, SOD, GPx, GST) were monitored monthly. Catalase and glutathione S-transferase were significantly higher during blooms than before and after blooms. All fishes showed ultrastructural alterations during blooms, which mainly are inosculation of foot processes in epithelial cell of glomeruli and mitochondria swelling in the proximal tubules. The results suggested that kidney impairment from chronic exposure of toxic cyanobacterial blooms might be the first step, and then followed by hepatic failure. Compared with livers in terms of physiological status, the weaker antioxidant ability of kidney made it more susceptible to chronic MCs exposure, besides its effective accumulation of MC metabolites.

[The clinical characteristics of hepatic failure with aspergillosis]

OBJECTIVES

To study the clinical characteristics of hepatic failure with aspergillosis.

METHODS

The data of hepatic failure patients with fungal infection hospitalized in our hospital form January 1985 to June 2006 were collected. This research mainly focused on the clinical characteristics of the patients co-infected with aspergillosis.

RESULTS

The occurrence of aspergillosis was 20.5% (104 cases) among 507 hepatic failure patients with fungal infection. Compared with other fungal infection in hepatic failure patients, the effective rate of antifungal therapy and the improvement rate of underlying disease were worse in patients with aspergillus infection (36.5% vs 57.8%, P = 0.000; 26.0% vs 36.7%, P = 0.049). Aspergillus fumigatus was the most common species among 108 fungal species. The species next to Aspergillus fumigatus were Aspergillus niger and Aspergillus flavus. The mainly infected organ was lung and its clinical manifestation was atypical. Liver function could be improved with effective anti-fungus therapy.

CONCLUSIONS

Diagnosis and treatment of aspergillosis is difficult in hepatic failure patients co-infected with aspergillosis. Early and effective antifungal therapy is helpful to the recovery of liver function in the hepatic failure patients suspected with aspergillosis co-infection.

Hepatic abscesses after liver transplant: 1997-2008

OBJECTIVES

Infectious complications (such as liver abscesses) remain one of the major causes of posttransplant morbidity and mortality. Management may be problematic and is often based on experience with hepatic abscess in nontransplant patients. We reviewed our experience with hepatic abscess in liver transplant recipients to assess their presentation, clinical features, treatment, and outcome.

MATERIALS AND METHODS

A retrospective review of all liver transplant in Shiraz transplant center from September 1997 through September 2008 was performed. Hepatic abscess was defined as a parenchymal hepatic lesion consistent with abscess (as described by a radiologist), positive liver or concurrent blood cultures, or both (within 24 hours), and compatible clinical findings.

RESULTS

Of 560 liver recipients, we identified 5 patients (23-42 y) who had experienced 7 episodes of hepatic abscess, 30-240 days after transplant. All patients had received liver from deceased donors. Biliary reconstruction was done by duct-to-duct anastomosis in 4 and hepatico-jejunostomy in 1 case. Pretransplant diagnoses included hepatitis B cirrhosis, autoimmune hepatitis (2 cases), Caroli disease, and cryptogenic cirrhosis. Liver aspirates showed E. coli in 4 cases, and Aspergillus in 1 case. The main predisposing factor was bile-to-duct anastomosis stricture in 3, diabetes mellitus in 2, and hepatic artery thrombosis in 1 of the patients. Two patients died owing to liver and multiorgan failure, despite percutaneous and operative drainage with broad spectrum antibiotics and antifungals.

CONCLUSIONS

Hepatic abscess, a rare complication after liver transplant, was associated with hepatic artery thrombosis, biliary anastomosis stricture, and diabetes mellitus. Mortality was higher than in patients who had not undergone transplant. Prolonged antibiotic therapy and drainage are required to improve the outcome in these patients.

Management of HCV infection: current issues and future options

Hepatitis C virus (HCV) is a common cause of chronic liver disease (CLD). Presently the standard regime comprises a combination of PEG-IFN and ribavirin. Sustained virologic response (SVR) is defined as the absence of HCV RNA in the serum six months after the end of treatment. With standard treatment, in patients with genotypel infections, SVR lies between 42% to 56%, whereas for genotypes 2 and 3 the SVR is from 76% to 82%. Thus, a large percentage of patients fail to achieve SVR even with improvised standard treatment. Such patients may be divided initially into relapsers and nonresponders. The decision to re-treat should be based on the presence of clinical, virological and histological factors that predict the possibility of successful outcome with further therapy. Both the type of previous therapy and previous response are very important factors in guiding re-treatment. The development of new therapeutic agents is critical for further improvement in the management of chronic hepatitis C as current therapeutic options have rather low efficacy in certain subgroups, such as those with HCV genotype 1 or patients with advanced liver disease, and most probably in nonresponders and relapsers. Moreover, pegylated IFNalpha and/or ribavirin are associated with frequent side effects and have a negative impact on the patient's quality of life. Therefore, the development of new effective and safe drugs is a matter of significant clinical importance.

[Cross-sectional study of leptospirosis cases admitted to the Iaşi Clinic of Infectious Diseases over a 5-years period]

Leptospirosis is a zooantroponosis manifested as an infection with a severe evolution, with liver and renal failure and haemoragic manifestation. The aim of the study was to present the epidemiologic, clinic and therapeutical aspects of 100 cases of leptospirosis admitted in the clinic of Infectious Diseases of Iaşi, during 5 years (2002-2006).

MATERIAL AND METHOD

The diagnostic was based on the clinical-biologic study and risk factors with febrile syndrome, mialgic syndrome, headache, meningial, liver and renal failure and hematological syndromes, with the serologic evidence of serotypes of leptospirosis.

RESULTS

All the patients were serologic confirmed with leptospirosis. Leptospirosis is an emergent disease with the possibility of severe evolution in some forms, with lever and renal failure.

Inducible histamine protects mice from P. acnes-primed and LPS-induced hepatitis through H2-receptor stimulation

BACKGROUND & AIMS

Inducible histamine and histamine H2-receptors have been suggested to be involved in innate immune response.

METHODS

We examined a functional role of inducible histamine in the protection against hepatic injury and lethality in Propionibacterium acnes -primed and lipopolysaccharide-induced hepatitis, using histidine decarboxylase knockout and H2-receptor knockout mice.

RESULTS

Lipopolysaccharide challenge after Propionibacterium acnes priming increased histidine decarboxylase activity in the liver of wild-type mice, associated with a marked elevation of histamine turnover. Histidine decarboxylase-like immunoreactivity was observed in CD68-positive Kupffer cells/macrophages. Treatment of wild-type mice with famotidine or ranitidine but not d -chlorpheniramine augmented hepatic injury and inhibited the survival rate significantly. The same dose of Propionibacterium acnes and lipopolysaccharide induced severe hepatitis and high lethality in histidine decarboxylase knockout and H2-receptor knockout mice; the former were rescued by the subcutaneous injection of histamine. Immunohistochemical study supported the protective role of histamine against the apoptosis of hepatocytes. Histamine suppressed the expression of IL-18 and tumor necrosis factor alpha in the liver, leading to the reduced plasma levels of cytokines including IL-18, TNF-alpha, IL-12, IFN-gamma, and IL-6.

CONCLUSIONS

These findings as a whole indicated that endogenously produced histamine in Kupffer cells/macrophages plays a very important role in preventing excessive innate immune response in endotoxin-induced fulminant hepatitis through the stimulation of H2-receptors.

[Dynamic variability of intestinal flora and endotoxin in rat with fulminate hepatic failure]

OBJECTIVE

To investigate the dynamic variability of intestinal flora and endotoxins in rats with fulminate hepatic failure.

METHODS

Establishing the fulminate hepatic failure models by intraperitoneal injection of Galactosamine. Forty Sprague-Dawley rats were divided into three groups: group A (n=10) were killed at the beginning of the experiment as control; while Group B (n=12) and C (n=18), the fulminate hepatic failure models, were killed 24 and 48 hours respectively after successful induction. Then, the contents of the jejunum, ileum and colon descendents were collected and a quantitative analysis was made about intestinal flora. Meanwhile, the concentrations of endotoxin in portal vein and right ventricle were determined and so were those in contents of ileums and colons.

RESULTS

Our experiments showed that the livers of rats in group B were injured most seriously among three groups, and a minor recovery of hepatic function was observed in group C with the decrease of total bile acids (P< 0.05). Analysis on intestinal flora show: the intestinal enterobacteriacea increase and the lactobacillus decrease in group B (P< 0.01 in jejunum and ileum and P<0.05 in colon). The comparisons between group C and B showed that the enterobacteriacea in the former decreased in both jejunum and colon (P< 0.05) while the number of lactobacillus recovered in the jejunum of group C (P<0.05). Quantitative analysis on endotoxins showed that the ileum endotoxin increased in group B (P< 0.05) and in group C, endotoxins in ileum and colons also increased (vs. control, P<0.01); portal endotoxin in group B showed higher level than that in group A and C (P< 0.01).

CONCLUSION

The alteration of intestinal flora was observed in fulminate hepatic failure rats. Abnormal intestinal flora might lead to incline of endotoxin in ileum, colon and portal vein, while the recovery of normal intestinal flora would decrease the level of portal endotoxin.

Fulminant liver failure in a child with invasive group A streptococcal infection

Liver involvement is mentioned in streptococcal toxic shock syndrome, but never as fulminant liver failure (FLF). We report the case of a 2-year-old child who developed isolated FLF secondary to invasive group A streptococcal infection without shock due to a M1T1-type strain expressing speA, speB and speC toxin genes. On antibiotics, he recovered rapidly without liver transplantation.

CONCLUSION

A streptococcal pyrogenic exotoxin likely constituted the initial insult leading to FLF. This etiology can be included in the differential diagnosis of FLF and would support early introduction of antibiotics.

Pulsed field gel electrophoresis typing of coagulase-negative staphylococci with decreased susceptibility to teicoplanin isolated from an intensive care unit

Increased isolation of coagulase-negative staphylococci (CoNS) with decreased susceptibility to teicoplanin prompted this epidemiological survey in the authors intensive care unit. Of 224 medical and surgical patients with hepatobiliary disease, in hospital between December 1998 and July 1999, 14 (6.3%) had at least one isolate of CoNS with decreased susceptibility to teicoplanin. A total of 27 isolates with decreased susceptibility to teicoplanin were recovered from these 14 patients. Pulsed field electrophoresis (PFGE) with Sma I endonuclease demonstrated that CoNS isolates obtained from different patients were unrelated. In addition, different isolates obtain from the same patient were also unrelated, with the exception of two patients. Eighteen out of 27 isolates (66.7%) with decreased susceptibility to teicoplanin were recovered after an earlier treatment with teicoplanin or vancomycin (median 13.1 g, range 2.4-32.7 g per patient). Only four CoNS strains with decreased susceptibility to teicoplanin induced serious infection, all of which responded well to vancomycin therapy. Emergence of CoNS strains with decreased susceptibility to teicoplanin remained limited in hospitalized patients, and was not related to a clonal spread of a particular resistant strain.

Bilirubin impairs bactericidal activity of neutrophils through an antioxidant mechanism in vitro

BACKGROUND

Liver failure accompanied by hyperbilirubinemia after major hepatic resection is profoundly associated with septic complications. Although the immune dysfunction in cholestasis has been intensively investigated, the contribution of increased serum bilirubin to the impaired resistance to bacterial infection remains to be elucidated. Because bilirubin possesses an antioxidant activity, we hypothesized that bilirubin may scavenge reactive oxygen species (ROS) produced by neutrophils and consequently impair neutrophil bacterial killing. To address this, we evaluated the effects of bilirubin on the bactericidal activity of ROS or of neutrophils in vitro.

MATERIALS AND METHODS

The antioxidant activity of bilirubin was determined using an ROS-sensitive fluorophore, dichlorofluorescin diacetate (DCFH-DA). Bilirubin concentration in the buffer solution was monitored spectorophotometrically after incubation with ROS. The effect of bilirubin on killing of Escherichia coli by ROS or by isolated human neutrophils was determined by counting the viable E. coli after incubation on nutrient agar.

RESULTS

The bilirubin concentration in the buffer solution was decreased by the addition of hydrogen peroxide, especially in the presence of peroxidase or ferrous iron. DCFH-DA oxidation by ROS or activated neutrophils was inhibited by bilirubin in a dose-dependent manner. The bactericidal activity of ROS or of isolated neutrophils was significantly attenuated by bilirubin.

CONCLUSIONS

Bilirubin impairs bactericidal activity of neutrophils through scavenging ROS. Increased levels of serum bilirubin may well be responsible for the impaired bacterial clearance in patients with hyperbilirubinemia.

Effect of Lactobacillus supplementation with and without arginine on liver damage and bacterial translocation in an acute liver injury model in the rat

In acute liver failure following hepatitis, toxic insults, or after major liver surgery, there is an increased bacterial translocation from the gut. This may explain some of the infectious complications seen in these conditions. To elucidate mechanisms and find possible preventive measures, we investigated the effect of rectal administration of arginine and probiotic bacteria (Lactobacillus spp.) on bacterial translocation and the extent of liver failure. Sprague-Dawley rats were used and five different Lactobacillus strains (Lb. reuteri R2LC, Lb. rhamnosus DSM 6594 (= strain 271), Lb. plantarum DSM 9843 (= strain 299v), Lb. fermentum 8704:3 (= strain 245), and Lb. reuteri (= strain 108) were administered rectally once daily for 8 days with and without 2% arginine. Acute liver injury (ALI) was induced on the eighth day by intraperitoneal injection of D-galactosamine (1.1 g/kg body weight), and samples were collected after 24 and 48 hours. Bacterial translocation was evaluated by bacterial culture from portal and arterial blood, mesenteric lymph nodes, and liver tissue. Liver enzymes and bilirubin were evaluated in the serum. The bacterial load in the cecum and colon was determined and the liver histopathological changes were studied. There was no mortality at any time. The liver enzymes and bilirubin decreased in some of the groups supplemented with lactobacilli with and without arginine compared with the ALI control group. The incidence of bacterial translocation and the number of the translocated bacteria decreased significantly in some of the supplemented groups. Lb. plantarum + arginine administration significantly reduced the level of the released liver enzymes, hepatocellular necrosis and inflammatory cell infiltration, bacterial translocation, and the number of Enterobacteriaceae in the cecum and colon. Rectal administration of different Lactobacillus strains with and without arginine in an ALI model significantly modulates the extent of the liver failure and reduces bacterial translocation. Lb. plantarum DSM 9843 (= strain 299v) with or without arginine seemed superior to the other Lactobacillus strains. The beneficial effect of arginine administration alone indicates a possible role of nitric oxide and polyamines in this process, and the lactobacilli may execute their action via the same mechanisms or via bacterial antagonism and/or enhancement of systemic and intestinal mucosal immunity.

The spectrum of septic encephalopathy. Definitions, etiologies, and mortalities

OBJECTIVE

To determine whether the severity of septic encephalopathy is correlated with gram-negative bacteremia and mortality and whether there exists a single or combination of metabolic derangements(s) that cause septic encephalopathy.

DESIGN AND SETTING

Prospective case series in an academic medical center.

PATIENTS

Fifty patients selected according to clinical and laboratory criteria for severe sepsis. The criteria included temperature, heart rate, respiratory rate, and hypotension and/or signs of systemic hypoperfusion.

MAIN OUTCOME MEASURES

A single or combination of metabolic and laboratory derangements and organ failures, three different methods to grade the severity of septic encephalopathy, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, gram-negative bacteremia and infection, and mortality.

RESULTS

Encephalopathy was associated with an increase in mortality when graded by the Glasgow Coma Score; a score of 15 had 16% mortality, 13 to 14 had 20%, 9 to 12 had 50%, and 3 to 8 had 63% mortality (P < .05). Bacteremia was associated with encephalopathy; 13% of septic patients without encephalopathy vs 59% of patients with encephalopathy had bacteremia (P < .001) when graded by altered mental status. Septic encephalopathic patients had elevated serum urea nitrogen and bilirubin levels, increased APACHE II scores, and a higher incidence of renal failure.

CONCLUSIONS

The severity of septic encephalopathy correlated with mortality, bacteremia, and renal and hepatic dysfunction. The Glasgow Coma Score is a useful tool for characterizing septic encephalopathy. Considerable variations can be found according to different criteria used to classify septic encephalopathy.

Acute hepatic and renal failure caused by Pneumocystis carinii in patients with AIDS

Clinical and pathological findings are described in two AIDS patients with Pneumocystis carinii infection who received prophylactic treatment with nebulised pentamidine and developed unusual hepatic and renal failure. Histological examination showed clumps of P carinii massively obstructing hepatic sinuses and portal vessels in the first patient, and merular and intertubular capillaries in the second. These findings could explain the unusual clinical features, characterised by acute hepatic and renal failure.

Effects of a water-soluble ethylhydroxyethyl cellulose on gut physiology, bacteriology, and bacterial translocation in acute liver failure

Bacterial infection and bacteremia are common complications in patients with acute liver failure. Bacterial translocation from the gut has been suggested to be a major cause of bacterial infections in experimental acute liver failure. In the present study, a water-soluble ethylhydroxyethyl cellulose (EHEC) was administered orally 1 and 24 hours prior to 90% hepatectomy in the rat in order to prevent bacterial translocation in experimental acute liver failure induced by subtotal liver resection in the rat. Ninety percent hepatectomy alone resulted in 80 to 100% translocation to mesenteric lymph nodes or blood 2 and 4 hours after operation. There was no translocation in rats undergoing sham operation or 90% hepatectomy with EHEC administration prior to operation (p < .01). Bacterial overgrowth, increased bacterial adherence onto the intestinal surface, and diminished intestinal and mucosal mass were also observed in animals with subtotal liver resection, but not in those administered EHEC. A delayed 2-hour intestinal transit time occurred in both groups receiving subtotal liver resection, with or without oral EHEC. EHEC inhibited bacterial growth and DNA synthesis and altered bacterial surface properties after 1-hour incubation with bacteria in vitro, an interaction that was not further influenced by time. These results imply that EHEC may alter enterobacterial capacities of metabolism, proliferation, and invasion by effects on the bacterial surface. Furthermore, EHEC seems to possess a trophic action on the intestine, though without enhancing the intestinal motility.

Role of fibronectin and complement in immunopathogenesis of acute and subacute hepatic failure

The present study describes the plasma levels of soluble fibronectin (FN), C3d, the breakdown product of C3 complement and Ba, the breakdown product of properdin factor B, in 30 patients of uncomplicated acute viral hepatitis (AVH), 64 patients of fulminant hepatic failure (FHF) and 29 patients of subacute hepatic failure (SAHF) with different hepatitis viral infections. Aetiological analysis of these patients demonstrated hepatitis B, hepatitis C and hepatitis non-A, non-B, non-C (NANB-NC) infections in 6.7, 13.3 and 80% cases, respectively, of the AVH group; 18.8, 42.2. and 39.0% cases, respectively, of the FHF group; and 31.0, 34.5 and 34.5% cases of the SAHF group. None of them had hepatitis A infection. The analysis of data showed that the plasma FN level was significantly reduced in patients with FHF and SAHF as compared to AVH patients and healthy persons. Fibronectin levels in AVH was comparable to that in the healthy group. Further, the FN level was not dependent on the nature of aetiological virus. The level of C3d in plasma was significantly high in all patients of FHF and SAHF, irrespective of their viral aetiology, compared to the AVH group and the healthy group. Like FN, the C3d level was comparable in the AVH and healthy groups. However, the Ba level was comparable to the normal value in all types of infections including the AVH, FHF and SAHF groups. These findings were used to explain the possible roles of fibronectin and complement in the immunopathogenesis of liver injury in patients of acute liver failure of viral aetiology.

Non-A, non-B post-transfusion hepatitis. Looking back in the second decade

OBJECTIVE

To determine the long-term course of non-A, non-B post-transfusion hepatitis.

DESIGN

Follow-up in 1989 to 1992 of patients prospectively identified as having contracted non-A, non-B post-transfusion hepatitis between 1972 and 1980.

SETTING

A university hospital.

PATIENTS

Patients who were prospectively followed from receipt of blood products and in whom otherwise unexplained abnormalities in their serum alanine aminotransferase levels developed without serologic evidence of exposure to hepatitis A or B.

MEASUREMENTS

The presence or absence of clinical evidence of liver failure or symptoms of chronic hepatitis.

RESULTS

Of 90 patients identified in the 1970s, 80 were recontacted and evaluated between 1989 and 1992. Based on the current status of these 80 patients and on the last known status of the remaining patients, the following observations were made: 1) Although about 40% had some symptoms during the early phase of the disease, none subsequently experienced significant clinical problems related to hepatic inflammation; 2) eight patients (seven with chronic hepatitis) developed hepatic failure; and 3) life-table analysis showed that the probabilities of developing clinical evidence of cirrhosis after 16 years of disease in the entire cohort, in the subgroup who developed chronic hepatitis, in the patients who had hepatitis C, and in those with chronic hepatitis C were 18%, 21%, 17%, and 20%, respectively.

CONCLUSIONS

For most of the study patients, non-A, non-B post-transfusion hepatitis was a biochemical and histologic disease that had not yet caused hepatic symptoms. If hepatic failure does occur, it is usually seen only after 10 or more years of disease. Before that time, many infected persons die due to other disease processes.

An open, comparative trial of aztreonam with vancomycin and gentamicin with piperacillin in patients with fulminant hepatic failure

Fifty patients admitted with fulminant hepatic failure and clinically suspected infection were allocated to receive either aztreonam and vancomycin or piperacillin and gentamicin as first line treatment. Fourteen patients died within 48 h of admission and were excluded from the analysis. Of the remaining 36 patients, 16 received aztreonam/vancomycin and 20 piperacillin/gentamicin. There were 18 episodes of infection in the aztreonam/vancomycin group and 24 in the piperacillin/gentamicin group (P = not significant). The most frequent bacterial pathogen was Staphylococcus aureus. Fungal infection developed in 13 patients (nine in the aztreonam/vancomycin group and four in the piperacillin/gentamicin group; P = not significant). Death attributed to infection occurred in 4 (25%) of 16 patients receiving aztreonam/vancomycin and 4 (20%) of 20 receiving piperacillin/gentamicin (P = not significant). Thirteen patients (three in the aztreonam/vancomycin group and ten in the piperacillin/gentamicin group) had clinical and microbiological improvement without addition or substitution of other antibiotics. No side-effects attributed to the study drugs were recorded.